Legislature ends session without health care reform

A health care reform measure slashed from House Bill 11, resuscitated in Senate Bill 306 and transplanted into House Bill 156, ultimately died in the Missouri legislature with the May 15 session end, along with the hopes of business leaders, hospitals and the working poor.

In the meantime, St. John's Hospital in Springfield is facing the problem of health care for the uninsured head-on through Project Access, a program aimed at providing care for patients with chronic conditions - outside of the emergency room.

As to whether there is hope for the plan next session, "I think that really is going to be determined by the temperament of the House and the Senate relative to compromise," said Dave Dillon, Missouri Hospital Association spokesman.

Post mortem: free money for health care

Through a unique agreement between Missouri Gov. Jay Nixon and the MHA, association members agreed to voluntarily contribute $52.5 million a year to provide health care coverage to almost 35,000 working Missouri parents.

The plan, endorsed by business interests including Associated Industries of Missouri and tied to the state appropriations bill, HB 11, would have generated an additional $93 million in matching funds from the federal government with no additional taxes on state taxpayers.

AIM supported the original proposal in HB 11 and the proposal in SB 306 as presented by bill sponsor Sen. Tom Dempsey (R-St. Peters), because the cost of uninsured care is ultimately passed on to those who pay for health care, particularly businesses.

Health care coverage for more people is good business, according to AIM leaders.

"First of all, they'll go and seek treatment earlier, with more reasonable costs of health care, but also, we won't have people showing up at emergency rooms where the care is most expensive, and then socializing that cost among the people who are paying for their health care, either directly or through their health insurance," said AIM President Ray McCarty.

As originally proposed, the MHA-backed financing would have allowed the state to raise the income level for Medicaid eligibility from 20 percent of the federal poverty level - about $3,700 per year for a single mother of two and $4,410 for a family of four - to 50 percent of the federal poverty level, or about $9,155 for a single mother of two and $11,025 for a family of four.

Contention regarding how the money should be spent led to irreconcilable differences that threatened to derail the appropriations bill. The measure was excised from HB 11, and the focus shifted to SB 306, which would have created the Show-Me Health insurance program. The House and Senate versions of SB 306 were not created equal, and had the House version prevailed, MHA likely would have withdrawn the offered funding, Dillon said.

"(Hospitals) are sacrificing money that they would be assured to receive for care for the uninsured," Dillon said on May 14, while the measure was still being considered. "They're not willing to give up that money that normally would go to the uninsured if it, in fact, is not used efficiently."

The House version of SB 306, which would have covered the uninsured or uninsurable through the state's high-risk insurance pool, "violates about every agreement that we've had on using hospital funds to fund this health care expansion," Dillon said, failing to efficiently serve the population MHA wanted to target - working poor parents.

"I'm sure to most people who are really engaged on this subject, this is kind of a no-brainer," Dillon said. "But it really hasn't proven that way."

Moving forward at St. John's

St. John's Hospital in Springfield is one MHA member that supported the legislative effort to aid the uninsured, but while that solution has failed, St. John's continues to move forward with its own initiative.

"We regret that the plan has failed," said Cora Scott, St. John's director of media relations, "but the bottom line is we'll continue to take care of people who need care and continue finding as many different ways as we can to manage the care of people who need health care."

To that end, St. John's has launched the Project Access Emergency Room Demonstration Project, bringing medical management to patients who repeatedly access the ER with chronic conditions, including heart disease, diabetes and asthma.

"These are particularly the individuals who need primary care," said Ann Cave, vice president of St. John's Health Plans Medical Management Services.

Enrollment in Project Access began in November. Participants in the pilot program are those with chronic disease diagnoses who visited the ER three or more times the previous year, Cave said.

Participants must meet certain requirements, including being uninsured and earning at or below 150 percent of the federal poverty level - $33,075 for a family of four.

Project Access participants meet with a case manager and a disease management nurse, gain access to St. John's 24-hour nurse-on-call and medication access programs, and are matched with a primary care physician.

Project objectives include decreasing ER use for nonemergency care by 50 percent among enrolled patients, and measuring and evaluating improvement in enrollees' health.

Project Access also looks beyond the health care setting with objectives of assessing patients' medical and social needs, and developing a network of medical and nonmedical partners to meet the needs of the uninsured. The program, initiated by Janet Pursley, now executive vice president of care management services for Mercy Health Plans, is funded through a $50,000 Mercy Caritas grant. Enrollees pay a small doctor's office co-pay, typically $5 or $10.

While it is still early in the process, Cave said the program already is generating hard and soft savings.

Hard savings are calculated on ER visits averted as patients manage care through their primary care physicians, case managers, disease management nurses, or the 24-hour on-call-nurse program.

"To date on that - and we're very conservative in our calculations - (hard savings) are just under $25,000," Cave said.

Soft savings, tangible but difficult to measure, result from practices as simple as referring patients to medication management and providing access to a primary care physician. A comprehensive evaluation of Project Access outcomes will take place at the one-year mark.