Q: You’re giving a talk tonight called “What you have to know about healthcare reform law.” What are the main things that we need to know about health reform?

A: Well, there are three things we have to think about: we have to think about cost, we have to think about access and we have to think about quality. The health reform law that was just passed only deals with access to insurance. It’s taken a barrier away – there are people who will have access to insurance now who didn’t have it before, and that’s a tremendous benefit. But that’s really the only thing that’s happened. So we have not really done anything about access to the kind of care that they need, we have not really done anything about changing the quality of the care, and we have not changed how we pay for the care, or done anything to rein in the cost, so it’s a very limited change that’s occurred, even though it’s being portrayed as radical and revolutionary… We need to understand that, and if we find that a lot of people seek care and can’t get it (which I’m absolutely sure is what’s going to happen) and if we find that costs go up because a lot of people who never had care are now coming in to get things taken care of (which I’m absolutely sure is what’s going to happen), that doesn’t mean it’s failing, it means we haven’t done a complete job.

View video for more:

Q: Say more about what in our healthcare system still needs to improve.

A: There are two important things that people need to understand before we start talking about healthcare reform. The first is that most (75 percent) of our healthcare costs are driven by chronic disease. The next thing you need to understand is that our payment system today does not help us do a good job; it isn’t designed around taking care of chronic disease; in fact, it gets in the way of doing a good job with chronic disease.

The next thing that you’ve got to understand is that of people who have chronic disease, more than half of them have more than one chronic disease. So it’s not at all unusual to have high blood pressure and heart disease or diabetes and high cholesterol and high blood pressure and heart disease.

The final really important thing to understand is that of the people who have chronic diseases in the United States, if you ask them if they know how to take care of themselves and prevent their disease from getting worse, most of them, 70 percent of the people, say no.

So the situation is that we have a huge cost driver (chronic disease), it involves most people, their conditions are not well controlled, and they tell us that they don’t have the tools they need and the knowledge they need to take care of themselves.

To me, that’s a huge call to action.

View video for more:

Q: What are the opportunities with reform to address some of these problems?

A: With the new healthcare reform law, we’ve got something called Accountable Care Organizations and what those might look like is really up for debate, but one choice is organizing as a community to provide care. I’m hoping that the Whatcom Alliance for Health Care Access can be a stimulus for that, an organizing force for that. Because I think organizing as a community, having direct accountability to the stakeholders in the community, and trying to bring all the caregivers together in an organized way to provide the best kind of care is really what we ought to be doing.

View video for more:

View the video below to hear the story of Nicky White, a patient who lost access to the care she needed keep her chronic condition under control.

Read Dr. Lynch’s blog at http://drdavelynch.blogspot.com/.

This is the second in a series of interviews with community members about their perspectives on healthcare reform.

Below are links to the presentations, along with background resources.

CHOICE ACO Learning Session Presentations

• ACOs: Issues for Consideration. Susie Dade, Director of Performance Improvement, Puget Sound Health Alliance
• AMGA’s ACO Developmental Collaborative. Mariella Cummings, Chief Executive Officer, Physicians of Southwest Washington
• ACOs: an Emerging Example in the Private Practice Community. Rick MacCornack, Ph.D., Chief Systems Integration Officer, Northwest Physicians Network

Background Materials

ACOs – Key Issues: A presentation from Providence Health & Services looking at the background and current status of ACOs under healthcare reform, including a detailed look at the Medicare Shared Savings Program.

ESSB 6522: State bill establishing accountable care organization pilot projects.

Response to ESSB 6522 RFI – Group Health Cooperative and University of Washington, Department of Health Services: Group Health’s application to serve as lead organization for the Health Care Authority’s ACO pilot program.

ACO Readiness Assessment: A tool from the American Medical Group Association to help healthcare organizations gauge whether they have the elements in place to succeed as an ACO.

Health Policy Brief – Accountable Care Organizations: Health Affairs brief examining ACOs under healthcare reform, including basic features, challenges and opportunities.

Accountable Care Organizations in California – Lessons for the National Debate on Delivery System Reform White paper by the Integrated Healthcare Association that looks at the common elements of and key lessons from ACOs in California.

What is an Accountable Care Organization and Why Should I Care? Information from the National Council for Community Behavioral Healthcare.

Accountable Care Organizations: What Are They and Why Do I Need to Know? Background information from the Governance Institute.

In Search of an Accountable Care Organization: A humorous video from Centura Health illustrating a health care executive learning about Accountable Care Organizations.

Q: Are there particular things that WAHA clients seem especially interested in or confused about with all these changes in healthcare reform?

A: I think back in the spring when it had just been signed, the biggest confusion was how long it was going to take to roll out — like “OK, what can I get now? What’s changed?” I think underlying everybody’s questions is “What does this mean to me? How will this affect me and my family, or my business, or my parents, or my kids?” Everybody’s situation is a little bit different so there’s a different answer for every person and every family.

View video for more:

Q: What kind of changes can your clients look forward to in the early stages of reform?

A: In Washington State, there is relatively good access for children up through age 18 and for people over 65, but it is that in-between population that really struggles, especially if they don’t have affordable employer insurance. So with healthcare reform we’re really hopeful that there will be more structures and resources in place to insure and care for these people. Some of the changes that are coming soonest are tax benefits for small businesses and their employees to help them access affordable coverage.

View video for more:

Q: From your position, what do you see as the greatest opportunities and the biggest promise of reform?

A: I think our biggest opportunity is that as a country we’ve decided we’re going to make some pretty significant changes to increase access to care, to provide healthcare for all people or a vast majority of people in our country. Now, how do we work together to make that happen? How will we do that in Whatcom County? There’s not a road map for it, there’s not an exact formula for it but I think that the process of figuring that out is our biggest opportunity. For myself here at WAHA, as a person who cares about health and healthcare in this community, it’s that working together to figure it out and really make a difference in terms of people getting the healthcare they need.

View video for more:

Q: What concerns do you have about reform?

A: The changes can’t all happen in one fell swoop, and from now until 2014, there’s going to be a period where the costs of some things may be higher — there are always costs associated with doing things in new ways and doing things differently. So I think it’s going to be a challenge to move through that transition time and persevere during that time when things get kind of stirred up but individuals don’t perhaps feel an immediate or direct benefit. I could see that there would be a lot of questions like, “So what’s the point of this? When are we going to see how great this is?”

We would be misleading ourselves if we thought that healthcare reform was going to completely solve all of our healthcare challenges in this country. So I think it’s important to be realistic about our expectations so that we can take advantage of the opportunities that are before us and not get disappointed when reform hasn’t fixed everything.

View video for more:

Exactly how this happens will vary by state, and even community, depending on local resources, needs and opportunities.

Here you’ll find straightforward information and tools to help you learn what you need to know to make the most of health reform in Washington State, including:

• a database of upcoming requirements and opportunities
• local stories about how health reform is working for people in our community
• resources for consumers, employers and providers

Below, CHOICE Regional Health Network Executive Director Kristen West talks about her hopes that this project will foster discussion and encourage collaboration across sectors to develop a shared vision for reform in our community.

The Regional Quality Improvement & Access Council is a group of health system partners from Grays Harbor, Lewis, Mason, Pacific and Thurston counties that aims to address immediate safety net issues through shared learning, exploration of potential opportunities, problem-solving, and collaborative action.  This group evolved from the Thurston County Safety Net Council—a similar group that is Thurston County-centric.  Partners from hospitals, public health, physician practices, and various state government agencies convened on Wednesday, November 17 to have their first meeting, and there was a great turn-out from every county.  This first meeting explored two critical issues facing the five-county region mentioned above: 1) opioid misuse and our Emergency Departments, and 2) the impact of Washington State budget cuts on the mental health safety net.

The council heard four guest speakers present their expertise and answer questions.  Dr. Gary Franklin, MPH, is a research professor at University of Washington, Medical Director for Washington State L&I, and Chair of the Washington Agency Medical Directors Group.  He gave his presentation titled Opioids for Chronic, Non-Cancer Pain: A Rapidly Changing Landscape, which presented in great detail the data and research associated with the drastic escalation of opioid-related deaths, opioid prescription practices, and the interventions being deployed to mitigate what can only be called a crisis.  Some of the more striking data include:

• Whereas a study published in 1986 showed that, from a group of 38 patients, only four were taking greater than 40mg of pain medication per day, in 2010 there are approximately 10,000 patients just in Washington State that are taking greater than 120mg of pain medication per day
• A study conducted in 2007 showed that 100% of patients on opioids develop some form of chemical dependence
• Over half of the “best practices” for the prescription of opioids are sometimes, almost never, or never used by prescribing physicians (as opposed to often, almost always, or always)

Dr. Franklin’s entire presentation can be viewed here.

Kara Elliott, RN, MPA, is the Emergency Department Consistent Care Program (EDCCP) administrative coordinator, and spoke to the program’s purpose, structure, and operations.  EDCCP exists in Providence St. Peter, Providence Centralia, and Grays Harbor Community hospitals, and uses a team comprised of physician and nurse care coordinators from the hospital ED, a community-based health resource coordinator who provides intensive client support, a primary care physician or clinic representative, and mental health and substance abuse specialists to redirect frequent and inappropriate users of the ED to a more efficient and better quality plan of care.  Ms. Elliot’s presentation also discussed the Emergency Department Information Exchange (EDIE)—a HIPAA-compliant technological solution to tracking inappropriate ED use across participating hospitals.  You can view the entirety of her presentation here, and can learn more about EDIE here.

John Masterson, CEO of Behavioral Health Resources, and Eric Cummins, Executive Director of Willapa Behavioral Health, presented on the Washington State budget cuts and their impact on the mental health safety net.  All of these cuts greatly affect the Regional Support Networks (RSNs) in the five-county region, to which state funding is given to administer mental health services at the local level.  One of the biggest concerns is with the $65 million cut to Non-Medicaid funding, which provides services for both voluntary and involuntary individuals who are acutely and/or chronically mentally ill.  You can view their presentation here.

In closing, this first meeting of the Regional Quality Improvement & Access Council  was a highly dynamic and encouraging session.  The health system partners in attendance were genuinely engaged and concerned about the issues presented (view agenda and minutes).  Though concrete, action-oriented outcomes have yet to be realized, the foundation has certainly been laid; and, again, it has been proven that often it simply takes getting the right people in a room together in the spirit of collaboration to affect change.

Stay tuned!

Q: What are your impressions about where we’re at with reform?

A: We’re finally starting to get it. We realize that the right care at the right time in the right place will eventually equal the right cost–and that more health care does not inevitably equal better health. It’s exciting to me to hear thoughtful, smart people who aren’t clinicians talking about the importance of primary care and talking about how we need a system that focuses on outcomes.

I think we have the opportunity to do this around the country, and it will look different in Georgia than it does it Maryland than it does in Maine and Minnesota and Washington. There are smart and dedicated and creative people who will make this happen, and we have to. The greatest logic that drove the need for healthcare reform was that we can’t keep doing what we’re doing.

Q: How might reform look here in Olympia, or Washington State?

A: I think that we’re going to continue to see a huge variety of different models. I think we’re going to continue to see the small one-person offices in primary care who serve a unique niche. We’re also going to see bigger consolidation. My practice moved from a small independent practice to a hospital employed practice and doubled in size in the past two years. I think we’re going to see more of that, because the right partner can equal the right outcome.

Q: Does the consolidation that some people believe will result from health reform have any upside for patients?

A: Sure. I think if I’m working more closely with the ERs where my patients are seen and … when there’s time and an incentive for the hospitalist to sit down and call me when they’re discharging a patient to make sure I have information on that patient, and I’m seeing that patient in the next day or two, that patients will have fewer errors, better information, stronger allies that will help them take care of themselves.

Q: What will it take to make these changes, and what is being done now to make them?

A: Change is hard and a lot of us learned how to succeed in the current set of rules, and we want to change the rules–for good reason, but it’s hard to change the rules, to get everybody to buy into playing by new rules and to determine what are these best rules going to be.

For providers, it’s hard, and in the patient-centered medical home collaborative that’s coming out of the Puget Sound Health Alliance, they’re talking about very small additional incentive payments for patient case management–$2 per member per month. Boeing, to do their intensive ambulatory care unit and really drive costs down, were spending in excess of $20 per member per month. Group Health spent 0 per member per month to save 4. If we don’t want to put resources into supporting this change, we won’t get the change we want.

Q: What are you hearing from your members about healthcare reform?

A: What I’m generally hearing from my members is that there certainly is a need for some kind reform in healthcare. For about 10 years now most of my members have experienced at least low double-digit increases in the amount of money that they’re paying in premiums for health insurance for their employees, and at some point in time it becomes for most businesses untenable to maintain the programs that they had. So they may not understand or like the changes that have been made, but I think that there is just general agreement that we’ve got to have a change.

At the same time, some of my members, especially the smaller businesses, are scratching their heads over how we got to the point that it is employers’ responsibility to provide healthcare insurance for their employees. Small business owners are at times having to take two to three full work days out of their time each year to be able to meet with insurance brokers and try to deal with healthcare issues. So I think that for the most part a lot of small businesses would love to see something where healthcare isn’t their responsibility anymore. If they need to help fund it, that’s one thing. But there’s a difference between partially paying into a system for healthcare and being the person who is responsible for providing healthcare coverage for your employees, and I think that’s where a lot of smaller businesses are starting to draw the line.

View video for more:

Q: What do you and your members see as the challenges and opportunities of healthcare reform?

A: The broad-based concepts certainly make some sense–the idea of finding ways to add folks into the system and broaden the pool so you get the costs down. The difficulty that we have is that in the next four years, before the things that are supposed to help buy down the costs are fully realized, we are going to continue to have large increases in premiums, plus new expenses tied to mandates that have been put in place, such as covering kids through their parents’ policies until they are 26 and covering preexisting conditions. That’s where our concern lies in the next 4 years: are we going lose so many businesses because of healthcare cost increases that we haven’t really achieved any sort of a benefit at all?

As far as opportunities to go, we want to continue to make sure that the elements of reform intended to help small businesses, such as tax credits, are fully developed and then let the business community know what opportunities are out there to help them continue to provide healthcare to their employees.

Also as we go forward, we need to ensure that there continue to be provisions in next four years for those who can’t afford or access care. WAHA has done a great job in the past of helping individuals to find healthcare. We need to continue that work, but I think we need to expand that into a lot of these small businesses to help them identify ways to find affordable healthcare coverage for their employees.

View video for more:

Q: What particular opportunities do you see for this region in implementing healthcare reform?

A: Bellingham is a very progressive city; it’s open to finding new ways of dealing with issues, looking at problems and seeing how others have solved these problems and bringing those best practices into place. From that perspective, you may see an ability in this community to adapt to these changes more quickly than a lot of other communities. Clearly through a group like WAHA, we’ve seen that this community, especially on healthcare, wants to be a leader, wants to find ways to deal with these things and is open to sharing those ideas out with other communities.

From an economic perspective, although our cost of living is high and our average wage is fairly low, we generally have a lower unemployment rate and much higher educational attainment than the rest of the state and the rest of the US. So I think you will find from an affordability standpoint that people here, on a broad basis, will be able to deal with whatever is coming forward more easily than in other communities.

View video for more:

Q: Any other thoughts about healthcare reform?

A: Often we talk about healthcare reform from the side of insurance and how it’s going to play out from that perspective. One of the things that I’ve heard more and more folks talking about is the actual provision of healthcare and the increasingly limited choices. We’re told that you have to bring providers together to get more efficient management so the costs go down, but are there other things we’re losing because you don’t have some of the competition and choice involved? It will be interesting as we go forward to see whether those sorts of concerns are addressed.

This is the first in a series of interviews with community members about their perspectives on healthcare reform.

Q: It sounds like a number of the changes that health reform brings or requires were already in place here in Washington?

A: Yes, we did already have a lot of the initial items that they rolled out. Covering children to age 26, a lot of the carriers in the state of Washington were doing 23 and 25, so that’s not a big change. The preventive care with no cost sharing, most of the plans in the state of Washington have preventive benefits, but there have been co-pays.

We have shorter pre-existing condition waiting periods then most other states because our association plans that cover most of the small businesses are typically 90 day pre-existing. So there really wasn’t anything onerous out front in the first round of changes, but it’s the things on the backside in the future–moving to the health insurance exchanges, having the four levels of bronze, silver, gold and platinum benefit design–that will make it different for the insurance companies. So here we’re not seeing the impacts and effects yet of the federal legislation.

Q: Do you think that Washington State is in a better or worse position than other places in the country to weather these changes?

A: We’re probably better off than most places in the country because we’re going to have the least amount of change to go through. We’ve already been through it. We in Washington State basically got Clinton’s health care plan in 1992. In 1995, the major things that were onerous about it got gutted. Then in 1999, because of the guarantee issue of the individual plans, the individual marketplace evaporated in the State of Washington; you couldn’t buy a health plan here if you were an individual for almost three years. So we moved to a modified guarantee issue and created a high risk pool. That’s worked very well and the insurance companies basically fund the entire cost of that.

The bad news is that politicians don’t like to learn from other people’s mistakes. We had healthcare reform, we went without an individual market for three years. You couldn’t buy a health plan in the State of Washington until the State and the insurance companies got together and said, what do we do to make this work? So while we’re probably in a better position to handle all these changes going forward, we’re also one of the highest cost tiers in the country already. So what does the country have to look forward to? They get to look forward to what we’ve had and all of a sudden people will start looking backward and saying, ‘well why don’t we look at Washington with the individual market before we made these laws?’

It’s going to be interesting to see, but pretty scary because if the legislation goes forward, what we’ve done here will go away by 2014.

Q: How so?

A: Because it will be back to guarantee issue for individuals and you can go on any health plan you want and as soon as you get what you need you quit and then you’ll be able to go on any other health plan because there will be no pre-existing conditions.

WP: The issue we have in health care today is the cost of care. It’s not whether people can get coverage or have a health plan or anything like that. It’s whether or not they can afford the premiums if they have to pay the premiums, but secondly is when you have large claims, the cost of care is astronomical. My wife had to have major brain surgery three months ago, and I think we were almost into $400,000.  MRIs are being billed at $5,000, CAT scans are being billed at two grand. When you look at the cost of care, where there’s preventative care or even major surgeries against premiums, and you couple that with prescription drugs, the carriers in Washington State right now are operating between a 82% and 88% loss ratio already without the mandated law. If your insurance premiums are $400 a month–$4,800 or $5,000 a year in premiums–you could be on two medications and use up 50% of that money. In the “old days” 50% of people never made a claim, prescription or otherwise or if they did, their prescriptions were five, ten, twenty bucks. In the new plan with the Feds, they want to give everything away, but who’s going to pay for it? We are. Number two, how are you going to get your care? Because there are a lot of doctors that are bailing out of Medicare and Medicaid and you’ve got a whole segment of doctors between 50 and 60 that are saying, ‘maybe this is a good time for me to quit and retire.’

Q: So do the reforms address affordability at all?

A: No. In fact, they add the extra administrative costs on top of it.

Q: What about the health insurance exchange?

A: It’s just another way of cost shifting. It’s another way for the government to manage and control health care and we can’t afford for the government to do it.

You’ve got to get the Feds out of pricing, and they’re into the pricing because of Medicare. They dictate the reimbursements to the doctors for Medicare and Medicaid patients. So, what do the doctors do? They raise their rates as high as they can under the preferred provider contracts in the commercial marketplace to offset the reimbursement they get from the Feds. So what a lot of doctors are doing now saying, ‘well, we’re not taking anymore Medicaid. In fact, we’re not going to do any Medicare.’ Especially down here. If you’re on Medicare, it’s hard to find a doctor to take you for primary care, even if you have a Medicare Advantage plan, because the doctors are just quitting. You have a balancing act between the providers, the insurance companies and the consumers and the more the government gets involved, the higher admin costs are going to be. They already added a new layer: the insurance companies are spending hundreds of million of dollars right now trying to determine and decipher and get ready for the new regulations that are three years away. Hundreds of millions of dollars we could be using on caring for people.

Q: So what are your predictions?

A: I think that in the end, we’ll have Medicare Part D for everybody paid through a payroll tax and the insurance companies will sell supplemental. The whole PPO network provider contract, all that will just go away. So, in the end, I think the best that could happen with the passing of the legislation is that people have to do something now, whether it’s repeal it or change it. You’re not going to get embracing, because it’s just not affordable.