1. Inadequate Access & health disparities Dr. Andy Agwunobi March 2, 2005

2. Exceptional Care. Remarkable Services. Extraordinary Grady. Population at risk for inadequate access Of 285 Million Americans  33 Million (12%) are underinsured  44 Million (15%) are uninsured Minorities Living Without Health Insurance  20% of African Americans  33% of Hispanic/Latino Americans

3. Exceptional Care. Remarkable Services. Extraordinary Grady. Georgia’s uninsured population is higher than the national average Source: U.S. Census Bureau

4. Exceptional Care. Remarkable Services. Extraordinary Grady. The number of the unemployed in Atlanta increased over 80% from 2000- 2002 Source: Georgia Department of Labor - Unemployment Rate %

5. Exceptional Care. Remarkable Services. Extraordinary Grady. Health Disparities: Target areas for improvement Nutrition Exercise Medical Home

6. Exceptional Care. Remarkable Services. Extraordinary Grady. Access to a Medical Home PCP Subspecialty care Emergency Care Inpatient Care Wellness care Birth Death

7. Exceptional Care. Remarkable Services. Extraordinary Grady. Distribution – Primary Care Distribution of Pediatricians and OB/GYNs problematic 60% of state poorly covered by Pediatricians, 40% for OB/GYN Large regions of state poorly covered by either, with the eastern region of state sharing deficits Strong implications for health care in early stages of life

8. Exceptional Care. Remarkable Services. Extraordinary Grady. Distribution – Primary Care Problems seen in General Surgery 30 out of 96 PCSAs undersupplied in General Surgeons This distribution is likely getting worse as effective number of General Surgeons is currently dropping

9. Exceptional Care. Remarkable Services. Extraordinary Grady. Contributing Factors Medical Education System Pursuit of medical careers facing challenges Education debt of students can be substantial – with 40% of GA students having debt of $80,000 or higher This could disproportionately impact rural Georgia – debt service will remain the same yet incomes drop when physician practice in rural settings.

10. Exceptional Care. Remarkable Services. Extraordinary Grady. Contributing Factors Medical Marketplace Reductions in reimbursement from public payer systems have been substantial Combination of state and federal cuts have reduced payments to physicians for their services Medicaid reimbursements do not cover physicians’ costs Impact in cuts in public programs disproportionately impacts rural physicians

11. Exceptional Care. Remarkable Services. Extraordinary Grady. Grady Health System  Grady Memorial Hospital (953 beds)  Hughes Spalding Children’s Hospital (84 beds)  Crestview Nursing Facility (388 beds)  9 Primary Care Health Centers  1 Airport Health Center  Grady EMS (Ambulances)  Infectious Disease Center (Ponce de Leon)

12. Exceptional Care. Remarkable Services. Extraordinary Grady. Services:  Level 1 Trauma Center  Burn Center  Emergency Care Center  Diabetes detection and control center  Georgia Poison Control Center  Cancer Center  Regional Perinatal Center  Rape Crisis Center  Sickle Cell Center  Regional Neonatal ICU  Hospice

13. Exceptional Care. Remarkable Services. Extraordinary Grady. Inadequate access 1.Lack of availability of any needed services 2.Financial Barriers to access 3.Poor quality of the care accessed 4.Lack of the knowledge necessary to access care 5.Poor coordination of the care being accessed 6.Other barriers to access

14. Exceptional Care. Remarkable Services. Extraordinary Grady. Lack of availability 1.Self Pay 2.Losses on Medicare 3.Losses on Medicaid

15. Exceptional Care. Remarkable Services. Extraordinary Grady. Sources of Revenue

16. Exceptional Care. Remarkable Services. Extraordinary Grady. Government Payments to Grady  Medicaid Payment for Inpatient & Outpatient Services Covers About 80% of Costs  Medicare payment is about 80% of costs for NAPH members (2002). This takes into account DSH and IME funds.  2 Counties pay between 35-60% of costs

17. Exceptional Care. Remarkable Services. Extraordinary Grady. Medicaid Cuts FY 2006  The FY06 State budget contains targeted cuts of $130 million to the Medicaid program.  The impact to Grady health System is $8.18 million.  Managed Medicaid  Decreased facility fees for hospital-based freestanding clinics,  Decreased reimbursement for ambulatory surgery provided in hospital outpatient setting  Reduction reimbursement for costly outliers.

18. Exceptional Care. Remarkable Services. Extraordinary Grady. Comparison of County Contributions to Total Operating Expenses ($ millions)

19. Exceptional Care. Remarkable Services. Extraordinary Grady. Trauma. Trauma total for 2002 (Grady) Disch LOS CHgs Cost Reimb Loss Fulton2,1128.1643.7M29.7M18.2M(11.5) Dekalb 7278.0114.8M10M 6M (4M) Others1,1269.3836.7M25M 16.4M(8.5M) Total3,9658.4895M64.6M40.7M(24 M)

20. Exceptional Care. Remarkable Services. Extraordinary Grady. Grady Health System Net Patient Service Revenue Payer Mix 2003 Net Revenue Payer Mix Source: Audited financial statements for 2003, June 2004 GHS Finance

21. Exceptional Care. Remarkable Services. Extraordinary Grady. The ICTF

22. Exceptional Care. Remarkable Services. Extraordinary Grady. Grady received $30.8M in unrestricted one-time DSH Funds in 1996 Negative Margin Net Income/(Loss) by Fiscal Year ($ millions) Source: Audited Financial Statements 1996-2001, 2002 audited Financial Statements Grady received $39.6M in unrestricted one-time DSH Funds in 1999

23. Exceptional Care. Remarkable Services. Extraordinary Grady. Lack of availability of services Emergency Department as Medical Home

24. Exceptional Care. Remarkable Services. Extraordinary Grady. Capital Needs Some Examples: Children’s hospital Renovation ($30M) Nursing home Renovation Project ($22M) Information Systems Upgrade ($50-75 M) Pharmacy Renovation Project ($4M) Labor and Delivery Renovation Project ($2.5M) Burn Unit Endowment ($5M)

25. Exceptional Care. Remarkable Services. Extraordinary Grady. Inadequate access Quality 1.Cultural competence 2.Customer service 3.Poor coordination of the care

26. Exceptional Care. Remarkable Services. Extraordinary Grady. Inadequate access Other Barriers 1.Transport 2.Language Barriers 3.Education and literacy

27. Exceptional Care. Remarkable Services. Extraordinary Grady. Thoughts Goals 1.Quality 2.Efficiency 3.Stable funding 1.Safety Net Providers not Insurers 2.Collaborate 3.Focus on providing a quality service 4.Competition where necessary to grow revenues 5.Manage Care efficiently