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Community Health AlliancePrimary Care Access and the Medicaid Expansion:

Charles Duarte, CEOCommunity Health Alliance

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Or How to Fit 10 Pounds of Beans in a 5 Pound Bag!

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We know the numbers…• Over the past three decades, the number of MDs in Nevada has

grown from 1,171 in 1980 to 6,153 in 2012 (425.4%). • Nevada’s physician-to-population rank among US states

dropped from 36th to 47th during the same time period.• The per capita number of patient care MDs in the United States

is 250.0 per 100,000 population. To meet or exceed the national per capita rate, the supply of patient care MDs in Nevada would need to increase by 48.0% to reach the national rate.

• In 2012, Nevada ranked 46th among US states in the number of active physicians (MD and DO) per capita.

Physician Workforce in Nevada 2014 Edition John Packham, PhD, Tabor Griswold, PhD, Laima Etchegoyhen, MPH, and Christopher Marchand, MPH, July 2014.

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Even Before the Medicaid Expansion…

• A 2008 Nevada study showed 65% of physicians accepted new Medicaid patients.

• Participation varied by specialty and location.

•An estimated 75% of all office-based physicians in Nevada accept new Medicaid patients. Higher fees correlate to higher participation.

Decker, Sandra L., “In 2011 Nearly One-Third Of Physicians Said They Would Not Accept New Medicaid Patients, But Rising Fees May Help,” Health Affairs, 31, no.8 (2012):1673-1679.

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2016-2017 Nevada Medicaid Rate Proposal

Primary Care Physicians currently paid 100% of 2014 Medicare for Medicine and E&M services.

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Medicaid caseload projected to reach 582,424 in 2016

Recession

Expansion Start

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Important Information!

Starts Here

Ends Here

Not Me!

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Expansion Success: Sort Of

“For Carolyn Oatman, enrolling in Medicaid this year was “a dream come true.” Uninsured since she lost her job five years ago in this desert gambling city, Oatman, 57, often couldn’t afford the drugs to control her asthma and high blood pressure. She would sell her blood plasma to scrape together enough money to see a doctor.

Since she signed up for Medicaid, though, her care is free, including her medicines. But there’s a downside: Sometimes, when Oatman needs to see a doctor in a hurry, she drives to the nearest emergency room – getting care where it costs taxpayers the most. “I love it on Medicaid because now I can go the emergency room when I need to and don’t have to worry about the bill,” said Oatman.”

Phil Galewitz, Kaiser Health News, Oct. 28, 2014

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A Different Expansion StoryKaren Silverman, 61, is one of those. In the past, working as a parking lot attendant without health coverage, she often could not afford the drugs to treat her high blood pressure and diabetes. “I would forgo my cholesterol or blood pressure medicine so I could afford my insulin,” she said. “It was scary but I had no choice.”

In February, she enrolled in Medicaid. Now she pays nothing for doctor visits or prescription drugs. After several months of taking her medications regularly, her diabetes and blood pressure are better controlled and she has started walking again. “I feel as if my life is back on track,” she said.

Phil Galewitz, Kaiser Health News, Oct. 28, 2014

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The Problem• Increasing Primary Care capacity is essential to the implementation of the Affordable Care Act (ACA).• Researchers have estimated that insurance expansion will generate 15-24 million additional primary care visits each year as a result of the ACA.

• Health literacy for New Eligibles is very low. Most have never had a primary care provider. •Nevada has the 6th highest primary care “access challenge.”*(Access-challenge index scores were calculated as the ratio of Medicaid expansion to primary care capacity in each state.)

Ku, et al, “The states' next challenge--Securing primary care for expanded Medicaid populations,” The George Washington University Health Sciences Research Commons, 2-2011.

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Expanding Primary Care Capacity – Long Term Picture

TRAIN MORE; LOSE FEWER; FIND SOMEONE ELSE

• Payment Reform• Care Delivery Reforms• Support Primary Care Training• Create New Primary Care Residencies• Scholarships and Loan Forgiveness• Expanding mid-level provider training programs• Law and regulatory changes

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Increasing Primary Care Capacity - DO MORE WITH LESS!

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Increasing Capacity in the Short Term – Reduce Inefficiency!

Thirty minutes of reduced time wasted per day = 30-40 million more primary care visits available each year without a single additional provider.

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How Do Primary Care Providers Spend Their Time?

• Each minute that a physician spends outside direct patient care costs the practice four to six dollars in lost revenue.• Delivering just the preventive services recommended by the US Preventive Services Task Force to an average-size panel of 2,500 patients would take 7.4 hours per day.• Up to two-thirds of the time of a typical patient visit is spent on data entry.• In 2011 researchers found that US physicians reported spending 50 percent more time interacting with payers than did physicians in Canada.

Scott A. Shipman and Christine A. Sinsky, “Expanding Primary Care Capacity By Reducing Waste And Improving The Efficiency Of Care,” Health Affairs, 32, no.11 (2013):1990-1997.

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Let’s Get Real!Short-term Approaches

• Teamwork

• Patient Engagement

• Expansion

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TeamworkPATIENT-CENTERED MEDICAL HOME• PCMH key functions:

medication management, self-management support care coordination

• Each of the key functions involves thecoordinated involvement of multiple members of the practice team:

Behavioral Health Providers Case Managers and Care

Coordinators Pharmacists Medical Assistants and Team Care Assistants Community Health Workers (CHWs)

• CHA developing resources to put together care teams and training. 

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Teamwork (continued)

•Team Care ModelTeam Care Assistants (TCAs) work with the

provider and do many of the functions that do not require a provider: gather history and data scribe the visit in the EMR patient education

Maximizes the provider efficiency in seeing patients and allows them to work at the “height of their license”

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Patient Engagement

Care Coordination• Work in collaboration with direct team care members (providers, team care

assistants)• Call center directs triage of patient communications (phone/portal) to

appropriate care team personnel • Care Coordination including:

Complex Care Chronic disease care Referral coordination/tracking Transitions of Care Self-management support

o Clinical pharmacistso Dieticiano Community Health Workers o Health coaches / Behavioral health specialists

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Patient Engagement (continued)

Population Health and Preventive Health Population HealthoDisease registry managementoRisk stratification operations oDatabase management and reporting

Preventive CareoCancer screeningoVaccinations oWell child care tracking oHeart health and obesity care

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Expansion• Wooster School-Based Health

Center• Integrated Chronic Care Center• Sparks?• Expanded Hours – Medical & Dental• Behavioral Health Services• Care Coordinators, TCAs and

CHWs

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Who We Are

Community Health Alliance (CHA) was formed in July 2012 through the merger of two non-profit Northern Nevada health care providers with similar missions, HAWC Community Health Centers and Saint Mary’s Mission Outreach. Today it includes:

• 195 employees serving at • 5 fixed-site locations and• 3 mobile units

• Dental Hygiene Van• Dental Restorative Van• WIC Van

• Wells Medical/Dental Health Center - PCMH• Homeless Outreach Clinic• Neil Road Health Center• Sun Valley Health Center• Wooster High School-Based Health Center 

s 

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Who We Serve

•Target population includes individuals and families living below 200% of poverty ($24,250 for a family of 4)

•87% of patients below poverty•33,500 unduplicated patients/clients•94,200 annual patient/client visits•35% of patients uninsured•50% covered by Medicaid/CHIP

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CHA Programs

• Primary Medical Care • Pediatric Care• General Dentistry• Behavioral Health Care• Laboratory Services• X-Rays• 340B Pharmacy• WIC (Women, Infants and

Children) Program• Mobile Dental Sealant Program• Hospital Dental Program

• Mobile Dental Restorative Program

• Northern Nevada Dental Health Program

• Adopt a Vet Dental Program• Immunizations• Women’s Health Care• Breast Health Program• Outreach and Enrollment for

Nevada Health Link and Medicaid

• Healthcare for the Homeless 

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Questions?

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Contact

Charles Duarte, CEOCommunity Health Alliance1450 Ridgeview Dr., Ste. 200Reno, NV 89619775-336-3017 Office775-781-1603 Cellcduarte@chanevada.orgwww.chanevada.org