"Leading the way in Health Care Reform and Equity: The Maryland Model"

National Medical Association’s 109th Annual Convention & Scientific Assembly
Wiley T. Armstrong, M.D. Memorial Lecture Series - Current Challenges to Implementing Health
Care Reform

Washington, D.C.

As Prepared for Delivery

July 24, 2011

 

Thank you for the opportunity to speak today at such an important and timely conference.

Welcome to Washington DC – a homecoming for those of you who received your medical training in our nation’s capitol, and in particular, Howard University, the country’s leading educator of African American physicians.

The National Medical Association is more than a professional association created in 1895. It is a powerful force for fairness and justice in the health care system. 

Your work to ensure that equity and access exists among all patient populations is critical to the health of our communities.
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Four years ago, Governor Martin O’Malley and I took office and we set ambitious goals for Maryland. We sought to improve public education, reduce violent crime, and create job opportunities. And we sought to expand and improve health care, because a healthy state is a productive state.

We believed then as we do today that our progress towards achieving these goals is only possible by the partnerships between the public and private sector.
And that is just as true in our efforts to expand and improve health care for all Marylanders.

So for four years, we have partnered with physicians and other providers, payers and insurers, patient advocates and the public health community to find the missing pieces in solving the healthcare puzzle.

Today I want to share with you my perspective on health reform, its challenges and opportunities, and some of our efforts to assist physicians during this historic transformation in the health delivery and payment system.
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My remarks are organized into three parts:

First, I’ll share with you how Maryland is working to implement the Affordable Care Act and some of the opportunities and challenges we face.

Second I will identify some ways that Maryland is trying to support the physician community, recognizing the important role that physicians have in the successful implementation of reform.

Finally, I want touch on the importance of addressing health disparities and how we plan to support physicians so they can provide high-quality care in communities of need while at the same time maintaining a financially sustainable practice.

Reform in the States and Maryland

While the ACA arrived in state capitols last spring, States have taken individual approaches towards reform for decades. 

In Maryland we established a waiver program that provided primary care access and prescription drug benefits to low-income individuals, created one of the nation’s largest high-risk pools and offered tax credits for small businesses.

And since taking office, our Administration has expanded Medicaid coverage to over 280,000 (funded primarily by a tobacco tax increase); required insurers to allow parents to keep young adults on their coverage up to age 25; and helped close the donut hole in Medicare Part D. I mention these efforts to illustrate that states were innovating in health care long before the ACA.
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The day after President Obama signed the ACA, Maryland established the Health Care Reform Coordinating Council, which I co-chair, to develop recommendations for state implementation.

An independent analysis done at the University of Maryland Baltimore County found that the ACA will save Maryland $850 million and cut the number of uninsured in half by 2020.

Our final report contained 16 recommendations covering the exchange, entry into coverage, safety net, workforce, health disparities, communication and education, and bending the cost curve.

And this April we took the first step by making Maryland the third state in the nation to establish its Health Insurance Exchange.

Challenges in Health Reform Implementation

The exchange is only one piece of the puzzle. There are other challenges for states to navigate in order to successfully implement reform.

One challenge is our workforce capacity.  While more individuals will have health insurance when federal reform is fully implemented, their coverage will only be meaningful if they have access to physicians and other health providers able to meet their needs.

Shortages in Maryland’s health care workforce already exist. That is why in Maryland, we are developing—with the support of a federal grant—a blueprint for how to enhance our primary care workforce and the capacity of our community health centers.

We’re looking at a broad range of tools, such as fostering educational and training programs; loan assistance and repayment; and incentives to enter primary care in underserved areas and to treat Medicaid patients.

A second challenge is the need to bend the cost curve.

Rising health care costs are leading employers to drop coverage and threaten state budgets across the country.

Reining in these costs is an essential condition for health care reform to succeed. In this regard, the Affordable Care Act presents a tremendous opportunity for states.

We can improve chronic disease management and care coordination through establishing patient-centered medical homes.

We can assist physicians with the adoption and meaningful use of health information technology.

And we can address the financial and moral responsibility to reduce health disparities associated with poverty, geography, race and ethnicity.

Physicians and health care reform

In Maryland, African-African physicians are nearly twice as likely to be in primary care as white physicians. 

We recognize the importance of primary care and community practices in delivering quality care.

We recognize that family medicine physicians and other primary care physicians and providers will play a critical role in the reform efforts to expand access to care.

And we also recognize the challenges associated with primary care and community practices.

One of the biggest challenges is low reimbursement rates. 

In Maryland, we’re looking for ways to enhance reimbursements by establishing new ways of paying for care, so that doctors who are really responsible for keeping patients healthy get rewarded for better outcomes.

For example, last year we established a statewide patient-centered medical home program to strengthen primary care.

The 300 participating physicians are receiving education on practice transformation from Johns Hopkins and University of Maryland.

And rather than just being reimbursed for a 15 minute visit, we are providing financial incentives for physicians to spend time and coordinate their patients care and emphasize wellness and prevention.

Finally, we are evaluating patient’s health so that physicians stand to gain financially as they keep their patients healthy.

A second major commitment in Maryland is to help all primary care physicians obtain and use electronic health records (EHR) and connect to our health information exchange.
Health IT is a critical tool for physicians.

The Governor and I believe that it is so important that we made it one of our fifteen statewide strategic goals and sought to lead the nation in the adoption of electronic health records and health information exchange by the end of 2012. 

Currently only 25% of Maryland’s 7,500 + non-hospital based physicians have adopted EHRs. We are working aggressively to encourage their expansion.

In 2009 we created state incentives for primary care practices that adopt electronic health records - the first legislation of its kind in the nation. And our state incentives dovetail with the CMS electronic health record incentive program.

Combined, State and federal incentives and funds for our Regional Extension Centers, have helped us sign up an additional 1,100 primary care doctors for electronic health records.

These physicians, from every corner of the state, are leading the way to a new era in health care, where better data can drive better care for patients.

Health Disparities and Health Equity

Finally, I want to briefly discuss the importance of addressing health disparities and the role that you,  the family medicine physician,  can play in helping us address a national problem that strikes at the heart of America’s promise. 

Maryland ranks among the highest in the number of primary care physicians per capita among all states.    Yet we rank 35th when it comes to geographic health disparities.  There are simply too many communities that are underserved by primary care physicians.

As a result, and notwithstanding some of the finest hospital and medical institutions in Maryland (Johns Hopkins and the University of Maryland Medical System), Maryland ranks 33rd overall in health quality indicators.

Infant mortality went down in Maryland last year while,  at the same time,  it ticked upward for African American babies.
In Maryland, nearly twice as many African Americans suffer from diabetes than whites, and African American babies are three times more likely to die before the age of one than white babies.

On a national level, a 2009 report estimated that between 2003 and 2006, nearly $230 billion could have been saved in direct medical care costs if racial and ethnic health disparities did not exist.

Unacceptable disparities in health care delivery are the very definition of poor quality care, which is why in Maryland we are making a renewed effort to address disparities.

We recently established a workgroup that will recommend strategies to address disparities in the health care system, including the use of financial incentives.

In the past, we have limited our discussion to cultural competence, greater diversity among providers, and the need for better data.  These continue to be important factors.

But there needs to be more.  We need to create Health Empowerment Zones, similar to Promise Neighborhoods, which create numerous incentives for physicians to work in underserved communities.  These could include income and property tax reductions and additional incentives for electronic health records. 

Reasons for healthcare disparities abound and with 54% of African American physicians working in primary care nationally, you are uniquely positioned to address them. 

As we advance the reform agenda and expand access to insurance, we must make sure that we are not leaving people behind.

Conclusion

In the end, health care reform is not just about reform – which has been going on for many years.

It is also not just about care, which is a means to an end.  It is about health…Health is why we’re all here.

For health reform to succeed we must:

• Improve our existing and future workforce;
• Provide incentives for doctors to coordinate care;
• Promote wellness and prevention;
• Utilize health IT effectively; and
• Make ending health disparities a priority.

This is a critical moment, as physicians in our communities your voices must be heard as states implement reform.

This is our challenge – we must work together to seize the moment. Let’s use the tools provided by the Affordable Care Act to build a better future for our nation.

Thank you very much.

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