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Grantmakers In Health Briefing on the Safety Net: Highlights from Presenters Ku and Siegel



November 10th, 2011
by Lee-Lee Prina

Grantmakers In Health’s Fall Forum, held in Washington, DC, included a well-attended one-day issue dialogue on the health care safety net. Following are a few highlights from speakers’ remarks and the subsequent Q & A session.

To start off the day, well-known analysts Leighton Ku of the George Washington University (GWU) and Bruce Siegel of the National Association of Public Hospitals and Health Systems provided attendees with background information on the safety net landscape.

As for the federal health reform law (the Affordable Care Act of 2010), Ku predicted that the United States would go down one of two paths:

(1) Large elements of the reform law may be overturned, and effects of that would mean more uncompensated care.

(2) Alternatively, health reform may be implemented “roughly as planned”; that would mean the number of uninsured people, as well as the costs of uncompensated care, would go down. Among the issues to follow is what will happen to the newly insured.

Ku suggested what foundations should be funding related to the health care safety-net. (He clarified his comments in a follow-up e-mail to me.) He said that foundations need to fund research on the safety-net—as they have in the past at GWU, where Ku is on the faculty. For example, the Commonwealth Fund, Blue Cross Blue Shield of Massachusetts Foundation, RCHN Community Health Foundation, and Kaiser Commission on Medicaid and the Uninsured (part of the Henry J. Kaiser Family Foundation) have all funded such research at that university. He also mentioned that foundations have funded the actual operations and activities of safety-net facilities, and he hopes such funding will be awarded in the future.

Near-term issues for the safety net include whether such providers can survive governmental budget cuts, and whether providers that want to improve quality of care will have enough staff and money to do so. Ku also mentioned accountable care organizations—he noted that the final regulations were recently released (in October), but he is still in the process of reading them! (Read this Urban Institute update, by Bob Berenson and coauthor, on accountable care organizations. The Robert Wood Johnson Foundation provided funding for it.)

Long-term issues that Ku mentioned include:

• Will safety-net providers be in the health insurance exchanges that are called for in the federal health reform law?

• Will Medicaid payment rates be enough to keep safety-net providers afloat?

• Will there be enough primary care health professionals? Ku noted that there is a “big need” to expand primary care clinicians, including physicians, osteopaths, nurse practitioners, physician assistants, registered nurses, and even medical assistants.

Bruce Siegel discussed the so-called Super Committee that has been tasked with balancing the federal budget and reducing the federal deficit by later this month. He does not see much consensus thus far on that committee. If a logjam occurs, then automatic triggers to cut the budget would be put into effect. Siegel predicted that even if triggers are activated, the country won’t see much budget pain for a few years.

As for federal health reform, Siegel questioned whether new care models can come online fast enough to help. He suggested to this audience of foundation staffers that grantmakers should think about helping hospitals move to the accountable care organization/medical home model.

Siegel included on his list of what he called “anxieties” the question: Who is going to train the next generation of safety-net provider leaders? For example, visionary Ron Anderson is going to be retiring soon from Parkland Health and Hospital System in Dallas, Texas, Siegel mentioned. (Anderson has been a long-time champion of the idea of health care for all, regardless of ability to pay, according to the Parkland website.)

The Affordable Care Act includes a substantial Medicaid expansion, and the safety net is the largest Medicaid provider. Thus, safety-net providers need tools to help them with the influx of people, or reform will fail, Siegel said.

There was widespread audience participation in the Q & A session. Siegel forecasted that even if the health reform law is repealed, some pieces of it would be retained. For example, both value-based care and pay-for-performance to achieve high-quality care will stay alive (he noted that much of the work on these concepts was begun during the George W. Bush administration). Ku later commented that community health centers are politically popular.

The health professions workforce gap and the effects of state scope-of-practice laws were also discussed. In response to a question from a San Francisco Foundation staffer, both speakers agreed that these laws are a challenge. (Of course, these are  especially challenging in areas of the United States where there is an insufficient number of primary care clinicians.) Ku said that fixing medical schools requires time; nurse practitioners can be trained faster.

Following up on an earlier comment by Siegel that in some localities, safety-net hospitals and community health centers have no interaction, an audience member asked if the speakers knew of examples of collaboration among such centers and hospitals. Siegel gave a couple of examples, including Denver Health, and added that this area of promoting collaboration is ripe for exploration by philanthropy.

A Pew Charitable Trusts staffer inquired about dental care for the safety-net population. This question led to a lively discussion among several attendees. Siegel responded that there are “huge unmet needs” for oral health care. People have died from lack of care, and the problem is now extending into the middle class, he said. Ku called oral health care the “poor stepsister” to medical care, but there has been some progress with kids getting oral health care through Medicaid.

Tracy Garland, a senior adviser to national programs of the DentaQuest Foundation, told the audience that there is work under way to integrate oral health care into primary medical care. Under this model, there are no scope-of-practice challenges, but there is a training gap, she said. In a subsequent e-mail, Garland explained to me that the National Interprofessional Initiative on Oral Health (a consortium of funders and health professionals) is working to engage primary care clinicians in delivering preventive services for oral health. She is also program director of that initiative. Physicians in family medicine and pediatrics, nurses, physician assistants, and pharmacists are trying to get their professions involved, and “the uptake is amazing,” Garland reported. The DentaQuest, Washington Dental Service, and Connecticut Health Foundations have supported the initiative, according to its website.

Pat Mathews of the Northern Virginia Health Foundation mentioned a survey report that this grantmaker released in September. (A foundation press release noted that this is the first-ever survey conducted on oral health in Northern Virginia—that is, the suburbs of Washington, D.C. Although it was a poll of adults in general, it focused on lower-income adults because there are so few programs helping this population.) Mathews commented that a local pediatrician, after reading the report, said that there is only one pediatric oral surgeon in Northern Virginia who accepts Medicaid, and children can wait as long as a year to be treated by that provider.

Mary Vallier-Kaplan of the Endowment for Health, a foundation located in New Hampshire, commented that integration of behavioral health with primary care has caught on in that state and nationwide, but not integration of oral health. And so philanthropy could play a role by both reminding foundation colleagues about this exclusion of oral health and only awarding funding to organizations that integrate mental and dental health care with primary care, she commented.

In her remarks at the conclusion of this session, Lauren LeRoy, president and chief executive officer of Grantmakers In Health (GIH), followed up on Siegel’s earlier remark that the National Association of  Public Hospitals and Health Systems has applied to be what he called  a “hub” in the Partnership for Patients initiative of the Centers for Medicare and Medicaid Services (CMS). (Read the press release on Partnership for Patients here.) Sixty-six public  hospitals have applied to work together on quality improvement—specifically, on reducing harm to hospital patients and reducing hospital readmissions.

LeRoy asked if there were opportunities for local foundations in communities where the sixty-six hospitals are located to support this effort to improve quality of care. Siegel responded, “Absolutely.” So that is something else for funders to consider. 

By March 2012, GIH will release an issue brief on the health care safety net. For more information on the November 2011 GIH meeting on the safety net, send e-mail to Anna Spencer, aspencer@gih.org.

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