State Health Plan 2011-2016 Access To Care Workgroup

1. State Health Plan 2011-2016Access To Care Workgroup Troy Alexander Texas Department of State Health Services Director, Centers for Program Coordination, Policy, and Innovation February 19, 2010

2. Presentation Purpose • To share preliminary thoughts on workforce implications with respect to access to care • Not a comprehensive review • Seeking input on missing gaps

3. Presentation Outline Uninsured Health Disparities Access To Care Primary Care & Beyond Various Populations

4. 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

5. 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

6. Uninsured Population, Total 5.4% - 11.1% 11.3 - 13.2% 13.6% - 16.2% 16.6% - 25.2% Source: Kaiser Family

7. Uninsured Adults, 19–64 Years 7.3% - 14.4% 14.4 - 17.8% 17.9% - 21.6% 21.8% - 31.5% Source: Kaiser Family

8. Uninsured Children, 0-18 Years 3.2% - 6.5% 6.7 - 9.1% 9.3% - 11.4% 12.0% - 20.1% Source: Kaiser Family

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. Health Disparities Uninsured Health Disparities Access To Care Primary Care & Beyond Various Populations

16. 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

17. 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

18. 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

19. Health Disparities in Texas • Diverse population • Population increasing faster than the national rate

20. Health Disparities in Texas • In 2009, the majority of the state’s PC physicians were White • Blacks and Hispanics have historically been under-represented

21. Health Disparities in Texas • Disproportionately impacted by already existent workforce shortages • Exacerbated by shortages of culturally competent workers for disadvantage populations

22. 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

23. 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

24. 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

25. Primary Care & Beyond Uninsured Health Disparities Access To Care Primary Care & Beyond Various Populations

26. 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

27. 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

28. 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

29. 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)

30. 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

31. 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)

32. 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

33. 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

34. 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

35. 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

36. 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.

37. 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

38. 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

39. Findings: Behavioral Health Professionals • 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.)

40. Findings: Behavioral Health Professionals • 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

41. 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

42. Findings:Behavioral Health Professionals • 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

43. Findings:Behavioral Health Professionals • 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

44. Presentation Discussion Uninsured Health Disparities Access To Care Primary Care & Beyond • Persons with Disabilities • Rural Population • Children and Adolescents • Elderly Various Populations

45. 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

46. 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

47. Findings:Persons with Disabilities • Need for Transition medicine • Disparities between Children’s Medicaid and Adult Medicaid programs • More study needed in this subject area

48. 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

49. 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

50. 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