Between October 1 and January 1 Americans will be intently focused on the Affordable Care Act (ACA). For most of us, it will be with a mix of anticipation, trepidation, excitement, frustration, hope, fear, and undoubtedly confusion.
Dr. Nancy Fey-Yensan, dean of the College of Health and Human Services (CHHS) at the University of North Carolina at Charlotte (UNC Charlotte) has studied and prepared for the ACA. As the overseer of 3,000-plus undergraduate and graduate students who will soon work in the new health care order, she understands better than most its promise and its peril.
Lighting the Way
Although she has concerns, Dr. Fey-Yensan is an advocate of ACA.
“The Affordable Care Act is shining a light on care-for-all,” she attests. Until the congressional debates of 2009, few considered care-for-all a realistic part of the American dream. The cost of caring for uninsured millions made it appear impossible.
“But,” says Fey-Yensan, “the societal costs of not caring-for-all are greater than the cost of doing something. Health is central to America’s success. Without good health,” she maintains, “education suffers, jobs are lost, and families fall into poverty.
“I’ve been in health care for 30 years and there has been a growing concern that health care needs to be proactive, comprehensive and accessible to all,” she says.
The War on Poverty that began in the ’60s kicked off those conversations, but it took a change in outlook to move the United States from a concern for economic opportunity to the Affordable Care Act.
“We have moved away from a health outcome perspective to a patient outcome perspective,” comments Fey-Yensan. “The old emphasis was on making medical procedures more effective and developing best medical practices. With the cost of a day in an American hospital averaging $2,000, that can’t go on,” she emphasizes.
Today doctors and hospital administrators pay attention to patient satisfaction, quality of life and informed individual decision-making. Many physicians are now compensated on the basis of patient outcomes. As Fey-Yensan says, “We are thinking more now about how to make individuals and families healthier and how to keep them out of the acute care system.”
The heart of the ACA is primary care—checkups and prevention. That is the starting point, the floor for the ACA’s minimum standards. In order for a health plan to be approved for uninsured individuals under ACA, it must have a strong benefit package and limited out-of-pocket costs.
The ACA’s Essential Health Benefits package ranges from wellness and pediatric oral and vision care, the prevention piece—to emergency services and hospitalization, the acute care benefits. The minimum standard for deductibles and co-pays is a 60/40 cost sharing, the so-called Bronze level. It’s the plan with the lowest premium and the highest out-of-pocket cost. For a higher premium, individuals may opt to have their plan pay 70 percent (Silver), 80 percent (Gold) or 90 percent (Platinum).
New Models and Methods of Care
“An important part of the ACA is that now there will be benchmarks for success. Organizations that meet those benchmarks will be rewarded,” explains Fey-Yensan. “The benchmarks are related to quality of care, safety and cost.” For example, recurring, redundant and unnecessary medical tests may be one irritant that benchmarks eliminate.
A novel way to achieve quality, safety and cost savings is the “medical home” model of care. The ACA supports this coordinated, proactive, patient-centered approach. Key to the medical home is a team of providers working together to meet a patient’s health care needs.
Much like hospice care for the past 40 years, medical home teams include physicians, physician’s assistants, nurse practitioners, nurses, nutritionists, pharmacists and social workers. Medical homes have extended office hours, communicate regularly with patients over the phone or Internet, and rely on shared data from electronic medical records.
In his keynote address at the 2012 Charlotte Chamber of Commerce Health Care Summit, Harry Reynolds, director of health industry transformation for IBM went so far as to say, “We will not work with an insurer that does not offer medical home.”
Teams dominate Fey-Yensan’s conversation. There’s good reason. She explains that, with 55 million previously uninsured Americans soon to be seeking community-based medical care, there are not going to be enough medical doctors to serve them. In the future, medical doctors will supervise interdisciplinary teams and provide less face-to-face care.
Ready to fill the M.D. gap are two new professional degrees offered by CHHS. The newest, a Ph.D. in public health sciences, debuted in August 2013. It follows closely the college’s Ph.D. in nursing practice which was approved earlier this summer. The latter degree is designed to take the place of the nurse practitioner. These 21st century professionals will be trained to work in non-traditional settings where inter-disciplinary, culturally competent teams make many of the clinical decisions typical of 20th century physicians.
CHHS coordinates the education of four disciplines at the bachelor, master and doctoral levels: Social Work, Public Health Sciences, Nursing and Kinesiology. Students wishing to start early and blur the lines between their related disciplines can apply for the college’s Health Connection program.
Beginning freshmen year, those accepted into Health Connection take classes together, participate in community service, develop teamwork skills and live together in the same residence hall. When they graduate, these social workers, nurses, occupational therapists and policy advisors will not only communicate with each other, but they will also fully understand and appreciate what the other is saying.
Big Data is a Big Driver
“Data drives everything we do,” says Fey-Yensan of her evidence-based curriculum. And Big Data is the biggest driver of them all. Big Data is revolutionizing every aspect of medicine from the laboratory bench to the bedside.
Google, Facebook and Target are not the only ones to mine terabytes of customer data. Hospitals, insurers and researchers are already sifting through mountains of medical data on electronic medical records, MRIs and CT scans. Their goals are to make sense of health care data, improve care, identify value, reduce costs and cure diseases.
In 2012, CHHS teamed with UNC Charlotte’s College of Computing and Informatics to develop the first Health Informatics Professional Science Master’s program in North Carolina.
“This degree is to train people with solid skills of technology and analytics while being expert in the business of health and health care and making the two work together,” explains Dean Yi Deng of the College of Computing and Informatics. Half the curriculum comes from Dr. Deng’s faculty, half from Fey-Yensan’s. Their motto seems to be, ‘We don’t work in silos anymore.’
For the past eight years, CHHS has graduated close to 50 Ph.D.s in health services research. This Big Data degree combines such diverse disciplines as biostatistics, epidemiology, sociology, social work, economics, medicine, nursing, public health, engineering, management and policy studies.
Recently, CHHS researchers have reached across the campus to the College of Business and the College of Liberal Arts to form a Health Informatics and Patient Outcome Collaborative. With colleagues in health economics and public policy, they are studying what was once the murky topic of heath care quality. There is a lot at stake. Quality measurements are playing an increasingly important part in determining physician performance incentives.
“The combination of Big Data and health care probably creates one of America’s most sought after professionals in health care right now,” remarks Fey-Yensan.
The Affordable Care Act is far from legislative perfection. There are a number of flaws that it acquired in its journey through Congress and after its examination by the North Carolina legislature. Three of them cause concern for Dean Fey-Yensan.
In March, Governor McCrory signed legislation that took North Carolina out of the system of state-run health care marketplaces or exchanges. These are real and virtual places where uninsured individuals and small businesses can shop for health insurance. North Carolina is one of 33 states that, for now at least, do not have their own program. The state will operate as a Federally Facilitated Exchange for 2014.
In July, the North Carolina Department of Insurance (NCDOI) approved rates for three private insurance companies that intend to sell plans to North Carolina’s 1.5 million uninsured: Blue Cross and Blue Shield of North Carolina, Coventry Health Care of the Carolinas and FirstCarolinaCare.
If North Carolina had a state-run exchange NCDOI’s approval would be sufficient. “Since the federal government will be operating the Marketplace in North Carolina, it will make the final decision as to which plans may be sold though the Marketplace in this state,” said the NCDOI in a July 30 press release.
“For folks who have to go out and shop around for health insurance, they really should have a broader market to choose from,” claims Fey-Yensan. And she says, since only Blue Cross Blue Shield will have a presence in every county, “What that means is that for some folks there won’t be a choice.”
Those seeking individual and family coverage and a government subsidy may face a long and tedious application process. Help in staying afloat in that sea of paperwork is to come from unbiased enrollment counselors aptly named Navigators under the Act.
California expects to hire 21,000 Navigators—some proficient in Spanish, some from faith-based organizations and some from non-profits. Nationwide, estimates for the number of Navigators needed run as high as 175,000. All will be full-time state or federal employees trained in taxes, insurance and the fine points of the law.
Some worry that the application process will be so burdensome that even with help from Navigators many uninsured will opt for a fine. Insurance companies have a different concern. They assert that the uninsured will be confused between Navigators and the more familiar insurance agent and broker since ACA requires that Navigators cannot be health insurers.
“The problem is that there will not be enough Navigators,” maintains Fey-Yensan.
To fill the gap, Certified Application Counselors and In-Person Assisters may be added to the mix. These latter groups have had years of experience working with applicants for Medicaid and the Children’s Health Insurance Program.
In the next month, local groups like Legal Services of Southern Piedmont and MedAssist will play a role in closing the information gap. “We are part of a consortium of 10 agencies and on August 15, we were awarded a grant to become Navigators,” says Kelly Musante of MedAssist.
Graduate students from UNC Charlotte are also planning to help, but they have too much on their plates to be full-time Navigators. According to Cicily Hampton, a public policy grad student, there is a university-wide steering committee working on immediate volunteer efforts as well as long-term involvement. Hampton points to a problem many of us share: “Those obtaining health care insurance for the first time may not understand co-pays and deductibles.”
There are two ways the Affordable Care Act envisioned the expansion of health care coverage. One was through standardized individual health care plans. The second was the expansion of the Medicaid program for low income Americans. It is this second tier expansion—or, more accurately she says, the lack of it—that concerns Fey-Yensan.
“North Carolina is one of 15 states that voted not to expand Medicaid. We still have 700,000 people who will not be eligible for Medicaid, all under the age of 64. These folks are going to be in trouble.” She explains that states that expanded Medicaid realized that, without expansion, low income Americans would continue to use the hospital emergency room for primary care.
Closer to home, expansion would have had a direct impact on UNC Charlotte’s students. “An increasing number of jobs would have come from Medicaid expansion,” says Fey-Yensan. “Expansion would have been an economic driver for North Carolina.”
The future of the Affordable Care Act depends more on colleges like UNC Charlotte’s Health and Humans Services than it does on what happens in the next three months. Look down the health care highway five or 10 years. In that more expansive view, Charlotte will witness the explosion of enrollment at the College of Health and Human Services, already the fastest growing school there.
“The demand for primary care providers who are not medical doctors will be huge,” maintains Fey-Yensan.
When the dust settles, Charlotteans may come to realize that it is not only cost-effective to be seen by non-M.D.s, but also more personal, holistic, satisfying and health-promoting.
Five or six heads may turn out to be better than one.
Like the Affordable Care Act itself, we may need to live with that idea a while. But those heads belong to the professionals graduating from Fey-Yensan’s programs and they are leading the way forward in American health care reform.