Who’s Got The Roadmap?Health Reform – Texas Style

Nancy W. Dickey, M.D.President, Texas A&M Health Science Center

Vice Chancellor for Health Affairs, Texas A&M System

“If you don’t know where you are going, any road will get you there”

The Cheshire Cat from Alice in Wonderland

Our goals today:

• A clear sense of major areas needed to be addressed in the State of Texas to successfully implement PPACA

• Remember time lines:– PPACA time lines– Texas legislative calendars

• A clinical reminder – keep the patient’s well-being in mind with every decision

Where do we start?

“Begin at the beginning and go on till you come to the end: then stop.” The King in Alice and Wonderland

One Roadmap will be the Act Itself:

• Today, September 23, is a BIG implementation day– Allowing parents to keep children on insurance until age 26– Eliminating lifetime limits on coverage– Prohibiting insurers from rescinding benefits if beneficiary

becomes ill

• One year after passage CMS must have defined “an acceptable plan”

• Within two years of passage, CMS must establish reporting requirements

Some “turns” will be Mandated/Some will be Optional

• Mandated insurance or pay a fine• Federal definition of what is acceptable

coverage• Participating in a Health Insurance

Exchange• State creation of a Health Insurance

Exchange

Three Issues

• Evidence Based Medicine• Changing Incentives in Medicare,

Medicaid, and private insurance• Workforce

Evidence Based Health Care

Passage of PPACA has laid the groundwork for … greater use of

evidence based medicine

shared decision making

comparative effectiveness research

evidence based benefit design

transparency of cost and quality information

We refer to these diverse efforts as evidence based health care.

• Carman KL, Maurer M, Veglan JM, et al. Evidence that consumers are skeptical about evidence based health care. HEALTH AFFAIRS 29:7,1400-1406. July 2010

Evidence Based Medicine

“The conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research." (Sackett D, 1996)

• Fifth Edition. Copyright 2010 Duke University Medical Center Library and Health Sciences Library, UNC-Chapel Hill

Clinical Expertise

EBPBest

ResearchEvidence

PatientValues &

Preferences

http://www.hsl.unc.edu/Services/Tutorials/EBM/welcome.htm

Evidence Based Medicine

The Public says…

Public perception of evidence based medicine and/or comparative effectiveness is that it is a back-door method for the government to “limit their choice of providers, inappropriately interfere with physicians’ recommendations for treatment, or “ration” care based on cost…”

• Carman KL, Maurer M, Veglan JM, et al. Evidence that consumers are skeptical about evidence based health care. HEALTH AFFAIRS 29:7,1400-1406. July 2010

The Profession says…

There is controversy and disagreement

around EBM.

• Bernadine Healy, MD, former director of NIH likened EBM to a “straightjacket” or cookbook approach in which both clinician judgment and patient values and circumstances are ignored.

Pena A. Physicians’ beliefs and evidence based medicine. Medical Education Online, 2007; 12 http://www-med-ed-online.org

Changing the Current Structure

• Many studies have shown that health care provided in the US is inappropriate, inefficient, and unsafe

• Current incentives tend to be in the direction of increased volume

• Few incentives exist based on quality– Guarantees for time periods post care?– Refusal to pay for “never events”

Workforce Issues

Active physician-to-patient ratio TX = 159 /100,000 (Ranked 42nd)US = 254 /100,000

Primary care physician-to-patient ratioTX = 68/100,000US = 80/100,000

Registered nurse-to-patient ratio TX = 676/100,000 US = 854 /100,000

Higher poverty rates and over-65 populations in rural/border counties mean greater need

Current US System

MostHighly

Specialized

Specialist

Generalist

Non-Physician Provider

Barriers = liability, solid training, competition, economics

Preferred System ?

MostHighly

Specialized

Specialist

Generalist

Non-Physician Provider

Community Health Worker

Handshakes = Incentives to collaborate, partner, Interdisciplinary training to build better teams

Existing Innovations

• DNP

• Promotoras

• Grandaids

• Navigators

Barbara Starfield Describes Primary Care as:

• First contact care

• Continuity over time

• Comprehensiveness

• Coordination with other parts of the health care system

….evidence suggests that (current) systems exert a powerful influence over the care that

individual providers deliver to their patients. In the absence of targeted efforts to reorient local health systems and enhance the capabilities of primary care providers, simply expanding the number of primary care physicians may

miss a crucial opportunity to improve the health care delivery in the United States.

Friedberg MW, Hussey PS, Schneider EC. Primary care: A critical review of the evidence on quality and costs of health care. HEALTH AFFAIRS 29:5, 766-771. May 2010.

Primary Care

An Example (one of several) Group Health Cooperative

• Invested $10 million to convert all 26 clinics to the medical home model

• On track to yield $40 million/year in cost savings by 2011 and beyond

http://content.healthaffairs.org/egi/content/full/29/5/757

PPACA Paves Way for Reinventing Primary Care

But will require changes:

• Operational

• Payment

• Regulatory

• Legal

• Education

Texas Steps

• Medical Education– $335,071,803

• Graduate Medical Education– $52,949,314

• Scope of practice issues• Advantage current liability environment

Texas Steps• Separate federal and state outlays to

create and operate the Health Insurance Exchanges are estimated to cost $37.7 billion. 

• Medicaid administration costs at the state and federal level are projected to increase by $31 billion over the same period.

• Facing a multibillion dollar shortfall with Medicaid being 24% and fastest growing sector.

Next legislative session –January 2011

• Establishment of a Health Insurance Exchange

• Decision about providing matching money for grants, pilots, demonstrations

• Changes in Texas Medicaid/CHIP to qualify for any pilots/higher funding (?)

Opportunities

• Should Texas or Texas groups be encouraged to participate in or compete for demonstration projects, pilots, and grants?– If there is a requirement for matching

funds, should the state step up to provide some/all of the match?