Making Georgia's health system more efficient and effective : final 2017 report of Georgia's Health Care Reform Task Force

Making Georgia's Health System More Efficient and Effective: Final 2017 Report of
Georgia's Health Care Reform Task Force
January 8, 2018

Task Force Members
Honorable Casey Cagle, Chair Lt. Governor of Georgia Honorable Dean Burke Senator, District 11 Honorable Jack Hill Senator, District 4 Honorable Chuck Hufstetler Senator, District 52 Honorable Kay Kirkpatrick Senator, District 32 Honorable Michael `Doc' Rhett Senator, District 33 Honorable Renee Unterman Senator, District 45 Honorable Ben Watson Senator, District 1
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TABLE OF CONTENTS
About the Task Force........................................................................................................................ 4 Introduction...................................................................................................................................... 5 Challenges Facing Georgia's Health System .................................................................................... 6 The Way Forward ........................................................................................................................... 10 Recommendations ........................................................................................................................... 12 Appendix I: Task Force Public Meetings ........................................................................................14 Appendix II: Federal Funding Opportunities for State Health Reform.........................................16
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About the Task Force
In January 2017, Lt. Governor Casey Cagle created Georgia's Health Care Reform Task Force with Senate leadership as a first step to develop a collaborative state-wide effort to slow the rising cost of health care, improve access to medical services, and provide consumers with better health coverage choices.
"It's up to us to find solutions that allow hardworking Georgians to keep more of what they earn and get quality care that leads to healthy lives. As our work with the Health Care Reform Task Force unfolds, we must act boldly to help the many Georgians especially those across our rural communities who are struggling because they don't have access to affordable insurance they can use. By leading with a strong vision to create a high performance health care system, we can unite stakeholders in every community of our state to innovate and lower the costs of care, premiums, and deductibles so that all our families have access to the care we need, at a price Georgians can afford." Lt. Governor Cagle
The Task Force is guided by four key principles:1
PATIENTS FIRST: The doctor-patient relationship is paramount. Reforming our health care system will make certain that Georgia's citizens receive high quality care from the doctors they choose. We will ensure every decision rests with the individual, not a network of bureaucrats.
PATIENT DRIVEN: Health insurance should be personalized to meet the needs of individuals and their families. Increased flexibility will allow for providers and doctors to innovate and offer their patients higher quality care at lower costs.
PATIENT ACCESS: People need access to health care choices that fit their needs and budgets. Reform will increase diversity and options for care in the marketplace so that all consumers can best determine the right policies for themselves and their families. Georgia's taxpayers should not be forced to shoulder the burden for federal mandates.
PATIENT-SPECIFIC: With more than 330 million people across our nation who each have very different health care challenges, we cannot afford to sustain one-size-fits-all insurance policies. Georgia's leaders are closest to the people who we serve and best suited to meet the evolving challenges our citizens face. Medicaid funding should be realigned to stretch our limited dollars further and provide the highest quality of care to those who need it most.
One-size-fits-all policies are not the solution to the many health challenges facing Georgians. Reforms must be tailored to the specific needs and capabilities of each community. After hosting a series of meetings across the state hearing presentations from experts and discussing solutions for the most pressing issues facing Georgians the Task Force has concluded that our state must create a permanent state-wide forum to develop innovative market-based reforms to improve the health and health care of Georgians. Consumers, providers, health systems, payers, employers, state and local governments, and others should join together to target the most acute problems with a strategic plan to address them. In addition to bringing together all levels of Georgia's health system, this strategy will cut duplication, streamline government, and result in net savings for our state's taxpayers.
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Introduction
The American health system has undergone significant changes over the past decade, but it remains burdened by excessive cost, inefficiency, and uneven quality of care. Pressure on our health system has continued to grow with an aging population, the epidemic of opioid addiction, the need for more efficient ways of providing mental health services, the difficulty of ensuring access to appropriate care in rural communities, and the challenge of paying for new generations of highly effective but expensive treatments for life-threatening diseases. New approaches to health care delivery that promote primary and preventive care and reduce pressure on hospital emergency rooms are needed to slow rising costs, improve access to appropriate services, and give patients better choices.
Georgia has an opportunity to develop new strategies to meet the health needs of every region, county, and community across our state. A collaborative approach that combines the ideas and efforts of the state, health care providers, insurers, employers, consumers, and other stakeholders is essential to the success of health care reform. The Task Force is the first step in this effort to develop reform proposals that can reduce health care costs and strengthen the doctor-patient relationship. These initiatives will focus on market-oriented policies that promote patient choice, better health insurance options, improved access to necessary services, and higher quality care.
The impact of such reforms is not limited to our health system. Better care at a lower cost can spur economic development. State agencies can find ways to work toward common goals and improve coordination with private sector reforms, moving past long-standing challenges with technology, data integration, and improved coordination.
Georgia has significant advantages in creating a more sustainable and effective health care system. Some of the best hospitals and universities in the country are located in Georgia. Major health systems in our state have invested in their own delivery reforms, including the use of telehealth and innovations to deliver care more efficiently. The need for reforms that fit local circumstances rather than a one-size-fits-all approach is broadly accepted by stakeholders statewide.
There is new willingness on the part of the federal government to provide flexibility to states proposing to reform their health systems. Waivers allow states to test new approaches in implementing federal programs that differ from current federal rules and ease some restrictions that would otherwise interfere with state reform objectives. Waivers can allow better coordination between government programs and private initiatives to improve health care. States now have the opportunity to reform their health insurance markets by applying for a state Innovation Waiver, also known as a Section 1332 waiver. The federal Centers for Medicare and Medicaid Services (CMS) is seeking new partnerships with health care providers, clinicians, states, payers, and other stakeholders to shift from a fee-for-service system to one that holds providers accountable for outcomes and allows them to innovate.2 In addition, states can implement market-based, patientcentered solutions for their Medicaid programs through Section 1115 demonstration waivers.3
The success of Georgia's health reform depends on the active collaboration and participation of key stakeholders from across our state. A crucial first step is establishing a Health Coordination and Innovation Council that will begin to shape a blueprint for action to promote local initiative within a broader strategy that includes reforms at the regional and state level. Building on these early efforts, the Council will shape new proposals to take advantage of federal resources and new flexibilities in the way health programs operate. Every day, Georgia's families and businesses sit down and figure out how to get better results at a lower cost. State government can and must be held to the same standard, particularly for such a major piece of taxpayer spending. These changes
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will all be accomplished using existing resources, and will not result in any growth in the cost or size of state government.
Challenges Facing Georgia's Health System
Health and health care are leading concerns throughout Georgia. A healthy population is the basis for economically and socially vibrant communities. A well-functioning health care system that provides the right care at the right time in the right place is critical in promoting the health of Georgians. Health reform that promotes efficient and effective care is a necessary step in improving the health status of our state's population. Greater public awareness of what each person can do to improve his or her own health is equally important in achieving that goal.
With over 10.4 million residents, Georgia is one of the most populous states in the U.S., and the health and health care of our communities has important implications for the state and the nation.4 However, Georgia's performance on several rankings of state population health lags behind the U.S. average.
Georgia ranks 41st among the 50 states in the United Health Care Foundation's report, America's Health Rankings 2017.5 In the Commonwealth Fund rankings of state health system performance, Georgia was also rated 41st in 2017.6
A snapshot of the health of the average Georgian helps explain why our state rankings are low.
31.4 percent of adults in Georgia are obese, and the adult obesity rate has tripled since 1990.7
Nearly a third of teens and pre-teens are either overweight or obese.8 29.4 percent of adult Georgians are physically inactive.9 36.2 percent of adults have hypertension.10 The number of heart disease cases is expected to more than quadruple over the next two
decades.11 11,700 adults in Georgia die from smoking-related illnesses each year, costing over $3.2
billion annually in health care expenditures.12 Georgia ranks among the top 11 states with the most prescription opioid overdose
deaths.13 14 percent of nonelderly Georgians were uninsured in 2016 compared with 10 percent in
the U.S.14
Health system reform can improve access, quality, and cost of care through greater coordination across providers and sites of care. Reform must also make better use of existing resources, including currently-untapped assets that can provide targeted help to address specific health needs. The State of Georgia should set a clear direction for reform and act to better coordinate and streamline state agencies and regulation. However, the bulk of the work must happen in the local communities, with active efforts by providers, health systems, employers, consumers, and others to shape the health care they want and need.
Private and public sector initiatives have been undertaken over the years to address critical issues in our health system. Those issues include insufficient access to care in rural areas, promoting primary and preventive services to reduce preventable use of acute care services (including emergency room use), improvements in mental health services, and the growing crisis of opioid addiction. The progress that has been made will provide a foundation for new efforts to address existing and emerging health problems.
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Rural Health
Rural Georgia communities are losing their capacity to support the health needs of their residents. Hospital closures, health care workforce shortages, and limited access to preventive services jeopardize rural residents, particularly older Georgians with chronic conditions. New models of health care delivery are needed that are more flexible, less capital-intensive, and that take advantage of new technologies to deliver care in a timely and efficient manner.
A recent survey of rural Georgians confirms the difficulties they face in obtaining health services.15 The biggest concerns revolved around the cost of care and access to services. Rural populations are less likely to have insurance and less likely to have a doctor within a reasonable distance from home. Even those with coverage may have to travel long distances to reach an in-network provider. When medical services are available, too many patients have concerns that the quality of care may be inadequate.
Telemedicine and telehealth could increase access to health care for many Georgians, particularly those in rural areas where specialized medical care is often sparse.16 According to the Georgia Board for Physician Workforce, 51 percent of Georgia's physicians serve 29 percent of the population.17 Our state also ranks 40th in the nation for distribution of doctors by specialty and geographic location.18
The Georgia Partnership for Telehealth was established in 2006 as a statewide collaboration among policy makers, health care providers, and patients.19 Telehealth provides physicians with a convenient and efficient way to refer patients to a specialist or subspecialist for medical advice and treatment. This partnership operates in conjunction with providers across the state and allows patients to receive personalized care without incurring the time and expense of traveling.20
The state Office of Telehealth and Telemedicine is also working to establish a sophisticated telemedicine network to bring specialized care to underserved areas of Georgia. Counties across Georgia currently have telecommunications connections to provide common telehealth services such as nutrition counseling, breastfeeding education, HIV consults and many more services to clients in remote areas using two-way, real-time technology. The state Department of Public Health is working to give this network greater capacity to deliver a wide variety of telemedicine, including medical services such as dental care, pediatric neurosurgery, asthma clinics, and monitoring for high-risk pregnancies.21 This system would save time and money for patients, providers, and public health staff, while serving as a method to increase access to specialized health care for those most in need.
During the 2016 and 2017 legislative sessions, the General Assembly took action to create a Rural Hospital Tax Credit program to facilitate donations to assist distressed rural hospitals. To increase the effectiveness of this program, Lt. Governor Cagle formed Rural Healthcare 180. Rural Healthcare 180 encourages individuals and businesses to directly donate to one of the financiallystressed rural hospitals in Georgia in exchange for up to $180 million in tax credits. Made up of business leaders, policymakers, and public institutions, the Rural 180 Task Force has worked to build a strong base of support behind Georgia's struggling rural hospitals, while studying solutions to improve both system performance and individual health outcomes. Importantly, Rural 180 has laid the groundwork for greater involvement from Georgia employers to serve as partners in developing ideas to improve access to quality care and innovative health care technology solutions. This past year, the program expanded to include 9 additional rural hospitals in counties with populations less than 50,000 residents extending this lifeline to 58 hospitals in 2018.
Additional strategies are needed to address the rural health problem. For example, networks of hospitals, health care systems, and physicians can work together to deliver cost-effective care in
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rural areas. One model is Stratus Healthcare, which provides services to 60 counties through a network of 18 hospitals, 11 health systems, and over 1,500 physicians.22 The Technical College System of Georgia along with our state's College and Career Academy Network have proven their potential to develop a strong work force of medical professionals in local communities to help fill that gap. These and other innovations should be developed and adapted to the specific needs and capabilities of rural communities statewide.
Opioid Crisis and Mental Health
The U.S. and Georgia face a growing crisis of addiction to prescription opioids, heroin, and other drugs. A recent audit completed in November 2017 estimated that 180,000 Georgians are struggling with opioid use disorder.23 Nearly 1,000 Georgians died from opioid-related overdoses in 2016 a spike of 55% from 2012.24 Between 2000 and 2012, the number of Georgia hospital admissions for overdoses of opiates alone not including heroin jumped by almost 1,000 percent.25 Estimates show that over the past decade, the cost of opioid-related inpatient care in Georgia has increased by approximately 80 percent.26
The impact on the state's economy is much larger than that. Drug abuse leads to higher costs of police enforcement and criminal justice activities. Adults who abuse drugs are less likely to maintain steady employment and be fully functioning members of their communities. This is a problem that transcends the health system and directly or indirectly affects everyone in our state.
Although substance abuse has no geographic boundaries, the problem is more heavily concentrated in rural areas, which have limited access to appropriate medical services to combat this crisis. According to the Substance Abuse Research Alliance (SARA), two-thirds of all counties in Georgia and 77 percent of rural counties have limited or no access to an evidence-based practice for opioid use disorder.27 Led by Lt. Governor Cagle and Senator Renee Unterman, the Senate has built a partnership with SARA to evaluate policy solutions to combat the epidemic of drug addiction and overdose.
A variety of strategies have been used to address various aspects of the opioid crisis. Prevention, the use of naloxone to prevent overdose deaths, medication assisted treatment (which can include behavioral therapy and medications such as methadone), and a combination of therapies and other services to meet an individual's needs are all components of a comprehensive approach to dealing with the crisis.28 For example, the Georgia Prevention Project is a statewide prevention program aimed at reducing the use of dangerous drugs among teens and young adults.29 That organization launched a project in 2010 in response to the state's critical methamphetamine problem, and has developed educational materials addressing teen prescription drug abuse.30
The Georgia Department of Behavioral Health and Developmental Disabilities has drafted an application for the Substance Abuse and Mental Health Services Administration (SAMHSA) Substance Abuse Block Grant Program.31 The grant aims to address the opioid crisis by increasing access to treatment, reducing unmet treatment need, and reducing opioid overdose deaths through the provision of prevention, treatment, and recovery activities for opioid use disorder.
Legislative initiatives addressing drug addiction have also advanced in Georgia. The Opioid Abuse Senate Study Committee was created in 2016 to increase access to naloxone, which can save the life of someone who has overdosed.32 As a result of Committee activities, the state Board of Pharmacy adopted a rule to allow pharmacists to dispense naloxone to individuals. Georgia's Prescription Drug Monitoring Program provides increased surveillance of prescribing practices and requires prescribers to review a patient's prescription history before prescribing an opioid.33 Last year, Senate Health and Human Services Committee Chair Renee Unterman toured our state, learning of the challenges faced by individuals and families battling the opioid crisis. A comprehensive bill addressing the opioid crisis will be introduced during the 2018 Legislative
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Session, and will work in conjunction with the Health Coordination and Innovation Council and Health System Innovation Center.
The overall capacity of Georgia's mental health system ties to the addiction crisis. A survey by Mental Health America indicates that Georgia has lower rates of mental health and substance abuse problems than most other states, but substantially less access to insurance and mental health treatment.34 Over 5 million Georgians live in federally designated Mental Health Professional Shortage Areas.35
Nationally, one in eight emergency room visits involve a mental health or substance abuse condition.36 Emergency rooms are often not well-equipped to deal with patients arriving with mental health problems and general hospitals limit the number of psychiatric beds. Those patients face substantially longer waits for service, and this adds to overcrowding in the emergency room.37 Care for many of these patients would be more effective and less costly if delivered in a clinical setting or a specialized psychiatric emergency department.38
In 2017, Georgia's Commission on Children's Mental Health addressed some of the issues facing the state's mental health system. The Commission recommended expansion of school-based mental health, support programs to promote employment of youth and adults with severe mental illness, use of telemedicine to provide necessary services (particularly to those in rural areas), and expanded hours for the Georgia Crisis and Access Line.39
Developing a more efficient and effective system for treating mental illness and drug addiction is part and parcel of health system reform. With better alignment of patient need and system resources, patient outcomes can improve and cost growth can be slowed.
Primary care and Prevention
By far the lowest-cost way to improve a patient's health is to take steps to prevent the onset of disease. When a patient has an illness, the health system should provide appropriate treatment in the lowest cost setting. However, the American health care system is geared toward diagnosis and treatment, not prevention. Fee-for-service payment and near-first-dollar insurance coverage promote more rather than less use of services, in more rather than less expensive settings.
As much as public health advocates emphasize the importance of exercise and a sound diet, diseases related to personal behavior are common. Smoking, excessive drinking, and obesity are problems throughout the nation and in Georgia.
A wide range of reforms is available to address various aspects of these problems. Primary care medical homes and accountable care organizations can promote efficient health care and give patients a better alternative than the hospital emergency room for necessary services. Patients can also take a more active role in managing their health. For example, there are smart phone apps and devices that allow diabetics to monitor their blood sugar and receive instant feedback on how they can maintain or improve their health.40
Another example that focuses on local health issues is the project undertaken by Georgia State University and the Morehouse School of Medicine to help reduce diabetes and heart disease in southwest Atlanta.41 The project supports community action to make neighborhoods safe for walking and biking, and to encourage local stores to carry healthier food options.
To address the epidemic levels of childhood obesity in Georgia, Lt. Governor Cagle created Healthy Kids Georgia in 2010. The program encourages schools to partner with their local communities and the Healthy Schools program to confront the childhood obesity crisis by implementing health and wellness programs in Georgia's schools. Along with the Alliance for a Healthier Generation's Healthy Schools Program and several other corporate and community
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partners, Healthy Kids Georgia has made a positive impact in over 1,000 schools across our state giving more students the tools to live healthy lifestyles.
The Georgia Department of Community Health partners with the Georgia Primary Care Association in assisting communities to develop and expand federally-qualified health centers and community health centers in Georgia's rural and underserved areas.42 These "safety net" providers increase access to care for low-income populations.
The Senate Study Committee on Barriers to Georgians' Access to Adequate Healthcare endorsed several proposals to promote primary care, including the Centering Pregnancy program.43 The program provides prenatal care in a group setting, which promotes greater engagement by expecting mothers and better outcomes for the babies.44
It is clear that many innovations and reforms could be implemented to improve the delivery of health care in Georgia. Moreover, there are often spillover effects from targeted interventions that help improve care and lower cost growth throughout the health system. An organized effort would bring together stakeholders from across our state to work on improving health care for all Georgians.
The Way Forward
Georgia's Health Care Reform Task Force recognizes the need to develop new approaches and leverage existing resources to address the serious problems adversely affecting the health and health care of Georgia's 10.4 million residents. Many initiatives already underway are addressing problems of access, affordability, and quality of care. However, these efforts would be significantly enhanced through greater collaboration among all stakeholders: consumers, providers, health systems, insurers, employers, and state and local governments.
At the same time, the Task Force recognizes that reforms will not be one-size-fits-all. What works to address a problem in one community will need to be modified to be most effective in another community with a different mix of challenges and capabilities. Private sector solutions that draw on the strengths of local communities are the foundation for sustainable health care reform. Reforms must also be flexible and sensitive to the changing landscape of health care at all levels: local, state, and federal.
An uncoordinated health care system reduces access and effectiveness of care while increasing unnecessary costs. Before we can effectively work together under a comprehensive vision to strategically improve the care available, we must first improve the coordination between state and local governments, research institutions, carriers, hospitals, doctors, nurses, employers, nonprofit organizations, and patients.
The Task Force recommends that the state initiate a stakeholder-driven process to develop and implement a blueprint to shape a sustainable high-performance health care delivery system. To achieve this objective, the Task Force proposes creating two organizations designed to promote collaboration, foster a more efficient decision-making process, and prioritize Georgia's investments: the Health Coordination and Innovation Council ("Council") and the Health System Innovation Center ("Center").
Health Coordination and Innovation Council
To unite the major stakeholders and components at all levels of the state's health system under a strategic vision for Georgia's future, the Task Force proposes to establish the Council as a permanent statewide coordinating platform. The Council will bring together all of Georgia's major health agencies, academic institutions, and leaders from the public and private sectors. It will
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serve as a forum to continually identify specific health issues of Georgia's greatest concern and promote public and private cooperation to test new and innovative ideas.
The Council will also evaluate the effectiveness of ongoing major health programs, and determine how to better achieve the goal of promoting innovation and improving Georgia's health system. To maximize the effectiveness of existing resources, expertise, and opportunities for improvement, the Council will provide independent, objective analysis and data on health conditions in our state and policy options to address the needs of Georgians. This will allow Georgia's leaders to continually assess the performance of our health system while ensuring that more Georgians have access to affordable, quality care.
The Council will empower the state's leaders to adopt innovative and market-oriented reforms, cut through the bureaucracy and silos of government, eliminate waste and duplication, and improve health outcomes for Georgia families. By advancing reform through a strategic plan that is built for long-term success, with all of the state's partners at the table, the State of Georgia will lead the way to a better quality and higher functioning health care system.
Health System Innovation Center
The Center is a research organization drawing on Georgia's academic, health policy, data, and workforce resources to develop new approaches for financing and delivering care. It will develop a research program to analyze significant health system problems as well as original solutions and best practices. By bringing together experts from academic institutions, industry, and state agencies, the Center will provide a forum to share information, coordinate the major functions of our health system, and develop innovative and improved approaches to lower costs, while improving access to quality care.
A particular focus for the Center's work will be improving access to affordable health care in rural Georgia. The Center will begin by synthesizing existing studies, reports, and data to provide a baseline assessment and set measurable goals as part of Georgia's strategic plan for reform. Furthermore, the Center should incorporate recommendations from other state reform efforts to build a complete blueprint for the future. For example, last year, the Joint Study Committee on Transparency and Open Access in Government led by Senator Hufstetler and Representative Dempsey worked to lay a foundation for a statewide data integration system to better evaluate and address major population health challenges. In coordination with the Council, the Center should utilize de-identified data from this system to develop and test innovative solutions.
Beyond developing milestones for achieving Georgia's vision for the future, the Center will address immediate needs of rural communities by offering technical assistance and expertise. This dual approach will help facilitate positive long-term transitions in health system configuration across Georgia.
In conjunction with public and private stakeholders, the Center will develop proposals for pilot projects statewide, identify innovative approaches to funding these projects each year, and then track and evaluate their performance. The Center will also serve as a clearinghouse for data integration and analysis to produce studies useful in the broader effort to reform Georgia's health system by addressing cost-drivers and duplication, eliminating barriers to care, and reducing consumer costs.
A strategic plan for the future of health and health care in Georgia
The Council, with the assistance of the Center, must develop a shared vision for health and health care in Georgia. That vision should incorporate the policy goals and service missions of health care organizations and other stakeholders. Developing that vision will help identify both the potential for improvement and the barriers to progress that must be addressed. Moreover, by
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working collaboratively, stakeholders will need to establish realistic expectations based on cooperation and a vision for Georgia's future with strong economic opportunity in every community, county, and region of our state.
The strategic plan starts with the shared vision statement and incorporates an assessment of critical issues that impede progress toward policy goals. This clear-eyed view of the current challenges facing Georgia's health system will help focus the activities of the Council and the Center initially. A periodic reassessment of those challenges and opportunities as well as progress toward policy goals is required to maintain focus on the highest priorities for reform.
The strategic plan would also identify current and future resources that could be used to support reform activities. Several existing programs may be revisited to maximize investments. For example, Rural Healthcare 180 is a task force developed to promote private donations to struggling rural hospitals. While Rural 180 marks a very positive step forward, continued adjustments could render the program even more effective in promoting better care in rural areas. Federal programs also provide funds to states implementing reform projects, and should be part of Georgia's strategic plan. Some of those programs are discussed in an appendix to this report.
Recommendations
Over the past year, Georgia's Health Care Reform Task Force worked to identify the greatest health and health care problems facing Georgia's citizens. A series of public meetings was held across the state to better understand problems facing Georgians in accessing quality care, local efforts to address them, and new innovations to make health care more accessible, affordable, and effective.
One-size-fits-all policies are not the solution. Reforms must be tailored to the specific needs and capabilities of each community and cannot be dictated by Washington. Georgia has both the opportunity and the need to institute a reform process based on collaboration.
The Task Force supports the creation of a state-wide process to develop innovative market-based reforms to improve the health and health care of Georgians. Consumers, providers, health systems, payers, employers, state and local governments, and others should join together to target the most acute problems and promote new ideas about how to sustainably improve access to affordable, quality care. The most immediate and vital opportunities for improvement are in rural health care, combatting the growing crisis of drug addiction, improving access to mental health services, and promoting primary and preventive care.
Recommendation:
Establish the Health Coordination and Innovation Council to provide a platform for stakeholders to identify and unite behind policy priorities, promote innovation, and oversee the implementation of a strategic plan for the future of health and health care statewide. The Council will focus on eliminating duplication, streamlining functions of government, and returning greater value to Georgia's communities, taxpayers, and patients by making care more efficient and effective.
Recommendation:
Establish the Health System Innovation Center to draw on and develop the technical expertise of our state's academic, health policy, data, and workforce resources. The Center will also provide technical assistance to support rural providers in leading a transformation that improves access to quality, affordable care.
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Recommendation: Charge the Health Coordination and Innovation Council in conjunction with the Health System Innovation Center with developing a strategic plan for the future of health and health care in Georgia. This strategic plan must include a baseline analysis of rural health conditions and policy recommendations to address the needs it documents. Working at the direction of the Council, the Innovation Center will measure progress toward achieving Georgia's vision for a high performance rural health system as a strategic plan is written and implemented. Recommendation: The Task Force should remain intact, and work throughout 2018.
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Appendix I:
Task Force Public Meetings
Lt. Governor Cagle selected the following Senate members to serve on the Task Force:
Senator Renee Unterman of the 45th
Senator Dean Burke of the 11th
Senator Judson Hill of the 32nd (Until 2/13/17)
Senator Jack Hill of the 4th
Senator Chuck Hufstetler of the 52nd
Senator Michael `Doc' Rhett of the 33rd
Senator Kay Kirkpatrick of the 32nd
Senator Ben Watson of the 1st
The Task Force held five public meetings to hear from local, state, and national experts on the central health issues facing Georgians:
Reforming health insurance and health care delivery systems, Atlanta, March 10, 201745 Joseph Antos, American Enterprise Institute Jim Frogue, FrogueClark The first meeting of the task force focused on policy developments in Washington and how they might affect Georgia.
Health care coverage in Georgia, Atlanta, May 15, 201746 Patricia Ketsche, Ph.d., MBA/MHA, Institute of Health Administration Melissa Haberlen, JD, MPH At Meeting 2, the Task Force was presented background information from the Georgia Health Policy Center (GHPC). Patricia Ketsche provided an overview of coverage in Georgia, including all sources of coverage, the role of Medicaid in Georgia, and a baseline description of the current statewide landscape of access to coverage. Ms. Ketsche was joined by Melissa Haberlen, Melissa Haberlen is an attorney and senior research associate at the Georgia Health Policy Center (GHPC).
The future of rural health care in Georgia, Tifton, July 10, 201747 Tift Regional Medical Center Emory University: Greg Esper, MD, MBA; Timothy G. Buchman, PhD, MD; Cheryl Hiddleson MSN, RN, CCRN-E; Elizabeth Krupinksi, PhD Keith Muller Ph.d. The third meeting of the Task Force was held on July 10, 2017 in Tifton, Georgia with a focus on improving access to care through telehealth initiatives, quality care reforms, and included a review of the benefits of data dissemination as a cost-effective means to enhance population health.
Behavioral health, addiction, and the opioid crisis, Marietta, September 25, 201748 John Brennan, M.D., WellStar Health System Deborah Robinson Bailey, RN, BSN, MSN, Northeast Georgia Medical Center
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Jim Langford, SARA/Georgia Prevention Project Missy Owen, Davis Direction Foundation Bryan Stephens, Cobb and Douglas County Community Services Boards Travis Johnson, Office of Attorney General Chris Carr Catharine Evans, Teradata Sally Satel, M.D., American Enterprise Institute/Yale University School of Medicine The fourth meeting of the Task Force was held on September 25, 2017 in Marietta, Georgia with a focus on behavioral health and the opioid crisis. Primary and preventative care, Rome, October 30, 201749 Redmond Regional Medical Center Floyd Medical Center Harbin Clinic Monty Veazey, Georgia Alliance of Community Hospitals Dev Watson, Georgia Association for Primary Care Tom Andrews, Mercy Care Martha King, National Conference of State Legislatures Laura Jacobson, M.D., Department of Public Health Scott Bohlke, M.D., Medical Association of Georgia Gerald Harmon, M.D., American Medical Association LaSharn Hughes, Georgia Board for Physician Workforce Lucy Marion, Ph.D., RN, FAAN, FAANP, Augusta University Jeff Selberg, Peterson Center on Healthcare The fifth meeting was held on October 30, 2017 in Rome, Georgia with a focus on primary and preventative care.
2017 report and recommendations, Atlanta, January 8, 2018 The Task Force met for a final time, at the Capitol in Atlanta, Georgia, to discuss findings, recommendations, and adopt a final report.
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Appendix II: Federal Funding Opportunities for State Health Reform
There are a number of federal programs that could provide new program flexibility and funding for Georgia's health reforms. They include State Innovation Waivers available under Section 1332 of the Affordable Care Act, Medicaid Section 1115 demonstration waivers, and federal grant programs targeting specific health reform areas. State Innovation Waivers can be used to pursue innovative state approaches to system redesign.50 Such waivers permit states to modify ACA requirements in the individual and small group insurance markets to address unique state insurance market issues or experiment with alternative ways to provide coverage to state residents.51 The ACA requires that the innovation plan will provide coverage that is at least as comprehensive, at least as affordable, and cover as many people as plans that are fully compliant with ACA rules. The state proposal must also be budget neutral. Medicaid demonstration waivers provide states an avenue to test new approaches in Medicaid that differ from federal program rules.52 Waivers can provide states considerable flexibility in how they operate their programs, beyond what is available under current law. States considering broader reforms are likely to seek both Medicaid demonstration waivers (which can only be used to modify the Medicaid program) and State Innovation Waivers (which can only be used to modify the rules of the private insurance market). President Trump and the new administration in Washington have signaled a willingness to consider state health reform proposals. A request for information seeking feedback on the future direction of the Centers for Medicare and Medicaid Services (CMS) Innovation Center was published in September 2017. CMS is interested in stakeholder input on ideas and concepts to promote patient-centered care and test market-driven reforms that empower beneficiaries as consumers, increase transparency and competition, and improve measures of quality, cost, and outcomes.53 CMS specifically mentioned their interest in state-based and local innovation, including Medicaid-focused models. Future guidance is likely as CMS responds to the suggestions they have received in response to the information request. The Department of Health and Human Services also provides grants targeted on the health needs of specific populations through its subsidiary agencies. The HHS Office of Rural Health Policy currently has several grant programs available, including the Medicare Rural Hospital Flexibility Grant program.54 The Substance Abuse and Mental Health Services Administration offers block grants to fund substance abuse and mental health services.55 These and other grant programs could be a source of new funds for Georgia's reform efforts.
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Endnotes
1 Press Release, State of Ga, Lt. Governor Cagle Launches Task Force to Repeal and Replace Obamacare, (Jan. 6, 2017), https://ltgov.georgia.gov/press-releases/2017-01-06/lt-governor-cagle-launches-taskforce-repeal-and-replace-obamacare. 2 Seema Verna, Opinion, Medicare and Medicaid Need Innovation: Trump's HHS seeks to encourage health-care innovation, Wall St. J., Sept. 19, 2017. Also see. Centers for Medicare & Medicaid Services, Centers for Medicare & Medicaid Services: Innovation Center New Direction, (Last updated Dec. 01, 2017). Also see. Amanda Makki, Corbin T. Santo, Ryan D. Hill, Trump Administration seeks Stakeholder Input on New Direction for CMS Innovation Center, K&L Gates, Oct. 2, 2017. https://www.wsj.com/articles/medicare-and-medicaid-need-innovation-1505862017, https://innovation.cms.gov/initiatives/direction, http://www.klgates.com/trump-administration-seeksstakeholder-input-on-new-direction-09-29-2017/ 3 Press Release, U.S. Dept. of Health and Human Services, Secretary Price and CMS Administrator Verma Take First Joint Action: Affirm Partnership of HHS, CMS, and States to Improve Medicaid Program, (Mar. 14, 2017), https://www.hhs.gov/about/news/2017/03/14/secretary-price-and-cms-administratorverma-take-first-joint-action.html 4 U.S. Census Bureau, State Population Totals and Components of Change 2010-2017. https://www.census.gov/data/tables/2017/demo/popest/state-total.html 5 United Health Care Foundation, America's Health Rankings-Senior Report: State Ranking Overview: 2017 (2017), https://assets.americashealthrankings.org/app/uploads/ahrannual17_complete-121817.pdf 6 David C. Radley et al. Aiming Higher: Results from the Commonwealth Fund Scorecard on State Health System Performance, 2017 ed. The Commonwealth Fund. http://www.commonwealthfund.org/interactives/2017/mar/state-scorecard/ 7 Laura M. Segal Et Al., Trust for America's Health: Robert Wood Johnson Foundation. The State of Obesity: Better Policies for a Healthier America (2017). https://stateofobesity.org/states/ga/. 8 Id. 9 Id. 10 Id. 11 Id. 12 Centers for Disease Control and Prevention, Extinguishing the Tobacco Epidemic in Georgia, (last updated Apr. 11, 2017). https://www.cdc.gov/tobacco/about/osh/program-funding/pdfs/georgia508.pdf. 13 Jim Langford Et Al., Substance Abuse Research Alliance: Georgia Prevention Project, Prescription Opioids and Heroin Epidemic in Georgia: A White Paper (2017). www.senate.ga.gov/sro/Documents/StudyCommRpts/OpioidsAppendix.pdf. 14 The Henry J. Kaiser Family Foundation, State Health Facts, Health Insurance Coverage of Non-Elderly: 0-64, https://www.kff.org/other/state-indicator/nonelderly-064/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7 D. 15 HealthVoices: Rural Health and Healthcare: 2016 Georgia Survey Results, Conducted by Matthew Towery, Opinion Savvy, LLC, and Reported by Healthcare Georgia Foundation, Issue 3, Publication #100, February 2017. http://www.healthcaregeorgia.org/uploads/files/HealthVoices_February2017.pdf. 16 Ga. Dept. of Public Health, Office of Telehealth & Telemedicine. https://dph.georgia.gov/officetelehealth-telemedicine. 17 State of Ga., Ga. Board for Physician Workforce, Georgia Physician Workforce: Based on 2014-2015 Licensure Renewal Data Primary Care / Core Specialties (July 2017). https://gbpw.georgia.gov/sites/gbpw.georgia.gov/files/GBPWDataBook2014-15.pdf 18 Ga. Dept. of Public Health, Office of Telehealth & Telemedicine. https://dph.georgia.gov/officetelehealth-telemedicine. 19 Georgia Partnership for Telehealth. http://www.gatelehealth.org/georgia-partnership-for-telehealth/. 20 Emory University / Georgia Tech: Healthcare Innovation Program http://hip.emory.edu/resources/support_units/regional/ga_partnership_for_telehealth.html. 21 Ga. Dept. of Public Health, Office of Telehealth & Telemedicine. https://dph.georgia.gov/officetelehealth-telemedicine.
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22 Stratus Healthcare. http://stratushealthcare.org/public_html/#page-top. 23 Georgia Department of Audits and Accounts, Performance Audit Division: Opioid Use Disorder Access to Medication Assisted Treatment, November 2017, Report No. 17-11 24 Jim Langford Et Al., Substance Abuse Research Alliance: Georgia Prevention Project, Prescription Opioids and Heroin Epidemic in Georgia: A White Paper (2017). www.senate.ga.gov/sro/Documents/StudyCommRpts/OpioidsAppendix.pdf. 25 Georgia Prevention Project. http://www.georgiapreventionproject.org/about-us/about-us.php. 26 Jim Langford Et Al., Substance Abuse Research Alliance: Georgia Prevention Project, Prescription Opioids and Heroin Epidemic in Georgia: A White Paper (2017). www.senate.ga.gov/sro/Documents/StudyCommRpts/OpioidsAppendix.pdf. 27 Id. 28 National Institute on Drug Abuse, Principles of Drug Addiction Treatment: A Research Based Guide (Third Edition), What is drug addiction treatment. (last updated Dec. 2012). https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guidethird-edition/frequently-asked-questions/what-drug-addiction-treatment. 29 Georgia Prevention Project. http://www.georgiapreventionproject.org/about-us/about-us.php. 30 Georgia Prevention Project: Georgia Meth Project. http://www.georgiapreventionproject.org/aboutus/about-ga-meth-project.php Also. Georgia Prevention Project: Georgia Rx Abuse Project. http://www.georgiapreventionproject.org/programs/ga-rx-abuse-program.php. 31 Ga. Dept. of Behavioral Health and Developmental Disabilities: Addictive Diseases. https://dbhdd.georgia.gov/addictive-diseases. 32 Senate Research Office, SR1165, 2016 Sess. Final Report of the Opioid Abuse Senate Study Committee. http://www.senate.ga.gov/sro/Documents/StudyCommRpts/2016FinalReportOpioidAbuse.pdf. 33 Ga. Drugs and Narcotics Agency, Ga. Prescription Drug Monitoring Program. https://gdna.georgia.gov/georgia-prescription-drug-monitoring-program-ga-pdmp. 34 Mental Health America, Mental Health in America 2017: Ranking the States. http://www.mentalhealthamerica.net/issues/ranking-states. 35 The Henry J. Kaiser Family Foundation, Mental Health Care Health Professional Shortage Areas. (last updated Dec. 31, 2016). https://www.kff.org/other/state-indicator/mental-health-care-healthprofessional-shortage-areashpsas/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22 %7D. 36 Pamela L. Owens Et Al., Healthcare Cost and Utilization Project, Mental Health and Substance AbuseRelated Emergency Department Visits among Adults, 2007. (July 2010). http://www.hcupus.ahrq.gov/reports/statbriefs/sb92.pdf. 37 Jane M. Zhu Et Al., Emergency Department Length-of-Stay For Psychiatric Visits Was Significantly Longer Than for Nonpsychiatric Visits, 2002-11, Health Affairs, Vol. 35, No. 9, (Sept. 2016), https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2016.0344. 38 Aaron Levin, Emergency Department Finds Successful Formula For Psychiatric Cases, Psychiatric News, Dec. 4, 2015. https://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2015.12a13. 39 Comm'r Frank Berry, Stephanie Blank, Dir. Bobby Cagle, Katie Childers, Comm'r Judy Fitzgerald, Dr. Jordan Greenbaum, Dir. Teresa MacCartney, Erica Fener, Sitkoff, The Commission on Children's Mental Health, Dec. 11, 2017. https://gov.georgia.gov/sites/gov.georgia.gov/files/related_files/document/The%20Commission%20on %20Children%27s%20Mental%20Health%20FINAL%20120717.pdf. 40 Dr. Francis Collins, National Institutes of Health, Mobile Health: Figure Out What Works, (Dec. 7, 2012). https://directorsblog.nih.gov/2012/12/07/mobile-health-figuring-out-what-works/. 41 Janel Davis, Georgia State, Morehouse tackle health issues in southwest Atlanta, AJC, July 10, 2015. http://www.ajc.com/news/local-education/georgia-state-morehouse-tackle-health-issues-southwestatlanta/pR8dOPV6En1qbmhzRhujyK/ Also see. Morehouse School of Medicine, CDC Awards $2.9 Million to Morehouse School of Medicine's Health Initiative to Reduce Diabetes and Cardiovascular Disease in Underserved Communities. (May 27, 2015). http://www.msm.edu/RSSFeedArticles/May2015/CDCAwards29Million.php. 42 Ga. Dept. of Community Health, Federally Qualified Health Centers / Community Health Centers. https://dch.georgia.gov/federally-qualified-health-centers-fqhcs-community-health-centers-chcs.
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43 S. Research Office, SR188, 2017 Sess. Final Report of the Barriers to Georgians' Access to Adequate Healthcare Senate Study Committee. http://www.senate.ga.gov/sro/Documents/StudyCommRpts/BarrierstoAdequateHealthcare.pdf. 44 Centering Pregnancy Georgia, Why Centering, http://www.centeringgeorgia.org/whycentering.html. 45 Press Release, State of Ga, Health Care Reform Task Force Hears From National Experts, (Mar. 10, 2017) https://ltgov.georgia.gov/press-releases/2017-03-20/health-care-reform-task-force-hearsnational-experts 46 Press Release, State of Ga, Health Care Reform Task Force Partners with Georgia Health Policy Center, (May 17, 2017) https://ltgov.georgia.gov/press-releases/2017-05-17/health-care-reform-task-forcepartners-georgia-health-policy-center 47 Press Release, State of Ga, Health Care Reform Task Force Considers Solutions to Improve Quality Care for Rural Georgians, (Jul. 10, 2017) https://ltgov.georgia.gov/press-releases/2017-07-10/health-carereform-task-force-considers-solutions-improve-quality-care 48 Press Release, State of Ga, Health Care Reform Task Force Works to Combat Opioid Crisis, (Sept. 25, 2017) https://ltgov.georgia.gov/press-releases/2017-09-25/health-care-reform-task-force-works-combatopioid-crisis 49 Press Release, State of Ga, Georgia Health Care Reform Task Force Evaluates Solutions to Reduce Costs and Improve Access to Primary and Preventative Care, (Oct. 30, 2017) https://ltgov.georgia.gov/pressreleases/2017-10-30/georgia-health-care-reform-task-force-evaluates-solutions-reduce-costs 50 Centers for Medicare & Medicaid Services, The Center for Consumer Information and Insurance Oversight: Section 1332 State Innovation Waivers. https://www.cms.gov/CCIIO/Programs-andInitiatives/State-Innovation-Waivers/Section_1332_State_Innovation_Waivers-.html. 51 The Henry J. Kaiser Family Foundation, Tracking Section 1332 State Innovation Waivers, (Dec. 12, 2017). https://www.kff.org/health-reform/fact-sheet/tracking-section-1332-state-innovation-waivers/. 52 Elizabeth Hinton Et Al., The Henry J. Kaiser Family Foundation, Section 1115 Medicaid Demonstration Waivers: The Current Landscape of Approved and Pending Waivers, (Dec. 13, 2017). https://www.kff.org/medicaid/issue-brief/section-1115-medicaid-demonstration-waivers-the-currentlandscape-of-approved-and-pending-waivers/. 53 Amanda Makki, Corbin T. Santo, Ryan D. Hill, Trump Administration seeks Stakeholder Input on New Direction for CMS Innovation Center, K&L Gates, Oct. 2, 2017. http://www.klgates.com/trumpadministration-seeks-stakeholder-input-on-new-direction-09-29-2017/. 54 Human Resources & Services Administration, Rural Health Funding Opportunities. https://www.hrsa.gov/ruralhealth/programopportunities/fundingopportunities/. 55 Substance Abuse and Mental Health Services Administration, Substance Abuse and Mental Health Block Grants, (last updated Sept. 15, 2017). https://www.samhsa.gov/grants/block-grants.
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