HEALTH & SCIENCE

Muskegon, Mich.: Local notion

A Michigan community's effort to expand access highlights the link between medical care and public health, and challenges the notion that system reform must come from the top down. Its success remains to be seen, however, and some public health leaders maintain that local efforts alone are not enough.

By Mark Moran, AMNews staff. Jan. 3/10, 2000. - Additional information.

And they'll be getting paid rates comparable to Medicare and, in most instances, far better than Medicaid.

Sound unlikely? If it happens, it will be the result of Access Health, an ambitious new collaboration between physicians, employers and employees to fund access to care for working individuals.

Many collaborative ventures around the country are focused on health education and disease prevention or on providing free care to the medically indigent. What makes Access Health different and a harbinger for system reform is that it's a funded access plan providing fee-for-service reimbursement to participating physicians.

For this reason, Access Health has garnered the support of both major hospital systems in the region -- Mercy General Health Partners and Hackley Hospital -- and approximately 200 physicians. In contrast, payment under Medicaid has dropped so low that many physicians refuse to treat patients who receive Medicaid, or they do not bother to bill if they do.

"[Under Medicaid] you have a provider who is local and a patient who is local, and those two can come together easily enough," said Dr. Kohn, associate medical director of Mercy Family Care Center. "What divides us [under Medicaid] is the financing, which is not local. Patients don't know whom to call, and physicians are met with so many restrictions they feel powerless."

This effort to expand access, which is a program of the Muskegon Community Health Project and has support from the W.K. Kellogg Foundation, stems from a discovery many communities have made: the importance to the overall health of the community for people to have access to medical care. In a region where local rates of diabetes and hypertension exceed state and national averages, access to primary care is expected to reap savings.

"Although this is primarily a medical model, it is also part of a larger healthier communities model," said Remington Sprague, MD, who is vice president for primary care services at Mercy General Health Partners. "It looks at the burden on the community of having a large uninsured segment of people not getting care until it is far more expensive and the impact on the work force in terms of missed days."

Access Health is available to small and midsize businesses with a median wage of $10 per hour that have not provided health coverage in the last year. Funding is split between employers and employees -- $38 a month from each -- and the community, which contributes $46.65 per month per employee. Contributions for child and dependent care are extra. Participating physicians receive a discounted fee and return 10% of the fee to Access Health.

The plan covers most services provided by participating physicians and hospitals in the county. Prescription drugs are covered up to $6,000 per member per year, with a $5 patient co-pay for generics and a 50% co-pay for brands. Total plan costs are projected at $122.65 per member per month, plus $71.01 for child care.

For doctors in this community of 165,000, local control is appealing. "Physicians see access as a significant problem as they struggle to provide care without reimbursement," Dr. Sprague said. "They are doing this for people they see in their office day in and day out, not a nameless group getting an undefined benefit."

Dr. Kohn said access for patients is also a matter of professional satisfaction. "It's very frustrating for me and a waste of time to write out a plan of treatment only to have the patient come back four or six weeks later, too embarrassed to admit that he or she couldn't afford a prescription," he said.

Paul DeWeese, MD, an emergency physician and Michigan state legislator who has championed Access Health, called local collaborations the most sustainable solution to the nation's access problem. Cost-sharing by all participants in Access Health and the plan's independence from political mandates imposed from outside the community give it a fiscal integrity typically lacking in entitlement programs initiated by federal or state governments. "Local ownership leads to stronger commitment and personal responsibility," he said.

Plans originating in Lansing (the state capitol) or Washington, D.C., generally come with political pressure to add reimbursement for things that have no connection to the people who are paying for the program, Dr. DeWeese added. "The businesses here have made a decision to provide basic health care to low-income workers, not to provide Viagra or toupees."

Dr. DeWeese's argument challenges the conventional wisdom that health system reform must come from the top down. It draws on a conservative political philosophy of "devolution" -- devolving responsibilities once assumed by state and federal governments to local entities -- and on traditional conservative preference for local control of affairs. Yet Access Health has been embraced by liberal politicians and by the public health community.

But success of Access Health is by no means ensured, and advocates said it is a "work in progress." Even if it achieves the expected enrollment of 3,000 people, the plan will have barely put a dent in the access problem in Muskegon County, where an estimated 16,000 people are without health insurance. By mid-December, Access Health had enrolled only 250 people; many of the uninsured are dispersed throughout the county, requiring outreach. For many uninsured, especially those in their 20s, the $38 contribution is problematic. Though plan benefits are generous, they are not exhaustive: Access Health will not cover services that patients must travel outside Muskegon County to receive, such as neonatal intensive care or treatment in a burn unit. For those services, patients will go to nearby Grand Rapids. In addition, the medical needs of the uninsured population are largely unknown, and the long-term fiscal viability of the plan remains to be seen.

Acknowledging the challenges that Access Health faces, Dr. DeWeese defied critics who would point to Muskegon's experiment and claim the glass is half empty. "This is a gigantic and creative step forward," he said. "It isn't perfect, but it provides a basis for enlarging the sphere of insured people."

Comprehensive solution

Local collaborative arrangements to finance access to care are not common, but they may become more widespread if the number of uninsured continues to grow. The U.S. Census Bureau found that in 1998, 16.3% of the American population, or more than 44 million people, were without health insurance.

Yet the shortcomings inherent in such "local fixes" underscore the demand by many public health leaders for systemic reform on a national level. They call for a comprehensive solution based on a vision of health as a social good and disease as a communicable threat that crosses state and regional boundaries.

Mohammed Achter, MD, executive director of the American Public Health Assn., hailed Muskegon's plan and said he hopes its success will put the state and federal governments "to shame" for failing to provide leadership. But he called such local collaborations "interim solutions" and said the problem of access to health care demands fundamental reform on a national level. "The public health community's interest in access stems from the fundamental fact that if some of us are sick, the whole community cannot be healthy," Dr. Achter said. "It takes only one sick child to go to school or one person in a nursing home with TB to spread a disease to everyone else."

Grassroots collaborations tend to thrive under circumscribed conditions; namely, in communities with: relative racial homogeneity, small numbers of uninsured, stable populations, and adequate capacity in terms of hospital beds and physicians to care for the sick. "Muskegon fits all of these criteria," Dr. Achter said. "Not every community will be able to say that."

Additionally, efforts such as Access Health depend for financing on the goodwill of local institutions that may lack permanence; consequently, such collaborations tend to be short-term arrangements, at best.

Finally, Dr. Achter said grassroots community solutions rely on a culture of public-spiritedness, a factor that varies from region to region. He noted that northern states tend to have fewer uninsured. In southern and Sun Belt states, where uninsured rates are higher, grassroots collaborative efforts may be less likely to take hold.

According to the Census Bureau report, states with the highest rates of uninsured are Texas (24.5%), California (22.1%), Nevada (21.2%), New Mexico (21.1%) and Mississippi (20%). States with the lowest rates of uninsured are Nebraska (9.0%), Iowa (9.3%), Minnesota (9.3%), and Vermont (9.9%). Michigan has an uninsured rate of 13.2%.

Dr. Achter also argued that ensuring universal access to health is an investment in "human capital," the best assurance for future competition in a global marketplace. On that, advocates of Access Health might agree. For this largely blue-collar community, once a thriving industrial area now struggling back from a long downturn, Access Health is seen in part as an effort at economic development with benefits to the larger community.

Carla Morat-Hill runs Wee Care, a daycare center where three of her employees have signed on to Access Heath; an additional four new employees are expected to become members. Without Access Health, buying health insurance for her employees would be prohibitive. Yet in a field where turnover is high, Morat-Hill said participating in Access Health is a way to "raise the performance bar" for day care by attracting and retaining qualified, dedicated workers. It translates into a more stable work force -- which means better, more consistent care for the children in her charge -- and healthier workers in an industry where illness is common.

"Access Health is a benefit to our center because health care coverage improves the quality of life for the child care providers, which improves the quality of life for the children," she said.

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