Mike Klein Online

Georgia Physician Shortage Just One Among Many Challenges

Mike Klein

Health care policy is a complex beast with seemingly intractable political positions, lots of data to support or refute almost anyone’s perspective, tons of financial impact analysis – just last week the Congressional Budget Office released yet another health reform cost impact study — and at the end of the day, lots of ragged emotions that cloud and obscure the conversation.

Here is an idea that should not be overlooked: People will get sick and have accidents regardless of who is making policy and whatever that policy-of-the-moment happens to include or exclude.  And when that happens, they need someone nearby who is able to help them.

In Georgia, we need help.  “You’ve hit on a significant issue for the state,” said state Department of Community Health deputy commissioner Blake Fulenwider.  “There is no doubt about that.”

Fulenwider, two other state officials, an Obama administration official and a national children’s advocate sat together last week for a Georgia Children’s Advocacy Network discussion about what the recent U.S. Supreme Court federal health care law decision might mean for Georgia children.  Might is a precarious word because of the November presidential election.

As the 90-minute session began to end, Fulenwider noted, “Today is an example that none of the things that we talk about have easy answers.”  Debate will continue here for months about whether to expand Medicaid eligibility and how to create a health insurance exchange, if at all.

Here is a reality check:  Today Georgia has a significant physician shortage and the state also anticipates a shortage of 38,000 nurses over the next decade.  That is what a Georgia Health Sciences University report concluded last August when it was submitted to the University System Board of Regents.  Urban medical facilities are overloaded and there are vast health care brownfields in rural areas.

An Association of American Medical Colleges report published in August 2011 said, “Without immediate statewide cooperation in expanding medical education and residency programs, the state may never again have an adequate supply of physicians.  For too long Georgia has relied on out of state and international physicians to make up for the lack of Georgia trained doctors.  Without changes in the state’s medical education system, Georgia will rank last in the United States in physicians per capita by 2020.”

No Silver Bullet for Medical Access

The University system report said the state is 1,450 graduate medical education positions below the national average and 315 below the average of southeast states.  That forces students to leave Georgia for medical education which, in turn, decreases the possibility they will return to practice medicine back in Georgia.  The state has 20.8 physicians per 100,000 persons; the national average is 35.7 physicians.

Governor Nathan Deal recognized the urgency of this shortage by creating 400 new physician residency slots in this year’s budget.  Unfortunately, training hundreds of new physicians when you are short by many hundreds more means you are still short.

To further stress the already stressed system, about one-third of physicians and almost 40% of registered nurses statewide are eligible to retire now or within ten years.  Many higher education programs are trying to address shortages but Georgia is clearly catching up, not getting ahead.

“Providing coverage does not mean providing access,” Fulenwider admitted.  “We continue to be challenged with our budget environment and landscape that we’re in, in maintaining and being an attractive payer for our Medicaid providers. We’ve got to be sure that we’ve got boots on the ground to deliver service.  I wish there was a silver bullet answer to that.  There is not.”

Supreme Court Decision Impact

The U.S. Supreme Court decision threw a wrench into health care policy decisions.  Whereas media was intently focused on what might happen with the individual mandate provision, the justices by a 5-4 vote blindsided nearly everyone by ruling states cannot be forced to expand Medicaid, and states cannot be penalized if they refuse to expand.  The individual mandate was upheld as a legal tax.  Health insurance exchanges were also upheld, although they will likely exist in many forms.

Here is part of the Georgia landscape.  State decisions on Medicaid eligibility expansion and what to do about a health insurance exchange will not be announced until after voters decide whether Mitt Romney will replace Barack Obama.  A state Medicaid redesign train that left the station early last year has been sent to a side rail but some elements will be implemented.

Georgia faces a November 16 deadline to tell the federal government how it plans to establish a health insurance exchange required by federal law unless a new Romney administration that would assume office in January issues exemptions and begins to dismantle the law.

“There will be an exchange in Georgia one way or another,” suggested JoAnn Corte Grossi, who works for the Obama administration as Mid-Atlantic States Director at the U.S. Department of Health and Human Services.  That was her message to the Georgia CAN! panel last week.

Will the Obama administration be flexible with states that would prefer to receive Medicaid block grants?  “We’ve obviously gotten lots of letters from lots of governors asking questions like that,” Grossi said.  “Sorry to punt on this one but the honest answer is decisions are still being made.”

Some State-Based Decisions Already Made

Some state-based changes will happen regardless of November elections:  Georgia foster care children – currently 26,409, according to the Department of Community Health — will move to care management organizations.  Medical records will follow children regardless of where they live or how often their placement changes.  This is similar to how the state manages health care for low-income Medicaid and PeachCare children.  The change is anticipated in mid-2014 when the state executes new managed care contracts.

Georgia also decided Medicaid eligibility will continue to be done in conjunction with eligibility for food stamps, temporary assistance for needy families and child care subsidies.  The state will launch a new consumer-focused web portal but that might take three years to develop.

Jonathan Duttweiler is Manager for Medicaid Eligibility at the Department of Human Services.  He said 2,100 staff caseworkers currently average 571 Medicaid recipient clients. The average caseload would increase by 400 additional clients to almost 1,000 per caseworker if Medicaid expands starting in 2014.  Duttweiler said the state has fewer caseworkers today than it had 15 years ago.

The state also requested and received a federal waiver from the health care law provision that insurers must spend 80 percent of each dollar earned on health care.  The state position was that “smaller insurers wouldn’t be able to meet that 80 percent threshold,” said Jay Florence, legal counsel for the state office of insurance.  The waiver required 70 percent spending levels last year, 75 percent this year and 80 percent starting next year.

The Georgia CAN! health care policy panel discussion was peppered with data.  Indeed, at times it seemed almost no sentence was complete without a number included.  One of those seated in the audience was Dr. Harry Heiman, director of health policy for the Satcher Health Leadership Institute at the Morehouse School of Medicine.

“I understand your lens,” Heiman told the panel.  “My lens as a family physician is I am seeing children every day, adults every day that suffer health consequences for lack of access to quality care.  Clearly, we need a balanced approach that understands your challenges and the challenges of the children and adults in our state.”

(Mike Klein is Editor at the Georgia Public Policy Foundation)

July 30, 2012 Posted by | Uncategorized | , , , , , , , , | Leave a comment

Medicaid Dominated when Governor’s Policy Advisors Took Questions

Mike Klein

Medicaid is a beast.  About one-in-five Georgians receives Medicaid health care.  That is 1.7 million people.  Fifty-nine percent of statewide births are Medicaid babies.  Another couple hundred thousand children are enrolled in PeachCare, the state children’s health insurance program.   Medicaid could grow by hundreds of thousands more if the U.S. Supreme Court upholds the federal health care reform law in its decision expected next month.

Not at all surprisingly, Medicaid redesign questions were abundant when three of Governor Nathan Deal’s advisors met with Georgia Children’s Advocacy Network members at the Freight Depot in Atlanta.  The advisors made no presentations and took questions for 90 minutes.

Health policy advisor Katie Rogers named telehealth reimbursement policies, portable electronic records, better outcomes for vulnerable children, physician shortages in some specialties, how to manage health care in counties that are medically underserved and treatment options for chronic childhood illnesses as part of the wide-ranging Medicaid redesign conversation.

Next month the U.S. Supreme Court will rule on constitutionality of the 2010 federal health care reform law.  If upheld the Patient Protection and Affordable Care Act provisions often known as ObamaCare could add 620,000 new Medicaid patients to the state program.  Rogers predicted, “People who haven’t had access to services are going to seek services probably very quickly.”

Georgia Medicaid cost $7.78 billion in fiscal year 2010, according to Kaiser State Health Facts.  Federal funds pay 66% and the state is responsible for the rest, about $2.7 billion.  Georgia Medicaid program redesign is being managed by the Department of Community Health with private partner assistance from Navigant. The project is described in a comprehensive design strategy report available on the DCH Medicaid website.

This project is so important to Georgia’s health care community that it is being closely monitored by many organizations outside government.  Cindy Zeldin is executive director at Georgians for a Healthy Future which advocates for improved statewide access to quality health care.

“The three buckets when we look at improving Medicaid would be one, just coverage, getting kids who are eligible but who are not enrolled today into the program so they at least have that front door access,” Zeldin told the Public Policy Foundation this week.

“Second, improving access to care, just making sure there is a mechanism to make sure that being in Medicaid means you can see a provider if you need to,” Zeldin said.  For instance, the state has no OB-GYN practitioners in 39 counties, which is an impediment to women’s health.

“Third would be improving outcomes and accountability, what you are asking managed care companies to report on and making sure you are measuring outcomes that ensure quality care.”

The Supreme Court opinion expected next month will also decide whether Georgia must create a health insurance exchange.  Last December a state report to Governor Deal said a private or quasi-governmental exchange would be preferable to one imposed by the federal government, but Georgia would prefer that it is not required to create any exchange.  Georgia opposes the federal health care reform law and it joined the suit that challenges the constitutionality.

“If the law is upheld as it stands now we will work very quickly to implement a state exchange,” Rogers said.  “If the law is not upheld the discussion will begin again on whether or not to move forward with a state exchange.  Part of the concern is without the individual mandate would people want to buy insurance through the exchange?”

Education and Public Safety Issues

Education and several public safety issues were also discussed during the open forum.

Education policy advisor Kristin Bernhard said several early childhood education programs lead the priority list heading into next year’s General Assembly.  Do not expect support for private school vouchers or increasing the age for compulsory school attendance from 16 to 18.

“The voucher conversation isn’t on the table for us,” Bernhard said.  “We’re more interested in increasing the quality of public education for all students everywhere.”  On compulsory school attendance she said, “The evidence is not necessarily compelling that raising the age of mandatory school attendance automatically results in an increased graduation rate.”

Education headlines over the next year will include incorporating the state’s version of new national core curriculum coursework, dual enrollment for middle school students taking high school courses or high school students taking college courses, tenth grade college readiness testing, and preparation to expand career pathways education now scheduled for fall 2013.

Also, Georgia admits that it has too many high school graduates who require remedial courses when they enter college.  “We know that students are graduating from high school not ready for college,” Bernhard told 100 Georgia Child Advocacy Network members.  Part of this discussion is how these students can be assisted by resources inside the state technical college system.

This week the Illinois Senate President proposed his state enact internet gaming legislation to get in front of a potential federal law that would grandfather existing state programs but prevent other states from creating new ones.  Do not expect anything like that in Georgia.

It is well documented that the lottery-funded HOPE scholarship, grant and pre-K programs can no longer afford to fully fund their commitments.  Governor Deal opposes a proposed casino-style project and Bernhard says, “What we’re looking at is what we can do to boost the existing revenue streams.”

Several folks applauded when public safety advisor Thomas Worthy said, “I have no doubt that we will probably see and definitely sign a juvenile code rewrite next year.”  HB 641 was a substantial effort to rewrite piecemeal juvenile laws that are decades old.  It passed the House but then was stopped before Senate consideration so more work could be done on cost.

“Everybody is in agreement on the policy side of things,” Worthy said.  “We are there.  The stakeholders are there.  Agencies are now there.  Now what we are tasked with doing is figuring out a way to not only pay for implementation but actually ascertain savings that will come under the bill.”  Worthy said consultation has begun with the Pew Center on the States; Pew assisted with criminal justice reform legislation that Governor Deal signed this month.

Worthy also acknowledged, “Not only do we have a horrible child trafficking problem within our state, (Interstate) 75 is used to move folks going to other states.”  This year HR 1151 in the General Assembly created a commission to study child trafficking and make recommendations.

(Mike Klein is Editor at the Georgia Public Policy Foundation)

May 17, 2012 Posted by | Uncategorized | , , , , , , , , , , | Leave a comment