Dr. Sara Ghori Tariq, an internist and medical director of the Center for Clinical Skills at the University of Arkansas for Medical Sciences (and named by her peers as a "Best Doctor"), described her encounter with an uninsured patient she saw as a volunteer physician at Harmony Health Clinic.
"I saw a gentleman a couple of weeks ago with a large abscess in his leg, a pocket of infection. ... It was extremely painful," Tariq said. He was employed as a dishwasher and couldn't afford insurance, so he'd waited to seek medical attention. His diabetes was a contributing factor, but he couldn't "consistently afford" insulin. He needed treatment, blood sugar tests and antibiotics. Had his blood sugar been too high, Tariq would have needed to send him to the UAMS Emergency Room for care.
Patients who don't have insurance "tend to be absolutely more sick, more challenging" to treat, Tariq said. They put off doctor visits to avoid the cost of paying out of pocket. The man with chest pain, the woman with a lump in her breast — had they come to the doctor at the first sign of trouble, they would have been better outcomes, both physically and financially. The effect of poverty, low health literacy, the lack of social support and homelessness on patient health is one of the things Tariq addresses in her clinical skills classes at UAMS.
If Tariq's patient (and others) had access to Medicaid, he wouldn't have had trouble paying for the medicine he needed, thus avoiding the complications from his disease as well as lost wages. UAMS could have been spared the cost of treating him in its ER. Taxpayers would have paid less, with contributions to Medicaid on the front end alleviating the need for emergency care.
Doctors at UAMS treat all comers, insured and uninsured; 12 percent of its admitted patients — 3,120 last year — are among the latter. Outpatient visits by the uninsured numbered 61,426 in 2012. Charity and unreimbursed care rose from $175 million in 2011 to $202 million in 2012. Those numbers would be less if Arkansas, which has the most stringent rules for Medicaid eligibility in the country, would agree to accept federal dollars to expand Medicaid — now limited largely to children, the disabled and impoverished pregnant women — to a wider group of Arkansans too poor to pay for private insurance. Two plans are under consideration: extending Medicaid to all Arkansans at or under 138 percent of the federal poverty level ($11,490 for individuals, $23,550 for a family of four) or a deal Gov. Beebe and the federal Health and Human Services Department worked out to extend the private insurance exchange option to that same group of people at no cost, with premiums picked up by Medicaid. (The Affordable Care Act allows tax credits to certain persons earning between 138 percent and 400 percent of the poverty level tax credits to pay for private premiums on the insurance exchange. Arkansas is the only state so far to be offered exchange coverage for persons whose income puts them under 138 percent.)
Tariq said she hoped the legislature would act to expand access to health care quickly.
It's been noted that putting off acting on Medicaid expansion by a year — something the legislature is, as of this writing, considering — would mean the state would sacrifice one of the three years in which expansion will cost it no money (2014, 2015 and 2016 are the years the federal government would pick up the tab; after that, states will contribute 10 percent). But the monetary loss is not the main concern of Dr. Joe Thompson, director of the Arkansas Center for Health Improvement.
Thompson cited the Rand Corp. study that found that offering insurance to the 200,000 Arkansans not now insured would save 2,300 lives a year. "I don't know whose family members we'd want to sacrifice" by putting off expansion, Thompson said. Expanding access to basic health care is "where I start" in the conversation about expansion, he said.
Anecdotal evidence — the man with the abscess, the patient with advanced-stage cancer that another of this year's Best Doctors, surgeon John Cone, saw — is one thing. Numbers are another. Dr. Joe Bates, the deputy state health officer and chief science officer for the Arkansas Health Department, recently assembled statistics showing the difference in mortality rates between persons insured under Medicare (65 and over) and those ages 45-64, who are still working and contributing to Arkansas's economy. The numbers are worrisome.
Arkansas is an unhealthy state, with mortality rates higher across the board than the nation's. But consider this: The rate of death from stroke among Arkansans ages 45-65 for the years 2005-2010 was 54 percent higher than the national rate. (In fact, Arkansas has the highest death rate from stroke of any state in the nation.) For Arkansans ages 65 and up, the death rate for that period was only 25 percent higher.
Take heart disease: The rate of Arkansans ages 45-65 who died of heart disease in that period was 62 percent higher than the national rate in that age group. But among the 65-plus age group, the rate of death was only 8 percent higher than that of all Americans.
Age-specific death rates from cancer for 2005-2010: the younger group's mortality rate is 26 percent higher than the nation's, its older group is only 6 percent higher.
The difference: health insurance. One of four Arkansans in the 45-65 age range does not have health insurance. Those 65 and over are eligible for Medicare.
The lack of insurance is only one of many things that play into Arkansas's low rankings in health. Another is culture: Arkansans are "more apt to wait until they have advanced disease" to see a doctor, whether they are insured or not, Dr. Paul Halverson said.
Arkansans are less likely, nationally, to take advantage of free or low-cost preventative screens that would lower mortality rates — like colon screenings and mammograms. "If we wait until people are sick [to treat their health needs] we'll never pull Arkansas up," Bates said; the culture has to change.
Ironically, while health providers worry about the adults who'll be left out in the cold if the legislature decides to leave the Medicaid roll as is, they've got another concern: How to handle the estimated 220,000 Arkansans who are now uninsured but are expected to buy into the insurance exchange.
The delivery of American health care in general needs an overhaul, thanks to skyrocketing costs, an increasingly sick population thanks to aging baby boomers, the need for more doctors in rural (and mostly uninsured) areas and myriad other problems. And as the state with the third highest population of retirees, Arkansas has more than its fair share of an aging population.
But while we are among the sickest states — coming in at No. 48 on the United Health Foundation's scale — Arkansas is getting accolades for its attempt to tackle the issues, from the Payment Improvement Initiative devised by the state Department of Human Services, Arkansas Medicaid, Blue Cross Blue Shield and Arkansas QualChoice; to steps to increase physician assistant and nurse practitioner enrollment, to the Comprehensive Primary Care Initiative, the patient-centered medical home idea being tested by 69 primary care clinics who provide Medicare services. The four-year initiative is being funded by the Centers for Medicare and Medicaid Services (CMS), which recently awarded Arkansas $42 million to test its State Health Care Innovation Plan, and private insurers Blue Cross Blue Shield, QualChoice and Humana.
At the crux of all these ideas is "team-based care," in which a doctor, nurse practitioner or physician's assistant, community health workers and pharmacists work together to both treat and educate patients.
"Primary care doctors spend most of their time treating chronic diseases," Halverson said. Once a patient's treatment has been established, he or she "can be cared for as well by a nurse practitioner. That's going to be our answer."
In the medical home model, doctors will spend more time with their sickest patients — "practicing at the top of their license," as Halverson described it. Physician assistants will too, handling chronic, controlled cases. Pharmacists will play a greater role in the management and tracking of medicine, which is what they are trained for. Community health workers will educate, answer questions. All will coordinate the care of each patient, not just within the medical home but with specialists and hospitals through electronic record-keeping and shared data bases.
The Payment Improvement Initiative addresses how we pay for health, shifting today's fee-for-service system — paying for each doctor visit — to paying for the treatment of the illness, an "episode" of care. This year, Medicaid and private insurers are tracking costs and outcomes in five areas of care; providers with good outcomes at lower costs will be rewarded, but those whose costs are excessive will have to pay a portion of that back.
Thompson and Andy Allison, who heads Arkansas's Medicaid program, presented ideas for cost containment to the Arkansas State Medical Board. Allison, Thompson said, told the board that Medicaid was spending $4.5 billion a year and only 8 percent of that was going to physicians. "If you help me manage the other 92 percent, I'll share the savings with you," Thompson quoted him as saying. Providers have told Allison and Thompson that under the current system, about 10 percent of costs are due to waste, such as duplication of services; some doctors estimated waste at 30 percent.
Two state legislators — both wives of doctors — recently expressed their objections to DHS' payment overhaul, complaining that nurse practitioners would take the place of doctors and that doctor pay would be cut "to the bone."
Thompson, on the other hand, said the medical home and payment initiatives have "surprising support from both physicians and hospitals. ... The opportunity for the primary care physician, I think, is to reorganize his practice so his net revenue is greater."
The Comprehensive Primary Care Initiative will pay participating clinics an amount based on the number of Medicare patients each practice sees to add the personnel they need to coordinate care and create a medical home. After two years, the practices will share in the savings.
Seven Robert Wood Johnson Foundation models have shown that primary practice medical homes reduce hospitalizations and ER savings, with a cost reduction of $7 to $640 per patient.
UAMS will begin offering a doctorate of nursing practice in the fall, and advanced-practice nurse degree programs have begun at UA Fayetteville and the University of Central Arkansas at Conway. Nurse practitioner programs at UAMS and Arkansas State University are expected to ramp up, Thompson said.
The pressure of new patients may come before the medical home becomes the standard, but state agencies are scrambling to meet the demand.
Trauma surgeon John Cone, who has been at UAMS since the 1980s, has played a pivotal role in the establishment of the state's Trauma System, sees yet another problem with access to care: The reluctance of younger doctors to put up with the "terrible lifestyle" of the surgeon and other specialists. "People don't schedule their illnesses," Cone said; "they get sick at 3 in the morning. ... What people want out of a specialty has changed." The situation, Cone says, puts emergency room care "in a bind," as it becomes more difficult to attract "almost any of the specialties."
Nor is it easy to see a primary care physician as it once was, Cone said. Even Cone had a hard time getting his father-in-law an appointment with a primary care doctor to treat a low-grade infection. Criticism of the government-run health care in Great Britain that patients must wait a long time to see a doctor doesn't make much sense anymore, given what patients go through here, and "the horror stories about the National Health Service are grossly exaggerated," Cone added.
But extending health insurance to more patients should mean fewer desperately sick people presenting at the ER with preventable problems. "I see a lot of people who wait until they're in late stage cancer they've neglected for one and a half years." Only recently he'd treated a patient whose tumor was "visible to the naked eye." Why did he wait so long to come in? "Money, maybe. Ignorance. Denial."
Professionals working in Arkansas to change the way medicine is delivered believe that insurance extended through Medicaid and the Affordable Care Act, plus the medical home idea, will address all three of those barriers to care.