1

HEALTH SEMINAR FOR NEWER LEGISLATORS

Access to Health Care Services

What’s Covered Today

Challenges in accessing health care services

State strategies to address challenges:

Scope of Practice

Oral Health

Rural Facilities

Community Paramedicine

Peer Support Specialists

Telehealth

Roundtable Discussion

2

Session Objectives

Understand key challenges and barriers to access to

care

Identify state strategies to improve access to health

care services for underserved populations

What’s the Problem?

More than 100 million Americans live in a Health Professional Shortage Area (HPSA)

More than three quarters of the nation’s rural counties are HPSAs

HPSAs are “geographic areas, or populations within geographic areas, that lack sufficient health care providers to meet the health care needs of the area or population.” (CMS, 2014)

HPSAs include primary care, oral health and mental health

Find HPSAs in your state: https://datawarehouse.hrsa.gov/tools/analyzers/hpsafind.aspx

3

What’s Causing Workforce Shortages?

Aging workforce and retiring practitioners

Low number of graduating students who want to practice in rural or underserved urban areas

Declining interest in certain fields for some providers (e.g., primary care physicians)

Comparatively low reimbursement rates for certain services especially from public payers

Lack of adequate training for certain issues and populations

Primary Care HPSAs

About 6,600

primary care

HPSAs in the U.S.

It would take over

9,000 additional

providers to

remove the HPSA

designation

4

Dental Care HPSAs

More than 51 million

Americans live in the

approximately

5,500 oral health

HPSAs

5

Mental Health HPSAs

There are currently about 4,600 mental health HPSAs

More than 106 million people live in a mental health HPSA

State Strategies

6

Scope of Practice

Scope of Practice: what a health professional can and cannot do to or for a patient

Defined by state boards of medicine, boards of nursing, etc., often with guidance or instruction (via statute) from the state legislature

Policymakers balance increasing access through expanding providers’ scope of practice, with ensuring patient safety and quality of care

Scope of Practice

Legislative tracking

Nurse practitioners, physician assistants, dental hygienists and dental therapists

http://www.ScopeofPracticePolicy.org

7

Oral Health

Public Health & Prevention

School-based sealants

According to the Pew Charitable Trusts, sealant programs are more cost effective when targeted to low-income schools

Cost of sealant: $31.70 per tooth versus extraction of decayed tooth: $147.32

Community Water Fluoridation

According to the Centers for Disease Control and Prevention, community water fluoridation saves $38 for every $1 spent

Coverage and Financing

Children’s Health Insurance Program (CHIP)/Medicaid

Oral Health

Workforce

Student Loan Repayment Programs

Can promote a diverse workforce, or can strengthen existing workforce, in dental care HPSAs

Midlevel Oral Health Providers

Dental Therapists (ME, MN, VT)

Dental Health Aide Therapists (AK, WA)

Dental Hygienists

8

Rural Facilities

Rural hospital: general acute, non-federal hospital that is not located in a metropolitan county; or a Critical Access Hospital.

Critical Access Hospital: Designation given to rural hospitals (by CMS) that meet certain criteria, such as having 25 or fewer

acute care inpatient beds, being located more than 35 miles from another hospital, and receive cost-based reimbursement.

Federally Qualified Health Centers (FQHCs): outpatient clinics that qualify for specific reimbursement systems under

Medicare and Medicaid. Must meet certain criteria such as serving an underserved area, offering a sliding fee scale, etc.

Free-standing emergency departments: facilities that receive individuals for emergency care. Can be independent of a

hospital system or be run by a hospital but is structurally separate and distinct from the hospital.

Indian Health Service (IHS) and tribally-operated facilities: managed directly by IHS, tribes or tribal organizations under

contract or compact with the IHS. Located mostly on or near reservations.

Rural health clinics: clinics located in rural areas. Provide primary care services using a team of physicians, nurse

practitioners (NPs), physician assistants (PAs), and certified nurse midwives (CNM). Receive enhanced reimbursement rates for

providing Medicaid and Medicare services.

Rural Facilities

Strategies:

Repurpose: urgent care, skilled nursing, outpatient care, emergency care, acute rehab, primary care

Accountable Care Organizations (ACOs) and other partnerships, e.g., frontier health system model

Telehealth

Mergers with larger health systems

Coordination between rural hospitals and other facilities, e.g., rural health centers or IHS providers

Value-based payments, e.g., global budgets for rural hospitals

9

Community Paramedicine

Community Paramedics are trained to provide non-emergency services to patients in their homes or other community-based settings

Perform an expanded role within their scope of practice

Aim to connect high-risk and underserved patients (e.g., frequent emergency dept. utilizers) with primary care services

Community Paramedicine

Services may include:

Assessment (e.g., blood pressure screening and monitoring)

Treatment/Intervention (e.g., providing wound care)

Referrals (e.g., mental health and substance use disorder referrals)

Prevention and Public Health (e.g., immunizations)

Many programs implemented as pilot programs

Reimbursement challenges

10

Peer Support Specialists

Services delivered by a person with similar life experiences and previous behavioral health challenges

Support groups, peer recovery education, and peer-run services such as mentoring and case management

May be able to better connect with patients and help them obtain treatment, social support and housing

Optional certification programs: Mental Health America and others

Increasingly, Medicaid and public mental health systems will pay for peer support services

11

Telehealth

“The use of electronic information and telecommunication technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration” (HRSA)

Primary, acute and specialty care

Chronic disease management, home health and long-term care

Oral health care

Behavioral health care

Four modalities:

Live video, Store and Forward, Remote Patient Monitoring, mHealth

Telehealth

State activity

150-200 bills each year

Key policy issues:

Reimbursement (public and private payers)

Licensure

Provider practice standards and patient safety

12

Key Questions to Ask

What are the greatest barriers to access to care? Where are the greatest needs?

E.g., workforce shortages, types of providers or services

E.g., rural areas, certain underserved populations

What state efforts are already underway to address access issues?

What are the costs and benefits of these efforts? What has been successful?

What new strategies are available to address access to health care services? What strategies presented today interest you most?

What stakeholders (e.g., providers, patients, insurers, etc.) need to be at the table? What data do you need?

Tools and Resources

Telehealth Policy Trends and Considerations http://www.ncsl.org/documents/health/telehealth2015.pdf

Incorporating Community Health Workers into State Health Care Systems http://www.ncsl.org/Portals/1/Documents/Health/CHWbrief2015.pdf

Improving Rural Health: State Policy Options http://www.ncsl.org/Portals/1/Documents/Health/RuralHealth_PolicyOptions2016.pdf

Scope of Practice Policy: http://www.scopeofpracticepolicy.org

Oral Health: State Policy Options: http://www.ncsl.org/Portals/1/Documents/Health/OralHealth2015.pdf

Community Paramedicine Article: http://www.ncsl.org/research/health/pinch-hitting.aspx

13

Roundtable Discussion

Six tables with an NCSL staff member at each table

Scope of Practice

Oral Health

Rural Facilities

Community Paramedicine

Peer Support Specialists

Telehealth

Each discussion is 15 minutes

Rotate three times to different topics/tables

NCSL staff will tell you when to switch

Cambridge, Massachusetts| April 28-30, 2017

HEALTH SEMINAR FOR NEWER LEGISLATORS