Health Care Access and Workforce Issues

A Colorado Perspective

April 11, 2012

IPHY 2500: Perspectives in Health and Medicine

1. Being uninsured is an important barrier to care.

2. Health insurance is just one part of the equation; health workforce is critical.

3. Health reform provisions aim to address coverage and workforce issues.

Today’s Discussion

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CHI is the most trusted and leading source of credible health information for Colorado leaders. Our insight is used to:• Inform policy• Contribute to effective implementation• Support state efforts to improve health

What is CHI?

Vulnerable populations Safety net Policy

decisions WorkforceNew

models of care

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Legislators and Policymakers:• Reform• Opportunities

in Policy

Foundations:• Measuring

Impact• Prioritizing

grants• Coordinating

efforts

Leading Health Organizations:• Informed

policy• Collaborative

approach

Our Focus: Stakeholder Communities

What determines health?

Health Care Expenditures Comprise a Growing Sharing of Our Economy

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Barrier #1: Financial

If Colorado Were Represented by a Room of Six People . . .

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If Colorado Were Represented by a Room of Six People…

About 1 of 6 Coloradans, or 16%, is uninsured.

About 1 of 6 Coloradans, or 13%, is

underinsured.

About 4 of 6 Coloradans, or 71%, are adequately insured.

Source: 2011 Colorado Health Access Survey 9

Health insurance coverage

Better access (primary and

specialty care)

Improved health

outcomes

The Importance of Access

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Why Coloradans are Uninsured . . .

Source: 2011 Colorado Health Access Survey 11

Reasons reported 2011Cost too high 84.6%Employed family member not offered or eligible for employer's coverage 40.6%

Employed family member lost job or changed employers 39.3%

Do not know how to get it 17.3%Lost eligibility for Medicaid or CHP+ 17.3%Do not need it 13.5%Have pre-existing medical condition and cannot get it 12.5%Family member who had it is no longer part of family 8.4%Other 11.0%

Table 3.1. Reasons the uninsured reported for lacking health insurance, Colorado, 2009 and 2011

Cost Matters: Health Insurance Premiums Compared to Other Economic Indicators

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The Skewing of Health Expenditures

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If Colorado’s Uninsured Population Was Represented by a Room of 50 People…

Key: Child (0-17) Parent(18-64)Adult without dependent children (18-64)

Older adult (65+)One figure represents ~15,000 uninsured Coloradans.

14Source: CHI analysis of the 2010 American Community Survey

Age Matters: Uninsured Coloradans by Age

Source: CHI analysis of the 2008-09 Colorado Household Survey and the 2011 Colorado Health Access Survey 15

• More generous Medicaid/CHP+ eligibility• 2/3 of uninsured Colorado kids are eligible for

Medicaid or CHP+ but not enrolled• Recession:

Why Do Kids Have the Lowest Uninsurance Rates?

Place Matters: Uninsured Coloradans by Region, 2011

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Income Matters: Poverty Correlates with Uninsurance

Uninsured Rates by Income as a Percentage of Federal Poverty Level, Colorado, 2009 and 2011

18Source: CHI analysis of the 2008-09 Colorado Household Survey and the 2011 Colorado Health Access Survey1818

Underinsured Coloradans by Region, 2011

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Coloradans Without a Usual Source of Care, 2011

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• They offer care to patients regardless of their ability to pay for those services; and• A substantial share of their

patient mix is uninsured, have Medicaid, or other vulnerability risk factors.

Institute of Medicine. 2000. America’s Health Care Safety Net: Intact but Endangered

What is the Safety Net?

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Colorado’s safety net landscapeColorado’s Safety Net Landscape

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Barrier #2: Provider Availability

A provider when you need one . . .

. . . who keeps you healthy . . .

. . . and takes your insurance

Health Care Workforce

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MAsCNAs

LPNs RNs PAsAPNs

GeneralistMDs

Specialist MDs

Sub-specialist

MDs

Range of Providers

Cost, access

Investment, skills

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Lifecycle of a Health Care Provider

School Residency,Fellowship Practice Retirement

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Finding a Provider: A Long Wait for Some

PHOTO: Health Policy Solutions

“Our single limiting factor is recruiting providers. It’s really frustrating and it’s hard to find family physicians…Typically it takes us about a year to recruit one provider.”

-Janet Fieldman, CFO of Pueblo Community Health Center

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How many physicians does Colorado have?

Count ‘Em Up

NOTES: Colorado providers include practicing/working providers only.SOURCES: Peregrine and CHI analysis of DORA licensure data and 2010 Colorado Advanced Practice Nurse Survey and 2010 Colorado Physician Assistant Workforce Survey

Physicians NPs PAs0

500

1000

1500

2000

2500

3000

3500 3,271

1,507

764

Primary Care Providers in Colorado

Num

ber P

racti

cing

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Physicians NPs PAs0

500

1000

1500

2000

2500

3000

3500

35%Aged 55+

39%18%

Primary Care Providers in Colorado

Num

ber P

racti

cing

Pending Retirements

NOTES: Colorado providers include practicing/working providers only.SOURCES: Peregrine and CHI analysis of DORA licensure data and 2005 Colorado Physician Workforce Survey 2010 Colorado Advanced Practice Nurse Survey and 2010 Colorado Physician Assistant Workforce Survey

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Primary Care Needs of the Future

2005 2010 2015 2020 20254,000

5,000

6,000

7,000

8,000

6,858

4,620

5,824

7,375

Prim

ary

Care

Pro

vide

r FT

E

Shortage in 2025:1,034 FTE

Supply

Demand

SOURCE: Colorado Health Institute Primary Care Supply & Demand analysis30

Is Anybody Here?

Licensed physicians per 1,000 population

NOTE: Note that providers may work less than full time or not at all. SOURCE: Active licensed Physicians from the Colorado Department of Regulatory Agencies, Jan 3, 2011. Population data from State Demography Office, February 12, 2010

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Keeping Healthy: Primary Care

SOURCE: Starfield B. (1998). Primary care: balancing health needs, services, and technology. New York: Oxford University Press.

First contact

Continuity

Whole person focus

Coordination

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$pecialty Choice

SOURCE: Leigh, JP, et.al. (2010). “Physician Wages Across Specialties.” American Medical Association 170(19):1728-1734.

Wages are 36%-48% greater than for primary care

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Medicaid policy of Colorado Physicians

A Provider Who Accepts Your Insurance

SOURCE: Fryer, GE, et al. (1998). “Personal and educational background predictors of physician practice profiles: The case of Colorado.” Evaluation and Programming Planning 21(3): 307-314.

54%Do not accept new Medicaid patients

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Where From Here? Health Reform and

the Road Ahead35

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An Important Distinction

U.S. HR 3590

Health Reform

Alpaca PPACA(or The ACA)

An Important Caveat

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The Road Ahead: Access and Affordability

Why Coloradans are Uninsured…

Source: CHI analysis of the 2008-09 & 2011 Colorado Health Access Survey 39

Reasons reported 2011Cost too high 84.6%Employed family member not offered or eligible for employer's coverage 40.6%

Employed family member lost job or changed employers 39.3%

Do not know how to get it 17.3%Lost eligibility for Medicaid or CHP+ 17.3%Do not need it 13.5%Have pre-existing medical condition and cannot get it 12.5%Family member who had it is no longer part of family 8.4%Other 11.0%

Table 3.1. Reasons the uninsured reported for lacking health insurance, Colorado, 2009 and 2011

. . . and How Health Reform Addresses These Issues

Reason for being uninsured What does health reform do?

Cost of health insurance is too highMedicaid expansions, premium

credits and cost-sharing subsidies, insurance regulations

Working family member is not offered or eligible for health

insurance

Employer mandate, small employer tax credit

Insured family member lost job or changed employers and lost health

insurance

Portability of coverage; high risk pools

Lost eligibility for Medicaid or CHP+ Medicaid expansions,

continuous eligibility for Medicaid 40

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Reason for being uninsured What does health reform do?

Have pre-existing medical condition and cannot obtain health insurance

Temporary national high risk pool, prevent denials for pre-

existing conditions

Do not know how to get health insurance

Insurance Exchanges and Education surrounding individual

mandate

Do not need health insurance Individual Mandate and Employer Mandate

. . . and How Health Reform Addresses These Issues

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UNINSURED BEFORE HR IMPLEMENTATION800,000

214,000 153,000 175,000

UNINSURED AFTER HR IMPLEMENTATION258,000

Colorado, Post-Health Care Reform

Medicaid, CHP+, and Subsidies in 2014

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The Individual Mandate and Affordability

Source: CHI analysis of 2008-09 COHSSource: CHI analysis of the 2011 Colorado Health Access Survey

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Shopping for Insurance and the Cereal Aisle

Why do we need to organize this marketplace?

What is a Health Insurance Exchange?

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A health insurance exchange is an organized marketplace for customers to shop for health

insurance based on price and quality.

Like a or for health insurance.

It also provides a level playing field for plans to comply with the new consumer protections and benefit requirements.

• Physical infrastructure• The ACA allocates $11 billion to FQHCs

• Electronic infrastructure

Other Access-related Health Reform Provisions

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Who will still be uninsured?

• “The reality is that really only 92% of Americans will be covered…If you think everyone is going to have health insurance, they’re not, even if this bill [The ACA] is implemented perfectly.”

• Former Sen. Majority Leader Bill Frist

The next frontier: Access to long-term care

SOURCE: Colorado State Demography Office, population estimates, 2000-203050

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The Road Ahead: Workforce

Potential Workforce Solutions

Pipeline Expansion

Incentives

Delivery System

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Expanding the Pipeline

• Workforce planning• Educational capacity• Faculty• Programs, institutions

• Residency

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US Med School Enrollment, 2002-2015

SOURCE: AAMC (2011) Results of the 2010 Medical School Enrollment Survey 54

• Scholarships & grants• Loan repayment• Recruitment incentives• Payment reform

Financial Incentives

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Colorado Health Service Corps

Colorado Health Professional Shortage Areas

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• Interdisciplinary teams• Patient-Centered Medical Homes• Accountable Care Organizations• Nurse Managed Health Centers• Technology

Delivery System Changes

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• Shared responsibility• Panel

management• Routine care• Complex

conditions

Interdisciplinary Teams

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Health Homes & ACOs

Broadening the Spectrum:• Community Health Workers• Patient Navigators• Care Coordinators

The Next Frontier

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Conclusion

1. Being uninsured is an important barrier to care.

2. Health insurance is just one part of the equation; health workforce is critical

3. Health reform provisions aim to address coverage and workforce issues

Today’s Discussion

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Athena Dodd 720.382.7093 dodda@coloradohealthinstitute.org Emily King 720.382.7085 kinge@coloradohealthinstitute.org