Anthony Wright summed it up pretty well.
“I just have to say, I love that we’re here,” Wright said. “That the exchange and health reform are actually happening.”
Wright, executive director of Health Access California, was a panelist at the 16th annual Insure the Uninsured Project conference in Sacramento last week.
“This is not some pipe dream, this is eminently doable and achievable,” Wright said.
Or, put in another way, health reform these days means taking action — actually implementing plans rather than talking about them.
“Enrollment and eligibility [in the exchange] is where it’s at,” Kim BelshÃ©, a board member for California’s Health Benefit Exchange, said. “This is where the action is. What we aspire to achieve — seamless, coordinated care for millions of Californians. We are not going to get very far in those goals if we don’t do this part of it right. And if we don’t get it right, and right off the blocks, then we will be in a world of hurt.”
The chance to re-form a vast, dysfunctional health care system in a state bigger than most foreign nations is a chance that comes along rarely, BelshÃ©, former secretary of the state’s Health and Human Services Agency, said.
“It’s exciting, and sobering and daunting,” she said.
Challenge 1: The Provider Shortage
The pool of potential exchange participants is enormous. “You’re looking at six million uninsured in California,” Lucien Wulsin of ITUP said. “Then another two million insured who may be eligible for the exchange, and maybe another three million small business families who could be involved.”
Even if the number of Californians who enroll in the exchange is much smaller — two million is a frequent estimate — access to health care providers still might be squeezed. California already has a shortage of physicians and other providers, and the state’s health care system may be hard-pressed to find enough professionals to care for millions of newly insured people.
A shortage of providers and the large wave of new patients pose a huge barrier to the success of health care reform, Wulsin said.
The solution, according to Mitchell Katz, who heads the Los Angeles County Department of Health Services, is to do more with the same provider level. He described Los Angeles county’s attempt to use a patient-centered medical home approach with low-income patients, by assigning them to a team of care providers. He termed the process “empanelling” patients.
“There is no scenario where there are enough primary care physicians, so the answer has to be: something different,” Katz said. “We need to empanel more people. We have 240,000 people in the [Los Angeles] program, and we gave them a specific doctor and a specific clinic, and those people will get better care.”
That model of care shifts some chronic-care responsibilities from physicians to other care providers, freeing physicians to see patients with more immediate and acute health needs, Katz said.
“We have created 34,000 new patient appointment slots, and we haven’t spent a single nickel. How did we do that?” Katz said. “As a primary care physician, it is not efficient for me to see drop-ins for diabetes. It is inefficient to take care of chronic diseases as a drop-in. Now, someone falling off a ladder, that’s someone you can see as a drop-in.”
Toby Douglas, director of the Department of Health Care Services and a panelist at the ITUP conference, said, “This is the most challenging issue. Whether it’s one-and-a-half or two million more people, there will be an access issue.”
He said, “We can address it in how we pay for primary care or specialty care. We need to give the flexibility to allow other types of care, to use physician extenders, to use existing capacity but use it differently.”
Challenge 2: Transition of Care
California has a number of enormous initiatives going at the same time. Beyond setting up the exchange, the state also is:
- Orchestrating a new system of care for about one million dual eligibles — those eligible for both Medi-Cal and Medicare benefits;
- Working on a plan to shift 875,000 children from the Healthy Families program to Medi-Cal;
- Moving seniors and persons with disabilities into Medi-Cal managed care plans; and
- Shifting 35,000 Californians from the former Adult Day Health Care services to the new Community Based Adult Services program.
In addition to all of that, the state is embarking on weighty administrative moves, such as moving the Department of Mental Health into DHCS.
Douglas feels the task, while daunting, is within reach.
“It’s all about delivery system reform,” Douglas said. “We are moving toward organized delivery systems.”
For instance, he said, the current system for dual eligibles is fragmented, with patients receiving care through two systems. If you eliminate some duplicative services, he said, that will result in better care and lower costs.
“We are proposing bringing all services under one accountable organization to provide more coordinated care,” he said. “We’re moving toward bundled payments. We want to reduce the length of stays in hospitals. Now, this is a touchy proposal, but in terms of expanding capacity, how do we approach our FQHCs (federally qualified health centers)? How do we pay, based on outcomes and value, to over time increase access to care?”
Douglas said eligibility rules will be simplified and enrollment eligibility will be reviewed electronically. “These are huge changes,” Douglas said. “The work is going to change; we’re going to be more phone-based and Internet-based. We’re going to need to look at benefits, and … we have to integrate the Healthy Families program into the Medi-Cal program.”
Challenge 3: The Exchange
Health Benefit Exchange officials have a lot on their plate.
Outreach, advertising, eligibility and enrollment, information technology issues, coordinating with all the governmental health agencies. In addition, a June deadline looms for applying for a federal Level 2 implementation grant.
Exchange officials need to figure out how to reach millions of Californians, work with health insurance plans and brokers, and many competing interests in the state — as well as devise a streamlined, competitive, high-quality insurance system that’s easy to navigate and extremely efficient.
“We need to change the narrative,” BelshÃ© said. “We will need to counter a lot of myth, a lot of fear, a lot of misinformation.”
Of course, this is what BelshÃ©, former HHS secretary for California, has been working toward for years. She is excited to see the reality of it slowly emerge, but she is nothing if not realistic.
“This no-wrong-door [policy] is going to be really, really difficult,” BelshÃ© Â said, referring to the goal of smooth administering of health coverage for all levels of eligibility in the exchange. “But the idea of a first-class user experience, I think, is long overdue and critically important.”
Wright said it’s important to work backward from Jan. 1, 2014, when all states will need to have their exchanges online.
At that point, he said, “It is not just important, but imperative, that on Day One, we have millions of people enrolled in coverage.”
To do that, the exchange is planning to have all systems ready to go six months before that, by July 1, 2013. That’s a little more than 16 months from now.
“I think there is a special burden in California,” Wright said, “to do it for the rest of the nation. Fill in for the Floridas and Ohios [states that are currently rejecting elements of health care reform], to show them what they’re missing out on, and hopefully create some political momentum.”
“California you could really think of as a nation state,” said panelist Andy Schneider, a Medicaid consultant based in Washington, D.C., noting that the state has 12% of the U.S. population younger than age 65 and 14% of the U.S. population that lives in poverty.
“California has 14% of the nation’s Medicaid beneficiaries, but receives only 11% of the nation’s Medicaid spending,” Schneider said. “And if you are spending 11% of the Medicaid dollars and then the feds decide to cut Medicaid, well, that can hit you pretty hard.”
But all California can do, Douglas said, is keep plugging along — trying to make do with the money it has, trying to be more efficient with the money that the state does have.
“The vision is there,” Douglas said. “In practice, it doesn’t always happen the way you expect. There certainly are pieces of the [California health care] infrastructure that will go away, but others that will sync up. So really, the question is, ‘How do we make sure we hit the milestones that will be required in 2014?'”
Health care reform in California might move in fits and starts, but at least it’s moving and maturing, Katz noted.
“It’s like adolescence,” Katz said. “It’s awkward; they grow too fast, they’re maybe too big for their body, they look older but act like they’re 11.”
“It doesn’t all fit the way you expect,” Katz said, “but hopefully, by young adulthood, it all comes out all right.”