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Critical Health Areas Project (CHAP) Newsletter 

Volume 1, Issue 1

April 6, 2006

Announcements

Chronic Care and Quality

Web Assisted Audio Conference on Disparities in Treatment of Chronic Disease

Coming soon!  A web assisted audio-conference on disparities related to chronic disease and quality.  Differences among groups in the rate of chronic illnesses, whether they get care and how they are treated are symptoms of quality problems that affect everyone.  This session will focus on what states can do and what they are doing to address disparities in health care among individuals with chronic illnesses. 

Look for email updates with details on this conference or check out NCSL's health audio-conference page at http://www.ncsl.org/programs/health/webcast2.htm

Healthcare Access

A Conversation about the Deficit Reduction Act of 2005

CHAP members and their staff are invited to call in to a conversation about the Deficit Reduction Act of 2005.  This is not an audioconference, it is a limited conference call Q&A session just for you that you can use to learn the highlights of the new DRA.  Donna Folkemer and Joy Wilson will be available to answer questions on April 21 at 2 PM.  You may send questions in advance to donna.folkemer@NCSL.org.  Put CHAP-DRA in the subject line.  We will summarize the conversation and post it at the CHAP web for CHAP members who cannot dial in at that time and others interested in the issue.

Providers and Workforce

Audioconference on Cultural Competency and Language Issues for the Healthcare Workforce

We are currently planning an upcoming audioconference on cultural competency and language issues for the health care workforce.  Stay tuned for details.

Featured Topics

Chronic Care and Quality

The Chronic Care Model

Chronic disease affects more than 125 million people in this country and is responsible for over $500 billion in direct medical costs each year.  People with chronic illnesses must interact repeatedly with various elements of our complex health-care system.  How well they fare is a barometer of how well the health system is functioning.

The Chronic Care Model identifies elements of a health care system that provide high quality care for individuals with chronic disease: 

• Community: community resources to meet needs of patients;
• Health system: a culture, organization, and mechanisms that promote safe, high quality care;
• Self management support: systems that empower and prepare patients to manage their health and health care;
• Delivery system design: assuring the delivery of effective, efficient clinical care and self-management support;
• Decision support: promoting clinical care that is consistent with scientific evidence and patient preferences; and,

Clinical information systems: systems that organize patient and population data to facilitate efficient and effective care.

Healthcare Access

Components of the DRA

The federal Deficit Reduction Act of 2005 makes a number of changes in Medicaid, including several that are particularly likely to affect children and families. One section gives states leeway to make substantial changes in Medicaid benefits and to require cost-sharing and premiums for people above the poverty line (although totals cannot be more than 5 percent of income).  This would have required a waiver in the past. Recent experience in states that have increased cost sharing, as well as  the Congressional Budget Office’s own estimates suggest cost sharing may discourage substantial numbers of people from participating in Medicaid or receiving needed care.

Another section encourages states to divert Medicaid patients from emergency departments by making it easier for them to charge higher copays for inappropriate ED use, and makes some limited funding available for alternate  places to obtain non-emergency care.

For certain “optional” groups, states are encouraged to build on experience gained with SCHIP and offer benefit packages that resemble benchmark plans such as public employee health plans, rather than the richer Medicaid package.  

The DRA includes transformation grants designed to change how the program is funded and delivered.  Among possible projects are state disease management programs and using integrated university hospital and clinic systems to improve access to primary and specialty care for the uninsured.

The new Medicaid program will allow up to 10 states to offer Health Opportunity Accounts, spending accounts that individuals may manage in conjunction with a sort of high deductible Medicaid program.  This project is designed to parallel health savings accounts.

Other features of the DRA affect long term care in a variety of ways, from expanded estate recovery to “money follows the person” demonstrations that simplify use of home and community-based care.

It includes the Family Opportunity Act, which allows families with severely disabled children that earn as much as three times the federal poverty level to buy into the Medicaid program.

Many of the DRA changes are opportunities that states may consider, not requirements.  Their effect on people in need will depend on how states use the new flexibility.

Non Medicaid access provisions include continued funding for some losses incurred by state high risk pools and allotments to eliminate SCHIP funding shortfalls for 2006.

Addiction Prevention and Treatment

President Bush Signs USA Patriot Act: Anti-Meth Provisions Take Aim at Methamphetamine Production, Trafficking, Use

On March 9, 2006, President Bush signed legislation making the USA PATRIOT Act Improvement and Reauthorization Act of 2005 law. The law includes important provisions to strengthen Federal, state and local efforts to combat the spread of methamphetamine use and production, including restrictions on the precursor chemicals required to make methamphetamine.

In August 2005, the Bush Administration announced a comprehensive strategy involving the Department of Justice, the Department of Health and Human Services and the White House Office of National Drug Control Policy (ONDCP). The agencies will work in conjunction with state and local officials to combat methamphetamine production, trafficking and abuse by focusing on four core areas: prevention and treatment, law enforcement, education and, management of the drug's unique consequences.

"We thank Congress for passing this important legislation. Meth is a loathsome drug, poisoning both users and the communities in which it is manufactured. The action taken today will help close the spigot on domestic meth production, and give us new tools to protect our nation from international meth trafficking" said John P. Walters, Director of ONDCP.

The Combat Methamphetamine Act adopts the principles urged upon Congress by Attorney General Alberto Gonzales, Health and Human Services Secretary Michael Leavitt, and Director John Walters. Namely, it eliminates the blister pack exemption for record-keeping of products containing pseudoephedrine, better controls the "domestic spot market" for pseudoephedrine and similar chemicals by imposing a 15-day restriction period on importers when the ultimate recipient of the sale changes after the shipment enters the United States, and imposes a domestic 3.6 gram per-day, per-customer limitation on the retail sale of these chemicals.

Minnesota Report on Substance Abuse Treatment

The Minnesota Office of the Legislative Auditor issued a program evaluation report on substance abuse treatment, both in the community and in state prisons.  The auditor’s office concluded that stronger state leadership and oversight are needed to improve the availability and effectiveness of treatment in Minnesota.  According to the report, despite uniform placement criteria, there is wide variation in counties' use of publicly-funded treatment. Moreover, the Minnesota Department of Human Services has not monitored local assessment and placement practices. The evaluation found that the effectiveness of substance abuse treatment is mixed, and that information on the outcomes of Minnesota's programs is limited.

In addition, only 17 percent of chemically dependent prison inmates completed substance abuse treatment prior to being released, and few enter treatment upon release.  The report found widely varying rates of re-arrest and reconviction among chemically dependent persons who completed substance abuse programs in prison--ranging from low recidivism rates for inmates who completed a program that combines chemical dependency treatment to high recidivism rates for inmates who completed short substance abuse education programs.  The report is available at: http://www.auditor.leg.state.mn.us/ped/2006/subabuse.htm.

New Report on Alarming Trends in Girls’ Use of Drugs, Alcohol, Cigarettes, and Prescription Drugs

On Feb. 9, 2006, Director of the White House Office of National Drug Control Policy (ONDCP) John P. Walters, the publishers of Seventeen magazine and teen medical experts released a new analysis on drug and alcohol use trends among girls.  Despite commonly held beliefs that boys are at higher risk for using illegal substances, data indicate that girls are in fact more vulnerable to drug and alcohol use. Girls have actually surpassed boys in cigarette and prescription drug use, and more girls than boys are using substances for the first time.

Although substance use among teens has declined steadily over the past few years, ONDCP warned parents that girls display unique vulnerabilities that can lead to substance abuse. Research also indicates that drug and alcohol use has a more profound impact on teen girls, both physically and psychologically.

The analysis shows that marijuana is the most commonly used substance by girls, surpassing cocaine, heroin, Ecstasy and all other illicit drugs combined.  Between 2003-2004, data that girls  started using marijuana, alcohol and cigarettes at higher rates that boys. The full report can be accessed at http://www.mediacampaign.org/ at http://www.mediacampaign.org/pdf/girls_and_drugs.pdf.

Providers and Workforce

Community Health Centers and a Shortage of Medical Personnel

A recent article in the Journal of the American Medical Association (JAMA) explored the implications of the planned federal expansion of community health centers (CHCs).  The study examined the status of the health care workforce in CHCs across the country, focusing on the types of providers who are the most difficult to recruit and retain, and on urban versus rural staffing patterns and retention rates. 

The results show that CHCs were understaffed in 2004, and were having difficulty recruiting essential health care personnel.  The greatest aggregate shortages were for family physicians.  In addition, obstetrician/gynecologists and psychiatrists presented some of the greatest recruitment difficulties, and dentists were also hard to come by.  The situation is even worse in rural areas, where CHCs play an even more important role due to poverty and low population density.  In rural CHCs, over a quarter of the funded positions for obstetricians, psychiatrists, and dentists were vacant. 

Despite the obvious need for more providers, two of the most important federal programs for channeling physicians to serve in health centers have been cut or frozen (Title VII and the National Health Service Corps).  States can do a number of things, including expanding programs that provide financial incentives for health care clinicians who serve in underserved locations, and experimenting with new approaches to loan repayment to improve the retention of physicians who complete their obligations (for example, continuing to pay year-to-year retention bonuses).

Useful Resources

Chronic Care and Quality

The Chronic Care Model and Disparities in Chronic Disease

Chronic care model

http://www.improvingchroniccare.org/change/index.html

http://www.researchchannel.org/prog/displayevent.asp?rid=2383

Disparities Resources

National Health Care quality report http://www.qualitytools.ahrq.gov/qualityreport/2005/browse/browse.aspx

National Healthcare Disparities Report http://www.ahrq.gov/qual/nhdr03/nhdrsum03.htm

Addressing Racial and Ethnic Health Care Disparities: Where Do We Go From Here? http://www.iom.edu/?id=33252

The National Health Plan Collaborative http://www.chcs.org/NationalHealthPlanCollaborative/index.html

Healthcare Access

More on the DRA

A number of summaries of the Medicaid provisions in DRA are now available. 

NCSL’s summary is at www.ncsl.org/statefed/health/ReconDocs0206.htm

The Henry J. Kaiser Family Foundation has prepared a series of analyses of the DRA.  These can be found at www.kff.org/medicaid/reconciliation.cfm

The Congressional Budget Office (CBO) looks at a number of aspects of the DRA including how many people may be affected by copayments, estate recovery, and the requirement to document place of birth.  http://www.cbo.gov/publications/collections/reconciliation.cfm and http://www.cbo.gov/ftpdocs/70xx/doc7030/s1932updat.pdf

Consumer-directed purchasing in Medicaid, such as the new health opportunity accounts, is engendering impassioned debate.   A 19-page brief from the RWJ-funded State Coverage Initiatives program identifies four critical success factors for state efforts: protect access; develop policies that anticipate how behavior of all parties will change; reformulate agency roles; and develop and implement new approaches to risk management. www.statecoverage.net/pdf/issuebrief106.pdf

From the same source, a review of recent innovations in state waivers Uncharted Territory: Current Trends in Section 1115 Demonstrations www.statecoverage.net/pdf/issuebrief306.pdf  

Providers and Workforce

Shortages of Medical Personnel at Community Health Centers:  Implications for Planned Expansion (abstract) http://jama.ama-assn.org/cgi/content/abstract/295/9/1042

National Association of Community Health Centers http://www.nachc.com/

National Association of Rural Health Clinics http://www.narhc.org/

Calendar of Events

May 1-7. Cover the Uninsured Week.  Thousands of events are planned around the country for this annual week that draws attention to the uninsured and efforts to expand coverage.  Check out what is planned, and register your own events at http://www.covertheuninsured.org/  

May 15.  NCSLTelemedicine Web-Assisted Audio Conference 2:00 p.m. - 3:00 p.m. ET, Contact: Allisa.Johnson@ncsl.org

August 14.   CHAP session at Annual Meeting, Nashville, TN. NCSL’s annual meeting is August 15-19 this year.  We’re planning pre-meeting sessions for CHAP members and Chairs.  More details on both meetings will be coming in the next bulletin.

 Newsletter Archive