Even after the federal healthcare reform law is fully implemented in 2014, safety net providers will play a central role in providing medical services to vulnerable patients.
To optimize the quality and efficiency of those services, safety net providers should restructure the way in which they provide care, emphasizing primary care and coordination across the entire continuum of inpatient and outpatient services.
But safety net providers alone may not be able to meet the demand for services from all of the newly insured, vulnerable patients, so financial incentives should be structured to encourage more providers to serve them.
Those were the major findings based on the opinions of a majority of respondents to the latest Commonwealth Fund/Modern Healthcare Opinion Leaders survey
A total of 73% of survey respondents said safety net providers will play a central role in the care of vulnerable patients for two reasons:
- They have the services and expertise necessary to best serve these patients, who often suffer from complex medical problems as well as language, transportation and other social barriers that make accessing the healthcare system difficult.
- Some patients will remain uninsured even with expanded insurance coverage for low-income patients.
“That broad support for safety net providers came through very strongly,” said Karen Davis, president of the Commonwealth Fund.
Harris Interactive conducted the survey, which focused on vulnerable populations, between June 14 and July 20.
A total of 186 opinion leaders from healthcare delivery, policy and finance participated in the survey, which was the 26th in a series designed to gather opinions from healthcare leaders on timely policy issues. The response rate was 14.3%.
Here is the breakdown of participants: 58% in academic or research institutions; 22% in healthcare delivery; 25% in insurance, pharmaceutical or other healthcare businesses; and 9% in government, labor or consumer advocacy organizations. (The total is more than 100% because survey respondents were allowed to put themselves in more than one category.)
O’Dell: Safety net providers are a “critical” resource.
Traditional safety net providers—such as public hospitals and federally qualified health centers—are “a critical healthcare resource for those who are low income, vulnerable individuals,” said Steve O'Dell, senior vice president at Molina Healthcare, Long Beach, Calif., which operates managed-care health plans for Medicaid as well as primary-care clinics in three states.
Most opinion leaders who responded to the survey said they think safety net providers should adopt delivery and payment models designed to improve the quality and efficiency of healthcare services.
For example, consider the percentage of respondents who said they either “strongly support” or “support” these measures:
- 83% for patient-centered medical homes.
- 82% for tightly integrated models of care.
- 74% for performance-based contracting with providers.
Taken together, support for these measures “means not having this fragmentation of care—where you have public hospitals doing their thing and safety net clinics and community health centers doing their thing—but really trying to pull all the resources together in a community to work toward the common goal of the best possible care for the populations that they are serving,” Davis said.
Dr. Bruce Bagley, medical director of quality improvement at the American Academy of Family Physicians, said, “I think the downstream result is that anybody who gets care is going to get more organized care.”
Bagley: Anyone who gets care will get “organized care.”
Indeed, organizations that serve low-income patients already are working to implement patient-centered medical homes. One example: Laurel Health System in Wellsboro, Pa., which operates six federally qualified health centers in rural Tioga County. Of the approximately 40,000 residents in the county, more than 6,000 are on Medicaid and between 5,000 and 6,000 are uninsured.
Laurel Health's clinics are in the midst of revamping the way they provide care to meet all of the requirements necessary to apply for certification as medical homes through the National Committee for Quality Assurance, according to Ron Butler, president and CEO of Laurel Health, which also includes Soldiers and Sailors Memorial Hospital in Wellsboro.
And O'Dell said Molina Healthcare contributes up to $10,000 toward the cost of medical-home certification for primary-care physician offices in its network.
While medical homes and integrated systems received widespread support in the survey, a much smaller percentage, 47%, of respondents said they strongly support or support the “adoption and spread of accountable care organizations.”
Why was there less support for ACOs? “A lot of people have focused on (the federal government's) proposed rule” and the criticisms of it, Bagley said.
For example, providers are concerned about the upfront costs to become an ACO and whether they will be able to offset the investment by sharing in cost savings that they generate. The CMS has estimated the upfront costs at $1.8 million, but many providers think that number is too low.
Molina Healthcare's O'Dell said safety net providers, in particular, would have trouble coming up with the money necessary to develop an ACO on their own.
Laurel Health “is up in the air like everyone else,” Butler said. “The regulations are just not clear enough yet on what the requirements are going to be.”
Butler said Laurel Health would be more likely to partner with a larger organization than to create an ACO on its own. He believes Laurel Health is well-positioned to become part of a larger ACO because the system operates many components of the healthcare continuum, including: primary care, inpatient services, behavioral health, skilled nursing, home care and hospice care.
Even if providers are uncertain about a Medicare ACO model, Bagley predicts that many providers would become part of an ACO eventually as the concept “ultimately will be in the commercial sector” as well.
But even with improvements in efficiency and accountability, the country will need to increase the number of providers who treat low-income patients beyond the traditional safety net. Implementation of the federal healthcare reform law is expected to significantly increase the number of low-income patients in the system—through Medicaid and the state-run health insurance exchanges.
In 2014, Medicaid eligibility rules will include nearly all patients with incomes below 133% of the federal poverty level, adding about 20 million people to Medicaid by 2019 for a total enrollment of about 78 million, according to the CMS.
In addition, the law provides federal subsidies to buy insurance through the state-run health insurance exchanges for people with incomes between 133% and 400% of the federal poverty level.
It is not surprising then that 81% of respondents to the Health Care Opinion Leaders survey said they strongly support or support the use of financial incentives to encourage more providers to serve vulnerable patients.
Specifically, 88% either strongly support or support the expansion of opportunities for providers to earn scholarships and forgiveness of education loans in exchange for their services in communities with a shortage of providers.
And 71% said they either strongly support or support a proposal to permanently bring reimbursement rates for Medicaid to the same level as Medicare. The reform law includes a provision for rate parity for only two years.
Far fewer survey respondents, 54%, said they strongly support or support a policy that would require providers who participate in Medicare to also participate in Medicaid.
The level of reimbursement makes a difference. O'Dell said it is much easier for Molina Healthcare to contract with providers in states with higher Medicaid reimbursement rates. “When you look at California, the providers that are in Medicaid, because the rates are so low, are almost all safety net providers,” O'Dell said. On the other hand, “most physicians in New Mexico take Medicaid.”
The index of fee-for-service Medicaid reimbursement versus Medicare reimbursement in 2008 was 0.56 in California, compared with 1.07 in New Mexico; the national average was 0.72, according to the Kaiser Family Foundation.
The access problem is particularly problematic in some specialties, such as dermatology, otolaryngology and orthopedics, O'Dell said.
“We think there has to be a minimum payment (for Medicaid). It needs to start with primary care, but probably needs to extend across the board,” O'Dell said.
Linda Wilson, a former
Modern Healthcare reporter, is a freelance writer based in McHenry, Ill. Reach her at firstname.lastname@example.org.