State Health Plan 2011-2016 Access To Care Workgroup

State Health Plan 2011-2016Access To Care Workgroup

Troy AlexanderTexas Department of State Health ServicesDirector, Centers for Program Coordination,

Policy, and InnovationFebruary 19, 2010

22

Presentation Purpose

• To share preliminary thoughts on workforce implications with respect to access to care

• Not a comprehensive review

• Seeking input on missing gaps

33

Presentation Outline

UninsuredUninsured

Access To

Care

Access To

Care

Health DisparitiesHealth Disparities

Primary Care & BeyondPrimary Care & Beyond

Various PopulationsVarious Populations

44

Uninsured Population

• Health insurance – Contributes significantly to an individual’s ability

to access healthcare services

• Inability to access primary care – Leads to costly hospital treatment for preventable

health problems

55

Uninsured Population

• Increasing numbers of uninsured– Places extraordinary economic burden upon

health care community

• Texas leads the nation in the percentage of uninsured adults and children

66

Uninsured Population, Total

Uninsured: Total Population (2008)

TX U.S.

25.2% 15.4%

Source: Kaiser Family

5.4% - 11.1%

11.3 - 13.2%

13.6% - 16.2%

16.6% - 25.2%

77

Uninsured Adults, 19–64 Years


7.3% - 14.4%

14.4 - 17.8%

17.9% - 21.6%

21.8% - 31.5%

Uninsured AdultsUninsured Adults19-64 Years (2008)

TX U.S.

31.5% 21.4%

88

Uninsured Children, 0-18 Years

Uninsured Children0-18 Years (2008)

TX U.S.

20.1% 10.3%


3.2% - 6.5%

6.7 - 9.1%

9.3% - 11.4%

12.0% - 20.1%

99

Where are the uninsured Texans?

• 80% uninsured population reside in 35 of the state’s 254 counties

• Common misconception– Uninsured are concentrated along the Texas-

Mexico border

1010

Where are the uninsured Texans?

• Five counties account for close to half of the uninsured statewide – Harris– Dallas– Bexar– Tarrant – El Paso

• Access to care is not just an issue for border and rural areas

Houston

Robertson

Limestone

Angelina

SanAugustine

SanJacinto

Cherokee

EllisSomervell

Anderson

McLennan

Williamson

Glasscock

NolanHoward

Crockett

Sterling

W ebb

McMullenLaSalle

Duval

Hood

Erath

Stephens

PaloPinto

Galveston

FortBend

Newton

Jasper

Sabine

Franklin

Hopkins

Delta

Marion

CampCass

Morris

RedRiver

BrownColeman

Mills

McCulloch

Callahan

Shackelford

Rusk

Crane

MidlandEctor

V anZandt

LibertyLee

KarnesAtascosa

LiveOak

Clay

Montague

Throckmorton

Gregg

Orange

Nueces

Borden

StonewallKent

Collingsworth

Hall ChildressBriscoe

Armstrong Donley

Bandera

Edwards

Brooks

Hidalgo

Pecos

Reeves

Aransas

Jones

Grayson

Haskell

DickensCrosbyLubbockHockleyCochran

SwisherCastro

Randall

HemphillHutchinson

Roberts

Hansford Ochiltree Lipscomb

Moore

Sherman

BrewsterPresidio

Dallam

Hartley

OldhamCarson

PotterGray Wheeler

Deaf Smith

Parmer

Hardeman

WilbargerMotley CottleLamb HaleBailey Floyd

FoardWichita

CookeLamarFanninArcherKing Knox Baylor

Bowie

Jack Wise Denton HuntCollinGarza

Parker DallasRockwall Rains

Scurry FisherDawsonGaines UpshurKaufman Harrison

SmithJohnson

MitchellMartinAndrews

EastlandPanola

Henderson

NavarroHill

Comanche BosqueWinkler Coke

Runnels

Hamilton FreestoneHudspeth Culberson

Loving Shelby

CoryellLeonUpton

ReaganConcho

IrionFallsLampasas

BellPolk

Milam

MadisonSchleicher MenardBurnet

BrazosMason LlanoGrimesBurlesonKimbleSutton

MontgomeryHardin

BlancoGillespie

BastropHaysKerrHarris

FayetteKendall Austin

Real CaldwellComal

Colorado

Chambers

GuadalupeGonzalesBexarMedina

WhartonLavacaUvaldeKinney

BrazoriaWilson DeWittJackson

MatagordaZavalaFrioMaverick

Goliad

Bee CalhounDimmitRefugio

Kleberg

ZapataKenedy

StarrWillacy

Cameron

Yoakum Terry Lynn Young

Tarrant Wood

Taylor

El Paso

Ward

Jeff Davis

Terrell

Val Verde

TomGreen

SanSaba

Nacogdoches

TylerWalker

Trinity

Travis

JeffersonWaller

Washington

Victoria

JimWells

SanPatricio

JimHogg

Titus

1111

Who are the uninsured Texans?

• Moderate to Low-Income Texans• Texans Who Do Not Receive Insurance Through

Their Jobs• Texans Who Work in Small Businesses • Texans Who Can Afford It, But Don’t Want It • Texans Eligible for, but not Enrolled in Government

Programs– 3 out of 4 uninsured Texas children are eligible for

Medicaid or CHIP but are not enrolled

• Texans with Catastrophic Medical Bills• Immigrants

1212

Emergency Medical Treatment

• Federal Emergency Medical Treatment and Active Labor Act (EMTALA)– Assures access to emergency medical care

services– Payments are below costs or unfunded – Utilization of emergency medical care services

are not financially sustainable

• Hospital Diversions– Impacts access to timely and more geographical

or culturally appropriate care

1313

Consequences of Uninsured

• Increasing numbers of uninsured Texans may result in… – Increased medical insurance costs – Higher expenditures in health services,

emergency care and physician services

• Uninsured individuals postpone preventive measures and early disease treatments with resulting…– Poorer health that impacts attendance and

performance in schools and the overall workforce– Shorter lives

1414

Workforce Implication

• Increased demand for health care

• Limited availability of healthcare professionals

• Texas currently has insufficient workforce capacity to accommodate the uninsured, much less the newly insured and individuals with existing insurance coverage

1515

Health Disparities

UninsuredUninsured

Access To

Care

Access To

Care




1616

Health Disparities

• Linked with social or economic disadvantage• Adversely affected groups of people who have

systematically experienced greater social and/or economic obstacles to health, including:– Racial or ethnic groups – Religious determination or groups – Socioeconomic status – Gender – Geographic location – Persons with mental illness or substance abuse,

cognitive, sensory or physical disability– Other characteristics historically linked to discrimination or

exclusion such as homeless or incarcerated persons

1717

Health Disparities

• Challenges associated with providing health care to individuals affected by health disparities – Communication – Cultural relevance – Diversity of physicians and health care

professionals– Generalization and stereotyping

1818

Health Disparities

• Healthcare access includes a consumer’s (or potential consumer’s) ability to locate providers– Deliver individualized services that address their

unique needs– Have offices located within a close geographical

proximity to where the consumer lives – Can develop a relationship based on mutual

respect, open communication, and trust

1919

Health Disparities in Texas

• Diverse population • Population increasing faster than the national rate

2020


• In 2009, the majority of the state’s PC physicians were White

• Blacks and Hispanics have historically been under-represented

2009 PC Physicians

White58%

Other42% White

Other

2121


• Disproportionately impacted by already existent workforce shortages

• Exacerbated by shortages of culturally competent workers for disadvantage populations

2222

2009 Texas Supply RatiosLicensed Healthcare Professionals

• Supply ratio is the number of health care professionals per 100,000 population

• Lower supply ratios for most licensed healthcare professionals than the overall U.S.

• LVNs are a notable exception• Ratios are higher in metropolitan counties than

nonmetropolitan counties • Non-border area has higher ratios than border areas• Panhandle, West Texas, and South Texas counties often

have lower supply ratios than the rest of the state; with most of those counties having no providers

• For most professions, the largest growth in supply has occurred in Central, East, and North-east Texas

2323

Disparities: Culturally Competent Care

• Meaningful Material in Curricula– Need for curricula to include unique cultural

factors

• Healthcare Quality Improvements – Disparities in quality of care have stayed the

same or worsened for ethnic groups

• International Medical Graduates– Helps to address PC shortage outside MSAs– Double culture increases complexity of

communication

2424

Disparities: Need for Health Literacy

• Populations most likely to experience low health literacy– Older adults, racial and ethnic minorities, individuals with less than a

high school degree or GED certificate, – People with low income levels, – Non-native speakers of English, and – People with compromised health status

• Persons with limited health literacy skills – More likely to skip or not understand the importance of taking

preventive measures – Have a higher rate of hospitalization and use of emergency services

• Much of health information is written at college level• Health literacy automatically limits many minorities from

participating in chemical dependency research studies

2525

Primary Care & Beyond

UninsuredUninsured

Access To

Care

Access To

Care




2626

Primary Care & Beyond

• Primary care includes– Health promotion, disease prevention, health maintenance,

counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings

• Access is affected by several factors– Economic– Health insurance– Geographic, and– Availability of PC and specialty care providers

• Supply and distribution of numerous types of health professionals may affect – Timeliness of access, and – Therapeutic milieu available to treat certain types of conditions

• Need to access different types of health care providers– Not just primary care

2727

Findings: Primary Care Physicians

• The Texas PC-to-population ratio = 67.7– Lags behind the national ratio = ~80

• Whole County PC HPSAs– 118 of 254 Texas counties designated

• Partial PC HPSAs– 16 additional counties designated

2828

Findings:Physician Assistants (PA)

• Texas (18.3) has fewer PAs per number of persons than the national ratio (~24)

• Lower ratio in nonmetropolitan areas than metropolitan areas

• Augmenting roles for PAs in areas including • Primary care services• Hospital inpatient services • Teaching centers

2929

Findings:Nursing Professions

• Advanced Practice Nurses (APNs) – Authorization by the Board of Nursing – To practice as…

• Nurse Practitioner (NP)• Certified Nurse Midwife (CNM)• Clinical Nurse Specialist (CNS), or • Certified Registered Nurse Anesthetist (CRNA)

3030

Nurse Practitioners (NP)

• Texas (17.1) has fewer NPs per number of persons than the national ratio (~39)

• Highest NP ratios are in the northern parts of the state

• Higher ratios in metropolitan counties than nonmetropolitan counties

• 59 counties have no NPs

3131

Certified Nurse Midwives (CNM)

• Texas lags the U.S. in the supply of CNMs relative to the female population of childbearing age, 15 to 44 years

• Compared to other health professions, Texas has very few CNMs

• 211 Texas counties without a CNM (2009)

3232

Registered Nurses (RN)

• More RNs in Texas than any other health profession– Texas (681.2) lags behind the U.S. in the number

of RNs-to-population (~835)

• In 2009, only four counties did not have an RN

3333

Findings: Optometrists (Doctors of Optometry)

• Texas lags behind the U.S. in supply ratios of optometrists– In 2009, there were 108 counties without an

optometrist – For lower Panhandle area and portions of West

Texas - one would have to travel through several counties to reach an optometrist

– Border counties also have very low supply ratios– 19 of 32 border counties have no optometrists

3434

Findings: Dentists

• Dental Health Professional Shortage Area (HPSA) – Oct 2009– 111 Texas counties had some type of designation, and– 44 counties with no dentists; most of these were in the

Panhandle, West Texas, and South Texas

• Slight net increase in supply of dentists (37.8) in Texas– Still significantly below the national average (~65)

• Border counties have fewer dentists than nonmetropolitan non-border areas – Widening gap in supply between metropolitan and

nonmetropolitan counties

3535

Findings: Community Health Workers (CHW)

• Low numbers of certified CHWs or promotores(as)– 605 certified CHWs located in 47 Texas counties (Sept

2009) – Harris County with the highest number

• 191 CHWs

– Several counties having just one or two– State also has uncertified CHWs

• Certified training programs – Only ten counties in the state – Limits access to, and the ability of potential community

health workers to complete required training for certification

3636

Findings: Community Health Workers (CHW)

• Represents an emerging resource • Helps overcome barriers to healthcare and

increases access to services, especially for disproportionately affected populations

• Can contribute to community development • Can improve coverage and access in environments

where formal health care services are limited or hard to access

• The role of PHWs and CHWS within the Texas health care delivery system may need to be clarified.

3737

Findings Related to Pharmacists

• State experienced a steady increase in the number of pharmacists

• Texas pharmacist-to-population ratios (78.7) exceed U.S. ratios– (Based on 1982 through 2003 data. Recent U.S. data are

unavailable)

• Even though the ratios have increased for Texas as a whole since 2000, 137 counties have experienced a decline in the ratios

• In 2009, 29 counties were without a pharmacist

3838

Findings: Behavioral Health Professionals

• Insufficient mental health workforce supply to meet future demand– Workforce supply trends– Distribution problems – High turnover rates – Anticipated retirement of current workers, and – Projected state mental health job growth rate of

20% or more

• 172 of 254 state counties are designated as an MH shortage area

3939


• Behavioral healthcare is provided by a wide range of licensed professionals– Psychiatrists – Psychologists – Primary care physicians – Social workers, and licensed marriage and family

therapists– Psychiatric nurses, and – Licensed professional counselors– Licensed chemical dependency counselors– Paraprofessionals (ex. Qualified mental health

professionals, psychiatric technicians, etc.)

4040


• In 2009 , the Texas supply ratio for specialists in psychiatry/psychoanalysis field was 6.6

• Ratio of specialists decreased from 6.8 in 1990

• Most located in major urban areas– Some in less populated counties containing state

psychiatric hospitals

4141

Findings:Behavioral Health Professionals

• Few child psychiatrists in Texas (based on 2005 data)

– 190 child psychiatrists– Supply ratio of 2.9, children ages 0-18

• No significant increase for psychologists – Counties in South Texas, West Texas, and the Panhandle had lower

ratios; most of these counties did not have any psychologist– Compared to five states with the largest populations, Texas has the

lowest supply of psychologists• Texas = 24.2, • New York = 49.9• Illinois = 43.3• California = 40.4• Florida at 27.1

4242


• Social workers– Among the five states with the largest populations, Texas

has the lowest supply ratio• Texas = 68.2• New York = 188.1• Illinois = 164.4• California = 124.7• Florida = 109.4

• Supply ratios of other professions that support mental healthcare have declined

• The supply gap likely to become even wider due to many factors– Aging workforce retiring – Fewer people entering the profession

4343


• Texas imports more psychiatrists from out of state than it graduates from its medical schools

• Texas state agencies that serve persons with mental health disorders consistently report difficulties recruiting – Mental health professionals (especially in rural areas)– Employees who serve persons with mental disorders

such as teachers, probation officers

• High turnover rates also pose a problem

4444

Presentation Discussion

UninsuredUninsured

Access To

Care

Access To

Care




• Persons with Disabilities• Rural Population• Children and Adolescents• Elderly

4545

Findings: Persons with Disabilities

• Many definitions of disability– Texas has its own definition of developmental disabilities– Based on eligibility requirements to some services

• The need for skilled medical interventions• Limitations in functional abilities

• Access to health care for persons with disabilities differ than those without disabilities

• Constrained access includes more than physical access to buildings, but also access to services, information, care and support – To respond adequately to health care needs of this

population, providers need to view this population in terms of their specific health needs and not strictly in terms of their disability

4646

Findings:Persons with Disabilities

• 20% of the population live with some kind of disability• Nationally, adults with disabilities have significantly…

– Lower self-reported health status, – Increased disease rates, – Higher incidence of suicide, and – Higher incidence of unhealthy behaviors

• Shortage of physician specialists and a severe shortage of subspecialists

• Limited number of training programs – devoted to producing physicians with expertise in treating individuals

with developmental disablities

• Preventable secondary conditions– Lack of awareness and responsiveness by clinical and public health

professionals about this population

4747

Findings:Persons with Disabilities

• Need for Transition medicine

• Disparities between Children’s Medicaid and Adult Medicaid programs

• More study needed in this subject area

4848

Findings: Rural Areas

• Lack of access to care cor populations living in rural areas is well documented

• Workforce shortage will most likely continue

• Vulnerability to workforce shortages – small population size and scale – loss of just one physician can have profound

effects

• Attracting and retaining practicing physicians in rural areas is a concern

4949

Findings:Children and Adolescents

• Child and adolescent psychiatrists are in great demand • The number of child and adolescent psychiatrists practicing

in the U.S. has not changed much in the last two decades– rural and poor populations clearly have the greatest shortage

• Surgeon General estimates only 20% of children with mental illness obtain any care at all

• Families turn to primary care for at least initial care for common mental health problems

• An opportunity to expand the role of primary care for early identification and interventions of adolescents in need of mental health services

5050

Findings:Elderly

• Growing elderly population in Texas may delay or forgo care because of these factors

• Services and resources are required at a disproportionately higher rate

• Health care costs is a significant factors associated with lack of access

• Trends – Substantial aging of the population– High co-morbidity rates for seniors (or elderly)– Likely that the percentage of the population as a whole

who have a disability will increase

5151

Questions??

State Health Plan 2011-2016 Access To Care Workgroup

Documents

Transcript of State Health Plan 2011-2016 Access To Care Workgroup