Wyoming Healthcare Commission Meeting Minutes
May 24, 2004
Attendance: T. Chris Muirhead, Chairman, George Bryce, Jack Glode, Carol Jenkins, Paul Lang, Steve Mossbrook, Dixie Roberts, John Vandel, Commissioners, Deb Fleming, Wyoming Department of Health Director and Ken Vines, State Insurance Commissioner, Ex-Officio Commissioners.
Meeting called to order by Chairman Muirhead, who then introduced the Commissioners, Ex-Officio Commissioners and Staff.
The first report to the Commission was from Rep. Doug Osborn, Chairman of the Joint Interim Labor, Health and Social Services Committee, which met in Casper on May 13. Among the issues on the legislative committee’s agenda was worker’s compensation, a program state statutes require to be fully self funded by 2008. The Department of Employment is concerned that the program will not be fully self-funded by 2008. The question being considered is, ‘what does fully self-funded mean, exactly?’ The program’s current balance is $430 million and using that balances projected expenses against no reserves, worker’s comp is now under-funded at the level of $204 million. In 2008, projections show the program will still be under-funded by $50 million. Legislation is needed to get this fixed one way or another. Worker’s comp is implementing cost control programs that include fraud detection software, a pilot PPO project, a prescription drug program, and mediation.
Commissioner Jenkins reported to legislators about progress being made toward mandated completion of a healthcare information technology study and the potential partnership between Duke Fuqua School of Business’ Health Data Exchange (HDx) and a yet-to-be-named Wyoming entity.
Ex officio Commissioner Fleming led a good discussion on health issues related to obesity intended to help the Committee see what is being done to address one of the leading health problems in the state. I think the Department of Health has good programs, Rep. Osborn said. They’re shooting for obesity reduction in high school students by 2010 to less than 5 percent. The Committee also heard from the American Heart Association, which reported that obesity has overtaken tobacco as the leading cause of death, disease and disability in Wyoming.
The Committee’s subcommittee on long term care reported on their first meeting, which involved beginning an examination of long term care at the WyomingRetirementCenter in Basin, a facility in Cody and another in Lovell. The state facility has difficulty with hiring and a lot of the problem seems to be related to barriers within Wyoming government administration system to being able to hire people rapidly. There are several bills the subcommittee is working intended to make long-term care more accessible and affordable.
Medicaid reimbursement for special education services remains on the Committee’s agenda; a bill put forth last session didn’t get heard but would have required school districts to apply for Medicaid payments for kids in special education who qualify. School districts are reluctant to do this because there are additional administrative costs attached, but if they do, it saves a good chunk of money for the state.
Mike Huston, director of the CommunityMentalHealthCenter in Casper, reported that there are six sites in the state offering comprehensive substance abuse treatment. The objective is to coordinate substance abuse treatment resources and make sure we have adequate treatment resources. The programs are working together and the coordinated effort seems to be going well.
Wendy Curran, Director of the Wyoming Medical Society, educated the Committee about the medical malpractice insurance cost impacts. Two physicians shared their personal experience with the difficulties of paying for medical malpractice insurance.
Director Harrop reported on WHCC studies under way, including an analysis of unreimbursed catastrophic and trauma care impacted by insurance companies’ refusal to pay claims associated with accidents involving illegal substances/alcohol. She also informed the Committee that only one Wyoming physician (a family practitioner from Kemmerer who delivered 6 babies in 2003) qualified for the OB subsidy enacted by the legislature in the 2004 session.
Kenneth McBain, Director of the Community Health Center of Central Wyoming, presented information about the structure and services offered by his facility (CHC1.pdf). CHCs were a product of the consolidation in 1976 of programs launched in the 1960s to provide economic development to inner cites and rural areas that included healthcare services. Section 330 of the Public Health Service Act includes CHCs, migrant health centers and homeless health centers. Today there are 1,400 CHCs nationwide that serve as the safety net provider to about 16 million people, with about 45 percent of them residing in rural areas. CHCs’ mission is to provide access to primary care for underserved populations. In the beginning, “underserved” was defined as the uninsured and the indigent. Today, a much broader definition is used and incorporates all those with limited or no access to care – frequently those who are Medicare, Medicaid, and Kid Care beneficiaries, and/or people who live in remote rural communities.
A needs assessment done in Casper in the late 1990s showed that there were 35,000 people in need of health care services provided at a CHC, resulting in the award of a grant in March 2000 that allowed a CHC to begin operations on Oct. 2, 2000. The organizational structure is one of a kind because the CHC is affiliated with the University of Wyoming Family Practice Residency Program. Under that affiliation, UW has sole jurisdiction over the education and training programs of the students in the residency. Everything else – patient care programs, billing, etc. – was transferred to the CHC. One of the unique elements of the partnership is that everyone became an employee of the CHC, with the exception of the faculty, who are university employees. In 2000, there were 22,000 patient visits to the UW Family Practice Residency Program by 9,800 patients, and the facility operated with a $3.2 million budget. Mr. McBain was the 57th member of the staff hired. Now there are 145 employees, and last year there were 65,000 patient visits by 21,000 patients in the expanded facility – now operating with a $12 million operating budget. The number of new patients continues to grow.
A year after the CHC was created in Casper, mental and dental health provisions were added to Section 330 program requirements. Casper’s facility received the funding needed to create a behavioral and mental health department and a full service dental clinic. The CHC has three full-time dentists on staff. The CHC has a full service pharmacy that is able to purchase drugs under the federal purchasing program used by the Veterans Administration. The CHC offers a sliding fee scale but no one is ever turned away because they don’t have health insurance or the money to pay for care. Patient counseling, patient educators, and bilingual staff are available.
A post-doctoral pharmacy residency that is fully accredited has been created at the facility and plans are underway to begin development of a dental residency. A major expansion of services is anticipated in six to nine months that will include an optometry department and a senior medical program. Mr. McBain is now interviewing a geriatrician who, if hired, will be a “rare find” because there only 9,000 certified in the country. A walk-in clinic is going to open for outpatients who can’t or don’t make appointments, along with a14-chair dental facility.
The CHC also serves as the parent organization for the Children’s AdvocacyCenter, a model under the National Children’s Alliance that brings together law enforcement, the Department of Family Services, schools, and private agencies dealing with child abuse and child neglect. Sixty percent of reported child abuse and neglect cases in Wyoming are in Casper.
Fifty physicians in Wyoming came out of the UW residency program, and of those, 17 are practicing in Casper. Most are not originally from Wyoming; they came to the residency program from other states and other medical schools. We believe we can do the same thing in dentistry. We have to find creative ways to attract new providers to Wyoming, Mr. McBain said. He elaborated on the growing shortage of health professionals in America and said his research has shown the root of the problem is the lack of capacity universities have to train healthcare professionals due to budget constraints and an inability to attract instructors. Seven dental schools closed in 2002. The remaining dental schools in America have 345 vacant professional teaching slots they can’t fill because the salaries offered are not competitive.
“We need providers in this state. We’re losing them left and right. We’ve lost five in Casper in the last six months, representing 15,000 patients who now have to find a new medical provider. If we recruit somebody to come to Casper, we’re taking him or her from somewhere else that could ill afford to lose them. We have to find a way to meet the growing needs of our people or they’re going to end up in hospital emergency rooms looking for primary care. CHCs are one answer. Tort reform is one answer. Bolstering our educational system is one answer. They are all interrelated,” Mr. McBain said.
Within the next 10 to 15 years, Wyoming will have the oldest population in the nation. The Bush Administration has been pouring tremendous monies into new and expanded CHCs. In rural areas, there are many small communities that do not have the financial resources and population to sustain even one physician. A clinic in Dubois last year became a satellite of the Casper CHC. We operate that with a full time nurse practitioner, and a part time physician assistant and physician. There are a number of communities in the state that could gain from the concept of a CHC, but there’s a lot of resistance among practicing physicians who view CHCs as unfair competition because they get federal money and don’t have to pay malpractice premiums. CHC physicians are federal employees and have federal protection, and therefore don’t need to buy medical malpractice insurance.
But even though the CHC gets federal subsidies and its physicians have federal protection, it suffers significant financial losses. The CHC is the safety net provider for the uninsured, indigent, and Medicare and Medicaid recipients. The CHC has written off more care than it would have paid in medical malpractice premiums and than it has gotten in federal subsidies, he said. “We take the patients no one else wants.”
Chairman Muirhead noted he is a member of the Wyoming Medical Center Board and said he thinks the Commission needs to better understand why the CHC is successful at recruiting physicians when other facilities are struggling to find new practitioners. Mr. McBain said he believes one of most influential factors is the CHC’s partnership with the UW Family Practice Residency. The affiliation creates a unique medical environment. “The opportunity to work in an environment of patient care and physician training is exciting. I think that has been a big player in our ability to attract people,” he said. “I think once they come and they see the full range of what is occurring in our facility, they then say, ‘you’ve got all the support mechanisms that make for a comprehensive delivery system’ and want to work with us.” Right now the CHC is recruiting for four internists. The need in the community is greatest for senior citizens. There are seven general internists left in the city. For the size of Casper, we should have 14 to 16.
Chairman Muirhead also asked Mr. McBain for an explanation of the reimbursement rates CHCs qualify for, in comparison with what a physician in private practice would receive. Mr. McBain said that in 1993, the federal government developed a reimbursement concept classified as “federally qualified health centers.” Those fitting within the classification getting reimbursement from Medicare and Medicaid receive “per visit” reimbursement rather than “per service” reimbursement. We have a whole list of services we provide and we have the choice of providing them in-house or making contractual arrangements to do so, Mr. McBain said. If a patient comes in the door with a runny nose or a shopping list of ailments, we get paid the same amount of money – it doesn’t matter whether we spend a few minutes or a few hours with that patient. We are the first CHC in the United States to also get reimbursement for the cost of medical education. As a result, we get $106 per patient visit plus $77 for graduate medical education. In a private office, you have a complex fee schedule ranging from first time patient visits of $120 and brief visits of $25. The average amount per visit is around $60 to $65. Medicare reimburses that provider about $28 to $30 per visit.
Chairman Muirhead wanted to know if there is any way to use CHCs as a temporary vehicle to employ physicians in communities if they are unable to get medical malpractice insurance or the cost is prohibitive. Mr. McBain said that the federal government prevents the sharing of advantages CHCs have in terms of financial considerations and ability to provide for those who can’t pay. Mr. McBain said the CHC’s patient distribution is about 30 percent Medicaid covered, 24 percent Medicare covered, 23 percent uninsured, and 22 percent with other kinds of health insurance. Patient revenues account for about 65 percent of the facility’s total budget.
Mr. McBain was asked whether the CHC is using medical technology to expand patient services. He said the facility is now accepting responses to an RFP for creation of an Electronic Medical Record system. We’re hoping to initiate that program after the first of the year. It will take two years to implement and will cost about a half million to do the complete system, including PDAs to be used by physicians when they are seeing patients in the hospital. We have to invest the money and make the change. We need to provide a cutting edge educational environment with the most effective patient care and quality of care with an ability to monitor that care. They’ve requested $250,000 in grant funding to acquire and install EMR capacity.
Dr. Steven Orcutt of Physicians United to Save Healthcare in Wyoming (PUSH) is an orthopedic surgeon who has been in Wyoming about a year who is seeing doctors leave the state and is working with his peers to advocate for passage of legislation intended to reduce medical malpractice insurance costs. PUSH is a statewide political action committee founded this year in NatronaCounty in the wake of the state Legislature’s failure to pass effective legislation intended to ease the medical malpractice insurance crisis. Doctors lack affordable, reliable malpractice insurance. Wyoming is ranked 47th in the nation for the number of doctors per capita. We’re approaching a 10 percent loss of physician workforce due to retirement, relocation and restriction of practice – about 65 doctors. The population of the United States and Wyoming is getting older and will need more healthcare. There are far more jobs for physicians than there are doctors. The average Wyoming physician is 51 so we can expect to lose half of our medical workforce to retirement over the next 10 years. We can’t recruit doctors right out of training. The average young physician comes out of training with a six-figure debt. They are going to go to places where they can play it safe on malpractice insurance and pay back school loans faster.
Wyoming’s difficulties were compounded by the AMA’s designation of the state as a medical malpractice crisis state. Dr. Orcutt said he gets two to three job offers a week. The grass is going to look greener on the other side eventually. In his practice, he relies on a network of physicians, from primary care to specialists, and as those doctors depart he will find providing care to his patients increasingly difficult. It’s going to take years to replace doctors we’ve lost already. Some of the doctors who left are gone specifically due to the lack of legislation this year. More are leaving due to the announced departure of insurer OHIC. UMIA is willing to take on some of the physicians but the cost of insurance is going to be higher and some doctors will not be able to obtain insurance at all if they are practicing in high risk specialties. We’re all waiting for quotes from other insurance carriers.
Tort reform has been shown to work in other states – California, Texas and Colorado – where there has been a decrease or slower rates of increase in malpractice insurance rates. The immediate remedy needed in Wyoming is for the governor to call a special session and for the Legislature to pass provisions for financial subsidies to physicians facing increasing medical malpractice premium costs. Some state funding assistance will help keep some physicians from leaving, but not the doctors who can’t get policies at all.
There also needs to be passage of a MICRA (Medical Injury Compensation Reform Act) package like they have in California, Texas and Colorado limiting non-economic damages, requiring the disclosure of collateral payment sources for the plaintiff at trial, expert witness qualification, periodic payouts of damages, a sliding scale for lawyers working for contingency fees, and public disclosure of all settlements made. Discussion followed concerning the Insurance Department’s ability to ascertain medical malpractice lawsuit settlement amounts. Insurance Commissioner Vines said he has broad authority to ask companies to disclose their settlements but a law would make it routine with data available every year. Sen. Charlie Scott’s medical errors commission should also be approved by the Legislature, Orcutt said. PUSH is meeting with the Wyoming Medical Society to prevent duplication of effort. PUSH is in favor of the medical review panel proposed for this year’s ballot (Constitutional Amendment C) but believes passage of that measure alone won’t fix the medical malpractice problem in the state. It may, hoerver, cut down on frivolous lawsuits. PUSH is taking the stand that it is important to support Amendment C because it is the only piece of tort reform legislation that really made it through this year’s legislative session. We need to show support for that and ask that the voters pass it resoundingly to send a message to the Legislature that we want tort reform.