How To Improve Health Care In The United States

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1 Greater Flint Health Calitin Health Care Impact Study Executive Summary Intrductin Histrically, Genesee Cunty, Michigan was a natinal center f aut prductin and the birthplace f General Mtrs and the United Aut Wrkers. In the early 197 s GM emplyed abut 8, wrkers in the area, making it a majr US aut cmmunity. Since then lcal GM emplyment has fallen t less than 7,1, and GM declared bankruptcy in 29. These develpments, a lack f ecnmic diversity, and the recent deep natinal recessin have fueled grwing pverty, unemplyment, and an ersin f the cmmunity s tax base. Table f Cntents Intrductin: 1 Study Apprach: 2 Genesee Cunty Health Impact Assessment: 2 Summary f Key Findings: 2 Key Findings: 3 Trends: 3 Impact Assessment Future Implicatins: 7 Cllabrative Healthcare Strategies fr the Cmmunity t Cnsider: 8 Shrt Term Strategies: 8 Lng Term Strategies: 12 Health Impact Assessment Next Steps: 13 Seeking t dcument the impact f the autmtive/ecnmic crisis and its implicatins fr Genesee Cunty s healthcare delivery system and ppulatin health status, The Lewin Grup, Inc. (Lewin) was cmmissined by the Greater Flint Health Calitin (GFHC) t cnduct a health care impact study. The study s purpse is t supprt an fficial cmmunity request fr federal aid t the federal Directr f Recvery fr Aut Cmmunities and Wrkers. The GFHC is a 51(c) 3 nn-prfit healthcare calitin that represents a cmmunity-wide partnership f healthcare prviders, purchasers, cnsumers, gvernment leaders, insurers, and educatrs whse missin is imprving the health status f Genesee Cunty residents and the quality and cst-effectiveness f the healthcare system. The study includes a baseline assessment f the cmmunity and lcal health care delivery system, future implicatins f the crisis, interventin strategies t cnsider, and a screcard f perfrmance indicatrs t mnitr future cmmunity changes and impacts. 1

2 Study Apprach Our apprach t develp the cmmunity baseline assessment and prpsed strategies and interventins is summarized in Figure 1. It integrated bth quantitative and qualitative data surces and analyses, including: Develping custmized interview prtcls and cnducting 27 semi-structured 45-6 minute interviews with cmmunity stakehlders. Develping custmized data requests and cllecting and analyzing primary utilizatin, financial and health care cverage data frm lcal prviders and payers. Cmpiling and analyzing secndary data, including demgraphic, sci-ecnmic, health status and ther imprtant cmmunity ppulatin indicatrs. Synthesizing analysis findings t infrm the develpment f prpsed shrt and lng-term interventin strategies. Presenting prpsed interventin strategies fr cmmunity cnsideratin and validatin. Phase 1: Phase 2: Phase 3: Phase 4: Figure 1: Phases f the Impact Study Phase 1 Phase 2 Phase 3 Phase 4 Cmmunity Baseline Assessment and Implicatins Strategy Develpment Cmmunity Stakehlder Cnsideratin and Validatin Indicatrs t Mnitr Cmmunity Changes and Impacts The remainder f this executive summary highlights key cmmunity impact assessment findings and summarizes interventin strategies develped and under cnsideratin by the cmmunity t supprt an fficial request fr federal aid. Readers are referred t the final reprt fr a mre detailed examinatin f these issues. Genesee Cunty Impact Assessment We derived a number f imprtant findings and implicatins frm ur analysis f the impact f the autmtive/ecnmic crisis n the cmmunity s ppulatin and healthcare sectr. These are summarized belw, fllwed by impact assessment data analysis highlights and cnclusins regarding future implicatins fr the cmmunity. Summary f Key Impact Assessment Findings Due t the autmtive/ecnmic crisis, pverty, unemplyment, and numbers f Genesee Cunty residents receiving public assistance are significant and grwing rapidly. Numbers f uninsured and underinsured ppulatins are als grwing due t aut related and ther manufacturing jb lsses and shrinking UAW retiree health benefits. Bth public and private schl enrllments are declining, as are lcal hme values and public tax revenue. Despite the ecnmic crisis, the ecnmic impact f healthcare in the cmmunity is significant and grwing. Hwever: Rising uncmpensated care and Medicaid payment cuts threaten lcal hspital revenues. Service demand amng cmmunity safety-net prviders (Hamiltn FQHC, Mtt Children s Health Center, Genesee Cunty Cmmunity Mental Health, and Department f Public Health) is trending upward sharply. Current numbers and mix f Genesee Cunty physicians are adequate but incmes are declining due t shrinking health benefits, falling cmmercial health plan enrllment and Medicaid payment cuts. 2

3 Summary f Genesee Cunty Baseline Data Assessment Highlights The selected highlights presented belw are rganized t prvide an verview f imprtant cmmunity trends that helped infrm develpment f targeted strategies. Where apprpriate and available, cmmunity trends are cmpared with Michigan and the United States. These include: Sci-ecnmic and ecnmic indicatrs. Health status indicatrs. Health sectr ecnmic impact. Healthcare sectr characteristics. Key Genesee Cunty Sci-Ecnmic and Ecnmic Trends We examined Genesee Cunty-wide trends in selected sciecnmic indicatrs that histrically have been predictrs f cmmunity scial stress. These include pverty, unemplyment and numbers f residents receiving public assistance. In general, we fund that Genesee Cunty s sci-ecnmic trends mirrred thse f Michigan and the natin, but at mre unfavrable levels. As depicted in Figure 2 belw, the universal gains achieved in reducing pverty during the 199 s have been largely reversed. Althugh pverty trends fllwed a cnsistent pattern during the past twenty years, the prprtin f Genesee Cunty s residents living in pverty has cnsistently exceeded bth Michigan and the United States Figure 2: Cmparative Trends in Pverty * Genesee Michigan US *Pverty level is defined as thse living at 1 f the Federal Pverty guidelines fr that particular year. Surce: US Census Bureau Similarly, as seen in Figure 3, trends in unemplyment ver the past ten years demnstrate that the Cunty s unemplyment rates parallel, yet cnsistently exceed bth Michigan and the United States. As f 29, the Cunty unemplyment rate was abut 3.5 times higher than a decade earlier in Figure 3: Cmparative Trends in Unemplyment Speaking t surces f cmmunity unemplyment, as depicted in Figure 4, jb lsses in manufacturing including mtr vehicle manufacturing were fur times the natinal average this decade. In marked cntrast, hwever, emplyment within the healthcare sectr cntinues t grw. Figure 4: Cmparative Trends in Emplyment by Selected Industry Sectrs Adverse emplyment trends have directly impacted bth the cmmunity at large and the UAW/GM. As depicted in Figure 5, numbers f UAW/GM cvered lives fell between largely due t a 43 decline in the number f emplyees and their dependents. 9, 8, 7, 6, 5, 4, 3, 2, 1, Transprtatin Equipment Manufacturing* Figure 5: Trends in UAW/GM Ttal Cvered Lives 31,439 86,752 86,44 53,377 27,916 1,935 1, 57,128 58,177 23,46 83,696 17,82 75,221 53,986 2,473 3, YTD Emplyees & Emplyee Dependents Retirees & Retiree Dependents Laid Off Emplyees & Laid Off Dependents Ttal Cvered Lives Bth State and Cunty-wide numbers f Medicaid enrllees als cntinued t grw thrughut mst f the decade (Figure 6). That grwth accelerated during cnsistent with State and Cunty unemplyment trends. 2,, 1,8, 1,6, 1,4, Manufacturing Health Care & Scial Assistance Retail Trade Figure 6: Trends in Medicaid Enrllment 1,343,257 1,41,31,467,533 1,265, ,534,7311,532, Genesee Michigan US Surce: US Department f Labr Bureau f Labr Statistics , 8, 7, 6, 5, 4, 3, 2, 1, 2, 1,797,59 1,655,228 18, 16, 14, ,2, 1,, 8, 6, 75,924 79,928 83,21 86,111 89,89 87,691 94,61 1,274 12, 1, 8, 6, 4. 4, 4, (Jul) Genesee Michigan US 2, , Surce: US Department f Labr Michigan Genesee Surce: Michigan Department f Human Services Greenbk 3

4 Key Genesee Cunty Health Status Findings Unfavrable cmmunity sci-ecnmic and ecnmic trends ften influence ppulatin health status, and Genesee Cunty is n exceptin. Althugh the Cunty des nt differ greatly frm Michigan and the US acrss selected behaviral risk factrs, we bserved higher mrtality rates fr the cmmunity s ten leading causes f death and significant racial disparities in chrnic disease mrtality cmpared t benchmarks. As depicted in Figure 7, Genesee Cunty mrtality rates fr eight f the ten leading causes f death in 27 exceeded bth Michigan and the US. Disparities in strke and kidney disease mrtality were particularly striking. Cunty mrtality rates fr strke were 43 percent higher than the natinal average and kidney disease mrtality amng Cunty residents exceeded the US experience by 48 percent. Figure 7: Cmparisn f Mrtality Rates fr the Ten Leading Cases f Death in Genesee Cunty: 27 (per 1, residents) Heart Disease Cancer Strke Tp Causes f Death Chrnic Lwer Respiratry Disease Unintentinal Injuries Diabetes Alzheimer s Disease Kidney Disease Pneumnia/Influenza Suicide Genesee Cunty Michigan Surce: Michigan Department f Cmmunity Health & Genesee Cunty Department f Health US Cnsistent with many cmmunities acrss the US, amng the tp causes f chrnic disease mrtality heart disease, cancer, strke, and diabetes, mrtality is much higher amng the state and cunty African-American ppulatins cmpared t the verall and white ppulatins (Figure 8). Genesee Cunty Health Sectr Ecnmic Impact In many respects, the current autmtive/ ecnmic crisis has created unemplyment levels in the cmmunity nt dissimilar t the depressin f the 193 s. The health sectr, hwever, remains a ntable exceptin. As depicted in Figure 9, the direct and indirect ecnmic impact f the Cunty s health sectr n lcal emplyment, wages and tax revenue is significant and grwing despite the crisis. Between 26 and 28 the health sectr s ttal ecnmic impact grew by ver 22 percent, frm $1.8 billin t $2.2 billin. Figure 9: Ecnmic Impact f the Health Sectr in Genesee Cunty: Direct Jbs Indirect & Induced Jbs Ttal Jbs Direct Indirect & Induced Ttal Federal, State & Lcal Tax Revenue Generated* Ecnmic Impact f the Health Care Sectr** 26 22,652 1,997 33,649 Wages & Salaries $1.1 billin $.3 billin $1.4 billin Tax Revenue and Ttal Ecnmic Impact $.4 billin $1.8 billin 28 Number f Emplyees 23,63 11,664 35,267 $1.3 billin $.4 billin $1.7 billin $.5 billin $2.2 billin Change * Refers t tax revenue generated t federal, state, and lcal gvernments paid by the cunty's health care sectr, their suppliers and emplyees Surce: The Ecnmic Impact f Health Care in Michigan Third and Furth Editin Additinally, as previusly depicted in Figure 4, healthcare and scial services prvide the nly grwth amng emplyment sectrs. Figure 8: Prfile f Racial Disparities in Selected Chrnic Disease Mrtality Rates: 27 (per 1, residents) Overall African-American White Genesee Michigan Genesee Michigan Genesee Michigan Heart Disease Cancer Strke Diabetes Surce: CDC and Michigan Behaviral Risk Factr Surveillance Survey (26-28) 4

5 (in millins) Dllars in Thusands Ttal Number f Unduplicated Patients Key Genesee Cunty Health Sectr Characteristics Our full impact assessment fcused in depth n cmmunity health care sectr rganizatins. This summary presents illustrative highlights fcusing n: Hspitals and Health Systems Hamiltn Federally Qualified Health Center Cunty Physician Capacity and Utilizatin Private Payers and Genesee Health Plan Hamiltn Federally Qualified Health Center (FQHC) Hamiltn FQHC is a key cmmunity-based resurce and access pint t primary and preventive care services fr lcal vulnerable ppulatins. The number f enrlled patients there grew 11 between 26 and 29, led by a 15 increase in Medicaid enrllment (Figure 12). Figure 12: Hamiltn Federally Qualified Health Center: Unduplicated Patients by Payer: , Hspitals and Health Systems Reflecting the impact f the ecnmic crisis n Cunty hspitals and health systems, the value f uncmpensated care prvided virtually dubled fr Genesys Health System and McLaren Reginal Medical Center between 26 and 29, while Hurley Medical Center, the cmmunity s primary safety-net prvider, als experienced a 25 increase n tp f cnsistently reprting the highest levels f uncmpensated care (Figure 1). These trends track clsely with grwing levels f pverty, unemplyment, and public assistance in the cmmunity. Medicaid patients are als the primary users f Hurley s emergency department. Abut 9 are treated and discharged, suggesting high levels f nn-emergent ED use treatable in ther settings Figure1: Trends in the Value f Hspital Uncmpensated Care: $17.9 $15.9 $45.1 $19.9 $19.8 $54.8 $29. $26.6 $33.7 $ $56.6 Genesys McLaren Hurley The cmmunity s medical centers prvide a high vlume f care t lw incme and uninsured residents and train the next generatin f physicians thrugh their graduate medical educatin (GME) prgrams. Figure 11 depicts recent trends in public supplemental payments received by each medical center fr prviding these imprtant missin-based services and cmmunity benefits. Despite variatins in the size f their GME prgrams and vlume f care prvided, supplemental missinrelated revenue rse cnsistently fr each lcal medical center t help ff-set uncmpensated care lsses. 2, 15, 1, 5, 7,42 8,474 6,982 9,454 6,516 9,79 1,238 1, ,22 1, Self-pay Medicaid Medicare Cmmercial Despite the ecnmic crisis, Hamiltn s financial health has imprved steadily since 26 (Figure 13). This favrable financial perfrmance was led by grwth in Medicaid patient service revenue and funding received under the 29 American Recvery and Reinvestment Act (ARRA). Figure 13: Hamiltn Federally Qualified Health Center: Revenue and Expenses: $12, $1, $8, $6, $4, $2, $ $7,339 $7,963 $7,513 $7,547 $1,958 $5,382 $1,939 $6,25 $8,725 $1,941 $7, Fee-Based Revenue Grants Expenses $9,683 Under the 29 American Recvery and Reinvestment Act, Hamiltn applied fr and received the fllwing funding t establish the new Burtn primary care site which included $921, fr dental, medical, pharmacy, x-ray and ffice equipment and $339, t supprt increased demand fr services by the uninsured and medically underserved due t the ecnmic crisis. In August 29, the Burtn primary care site pened and plans t serve 6,3 primary care encunters annually. Figure 11: Trends in Missin-Based Revenue 26-29, Genesee Cunty Hspitals Genesys Health System McLaren Reginal Medical Center Hurley Medical Center

6 ER Visits per 1 Members Services Cmmercial Membership Genesee Cunty Physician Capacity and Utilizatin A 27 study fund that Michigan s physician shrtage was 5 abve the natinal average. 1 In additin, the Michigan State Medical Sciety prjects a shrtage f 8 physicians in Flint, mid- and nrthern Michigan by 22 due in part t an aging physician wrkfrce. Figure 14 demnstrates that while grwing natinally, the prprtin f Cunty practicing physicians relative t the lcal ppulatin has remained adequate and stable since Figure 14: Physician Supply in Genesee Cunty: Physicians in Clinical Practice-t-Ppulatin Ratin (per 1,): 1994 t Genesee Cunty US 16 Ttal Primary Care Specialists Nte: Fr this analysis physicians prviding patient care are reprted as full-time equivalents and residents are excluded Surces: US Census Bureau; HRSA Area Resurce File Genesee Cunty US Michigan 126 Ttal Primary Care Specialists Hwever, lcal physicians reprt recent declines in incme stemming frm the autmtive/ecnmic crisis due t lst health care cverage, shrinking medical benefits and Medicaid payment cuts. The findings depicted in Figure 15 suggest that these anecdtal reprts may be accurate. Between 27 and 29 ttal prfessinal service use by Cunty residents enrlled in cmmercial health plans fell nine percent. This decline was led by an eleven percent drp in physician ffice visits. This evlving situatin threatens t negatively impact future physician incmes. Figure 15: Cmmercial Insurers: Trends in Prfessinal Services Used by Genesee Cunty Enrllees Ages -64: (est.) 1,2, 1,, 8, 6, 4, 2, 15, , ,326 99,76 93, , , ,32 135,77 475, , , (est) Office Visits Outpatient Surgery Radilgy Chirpractic Cardivascular Psychiatric Physical Medicine Immunizatins Mammgraphy Pdiatrist Well Baby Exams Dialysis Hme Visits Cmmercial Payers and Genesee Health Plan Blue Crss Blue Shield f Michigan, Blue Care Netwrk, and HealthPlus f Michigan are the primary cmmercial payers and health insurance prviders in Genesee Cunty. As depicted in Figure 16, membership declines have ccurred fr each rganizatin with reductins f 8 fr Blue Crss Blue Shield f Michigan, 6 fr HealthPlus f Michigan, and 1 fr Blue Care Netwrk since Surce: Center fr Health Wrkfrce Studies: Albany Schl f Public Health Figure 16: Cmmercial Insurers: Membership f Enrlled Genesee Cunty Residents Ages -64: (est.) 16, 14, 12, 1, 8, 6, 4, 2, 142, ,376 13,915 61,823 61,782 61,513 37,94 37,231 35, BCBS HealthPlus BlueCare Netwrk In cntrast, Genesee Health Plan, a cmmunity-spnsred healthcare prgram that prvides nly basic healthcare t lw incme residents (the plan des nt cver cmprehensive r hspital care) saw membership enrllment increases f abut nine percent between 26 and 29 (Figure 17). That grwth tk place amng the mst medically indigent, individuals with incmes less than 35 f the federal pverty level. Figure 17: Genesee Health Plan: Membership f Enrlled Cunty Residents, Ages -64: , 6, 5, 4, 3, 2, 1, 22,236 3,116 24,459 1,674 3,583 2,562 6,133 21, , 24, 23, 22, 21, 2, 19, 18, - Cvers the medically indigent, r individuals with incmes less than 35 f the FPL - Cvers nn-elderly lw incme adults with incmes less than 175 f the FPL Interestingly, grwth in enrllment f lw incme individuals was accmpanied by sharp declines in their emergency department utilizatin. As depicted in Figure 18, the number f ED visits amng GHP members fell by half frm 24 t 27, which appears t supprt assumptins that medical hmes fr the medically indigent will decrease inapprpriate ED use. Figure 18: Genesee Health Plan: Emergency Department Utilizatin fr enrlled Cunty Residents Ages -64: (per 1 GHP members)

7 Future Implicatins f Impact Assessment Findings Analysis f available primary and secndary data led t a number f cnclusins regarding future implicatins fr the cmmunity f key impact assessment findings unearthed. These include: Grwing pverty and unemplyment may speed Cunty ppulatin shrinkage due t ut-migratin. Despite the crisis, the cmmunity s health sectr remains an engine f ecnmic grwth. Yet, grwing numbers f medically uninsured may: Threaten future hspital and cmmunity physician s financial health. Strain available capacity amng cmmunity-based safety-net prviders. Spur physician ut-migratin and hinder future recruitment effrts. Therefre, future strategies and interventins shuld seek t better balance the health care system thrugh selectively building new safety-net capacity, imprving crdinatin f care and retaining adequate physician capacity. Key baseline findings and their future implicatins fr the cmmunity are utlined in Figure 19 belw. Figure 19: Key Impact Study Findings and Implicatins Key Baseline Findings Pverty and unemplyment rates are significant and grwing and the lcal tax base cntinues t erde Uninsured and underinsured ppulatins are grwing due t jb lss and retiree benefits shrinking Public and private schl enrllment, hme values and tax revenue cntinue t decline The ecnmic impact f the lcal healthcare sectr is significant and grwing. Hwever: Service demand amng cmmunity-based safety-net prviders is trending upward Hspitals are experiencing rising uncmpensated care and Medicaid payment cuts Current numbers and mix f Cunty physicians are adequate but incmes are declining due t shrinking emplyee medical benefits and cverage, falling cmmercial plan enrllment, and Medicaid payment cuts Future Implicatins Shrinking cmmunity ppulatin due t utmigratin Ripple effects n lcal service sectr and gvernment jb s, incme, hme values, tax revenue and schl enrllment Rising uncmpensated care csts cupled with Medicaid payment shrtfalls may jepardize hspital financial stability and lcal ecnmic grwth Increasing demand fr cmmunity-based safety-net services amid shrinking resurces may adversely impact access t care Declining prvider incmes may trigger utmigratin and hinder future recruitment Bttm Line Shrinking lcal health resurces and grwing vulnerable ppulatins may adversely impact future cmmunity health status. 7

8 Cllabrative Healthcare Strategies and Interventins fr the Cmmunity t Cnsider After assessing the extent f stresses n Genesee Cunty's ppulatin and health sectr stemming frm the effects f the autmtive/ecnmic crisis and their future implicatins, we cncluded that the scpe f the prblem in Genesee Cunty calls fr a multi-faceted and well crdinated apprach. We identified a set f criteria arund which t develp distinct shrt and lng term strategies that: Target needs identified by the cmmunity. Build n existing successful cmmunity prgrams. Cmplement each ther t achieve efficiencies. Have the ptential t attract external funding. Selectively adapt prgrams successful in ther cmmunities. The strategies that supprt these criteria are presented belw. They call fr selectively expanding existing cmmunity safetynet capacity, imprving safety-net care crdinatin, and supprting Electrnic Medical Recrd (EMR) adptin and retentin f cmmunity physicians. Each strategy is supprted by a set f specific prpsed prgram interventins. Figure 2: Critical Elements in Shrt-term Strategic Optins Supprt EMR Adptin Amng Cmmunity Prviders Selectively Expand Safetynet Capacity Shrter-term Strategies t Strengthen Cmmunity Health Sectr Infrastructure Supprt Retentin f Cmmunity Physicians Imprve Care Crdinatin and Efficiency Recent grwth in numbers f enrllees and primary care visits at Hamiltn s new Burtn site will create demand fr additinal specialty care. A new Hamiltn specialty care satellite site wuld efficiently absrb this and additinal future demand by grwing lcal safety-net ppulatins. Ptential cmmunity benefits f a new specialty FQHC satellite site include: Imprved access t specialty care fr grwing safetynet ppulatins. Cst savings t lcal hspitals frm reduced inapprpriate ED use and hspital-based specialty care. Imprved future ppulatin health utcmes. Ptential cmmunity challenges include: Future state Medicaid and ther funding cuts that may adversely impact Hamiltn s financial health. Future ability t recruit and retain specialty prviders due t effects f the ecnmic crisis. Ensuring equitable distributin f specialty referrals fr safety-net patients with lcal hspitals and ther cmmunity health centers. Interventin 1B: Encurage Hamiltn FQHC Participatin in a New Medicare Advanced Primary Care Demnstratin Initiative. In December 29 President Obama annunced a new threeyear Medicare pilt prgram t supprt delivery f advanced primary care t Medicare enrllees thrugh cmmunity health centers. Natinally, 5 FQHCs are expected t participate. Pilt prgram gals include imprving access and quality, prmting apprpriate service use and cntrlling health care csts. The Centers fr Medicare and Medicaid Services (CMS) plans t slicit applicatins frm interested FQHCs in spring 21 and begin prgram implementatin in January 211. FQHCs must demnstrate the ability t perate as a medical hme, with the capacity t deliver crdinated care acrss prviders and settings. In return, participants will receive mnthly care management fees fr enrlled Medicare fee-frservice beneficiaries plus payments fr any ther cvered Medicare services prvided. Strategy 1: Selectively Expand Cmmunitybased Safety-net Capacity Interventin 1A: Establish a Hamiltn FQHC Satellite Site t Meet Grwing Cmmunity Demand fr Specialty Care. Natinally, abut 25 f FQHC visits result in medically necessary referrals fr specialty and ther services nt prvided by the center and Medicaid and uninsured patients ften have difficulty accessing these services ff-site. Hamiltn recently received federal stimulus funding t establish the new Burtn site. Ptential cmmunity benefits include: Participatin wuld psitin the cmmunity n a cutting edge f future care delivery mdels under natinal health refrm. Crdinated family centered care shuld imprve utcmes and better cntrl chrnic care csts fr prviders and FQHC Medicare enrllees. The current FQHC delivery mdel and its care crdinatin features are well aligned with many features f the Medical Hme mdel. 8

9 Ptential cmmunity challenges include: Develping required netwrk infrastructure: Ensuring adequate primary care physician participatin. Cmplying with as yet unclear Federal requirements fr use f health infrmatin technlgy t track and crdinate care. Ability t crdinate care acrss prviders. Adequacy f mnthly care management fees. Wuld establish crdinatin f care infrastructure needed t create Medical Hme pilt prgrams under health refrm. Ptential cmmunity challenges include: Develping needed crdinatin and infrastructure: This includes brkering relatinships with ambulatry care sites and hspitals, develping prtcls fr directing an equitable allcatin f safety-net patient referrals and establishing payment arrangements. Next Steps t Cnsider in Selectively Expanding Cmmunitybased Safety-net Capacity: Cnsider wrking with the GFHC and tgether appraching the Department f Labr t help crdinate bth prpsed initiatives. Apply t the Federal Health Resurces and Services Administratin (HRSA) t establish the new Hamiltn specialty care satellite site. Begin wrking with lcal hspitals and ther prviders t develp referral agreements and prtcls fr safety-net patients. After prgram and netwrk infrastructure fr the Medicare Advanced Primary Care pilt prgram is in place at Hamiltn cnsider expanding capacity by inviting lcal Blue Crss Blue Shield f Michigan, Blue Care Netwrk, and HealthPlus f Michigan plans t participate. Interventin 2A: Establish a Safety-net Specialty Care/ED Referral System. In 21, Ck Cunty, Illinis received a federal grant t establish a web-based referral system t imprve access t utpatient specialty care and lwer inapprpriate ED use by vulnerable ppulatins. The netwrk allws clinics in Ck Cunty s Ambulatry & Cmmunity Health Netwrk and nnnetwrk affiliated clinics t refer uninsured and indigent patients t Ck Cunty Hspital s Specialty Care Center. It als allws Ck Cunty s ED t re-direct nn-emergent patients t cmmunity clinics fr mre apprpriate care. The system priritizes patients clinically based n care standards and prvides direct clinic referrals using the Cunty s Internet Referral Infrmatin System (IRIS). Primary Care Physicians abide by referral rules detailed in the Web-based system. Strategy 2: Imprve Cmmunity Safety-net Care Crdinatin at the Prvider and Cmmunity Levels Ptential cmmunity benefits include: An efficient web-based safety-net specialty care/ed referral netwrk t ptimize available resurces and imprve access t specialty care. Wuld align well with a new specialty care FQHC satellite and the GHP netwrk. Next Steps t Cnsider in Establishing a Safety-net Specialty Care/ED Referral System Pursue Federal/fundatin funding fr a feasibility study t explre: Develping cunty-wide specialty care/ed referral agreements fr safety-net and ther vulnerable ppulatins. Identifying an apprpriate referral and integrated call system. Develping new r mdifying available referral prtcls based n clinical care standards. Interventin 2B: Expand the Cmmunity s PPI Answering Service (develped by the Genesee Cunty Medical Sciety) and BCBSM Nurse Line t Imprve Cmmunity Safety-net Care Crdinatin. A number f cmmunities have successfully imprved their crdinatin f medical health care services t better ensure access t apprpriate care fr vulnerable ppulatins. Fr example, The Denver Health NurseLine was established in 1997 t prvide 24-hur infrmatin t the public regarding medical triage f health cncerns, and recmmendatins fr further medical evaluatin as apprpriate. Frmal evaluatins f the Nurseline shw that ED visits fell by 31, and unnecessary dctr s ffice r clinic visits fell by 29 fr callers. T imprve the crdinatin f medical and behaviral health care services, reduce inapprpriate ED use amng grwing Cunty safety-net ppulatins, and build n existing cmmunity infrastructure, a strategy t cnsider includes: Expanding the PPI, Inc. answering service beynd its current capacity t include RN call center staff. PPI, Inc. is a Genesee Cunty nn-prfit medical answering service develped by the Genesee Cunty Medical Sciety. Explring cllabratin with the existing BCBSM Nurse Line mdel. Adding a 24/7 behaviral health call center cmpnent t prvide cunseling and referral services t imprve crdinatin f behaviral health services within the existing infrastructure. 9

10 Ptential Cmmunity Benefits f Expanding Current Capacity Include: Triage advice culd reduce unnecessary ED and physician visits. The strategy builds n existing cmmunity infrastructure. Wuld establish useful infrastructure t supprt Medical Hme pilt prgrams under health refrm. Ptential Cmmunity Challenges Include: Recruiting specialized, telephne triage nursing staff. Building acceptance by vulnerable ppulatins thrugh media and public awareness campaigns. Next Steps t Cnsider in Expanding the Cmmunity s PPI Answering Service and BCBSM Nurse Line include: Finalizing an apprpriate Genesee Cunty safety-net prgram mdel. Establishing realistic nurse line capacity and expected utcmes. Develping cntractual service and funding agreements t supprt the prgram. Building safety-net cmmunity acceptance and use thrugh media and public awareness campaigns. Interventin 2C: Request Federal Funding t Develp a Health Educatin Center t Help Displaced Wrkers and Others Access Health Services. Due t rising numbers f displaced wrkers and healthcare cverage and benefit cuts stemming frm the nging autmtive/ecnmic crisis there is a need t educate lcal cnsumers n hw t access apprpriate cmmunity health services. This prpsed strategy calls fr requesting Federal funding t develp a cmmunity health educatin center. The center wuld: Teach displaced wrkers, retirees and ther cmmunity cnsumers hw and when t access apprpriate health services. Crdinate cmmunity health educatin campaigns and utreach strategies t prmte apprpriate use f health services. Establish linkages t a prpsed expanded medical/behaviral health call center t tailr health educatin t emerging cmmunity needs. Prpsed call center and health educatin center linkages are depicted in Figure 21, belw. Figure 21: Call Center and Health Educatin Center Linkages Call Center Analyze call vlume t identify issues and trends. Liaisn/Cllabrate Health Educatin Tailr health educatin tpics and utreach strategies t address majr issues and trends. Interventin 3A: Request Federal Funding t Pilt a Cmprehensive Lcal Physician Retentin Strategy Histrically, Genesee Cunty s supply f primary care and specialty care physicians has been adequate. Hwever, declining physician incmes due t the autmtive/ecnmic crisis threatens t spur future ut-migratin and hinder recruitment. Cnsider crdinating a prpsal fr Federal funding thrugh the Department f Labr t pilt a cuntywide cmmunity physician retentin strategy. Cmpnents f the prpsed cmmunity physician retentin strategy wuld include: Tax abatements fr physicians practicing in Genesee Cunty. Medical schl lan frgiveness fr physicians practicing in the Cunty. Lw interest lans where necessary t maintain physician practices in the cmmunity. Future participatin in federally funded state-level demnstratin prjects t reduce malpractice litigatin. Next steps fr the cmmunity t cnsider in supprting such a physician retentin strategy include crdinating thrugh GFHC t prepare and submit a request fr federal aid t the Department f Labr s Directr f Recvery fr Aut Cmmunities and Wrkers. Request culd be stand-alne r part f a larger cmmunity prpsal fr federal aid. Department f Labr staff has indicated that they have received similar requests frm several cmmunities. Upn receipt f the request fr federal aid they plan t parse ut and frward it t HHS t explre pssible existing and/r new waiver authrities and tax incentives that might be applied. Interventin 3B: Prpse a Federal Pilt Prgram t Supprt Physician Adptin f Electrnic Health Recrds (EHRs) In Cmmunities Impacted By the Autmtive Crisis Physicians in cmmunities impacted by the autmtive crisis face grwing financial challenges, including shrinking incmes due t: Strategy 3: Supprt Retentin f Cmmunity Physicians Declining numbers f cmmercially insured patients. Grwing numbers f Medicaid and uninsured/underinsured patients. These trends, supprted by data in Genesee Cunty, threaten retentin amng current physicians, present challenges in recruiting new physicians, and impact future cmmunity access t care. Declining financial health als challenges the ability f cmmunity physician s t invest in cstly federally mandated EHR adptin. 1

11 A federally spnsred pilt prgram supprting adptin f EHRs in cmmunities impacted by the autmtive crisis wuld supprt HIT capacity building and increase adptin rates amng cmmunity physicians. The stimulus EMR subsidy: Shuld the Cmmunity Take it r Leave it? Next steps fr Cunty hspitals and physicians t cnsider: Next Steps t Cnsider in Supprting Physician Adptin f EHRs in Cmmunities Impacted By the Autmtive Crisis: An immediate next step t cnsider includes cnducting a cmmunity needs assessment t identify: The current and prjected future levels f financial challenges impacting cmmunity physicians. The anticipated levels f cmmunity physician participatin in such a pilt prgram. Estimated planning and EHR hardware, sftware and n-ging supprt csts. Other pssible surces f supplemental funding r discunted EHR surces t help supprt cmmunity physicians (payers, hspitals, fundatins, vendrs, etc.). Leverage EMR adptin effrts t date by Genesys and McLaren Medical Centers. Assess the cst/benefit and ROI f full EMR adptin. Assess ability t cmply with federal meaningful use requirements, including upcming HIPAA electrnic transactin standards and new ICD-1 cde set. Explre the feasibility f private payers creating cntract incentives t cmmunity hspitals and physicians fr use f EMR technlgy. Prpse t HHS via the Department f Labr s Directr f Recvery fr Aut Cmmunities and Wrkers the develpment f a Federal EHR adptin infrastructure prgram fr physicians in cmmunities impacted by the autmtive crisis. Strategy 4: Supprting EHR Adptin Amng Cmmunity Prviders Beginning in FFY211 Medicare and Medicaid incentive payments and lans are available fr hspitals and eligible nnhspital based clinicians demnstrating meaningful use t purchase certified EHR technlgy. Qualifying fr subsidy payments depends n a clinician s patient mix and EMR adptin date. The higher the share f Medicare r Medicaid patients and the earlier EMRs are adpted, the larger the incentive payments will be. Ptential Benefits fr Cunty Prviders: Cunty medical centers may have the ptential t maximize Medicare incentive payments due t their high Medicare patient shares. Patient recrds can be quickly shared acrss Cunty prviders. Imprtant and mre cmplete medical infrmatin can be accunted fr quickly. Ptential Challenges fr Cunty Prviders: Heavy upfrnt implementatin and nging csts. Initial prductivity and revenue lsses transitining frm paper recrds. Mst EMR csts will be absrbed by hspitals and physicians while many benefits accrue t payers and cnsumers. 11

12 The recently passed Federal health refrm legislatin includes prvisins encuraging the creatin f Accuntable Care Organizatins (ACOs), initially limited t Medicare. ACOs are defined by the Medicare Payment Advisry Cmmissin (MedPAC) as a health care prvider r grup f prviders, including primary care and specialty physicians and hspitals, accuntable fr the cst and quality f care delivered t a defined ppulatin. In cntrast t the current fragmented mdel f care, ACO gals include crdinating and integrating care t slw cst grwth and imprve quality thrugh: Prvider payment refrm and financial incentives. Imprved efficiency (prcess redesign, efficient purchasing f medical devices, etc.). Imprved quality (reduced adverse events and preventable ED visits, admissins and re-admissins; imprved patient satisfactin). There are a wide range f ptential ACO mdels including varying levels f prvider invlvement and supprt. Lnger Term Strategy 1: Cnsider Establishing a Pilt Accuntable Care Organizatin (ACO) Ptential Benefits fr Genesee Cunty include: The ability t cmplement ther natinal health refrm initiatives, including: Patient centered medical hme pilts. Lnger Term Strategy 2: Cntinue Assessing the Feasibility f Expanding Graduate Medical Lnger Educatin Term in Strategy Genesee 2: Cunty Cntinue Assessing the The American Assciatin f Medical Clleges (AAMC) estimates the annual ecnmic impact f Michigan s medical schls and teaching hspitals is abut $18 billin. Expanding lcal graduate medical educatin capacity culd help address prjected physician shrtages and advance health care and educatin as lcal ecnmic develpment engines and alternatives t manufacturing. During 29 Hurley, Genesys and McLaren Medical Centers and Michigan State University (MSU) discussed expanding MSU s prgram in Flint by increasing the numbers f 2nd, 3rd and 4th year medical students. A critical nging challenge is the caps impsed by Cngress in 1996 limiting the number f residents paid fr by Medicare. Caps discurage teaching hspitals frm increasing numbers f residents r training prgrams and are hw gvernment limits physician supply. Hwever, in May, 29, tw Senate and Huse bills titled The Resident Physician Shrtage Reductin Act f 29 were intrduced t increase the number f Medicare-supprted hspital residency psitins by 15,. Preference wuld be given t primary care, general surgery and training in nnhspital settings. Bth bills are currently in cmmittee in the Senate and Huse. Next steps fr the cmmunity t cnsider include: Electrnic health recrds. The pprtunity t build n the infrastructure established by existing cmmunity resurces and the recmmended shrt-term strategies summarized abve. Cntinue explring the feasibility f expanding medical educatin capacity in Flint thrugh MSU. Wrk with yur cngressinal representatives t supprt passage f the Act. Ptential Challenges fr Genesee Cunty include: The ability t cmply with expected federal qualifying criteria fr demnstratin participants, including: Acceptable legal structure fr the ACO and participants t receive and distribute payments. Minimum number and types f physicians required. The need fr time and capacity building in key health sectr peratinal areas such as HIT and care management prcess redesign. Next steps fr the cmmunity t cnsider include: Cnsider Federal funding fr an ACO planning grant. Facilitate actin planning by lcal stakehlders thrugh the GFHC. 12

13 Health Impact Assessment Next Steps On balance, we believe that the recmmended strategies emerging frm the cmmunity health care impact study will strengthen the cmmunity s health sectr as a vehicle fr future ecnmic grwth. While challenges remain, we believe implementing sme r all prpsed strategies will reduce fragmentatin f care in an efficient and effective manner, help assure ptimal use f public and private financial resurces, imprve ppulatin health status and psitin Genesee Cunty fr the future f natinal health refrm. Please direct inquiries regarding the Health Care Impact Study t the Greater Flint Health Calitin, as listed belw: Greater Flint Health Calitin 519 S. Saginaw Street Flint, Michigan, 4852 Phne: (81) gfhc@flint.rg Fax: (81) Immediate next steps fr the cmmunity t cnsider include: Triaging and priritizing recmmended strategies t supprt an fficial cmmunity request fr federal aid. Develping and submitting an fficial request fr federal aid. Deplying the prcess and screcard f perfrmance measures develped t mnitr future cmmunity impacts and the status f interventin strategies. Develping and planning the implementatin f prpsed strategies fr interventin. This Executive Summary was prepared by The Lewin Grup, Inc. fr the Greater Flint Health Calitin t assist in creating actinable strategies t supprt an fficial request fr federal aid t the federal Directr f Recvery fr Aut Cmmunities and Wrkers. The Lewin Grup, Inc. 313 Fairview Park Drive, Suite 8 Falls Church, VA