Happy birthday to you! Happy birthday to you! Happy birthday Beats Per Minute….Happy birthday to you!

It is fitting that your first birthday (and your future ones too) fall around the time of the Martin Luther King Holiday.  Dr. King’s themes of social justice ring true in over 130 posts during your first year.  Just look at the topic tags to the right of this post to see what you have covered:  health care reform, the Illinois budget crisis, childhood obesity, community health, dental services, care for the uninsured and a lot more.

Your first year was a chronology of the challenges we face in health care both locally and nationally. Here are a few examples of the issues you raised and what’s happening now.

Last winter, the H1N1 flu epidemic raged. Erie’s pediatric services were stretched to the limit.  Just nine months later, Erie opened our first pediatric urgent care services with evening and weekend hours to provide more same day services to kids.  Just about the same time, the flu is back with widespread activity in Illinois.  This time it’s not so much H1N1.  Its cousins H3N2 and Influenza B have joined the scene. Luckily, this year’s flu vaccine seems to cover the flu viruses which are now circulating in the community. 

Similar to a flu epidemic, the Illinois budget crisis caused a year long malaise. During 2010, Illinois delayed or held hundreds of millions of dollars in payments to health care providers.  Only last week did the General Assembly vote to raise the income tax from 3% to 5% for individuals. Businesses sustained a hike as well.  This may help resolve the budget fiasco by bringing urgently needed cash to State coffers, but what about long term solutions?  Legislators also voted to move Illinois Medicaid significantly more towards managed care within 5 years. This means more Medicaid HMOs and more accountable care in Illinois. It could be a good thing for health care quality if the design is right.

While Illinois may be moving more towards managed care, the nation as a whole engaged in a passionate debate about health care reform.  The Affordable Health Care Act for America passed along starkly partisan lines in Congress. Almost one year later, insurance companies can no longer deny coverage due to pre-existing conditions, young adults can remain under their parents’ insurance coverage until age 27 and many other provisions are taking hold. For example, new health plans must provide cost-free preventive services and there can be no lifetime cap on benefits for costly treatments such as cancer.  There is a move in the House of Representatives to repeal health care reform, which doesn’t have much of a chance in the Senate or on President Obama’s desk. I’m sure Beats per Minute will cover this widely in 2011!

While the debate over health care reform rages in Washington, in the neighborhoods that Erie serves, the struggle continues to address health issues most impacted by social justice inequalities.  In the Humboldt Park neighborhood, classic diabetes research is being done as the Block by Block project attempts to describe why diabetes is at epidemic levels in the neighborhoods served by Erie.  Meanwhile, researchers in childhood obesity collaborate with Erie physicians to collect data to find out what works to reduce this epidemic which certainly leads to more teen and adult-onset diabetes.

Whatever the health topics may be in your second year, Beats Per Minute, I hope you take a minute to make a wish and to blow out that first candle.  Job well done! There is stillmore to come, readers – so read on!

It’s not every day that a nationally known figure parachutes into your health center.  But that is what happened yesterday when Dr. Donald Berwick, President Obama’s  Administrator for the Centers for Medicare and Medicaid arrived to check out Erie Family Health Center’s West Town location.

Dr. Berwick is nationally known for his work to improve health care quality.  As a founder of the Institute for Health Care Improvement, a pediatrician, and a professor at Harvard, he knows first hand how to move health care quality in the right direction.

Dr. Berwick is all about providing better health care at lower cost. I think that is what community health centers are about.  So his visit was a good philosophical match.

As he walked through Erie yesterday he stopped in the waiting area to talk to a new dad with a 4 day old daughter asleep on his lap. He peeked in at our new construction which will bring 7 more medical exam rooms and pediatric urgent care to Erie West Town Health Center.  And he had lots of questions about how we share information via our electronic health record system in order to improve quality. He seemed most impressed by our call center operations where our operators handle up to 2,000 phone calls per day, an important link in the health care quality chain.

As health centers expand over the next few years, showing quality outcomes will continue to be an important ingredient to our success and can serve as an example of best practices in primary care delivery.

We welcome Dr. Berwick to parachute back in any time.  We all have much to learn from his career and his leadership.

Can you say “rollercoaster?” 

Ok:  “Rollercoaster!”

Last week Governor Quinn announced $1.4 billion in cuts to the Fiscal Year 2011 (FY11) state operating budget.  These cuts and the rest of the budget went into effect July 1, 2010.   We now have a little more information on what this will mean to community health centers in our state, including the impact on Erie Family Health Center.

We could be talking a big impact here as community health centers in our state now serve over 1 million patients in Illinois.  A recent Perspectives article in the New England Journal of Medicine notes that 7.6% of Illinois residents receive their health care from a community health center like Erie (tops is West Virginia, 19.1%, bottoms are Minnesota and Virginia, 2.9%).

Before we get to the state’s FY11 budget, it’s important to note that there is still unfinished business from FY10.

Illinois ran in the red to the tune of $13 billion in FY10.  Needless to say, payments to vendors are way behind.  Springfield currently owes Erie payments for services already provided in high risk case management for pregnant women, breast cancer prevention, and oral health services. That’s for last year.  Erie is in the same boat as many other state vendors as Illinois tries to figure out how to pay the nearly $6 billion in back payments for FY10. The state comptroller says maybe service providers will (maybe) get last year’s payments by December.

According to Jill Hayden at the Illinois Primary Health Care Association, in the Governor’s introduced budget, the Department of Public Health (IDPH) was to take a $13 million cut from the FY10 appropriation.   IDPH traditionally has offered competitive opportunities for health centers to expand services with 3 to 4 year jump-start grants.  Under this most recent announcement, the Department is to take a $17 million cut plus another $7 million to be held in reserve – resulting in the following: all funding is eliminated for downstate and rural health grants; community health center new expansion grant opportunities are cut, existing health center expansion grants are cut to 50% of promised funding.

Additionally, the Illinois Department of Human Services will have fewer dollars to grant in FY11.  Erie anticipates cuts in family planning and high risk pregnancy case management funding.

Last night, Erie Family Health Center’s Board of Directors passed our FY11 budget.  Built into the budget were our best predictions for State of Illinois budget cuts and payment delays.  We are continuing our case management services, family planning, and oral health services by using innovative strategies to adjust.  Our budget process this year was incredibly tough as we worked closely with our dedicated Board of Directors to create out of the box methods of balancing our own budget to ensure services continue for our patients.

As we move forward into FY11, the roller coaster for community health centers and other state agencies continues. When will we receive our payments for services rendered last year? What will happen after the November elections? How can we continue to meet the growing demand for health care when our funding continues to be cut? The ups and downs of the state budget crisis did not end last week when Governor Quinn signed off on the budget. And this roller coaster will keep going until Illinois is able to present a budget that balances revenues and expenses, while still maintaining vital services such as health care. Until then, Erie will continue to implement innovative strategies to ensure that our patients receive the quality care they need and deserve. As always, we stay tuned and hope for the best.

“This really means so much to him not to have to pay so much,” McCormick explained.  “George uses about 2 bottles of insulin per month and he was paying retail prices of about $55 per bottle at a large chain pharmacy.” 

George is one of the first Erie patients to take advantage of the new 340B discounted pharmacy services which Erie is offering in partnership with Pharmacy One, a local pharmacy right next door to Erie Helping Hands.

In 1992, Congress created the 340B Drug Pricing Program.  This allows health care providers serving low income populations, such as federally qualified health centers like Erie, to purchase medications at deeply discounted prices. Health centers can then pass these savings along to patients who have no health insurance.

“We decided we would partner with local mom and pop pharmacies close to each of our large sites,” explained Zizi Atia, Erie’s Chief Financial Officer who helped push the program through.  “The mom and pops tend to speak our patients’ languages and offer education and counseling.” 

This is how this program works:  using a list of medications approved by Erie’s pharmacy committee, Erie purchases medications from a special federally approved vendor at a deep discount.  The medications are shipped directly to the pharmacy, where they are dispensed to patients as Erie providers write prescriptions.  The patient pays cost and the pharmacy adds a reasonable dispensing fee to cover processing costs.  Each month, Erie and the pharmacy reconcile the books and replenish supplies. To qualify for the program, Erie’s patients may not have any other source of insurance coverage for medications.  When all is tallied, the discount from the average retail pharmacy price is more than 50% per medication, even if it is brand name and not generic.  With generic medications, the prices are even lower.

The 340B program will soon be launched at other Erie sites, adding to the menu of pharmacy services Erie already offers to help patients access affordable medications.

It’s not unusual for patients to forgo taking needed medications. For example, a recent study revealed that only 34% of all patients being treated for high blood pressure have their condition under control.  “One reason is poor adherence to medication regimens and one reason for that is the sheer expense of the treatment,” according to David Buchanan, Erie’s Chief Medical Officer. 

Who knows what “340B” actually means in government speak.  But one thing is for sure: it means more Erie patients will be able to afford their medications.

“George has now switched all his other meds into the 340B program, “McCormick beamed.  She can’t wait to replicate the success with more of her patients.

Millions more to seek primary care by 2014

With the ink of President Obama’s signature barely dry on the Patient Protection and Affordable Care Act, a transformation is about to happen over the next decade.  For the first time in our country’s history, there will be a major effort to make health insurance available to almost all Americans – nearly 32 million will be added to the health insurance rolls. 

Most community health centers like Erie care for high volumes of patients without insurance (34% at Erie) or covered by Medicaid (62% at Erie). Medicaid is the federal-state partnership to provide health care coverage for those living at the federal poverty level or below.  Starting in 2014, some 16 million more people  will become eligible for Medicaid as the income limits to qualify are raised from 100% of the federal poverty level (about $22,000 per year for a family of 4) to 133% of the federal poverty level (about $30,000 per year for a family of 4). 

Where will 16 million more Americans seek health care?  Community health centers already serve almost 20 million Americans; over a million in Illinois and over 600,000 in the Cook County area.  Located in neighborhoods and towns which are some of the most medically underserved and economically challenged in the country, community health centers are perfectly positioned to expand services. 

Placing a brand new Medicaid card in the hands of millions will not solve the daily challenges people living in poverty face every day:  challenges in literacy, joblessness and lack of transportation.  Although the health care reform bill makes efforts to pay private doctors better for seeing Medicaid-covered patients, many private physicians, private physician groups and university-based practices do not accept or severely limit access for Medicaid patients.  A massive increase will be needed in primary care capacity at the community level. 

Overall, this is good news for community health centers.  Many health center patients who have no health insurance will now be eligible, either for Medicaid or for more affordable insurance through their employer or purchased on their own.  Let’s not forget, that another 16 million Americans will get on the health insurance bus through insurance exchanges, employer-based insurance and other means. 

More bricks and mortar are needed

The health care bill provides $11 billion in new funding for the health center programs over the next five years.  Health centers successfully competing for these funds will be able to expand.  Expect 20 million more people to access high quality, culturally competent behavioral, medical and oral health care at community health centers over the next 10 years – a doubling of the current capacity.

There’s not enough primary care work force

Currently, there simply is not enough primary care doctors and advanced practice nurses to meet the coming demand.  The health care reform bill provides funding for health centers to become teaching centers for the next generation of primary care doctors. Erie is already launching a training program sponsored by Northwestern McGaw Medical Center and Norwegian American Hospital.  Within 3 years, twenty-four family physicians-to-be will be in training at Erie.

Once physicians are trained, they need an incentive to work in medically underserved communities.  Many graduating medical students carry the burden of well over $100,000 in school loans.  The health care bill includes $1.5 billion over the next 5 years to expand the National Health Service Corps, a loan repayment program for doctors who choose to practice in medically underserved areas.  This initiative will place an additional 15,000 primary care doctors, nurse practitioners, dentists, and behavioral health specialists in communities of need.

Will community health centers vanish?

With the demand for primary care services increasing by 32 million over the next decade and low acceptance of Medicaid amongst healthcare providers, the need for community health centers has never been greater.

Push the throttle forward, fasten seat belts and get ready for take-off!

For many, it feels like the flu has gone away. Away from the headlines on TV, the web, radio.  Away from the ERs and health clinics.  After H1N1 influenza ravished an unprepared America in the late spring 2009, and again in the fall and early winter, it has basically disappeared.  But should we let down our guard and stop worrying?

It’s true that most areas of the country are reporting either no or only sporadic (Illinois) flu activity. The most activity is in the South and in Maine.  All of it is well below epidemic levels and it’s all H1N1, not other strains of flu virus that we sometimes call the “seasonal flu.”

Despite the media’s doomsday reporting around H1N1, it caused relatively mild illness for most people.  Although this mild-mannered virus caused the deaths of thousands, which is significant, it could have been much worse.  The pandemic H1N1 of 1918 killed almost 500,000 in the US and at least 50 million world-wide.  This past year saw a much more tame H1N1 statistics. According to the Centers for Disease Control and Prevention, “from August 30, 2009 to March 6, 2010, 2,042 laboratory-confirmed influenza-associated deaths were reported to CDC,” including 277 children. Estimates say that up to 14,000 actually died since not all patients had lab confirmed tests.   By contrast, the seasonal flu normally kills some 36,000 Americans annually. 

Even though the impact of H1N1 could have been much worse, we still need to be prepared. H1N1 could come back, either soon, or next flu season. Young adults, children, pregnant women, as well as those with chronic illnesses are at a higher risk for more severe flu symptoms.

That’s why the expert panel that makes recommendations to the CDC has decided to include the H1N1 virus in next year’s seasonal flu vaccine.  This year, we all faced the task of receiving two vaccinations: H1N1 and the seasonal flu vaccine. Next year the vaccination will be a single seasonal flu shot, with a mixture of several different flu strains. 

Erie Family Health Center was a leader in providing H1N1 vaccinations this flu season, providing over 5,000 vaccines to children, more than 850 to pregnant women and over 700 to chronically ill adults. Erie opened its doors and made it easy for patients, relatives and others to walk in and receive a vaccination.

Haven’t yet gotten an H1N1 shot?  Should you still get one?  Yes.

The CDC is now encouraging everyone to get vaccinated.  This could give you a head start even if the flu season is over for this spring, since H1N1 may come back before the 2010-2011 seasonal vaccine is available next fall.  Supplies of H1N1 vaccine are still readily available – so it is not too late!

Flu prevention business is a tricky one.  Every year, we are reminded to wash our hands and cover our cough, while public health experts try to outguess Mother Nature and predict the best vaccine.  We know that the TV weatherperson has a difficult time telling us if it is going to rain, snow or be sunny tomorrow—and predicting the patterns of a virus is even more complex.  H1N1 is still smoldering in certain parts of the country.  We should be worried and prepared for the flu if and when it decides to return. 

For weekly updates on the flu, visit flu.gov.

They way I look at it, the health care “pie” is divided into three slices.  The first slice is primary and preventive care like Erie provides, a good deal as you’ll read about below.  The second is both basic and sophisticated outpatient testing such as x-rays, mammograms, CT scans and MRIs, to which Erie arranges affordable and deeply discounted linkages with partners.  The third is the most expensive—hospitalization, surgery, rehabilitation—and Erie provides linkages as well.  And I’m not even going to touch the issue of long term care (a whole other pie).

Health care reform pie is on a lifeline in Washington, DC, and cost is of high concern.  Meanwhile, around the country, at over 1,200 health centers like Erie, data staffers hit the send button this week and uploaded information for 2009 on the 20 million medically disadvantaged people cared for at community health centers.  The fix is in, and the data show that health centers provide very cost effective primary care and preventive services. 

I’d like to show some of Erie’s results is example.

Over 33,000 patients now access primary care services at Erie. Perhaps an indication of our economic times, the number is up 10% from a year ago. And patient visits climbed accordingly, to 142,000 in 2009, up 7% from 2008.

Our annual report to the feds allows us to calculate the average cost to provide a year of health center services to an Erie patient: $700 per year, or $59 per month, or $1.94 per day. This includes unlimited doctor visits, laboratory services, counseling, case management, oral health care, delivering your baby, 24/7 answering service and coordination of care with our hospital partners. Erie competes for federal grant dollars to help support the 34% of our patients who are uninsured.  The annual cost to the feds per uninsured Erie patient is $360—less than a dollar a day.

If you like a bargain, you are thinking – good deal!

A recent report by Lo Sasso and Bryck in the journal Health Affairs  predicted that for every $500,000 additional funds a health center receives, 540 additional patients can be served — $925 per patient per year, $2.50 per day.  Erie is doing better than the national average.

It’s that first slice of pie, the $1.94 per patient per day for primary care, which has the most potential to prevent over use of the other two slices.  The other two slices are super expensive, their costs are rising, and they are breaking our health care system.

As negotiators try to resurrect health care reform in Washington, they should keep an eye on health centers as a cost-effective and expandable slice of the health care pie. We are ready to do more.

With partners Northwestern University Feinberg School of Medicine and Norwegian American Hospital, the program will accept its first class of eight resident physicians in July 2010.  By July 2013, twenty-four residents will be in training, completing their out-patient clinical duties at Erie Family Health Center and their inpatient training at Norwegian. These residents will also have access to specialty rotations at other hospitals, including Children’s Memorial Hospital and Northwestern Memorial Hospitals. This program is unique in that students will complete a high quality training program that is university affiliated but based within the underserved communities of Chicago.

The needs of community-based health care are changing and a new generation of high quality, exquisitely trained family physicians are needed for the medically underserved.  I like to call it training the next generation of “urban combat” primary care physicians who will choose to build their practices in the same neighborhoods in which they trained. 

What is an “urban combat’ primary care physician you ask? First, the students will be immersed within the community. This urban experience will take them outside the confinement of university walls and into the heart of underserved communities. And combat, because delivering quality health care in under- resourced areas requires the savvy and skill of veteran soldiers. A partnership between a world-renowned academic institution, a long-standing community hospital and a community health center is going to be a winning combo to train a force of “urban combat” physicians.

This project is not without challenges, however.  Will enough medical students be drawn to such a unique training program?  Will the surrounding community embrace this new partnership?  And, will graduating residents choose to plant their roots in medically underserved communities?

I hope that you will continue to tune into Beats per Minute as the details and news unfold for our new Residency Program. Erie is thrilled to be partnering with Northwestern and Norwegian on this innovative program that will train our future community health care leaders and physicians.

Unless we increase our health care system’s capacity to provide primary care services, adding 30 million more health care consumers into the system will be like cramming crowds of primary-care-seeking subway passengers onto an already packed health care train.  There’s not enough primary care capacity to satisfy the new demand.

For one thing there is a projected 10% shortage of primary care doctors by 2020. Some are predicting a perfect storm whereby the supply of pediatricians is good but the supply of other primary care doctors, such as family physicians and internal medicine doctors, is bad; this will create a care provider shortage for adults, just as more adults become insured.

For another, there are 1,200 community health centers nationwide with 7,000 service locations caring for 20 million patients.  Most of the newly insured under health care reform will be low and middle income individuals. In addition to the patients we care for today, add dad, mom, sister and brother, cousin, aunt or uncle.

Many more adults will seek health care, and they will seek it in the very communities in which they live – neighborhoods, towns, locations where community health centers exist. Research at George Washington University has suggested that health centers could double their capacity by 2019 in a cost-effective manner. This is largely due to the fact that health centers will see less uninsured patients and more with Medicaid coverage. Medicaid pays community health centers well in most states.   Of the 30 million newly insured, 15 million will be new Medicaid recipients.

Expanding community health centers is a cost-effective and sensible part of the solution to the primary care shortage.  Why?  A health insurance card alone will not solve all of the determinants of poor health.  Public health experts say that poor health status is tightly linked to low family income, education level, and literacy, among other things. These are our patients, the ones we are experts in serving.  I doubt they will be willing or able to travel far outside the community to seek health care.  The conditions are ripe for community health centers to double their capacities nation-wide over the next decade so new consumers of health care can receive culturally competent care close to home.

We stand ready to do more.

Welcome to Beats Per Minute!

Welcome to Erie Family Health Center’s brand new blog, Beats Per Minute! We are thrilled to embark on this journey in social media, building upon our other sources of new media, such as Twitter and Facebook. As one of the few community health centers in the nation to launch a blog, Beats Per Minute will provide you with news, resources and information on areas of interest impacting Erie and our community.

You can visit Beats Per Minute frequently to receive up to date news about Erie, community based health care and the fragile safety-net. Whether you’re interested in learning about new Erie events or reading about the latest research on care for the uninsured, Beats Per Minute is the place to be! Erie hopes that through these posts we can share with you – the reader and Erie friend – information about Erie Family Health Center and all the news that affects the populations we serve.

You can even tune in every Wednesday afternoon for our Health Beats segment, which will bring you the top five health stories of the week!

Beats Per Minute will be updated by a team of bloggers from within Erie: you can learn more about our writers, Ginny, Jaclyn and Steph by clicking on About Us. You can also look forward to reading posts by Erie medical providers and support staff.

Don’t be overwhelmed by the amount of digital information blanketing the blogosphere. Beats Per Minute is your safety zone for focused and innovative thinking about community based health care delivery, cutting edge health care news and clear explanations in the setting of challenging times.  Won’t you join us?