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 2

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 3 What is CHI? Vulnerable populations Safety net Policy decisions Workforce New models of care

Legislators and Policymakers: Reform Opportunities in Policy Foundations: Measuring Impact Prioritizing grants Coordinating efforts Leading Health Organizations: Informed policy Collaborative approach 4 Our Focus: Stakeholder Communities

What determines health?

Health Care Expenditures Comprise a Growing Sharing of Our Economy 6

7 Barrier #1: Financial

If Colorado Were Represented by a Room of Six People... 8

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 10

Why Coloradans are Uninsured... Source: 2011 Colorado Health Access Survey 11 Reasons reported2011 Cost too high84.6% Employed family member not offered or eligible for employer's coverage40.6% Employed family member lost job or changed employers39.3% Do not know how to get it 17.3% Lost eligibility for Medicaid or CHP+17.3% Do not need it13.5% Have pre-existing medical condition and cannot get it 12.5% Family member who had it is no longer part of family8.4% Other11.0% 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 12

The Skewing of Health Expenditures 13

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. 14 Source: CHI analysis of the 2010 American Community Survey

Age Matters: Uninsured Coloradans by Age Source: CHI analysis of the 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,

Income Matters: Poverty Correlates with Uninsurance Uninsured Rates by Income as a Percentage of Federal Poverty Level, Colorado, 2009 and Source: CHI analysis of the Colorado Household Survey and the 2011 Colorado Health Access Survey 18

Underinsured Coloradans by Region,

Coloradans Without a Usual Source of Care,

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 America’s Health Care Safety Net: Intact but Endangered What is the Safety Net? 21

Colorado’s safety net landscape Colorado’s Safety Net Landscape

23 Barrier #2: Provider Availability

A provider when you need one who keeps you healthy and takes your insurance Health Care Workforce 24

MAs CNAs LPNsRNsPAs APNs Generalist MDs Specialist MDs Sub- specialist MDs Range of Providers Cost, access Investment, skills 25

Lifecycle of a Health Care Provider School Residency, Fellowship PracticeRetirement 26

Finding a Provider: A Long Wait for Some SOURCE: CHI analysis of 2011 Colorado Health Access Survey data 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 27

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 28

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 29

Primary Care Needs of the Future Shortage in 2025: 1,034 FTE Supply Demand SOURCE: Colorado Health Institute Primary Care Supply & Demand analysis 30

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, Population data from State Demography Office, February 12,

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 32

$pecialty Choice SOURCE: Leigh, JP, et.al. (2010). “Physician Wages Across Specialties.” American Medical Association 170(19): Other SpecialistsSurgeons Internal Medicine & Ped. Sub-spec. Loan debtPrimary Care Wages are 36%-48% greater than for primary care 33

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): % Do not accept new Medicaid patients 34

35 Where From Here? Health Reform and the Road Ahead 35

An Important Distinction U.S. HR 3590 Health Reform Alpaca PPACA (or The ACA) 36

An Important Caveat 37

38 The Road Ahead: Access and Affordability

Why Coloradans are Uninsured… Source: CHI analysis of the & 2011 Colorado Health Access Survey 39 Reasons reported2011 Cost too high84.6% Employed family member not offered or eligible for employer's coverage40.6% Employed family member lost job or changed employers39.3% Do not know how to get it 17.3% Lost eligibility for Medicaid or CHP+17.3% Do not need it13.5% Have pre-existing medical condition and cannot get it 12.5% Family member who had it is no longer part of family8.4% Other11.0% 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 uninsuredWhat does health reform do? Cost of health insurance is too high Medicaid 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

Reason for being uninsuredWhat 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

800, ,000153,000175, , Colorado, Post-Health Care Reform

Medicaid, CHP+, and Subsidies in

The Individual Mandate and Affordability 44 Source: CHI analysis of COHS Source: CHI analysis of the 2011 Colorado Health Access Survey

Shopping for Insurance and the Cereal Aisle 45 Why do we need to organize this marketplace?

What is a Health Insurance Exchange? 46 A health insurance exchange is an organized marketplace for customers to shop for health insurance based on price and quality. Like aorfor 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 48

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 49

The next frontier: Access to long-term care SOURCE: Colorado State Demography Office, population estimates,

51 The Road Ahead: Workforce

Potential Workforce Solutions Pipeline ExpansionIncentivesDelivery System 52

Expanding the Pipeline Workforce planning Educational capacity Faculty Programs, institutions Residency 53

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

Scholarships & grants Loan repayment Recruitment incentives Payment reform Financial Incentives 55

Colorado Health Service Corps Colorado Health Professional Shortage Areas 56

Interdisciplinary teams Patient-Centered Medical Homes Accountable Care Organizations Nurse Managed Health Centers Technology Delivery System Changes 57

Shared responsibility Panel management Routine care Complex conditions Interdisciplinary Teams 58

Health Homes & ACOs

Broadening the Spectrum: Community Health Workers Patient Navigators Care Coordinators The Next Frontier 60

61 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 62

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