Affordable Care Act

July 19, 2012

Transcript:

Richard Ruelas: IN A MIXED DECISION, THE U.S. SUPREME COURT LARGELY UPHELD THE AFFORDABLE CARE ACT. THE DECISION DID SIGNIFICANTLY RESTRICT ONE MAJOR PORTION OF THE LAW, THE EXPANSION OF MEDICAID, THE GOVERNMENT'S HEALTH INSURANCE PROGRAM FOR LOW-INCOME AND SICK PEOPLE. THE RULING GIVES STATES SOME FLEXIBILITY NOT TO EXPAND THEIR MEDICAID PROGRAMS WITHOUT PAYING THE SAME FINANCIAL PENALTIES THE LAW CALLED FOR. JOINING ME IS MONICA COURY FOR AHCCCS, ARIZONA'S MEDICAID PROGRAM, AND DR. NICHOLAS VASQUEZ FROM THE ARIZONA COLLEGE OF EMERGENCY PHYSICIANS. THANK YOU VERY MUCH FOR JOINING US THIS EVENING. MONICA, WHAT IS THE STATE OF ACCESS NOW? WHAT'S THE PROGRAM LOOK LIKE?

Monica Coury: WELL, TODAY, ACCESS HAS OVER 1.2 MILLION ENROLLEES. PRIMARILY WE COVER ARIZONA UP TO 100% OF THE POVERTY LEVEL. RECENTLY, WITHIN THE LAST YEAR, WE FROZE ENROLLMENT FOR A CATEGORY OF OUR POPULATION KNOWN AS THE CHILDLESS ADULTS, SO WE HAVE 100,000 FEWER CHILDLESS ADULTS ENROLLED IN THE PROGRAM THAN WE DID AT THIS TIME LAST YEAR.

Richard Ruelas: AND HAVE YOU GAMED OUT SCENARIOS ON IF THE STATE -- 'CAUSE NOW IT'S UP TO THE STATE, ACCORDING TO THE SUPREME COURT. THE STATE HAS THE OPTION OF JOINING IN WITH THE FEDERAL PROGRAM OR NOT. HAVE YOU GAMED OUT THE SCENARIOS OF WHAT IT WOULD LOOK LIKE IF THE STATE JOINS IN?

Monica Coury: WHAT WE'RE DOING AT THIS TIME IS LOOKING THROUGH WHAT OPTIONS MIGHT BE AVAILABLE TO THE STATE. THE SUPREME COURT'S DECISION UPHELD A CONSTANT THAT'S BEEN PART OF THE MEDICAID PROGRAM, AND THAT IS FLEXIBILITY, FOUNDED ON A STATE AND FEDERAL PARTNERSHIP. THE ARIZONA PROGRAM IS REALLY BUILT UPON THAT PRINCIPLE OF FLEXIBILITY AND PARTNERSHIP WITH THE FEDERAL GOVERNMENT. SO IT'S NOT -- WHAT WE'RE LOOKING AT IS IS IT AN ALL OR NOTHING ISSUE? I THINK THERE'S A MIDDLE GROUND TO WHAT THE STATE MIGHT LOOK AT IN TERMS OF POLICY OPTIONS. SO THERE IS OF COURSE DOING NOTHING, THERE IS A FULL MEDICAID EXPANSION, AND THEN THERE MIGHT BE SOME THINGS IN BETWEEN LIKE RESTORING FUNDING FOR THE PROP 204 PROGRAM, WHICH IS THE CHILDLESS ADULT PROGRAM.

Richard Ruelas: THE VOTERS SAID, 100%, THEY'D BE BRINGING IT BACK UP TO THAT. WITH THE ENROLLMENT FREEZE, WHAT DOES AN EMERGENCY ROOM LIKE LIKE THESE DAYS? HAS THERE BEEN A NOTICEABLE INCREASE IN PATIENTS IN EMERGENCY ROOMS AROUND PHOENIX?

Nicholas Vasquez: ONE OF THE THINGS I CAN TELL YOU IS THAT EMERGENCY ROOM VISITS HAVE BEEN GOING UP CONTINUOUSLY FOR OVER A DECADE. THERE IS A PROBLEM OF FINANCING, BUT THERE'S ALSO A PROBLEM OF ACCESS, TRYING TO GET IN TO SEE PRIMARY CARE PROVIDERS, TRYING TO GET YOUR COMPLEX PROBLEMS TAKEN CARE OF. A PROVIDER WHO'S GOT 10 OR 15 MINUTES OF YOU, ALL OF THIS HAS LED TO A STRAIGHT INCREASE IN E.D. VISITS ACTUALLY SINCE EMTLA WAS BROUGHT IN. EMERGENCY MEDICAL TREATMENT AND LABOR ACT WHICH WAS PASSED IN, I THINK, 1983. RONALD REAGAN SIGNED IT. IT GUARANTEES EVERYONE THE ABILITY FOR A MEDICAL SCREENING IN AN EMERGENCY ROOM -- I GUESS BEFORE PEOPLE WERE DOING WHAT WAS KNOWN AS A WALLET BIOPSY TO CHECK TO SEE IF THEY COULD PAY FOR SERVICES -- AND THEN SOME PRIVATE HOSPITALS WOULD SEND PEOPLE ELSEWHERE. THE GUY WHO INVENTED BLOOD TYPING GOT SENT ELSEWHERE TO HIS DEATH BECAUSE OF A WALLET BIOPSY.

Richard Ruelas: SO WE'VE SEEN PEOPLE START USING THE EMERGENCY ROOMS AS PRIMARY CARE?

Nicholas Vasquez: AS PRIMARY CARE. I THINK THAT'S THE THING THAT WE REMEMBER FROM THE '80s. THEY'RE REALLY USING IT FOR ANY CARE. WHAT I SEE IN THE EMERGENCY ROOM IS THAT A MAJORITY OF MY PATIENTS HAVE A PRETTY GOOD REASON FOR BEING THERE. THE MINORITY USE IT FOR CONVENIENCE. MOST OF THESE FOLKS ARE PEOPLE WHO ARE TRYING TO GET CARE SOMEPLACE, WHO HAVE EITHER BEEN SENT TO THE EMERGENCY ROOM BY THEIR PRIMARY DOCTOR OR ARE IN TOO MUCH PAIN OR THE PROBLEM IS SO ACUTE THAT THEY CAN'T WAIT. HOW BAD DOES YOUR BACK PAIN HAVE TO BE BEFORE IT BECOMES AN EMERGENCY? BACK PAIN IN RETROSPECT DOESN'T LOOK SO BAD BUT, IN THE MIDST OF IT, YOUR BACK PAIN CAN BE ACUTE. SOME PEOPLE COME IN FOR AS SIMPLE AS THAT.

Richard Ruelas: IS THERE ENOUGH ACCESS, NOT THE PROGRAM BUT THE NOUN, TO PRIMARY CARE PHYSICIANS? ARE THEY HAVING TROUBLE FINDING A DOCTOR IN THEIR AREA, LOWER INCOME LATINO AREAS?

Monica Coury: NOT AT THE CURRENT TIME. SO WE DO MONITOR FOR NETWORK ADEQUACY TO ENSURE THAT OUR HEALTH PLANS ARE ABLE TO MEET THE NEEDS OF ALL OF OUR MEMBERS, AND PRIMARY CARE IS A SIGNIFICANT PRINCIPLE WITHIN THE AHCCCS PROGRAM, SO WE WANT TO DRIVE PRIMARY CARE PREVENTION, EARLY INTERVENTION TO ENSURE THAT WE'RE APPROPRIATELY MANAGING CHRONIC DISEASE AND REACHING PEOPLE BEFORE THEY DEVELOP A CHRONIC DISEASE.

Richard Ruelas: IF SOMEONE IS ON AHCCCS, STATISTICALLY WOULD THEY BE CALLED INSURED? THEY'RE NOT AMONG THE UNINSURED?

Monica Coury: YES. THAT IS CORRECT. SO IF YOU'RE ON MEDICAID, YOU'RE NOT COUNTED AMONG THE UNINSURED.

Richard Ruelas: WHITE HOUSE STATISTICS, 32% OF LATINOS WERE UNINSURED IN 1999, HIGHER THAN ANY OTHER RACIAL GROUP, AND 20% OF LOW-INCOME HISPANIC YOUTH WENT A YEAR WITHOUT A HEALTHCARE VISIT. I DON'T KNOW IF THERE'S A CORRELATION THERE OR IF YOU SEE, EVEN IF SOMEONE HAS AHCCCS, IF THEY'RE DECIDING NOT TO SEEK PREVENTATIVE CARE, GET A PHYSICAL OR A CHECK-UP OR IF THEY SEE THEIR AHCCCS PLAN AS AN EMERGENCY SITUATION OR A WAY TO SEE A DOCTOR 'CAUSE WE'RE IN TROUBLE.

Monica Coury: NO. MEMBERS ON AHCCCS ARE ASSIGNED TO A PRIMARY CARE PROVIDER. IF THEY WANT TO ELECT A DIFFERENT PROVIDER, THEY CAN DO THAT. CHILDREN ARE GETTING THEIR PHYSICALS, THEIR SCREENINGS. THERE ARE CONTRACTUAL OBLIGATIONS THAT WE PLACE UPON OUR HEALTH PLAN.

Richard Ruelas: OH. THE DOCTOR NEEDS TO MAKE SURE THE PATIENTS ARE COMING IN.

Monica Coury: THE HEALTH PLAN DOES. THE AHCCCS ADMINISTRATION CONTRACTS WITH HEALTH PLANS THAT ARE PRIVATE HEALTH INSURERS, AND THEN THEY CONTRACT AND DEVELOP THEIR OWN NETWORKS WITH PHYSICIANS ACROSS THE COMMUNITY.

Richard Ruelas: AND HOW KEY IS THAT ACCESS TO PRIMARY CARE TO EASE THE BURDEN ON EMERGENCY ROOMS?

Nicholas Vasquez: WELL, THERE ARE A LOT OF DIFFERENT -- YOU KNOW -- THERE ARE A LOT OF DIFFERENT BURDENS ON EMERGENCY ROOMS. BUT TO ADDRESS YOUR QUESTION, I THINK IT'S VERY KEY. LOOK. OUR HEALTHCARE SYSTEM SPENDS A LOT OF MONEY, BUT IT SPENDS A LOT OF MONEY ON THE 5% SICKEST PATIENTS. THAT'S HALF THE MONEY WE SPEND ON 5% OF THE SICKEST PATIENTS WE HAVE. WE TRY VERY HARD TO SAVE LIVES, TRY VERY HARD TO TURN THEM AROUND. ANYTHING WE COULD DO TO PREVENT PEOPLE FROM GETTING THAT SICK WOULD SAVE US A LOT OF MONEY IN THE LONG RUN. IT WILL REQUIRE INVESTMENT UP FRONT, MONEY UP FRONT, BUT ANYTHING WE CAN DO TO DECREASE THESE SICK, SICK PATIENTS, 'CAUSE DOCS ARE NEVER NOT GOING TO TAKE CARE OF THE PATIENT. AT LEAST I HOPE NOT. I THINK THEY'RE GOING TO CONTINUE TO DO THAT TO THE BEST OF THEIR ABILITIES. AS LONG AS WE EMPLOY TECHNOLOGY AND NEW MEDICATIONS, WE'LL DO THE BEST WE CAN. CARE AT THE END OF LIFE GETS VERY EXPENSIVE. ANYTHING WE CAN DO TO PROLONG THE PERIOD PEOPLE ARE HEALTHY WOULD BE GREAT. AND GETTING PEOPLE POSITIVE INFLUENCES FOR HEALTHY BEHAVIORS IS KEY. YOU ALREADY KNOW THAT YOU'RE SUPPOSED TO NOT SMOKE, NOT DRINK TOO MUCH, EAT YOUR FRUITS AND VEGETABLES, EXERCISE, AND GET EIGHT HOURS OF SLEEP --

Richard Ruelas: YOU WERE TELLING ME BEFORE THE SHOW --

Nicholas Vasquez: -- AND NOT VERY MANY PEOPLE DO THAT. WE HAVE A PROBLEM, I SUPPOSE, IN ARIZONA, AS WELL AS THIS COUNTRY, OF A BEHAVIOR GAP. THE WHOLE IDEA, IF WE GIVE PEOPLE INSURANCE, IS THAT THEY GET CLOSER TO A PROVIDER, CLOSER TO A SOURCE OF INFLUENCE, AND START TO CHANGE THEIR BEHAVIOR. THAT'S THE HOPE. ONCE THEY GET TO ME, THERE'S ONLY SO MUCH I CAN DO. IF THEY HAVE A HEART ATTACK, I CAN'T GO BACK 20 YEARS AND GET THEM TO STOP SMOKING. I CAN'T GO BACK AND CHANGE THEIR OUTCOMES.

Richard Ruelas: DO YOU SEE THE AFFORDABLE HEALTH CARE ACT MAKING A DIFFERENCE IN HEALTHCARE?

Nicholas Vasquez: I THINK THE PROBLEM -- WELL, THERE'S AGAIN A LOT OF PROBLEMS, BUT ONE OF THE PROBLEMS WITH HEALTHCARE REFORM IS THIS ONGOING FIGHT. IS IT GOING TO BE IMPLEMENTED? IS IT GOING TO NOT? BUT IT'S REALLY A FIGHT OVER HOW DO WE FINANCE HEALTHCARE? THEY'RE GOING TO TRY TO GET CHANGES TO THE DELIVERY SYSTEM, AND I REALLY THINK THAT'S WHERE THE KEY IS. YOU HAVE A LOT OF KNOWLEDGE AND EXPERTISE IN NURSES. WE HAVE TO UNLEASH THAT TO LET PEOPLE USE CREATIVITY IN EXCHANGE FOR GREATER ACCOUNTABILITY TO FIND DIFFERENT WAYS. RIGHT NOW, I'VE GOT A LIST OF THINGS THAT I GET PAID FOR, AND THEN THERE'S WHAT I DO. WHAT I DO IS DIFFERENT THAN WHAT I GET PAID FOR. I THINK THAT'S ONE OF THE TENSIONS THAT A LOT OF DOCS FACE.

Richard Ruelas: HAS AHCCCS COME UP WITH CREATIVE WAYS TO MAKE SURE HEALTHCARE PLANS ARE PROVIDING THE PROPER CARE AND NOT JUST THE CRITICISM WE'VE HEARD OF GETTING PAID FOR ORDERING TESTS OR SCREENINGS? WHAT'S THE QUALITY OF CARE LIKE FOR AHCCCS PATIENTS?

Monica Coury: SURE. A LOT OF OUR HEALTH PLANS HAVE IMPLEMENTED A NUMBER OF DIFFERENT TYPES OF PILOT PROGRAMS LIKE MEDICAL/HOME TYPE OF CONCEPT. WE'LL HAVE A HEALTH PLAN IN A LOCAL AREA, WORK TOGETHER WITH THE HOSPITAL AND COMMUNITY HEALTH CENTERS OR CLINICS AND PRIMARY PROVIDERS IN THAT AREA. THEY MIGHT CREATE A PATIENT REGISTRY AND CONNECT THOSE PROVIDERS THROUGH ELECTRONIC DATA ON THEIR PATIENT'S ISSUES SO THAT A PRIMARY CARE PHYSICIAN WILL KNOW WHEN A PATIENT OF THEIRS HAS GONE INTO THE HOSPITAL OR EMERGENCY ROOM WITH SOME KIND OF ISSUE, AND THEN THEY CAN WORK WITH THE HOSPITAL TO MAKE SURE THE PRIMARY CARE PHYSICIAN IS SEEING THAT PATIENT WITHIN SEVEN DAYS TO MAKE SURE THERE IS ONGOING CARE FOR THAT INDIVIDUAL.

Richard Ruelas: WHAT'S THE INCENTIVE, THOUGH, TO MAKE SURE THE PATIENT GOES BACK TO SEE THE DOCTOR AND NOT GO TO THE EMERGENCY ROOM?

Monica Coury: IT'S A DIFFICULT ISSUE WITH RESPECT TO THE PROVIDERS. IF YOUR HOSPITAL -- FOR INSTANCE, THE FEWER PEOPLE YOU HAVE IN YOUR BEDS, THE LESS YOU GET PAID. SO WE'RE TRYING TO CHANGE THE WAY THAT WE LOOK AT PURCHASING HEALTHCARE FROM A BROADER POLICY PERSPECTIVE.

Richard Ruelas: YOU WANT TO JUMP IN ON THAT POINT?

Nicholas Vasquez: I WANT TO BRING UP ONE THING. IF I END UP GETTING SOMEBODY TO QUIT SMOKING, I'VE JUST LOST A PAYING CUSTOMER ON ONE END, AND I'M OK WITH THAT. THE MISSION SHOULD BE HOW DO WE COMBAT DISEASE? HOW DO WE GET PEOPLE HEALTHIER? HOW YOU PAY FOR IT, THAT'S A VERY TRICKY QUESTION THAT NOBODY'S ANSWERED. WHAT IS A DOCTOR WORTH? HOW DO YOU PAY A DOCTOR? IS IT ETHICAL TO HAVE A DOCTOR PAID FOR ALLEVIATING PAIN BUT NOT ALLEVIATE IT IF THEY CAN'T PAY? I MEAN, NO ONE'S TALKING ABOUT THESE THINGS, BUT REALLY AT THE HEART OF IT IS HOW DO WE VALUE A DOCTOR? EMERGENCY DEPARTMENTS ACROSS THIS COUNTRY AND IN ARIZONA, WE REALLY GET A FULL WINDOW INTO WHAT GOES WRONG WITH OUR HEALTHCARE SYSTEM AND WHAT GOES RIGHT, AND WE HAVE TO DEAL WITH THE REALITY THAT OUR SYSTEM IS FRAGMENTED AND VERY POORLY CONNECTED. I'VE TRIED MANY TIMES TO CALL PRIMARY CARE DOCTORS AND HAD A LOT OF DIFFICULTY IN GETTING IN TOUCH WITH THEM.

Richard Ruelas: IS IT DEPENDING WHAT REGION THEY SERVE?

Nicholas Vasquez: NO. IT DEPENDS UPON THE DOCTOR. THERE ARE A COUPLE DOCTORS I KNOW THAT I CAN CALL AND GET IN RIGHT AWAY. WE DO PHONE CALLS. I JOKE WITH PEOPLE, BECAUSE THEY CAN'T BELIEVE IT. WE WORK ON PAGERS AND FAXES. IT'S 2011, AND WE'RE USING 1980s TECHNOLOGY. THERE'S A LOT WE COULD DO, BUT YOU DON'T HAVE, ON THE FINANCING SIDE YET, A BROAD WILLINGNESS -- ASIDE FROM MEDICAID A BROAD WILLINGNESS BY THE PAYERS FOR INNOVATIVE WAYS OF DOING BUSINESS. THEY'LL PAY FOR X BUT NOT FOR Y. WHEN YOU'RE TRYING TO CREATE A DIFFERENT WAY TO GET FROM POINT A TO POINT B, YOU NEED SOME HELP IN CREATIVITY TO DO THIS, JOINING FORCES RATHER THAN JUST SHOWING UP FOR A JOB, TO DO BILLING, NOT DOWNGRADE THAT CHART. WE GET INTO THIS GAME, AND SOMEWHERE IN THE MIDDLE PATIENTS GET CAUGHT.

Richard Ruelas: IT'S ALWAYS A FASCINATING COMPLEX TOPIC. I'M SURE, AS THE FEDERAL HEALTHCARE ACT GETS IMPLEMENTED, THERE WILL BE A LOT MORE TO TALK ABOUT. THANKS FOR JOINING US THIS EVENING.

Nicholas Vasquez: THANK YOU.

Monica Coury: THANKS FOR HAVING ME.