Representative Thissen toured hospitals and health care facilities across Minnesota last week to discuss options for health care providers in the wake of Governor Pawlenty’s GAMC cuts.
By Tim Nelson, Minnesota Public Radio, July 3, 2009
Minneapolis — Gov. Tim Pawlenty’s plan to balance Minnesota’s budget is getting some of its stiffest resistance from health care providers.
The unallotment of millions of dollars in health care spending for the poor has them worried about tens of thousands of Minnesotans that may have no more medical coverage next spring.
Democratic lawmakers have been traveling the state this week, trying to come up with another plan for those who are cut off.
Minnesota’s financial crisis may hit hardest in downtown Minneapolis, at the sprawling Hennepin County Medical Center. It’s the flagship of a public health system that gets gets more more than 300,000 clinic visits alone every year.
Cuts to General Assistance Medical Care, or GMAC, could cost HCMC $43 million over the next two years. The money pays for care for people who make eight thousand dollars a year or less.
Former Minneapolis mayor and hospital board member Sharon Sayles Belton laid out for lawmakers what that may mean.
“We will have to reduce or eliminate the services that are what we call the worst financial providers,” she said. “This could include things like our primary care clinic, our specialty services for problems like diabetes, our dental services and some of the components of our mental health service continuum.”
It’s a story that lawmakers have been hearing all over the state.
But they’re offering little hope to health care providers that the cuts will be averted.
State Sen. Linda Berglin, DFL-Minneapolis, pointed out that the cuts are set to take effect next March, just three weeks after the Legislature reconvenes for its 2010 session. She told dozens of people at the House Health and Humans Services Policy and Oversight Committee that there simply may not be enough time.
“I have no idea. If I had a great master plan, in my hip pocket, I’d whip it out and say, oh, look, this isn’t so hard,” she said.
She urged her fellow lawmakers and the health and state at HCMC to come up with a list of where else in the state they could find $400 million to pay for health care for the poor.
But officials are eyeing ideas, too, and hinted at some of them at today’s hearing.
Hennepin County Board Chairman Mike Opat said that the county’s hospital won’t turn the needy away, but property tax payers may have to pick up more of the burden for their care.
Rep. Julie Bunn, DFL-Lake Elmo, suggested that as many as one-third of Minnesotans in their 20s might be eligible for cheap insurance for catastrophic care they could buy in the private market for less than $1,000 a year.
Committee chair Rep. Paul Thissen, D-Minneapolis, said there may be other programs, like housing or social services, that could avert some of the need for health care among the poor.
He also offered some other proposals, like paring back the overall benefit levels offered to the poor and getting more people signed up for Supplemental Security Income, a federal program for the disabled and elderly.
“And you know the governor proposed putting this uncompensated care, reducing funding significantly but putting an uncompensated care pool in place so that the money would not go toward insurance, and getting insurance so the individuals and just having a pool of money that would support places like HCMC or community clinics,” Thissen said.
“We’ve kind of gotten mixed reviews to that kind of thought, because there is a benefit to getting people insured once they leave the hospital doors.”
State and health officials have eight months to come up with a plan B. The existing money officially runs out Feb. 28.
By Brad Swenson, Bemidji Pioneer, July 3, 2009
State cuts to health care for Minnesota’s poorest adults means a 28-year-old diabetic may go without insulin, or a 63-year-old diabetic alcoholic with cancer goes without treatment.
“You need to put a face to who this is going to impact,” Margaret Demers, North Country Regional Hospital lead social worker, told a Minnesota House panel Thursday morning about the effect of eliminating the General Assistance Medical Care program.
The 28-year-old, she said, is on two different insulins which he can’t afford without GAMC coverage. Not taking insulin will lead to more serious medical problems such as organ failure, foot wounds, amputations, and leading to losing the ability to work.
The 63-year-old is short of qualifying for Medicare. “In our area, we have a significant population of chemically dependent patients who fall into the GAMC category,” Demers said. “They struggle with life, their addiction and serious health problems. By its nature, chemical dependency affects their ability to function normally and as their illnesses progress, so do their medical problems.”
Gov. Tim Pawlenty, as part of an effort to bridge a $3 billion budget gap between the DFL-controlled Legislature’s spending bills and expected revenues for the biennium that started Wednesday, line-item vetoed funding for the GAMC program.
The program, which provides health care coverage for the state’s most destitute adults, would see funding cut as of March 1 and into the second year of the biennium. Pawlenty excised about $400 million, a figure that will be $888 million in the next biennium if it is not restored.
The House Health and Human Services Policy and Oversight Committee is traveling northern Minnesota to hear from local hospitals about the affect of losing GAMC, and was in Bemidji on Thursday.
Committee Chairman Rep. Paul Thissen, DFL-Minneapolis, and Rep. Erin Murphy, DFL-St. Paul, and panel staff met with about 25 local medical and social services officials.
Demers outlined six cases of real people on GAMC. “The person may choose to not even seek treatment or not even try because they can’t pay for it. We see that a lot with populations that don’t have coverage. They wait until its turned into a very, very huge medical problem. They don’t come in for prevention or day-to-day management.”
A survey of 10 percent of about 650 GAMC enrollees served by North Country Regional Hospital shows an average age of mid-30s, from 21 to 63, said Jim Hanko, president and CEO of the parent North Country Health Services.
Of the sample, 63 percent were self-designated as American Indians who live in Bemidji or on an area reservation. Seventy-two percent were self-designated as unemployed.
“The majority of the services — 60 percent — were provided in the emergency department,” Hanko said. “And 20 percent were in the imaging department, which is an expensive modality.”
Under a fee for service program, 652 individuals had 1,033 GAMC accounts last year, Hanko said, with gross charges of $3.2 million. State reimbursements were $1.1 million while the cost to provide services was $1.7 million.
And, under the state Pre-Paid Medical Assistance Program, only 55 percent of costs is reimbursed, he said.
“We have an estimate from the state that the total impact for GAMC in our particular locality is about $4.8 million to $4.9 million,” Hanko said. “That includes clinic services received by people at MeritCare and other clinics and includes the emergency department and any in-patient services.”
That amount will become the uncompensated care if all the GAMC patients became patients at NCRH, mostly likely through the emergency department, he said. The emergency room then becomes the safety net for all who can’t afford medical care.
Thissen said the Legislature’s focus will be on the “bigger health care reform that we need to do in this state. … We really need to focus on how we’re going to help this population — folks who are going to be with us regardless whether we’re paying for them or not.”
Murphy is floating around some ideas that may help, she said.
“A lot of them are poor because they’re sick,” she said of GAMC patients. “We know they’re poor because the income standards are so low. … A lot of them are sick and probably not able to work.”
Legislators need to understand the population in order to find solutions, Murphy said, listing off pretty sick, some mentally ill, suffering from chemical dependency, chronic diseases.
“A lot of states are looking at care coordination,” she said. “We keep hearing from hospitals that this population looks at the hospital as their primary care source, to come here to the emergency room because that’s what they know. Is it possible for us to figure out how to deliver care in an out-patient way where the patient is, get them healthier, keep them healthier so they’re not coming to the hospital in their most chronic state, and then we’re incurring these large costs.”
The benefits of coordinated care is savings to the system, delivery of better care, and allowing a better life for the GAMC population, she said. “To do it means we’ll have to work across the system – the health care system and the social services system … to do that kind of intensive coordination.”
It was suggested that the population could be served by more urgent care or “minute clinics,” but there is a lack of primary care providers. It’s tough to recruit new doctors to Bemidji, as rural salaries are lower and on-call hours greater than in the metro area, said NCRH Dr. Robert Rutka.
There were discussions of starting a “minute clinic” but there aren’t enough primary care physicians to staff it, he said.
State changes in credentialing are needed to allow mid-level practitioners to perform some duties now delegated to physicians or physician assistants, said Bob Verchota, NCHS vice president of human resources and ancillary services.
“From a human resources perspective, there’s one thing you could do,” he said, “and that is to support some changes in the licensure requirements through either the credentialing, certifying licensure, etc., to increase the capacity.
“We don’t have the capacity up here from an access standpoint to even get people in if we wanted to,” Verchota added. “We’re sending people … to Park Rapids and Deer River for primary care.”
Some positions are fully capable of providing primary care, such as in lab, rehab or imaging, and in mid-level area alternative to physicians, he said. The problem affects all who seek medical care, not just GAMC patients, he added.
“No supply, the price goes up,” Verchota said.
“It doesn’t make sense to pay lower reimbursement rates to rural communities that are having the hardest time attracting doctors,” said Sen. Mary Olson, DFL-Bemidji.
“We’re actually seeing an outflow of nurse practitioners,” Rutka said. Another problem is while MeritCare has an urgent care office, it closes at 5 p.m., with center referring patients to the hospital emergency room after about 3:30 or 4 p.m.
?We’ve had a net outflow of nine primary care providers in this community in the last three years,” Rutka said. “I, as a family doctor, can probably take care of 92 percent of the things that come through my door.”
Another problem, participants said, with the high percentage of American Indians on GAMC, U.S. Indian Health Service is not always paying for services.
Georgia Downwind of Beltrami County Human Services at Red Lake, said IHS once paid for most services, but the number of those seeking services has grown while money to pay for services hasn’t, forcing partial or no payment.
And, if an Indian who lives on the reservation gets a heart attack while in Bemidji, HIS won’t pay for those services, she said.
“The misperception is that Indian people in this area in the treaties that were signed 100-plus years ago the federal government guaranteed health care services to them,” said Rep. John Persell, DFL-Bemidji. “That’s not being provided, obviously.”
It’s a shortcoming of the federal government, he said. “Indian people believe, and they know because it’s written on paper, we are guaranteeing health care services. That adds to the overall complexity of the situation.”
Indian people have to apply for some other medical service and get denied before using HIS, which Persell said “befuddles” him.
Participants also said transportation was a problem, as many poor adults have no means to seek medical care if they live outside of Bemidji. And, some are homeless and the system can’t find them after they’ve sought initial care.
“In many ways it isn’t a problem of having people finding people, it’s having them stay found,” said John Pugleasa of Beltrami County Health and Human Services. Continuity of care is hard, he added. “Having this population stay found, leading to any kind of continuity, is a real challenge.”
That could be helped with more affordable housing and transitional housing, he said.
By Mike O’Rourke, Brainerd Dispatch, July 3, 2009
Area health officials told state lawmakers Thursday how their institutions will be affected by the March 1 elimination of a state medical assistance program for low-income patients without private insurance.
The General Assistance Medical Care program was among the unallotment cuts Gov. Tim Pawlenty made in order to balance the budget after he and lawmakers failed to reach agreement.
The discussion Thursday took place before members of the Minnesota House Health Care and Human Services Policy and Oversight Committee at St. Joseph’s Hospital in Brainerd.
Dr. David Boran, chief medical officer of the Brainerd Lakes Health System, said St. Joseph’s Medical Center cared for 530 GAMC patients this year. Sixty-two percent were seen in the Emergency Department and 20 percent of the 530 patients were admitted to the hospital. He said the gross charges for these patients exceeded $2.8 million. After partial reimbursements are made by the state the hospital costs are $1,093,259, resulting in subsidy of $420,00 to care for these patients.
he GAMC patients, Boran said, are primarily very low-income adults between the ages of 21-64, without children. They often suffer from chronic health problems such as diabetes mellitus, AIDS, heart disease, chronic mental illness or chemical dependency.
Boran noted that as a result of the governor’s veto $18 million in federal revenue in Fiscal Year 2011 will be lost across the state. This year, he said, St. Joseph’s Medical Center will receive $650,000 in Medicare payments for providing a “Disproportionate Share” of care to the poor.
“This plan is penny-wise and pound-foolish,” he said of the veto that will also result in the loss of federal matching funds.
“Minnesotans who pay federal income taxes will, in effect, be subsidizing the Medicaid programs in all those other states that do not cut their Medicaid funding,” he said.
He said the cost shifting that’s part of the health care system – charging those with private insurance more to underwrite the cost of government programs – is a hidden tax.
“This cannot go on,” he said. “Employers in Brainerd and elsewhere are stretched to the limit,” he said. Some can no longer afford to provide health insurance for their own employees, let alone underwrite the cost for others. Brainerd Lakes Health is unable to underwrite additional costs.”
Jani Wiebolt, president of St. Joseph’s Medical Center, said the hospital has implemented a wage freeze, a hiring freeze and has had workforce reductions. She said St. Joseph’s average daily census is 70 patients and noted that there are four hospitals within a 35-mile radius.
Susan Beck, Crow Wing County Community Services director, said the budget cuts would unravel the current health system and force more people to the emergency rooms for health care.
“We’re very reliant on the services of St. Joe’s,” she said. “Without St. Joe’s we lose a huge piece of the mental health puzzle.”
While Beck said she didn’t have a simple solution she told the panel care coordination would be a part of the answer. The needs of GAMC patients often include housing, employment, mental health and medical, she said.
Rep. John Ward, DFL-Brainerd, discussed the good work being done by the Region 5 Adult Mental Health Initiative.
Wiebolt said the hospital has not planned another round of layoffs. She said whatever cuts might come would likely be in the supervisory and support areas rather than “care at the bed side.”
Rep. Erin Murphy, DFL-St. Paul, said “If we don’t solve this problem hospitals are going to take a financial hit.”
Rep. Paul Thissen, DFL-Minneapolis, said an integration of services that would provide ongoing support in such areas as housing, might be part of the solution. Before March, he said after the meeting, he hoped that a different model of GAMC can be structured with an existing revenue source or reform proposals can be initiated that might lead to refunding of the program.
“It’s clear … just eliminating health care coverage is not the way to get there,” he said during the meeting.
Other lawmakers who attended the committee meeting were Rep. Al Doty, DFL-Royalton, Rep. Karla Bigham, DFL-Cottage Grove, Rep. Tom Huntley, DFL-Duluth.
By Jason Atkins, Detroit Lake Tribune, July 3, 2009
Health care reform continues to be a tricky issue to wade through.
A few members of the state House Health Care and Human Services Policy and Oversight Committee came through Detroit Lakes on Wednesday to solicit comment from local stakeholders on what is needed in health care reform.
“We need to get the perspective of those on the ground,” said Committee Chairman Paul Thissen (DFL-Minneapolis).
St. Mary’s Innovis CEO Tom Thompson said that the elimination of the state General Assistance Medical Care program will hit hospitals hard, since those without insurance will turn to local emergency rooms for medical care.
“It’s one thing to complain about cuts, but we’re facing a world with difficult decisions,” Thompson said.
Thompson said that the reality for St. Mary’s Innovis is that over half of its revenue comes from the federal and state government in the form of Medicare, Medicaid and other public insurance programs.
He said that his organization is what’s called a “tweener” hospital because it’s too big to qualify for critical access payments, but too small to offer more profitable services that hospitals in major metro area have available.
With the cut to GAMC, Thompson said that St. Mary’s Innovis stands to lose $3.5 million in revenue. The total operating budget for the organization is $76 million.
He said that the goal for health care reform should be to provide coverage for everyone.
Becker County Human Services Director Nancy Nelson said that Becker County, along with adjacent counties, suffers from a disproportionate number of people living under the poverty level. She said that the poverty rate in the county is about 12 percent, while the statewide average is around 7 or 8 percent.
She said that 449 people in the county have GAMC, about one percent of the total county population.
“It serves the poorest of the poor,” Nelson said.”
With the elimination of GAMC, she said that the ultimate cost of providing health care for the poor would fall on taxpayers under the current system.
Rep. Paul Marquart (DFL-Dilworth), whose district covers the city of Detroit Lakes, said that the current system is unsustainable.
“If we don’t get a handle on this, it will take up all of the budget,” he said.
What’s not up for discussion is cutting back on services, Thompson said.
“We sure as heck won’t cut care,” he said.
St. Mary’s Innovis physician Dr. Bob Koshnick said that a system of assigning people a medical home would help cut down costs.
Under such a proposal, those who have GAMC or similar coverage could only see a doctor in one health organization. The definition of a medical home is still subject to debate.
Koshnick said that a medical home would be more efficient and stop people from physician hopping.
“If you have a personal relationship with a medical home, you reduce costs,” he said.
Besides a medical home, the poorest of the poor may also need help with stable housing and mental health care, Nelson said.
She said that mental health holds at hospitals cost up to $1,000 a day. Those who need help with drug and alcohol detoxification cost $300 per day.
And the ER isn’t a solution either.
“It is not the place to receive primary care,” Thompson said.
Rep. Erin Murphy (DFL-St. Paul) said that solving the ER problem is tricky.
“Are we under the false assumption that we could change people’s behavior so that it will drive down costs?” she said.
Ultimately, a solution will depend on what the federal government does with an overhaul to the health care system.
“We need to come together and make the best use of these resources,” Murphy said
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