Monthly Review & Commentary On Health Issues From A Rural Perspective - January 1st, 1998


Sauk County Quality Initiative
At the request of Seats, the Flambeau Corp., Lands End and other Sauk County employers, the Employer Health Care Alliance Cooperative based in Madison organized an initial meeting of employers with Sauk County providers in early December.
The Alliance reviewed similar work it has been doing for some time in Dane County; RWHC presented an overview of the quality projects it has done for the last seven years as well as new initiatives planned as part of the Rural Zones of Collaboration Initiative, and MetaStar (Previously WIPRO) shared data it had acquired from state and federal resources regarding various provider specific indicators.
It was agreed that there was significant interest among both providers present and employers to move forward with a Sauk County Quality Initiative. The organizing philosophy will be based on finding ways for providers and employers to work together to further improve the quality of care available locally. The Alliance was requested to arrange the next meeting at which discussion is expected to focus on specific quality improvement projects most relevant for the Sauk County area. .
We Can Detect Breast Cancer Earlier
The Medicare data for Wisconsin and the statements below are from the following Federal web site:

www.hcfa.gov/stats/mamm/mammover.htm

"Older women face a greater risk of developing breast cancer than younger women. Yet older women do not take full advantage of the lifesaving potential of mammograms to detect breast cancer early, when it may be cured. The Department of Health and Human Services (DHHS) goal for the Year 2000 is for at least 60 percent of all older women to receive a mammogram and a clinical breast exam every two years."
"During the 1994-95 period, no State had reached the Year 2000 goal of 60 percent. Biennial rates of mammography services by State ranged from 32.2 to 48.4 percent. On average, Caucasians had higher biennial rates (range: 34.0 percent to 49.0 percent) than African Americans (range: 20.2 percent to 45.3 percent). However, most rates did increase slightly, between 1 and 4 percentage points, from the prior 1992-93 reporting period."
"When applied to the approximately 19.5 million elderly Medicare women who receive services in the fee-for-service sector, these percentages imply over 11.5 million elderly women have not received a mammogram in the past 2 years. When translated by race, these data imply approximately 10 million Caucasian women and 1.2 million African American women did not receive this important Medicare-covered service."
The steering committee of the Rural Zones of Collaboration Initiative has asked the Zone's Outcomes Advisory Committee to look at this issue and suggest how rates may be improved in the RWHC service area. It believes, lacking any better data, that the lower than average Medicare mammogram rates can be generalized to younger women in the region as well.
The Uninsured in These Ununited States
The following is from "Who Goes Without Health Insurance?, Health Insurance Coverage, 1996" on the U.S. Census Bureau web site: www.census.gov
"An estimated 41.7 million people in the United States (15.6 percent) were without health insurance coverage during the entire 1996 calendar year. This number was up 1.1 million from the previous year, but the proportion was statistically unchanged."
"Employment is the leading source of health insurance coverage. Most people (70.2 percent) were covered by a private insurance plan for some or all of 1996. A private plan is one that was offered through employment (either one's own or a relative's) or privately purchased. Almost all private insurance was obtained through a current or former employer or union (that is, was employment-based)."
"The remaining insured people (25.9 percent) had government coverage--Medicare (13.2 percent of the population), Medicaid (11.8 percent), and military health care (3.3 percent). Many people carry coverage from more than one plan."
"The poor are more likely not to have coverage. Despite the existence of programs such as Medicaid and Medicare, 30.8 percent of the poor (11.3 million) had no health insurance of any kind during 1996. This percentage--which was double the rate for all people--was statistically unchanged from the previous year. Poor people comprised 27.0 percent of all uninsured people, although they make up only 13.7 percent of the total population. Medicaid was the most widespread type of coverage among the poor. About 45.5 percent of all poor people were covered by Medicaid at some time during the year."
"Firm size play important roles. Of the 142.9 million workers, 53.1 percent had employment-based health insurance policies in their own name. The proportion varied by size of employer, with workers employed by small firms (less than 25 people) being least likely to have employment-based health insurance policies in their own name. These estimates do not reflect the fact that some workers are covered by employment-based coverage through another family member. In fact, 92 percent of firms with 1,000 or more employees offered health insurance plans in 1993/3."
"More children lacked coverage in 1996 than in 1995. The number of uninsured children less than 18 years of age grew to 10.6 million (14.8 percent) in 1996; both the number and percent were statistically higher than the 1995 figures of 9.8 million and 13.8 percent, respectively."
"States show differences in noncoverage rates. Using three-year averages between 1994 and 1996, uninsured rates ranged from 8.2 percent in Wisconsin to 24.3 percent in Texas. However, we advise against using these estimates to rank the states. Results from different samples could easily show different estimates and rankings because of small sample sizes. For example, the high noncoverage rate for Texas was not statistically different from that in New Mexico, while the rates for South Dakota, Minnesota, Hawaii, and North Dakota were not statistically different from Wisconsin."
"This report presents data on the health insurance coverage of people in the United States during the 1996 calendar year. The data were collected by the March 1997 Supplement to the Current Population Survey."
Ongoing Dance of Competition & Regulation
The following is from an Editorial in The Washington Post, "Managing Managed Care," 12/25/97:
"A few years ago, managed care and its cousin, managed competition, were just about everyone's favorite means of achieving health care cost containment. The promise was that they could cut the cost of health care without reducing quality. The evidence was the dramatic success they appeared to be having in flattening private-sector costs. Their particular virtue, not least to the politicians, was that the thing could be done without government intervention, meaning that the politicians weren't the ones who had to say no to anyone. For a fee, the private cost police would do it for them."
"The bloom is now off that always improbable rose, if ever it was on. Doctors and other providers were the earliest to rebel. The care companies amassed great buying power and used it to limit the accustomed authority of the sellers of care to do and charge what they pleased. Patients -- not all, but enough -- began to complain as well, as they found that the companies in the name of cutting costs were limiting the array of available care. Now a third collision may be in the offing from the opposite direction, between the companies and their principal clients, the businesses and governmental bodies that are the main payers for care."
"We are in a period of adjustment when the government has begun to regulate the excesses of the managed care industry, having earlier cheered on the industry as it went off to regulate the excesses of the health care system more generally. It isn't clear how the regulation will shake out. What is clear, though, is that managed care is less than a magical device. It may be a partial solution to the cost containment problem; it is not a complete one."
Both Market & Government
The following is from "Markets And Collective Action In Regulating Managed Care" by Alain Enthoven and Sara Singer in Health Affairs, Vol. 16, No. 6, Fall 1997:
"Market forces can motivate continuing innovation to improve value--including improving quality, customer service ,and satisfaction and lowering cost. Market forces also cater to various tastes and preferences and adjust to changing conditions. Government actions tend to be more rigid. Market forces create accountability, investment in information technology, elimination of unwanted variation in medical practice patterns, coordinated care, fewer inappropriate procedures through guideline concentration on volume sensitive procedures in high-volume hospitals and use of preventive services."
"In addition, markets can lower prices more effectively than government price controls can... Markets can allocate resources efficiently by bringing marginal benefits and costs into approximate equality... Government as a resource allocator is inherently inefficient. Legislators, however well-intentioned personally, are under great pressure to deliver or protect particularized benefits for electoral supporters... Market forces are the only practical means of containing costs while maintaining quality."
"Health care and health insurance markets work better today than they did several years ago, particularly for large employers and purchasing coalitions. Nevertheless, they are still prone to fail for many in the population, and it is still difficult even for large purchasers to get the kinds of cost reductions and increases in quality and service performance they want to see."
"Market failure in health insurance is an important public policy problem because health care has a special moral status. Most people consider it unacceptable for people to suffer, to be disabled, or to have shortened lives because they cannot pay for care... Thus, any realistic discussion of regulation of health insurance and health services must be in the context of widely supported social goals. Insurance should be widespread if not universal, affordable and distributed equitably. Because of the moral imperative, collective action at some level is needed to make access and coverage widespread and to make the market work with tolerable efficiency."
"The private sector, through organizations such as the Pacific Business Group on Health can organize and is organizing a great deal of collective action on the demand side, maintaining the advantages of markets relative to government intervention. Its role as purchaser, however, has been far from perfect, and it is difficult to see how the benefits of private-sector pooled purchasing can be extended to the whole population without government action. Obstacles include risk selection and lack of pooling, employer frustration with the expertise and resources to offer choices, 'cultural difference' among groups and free riders. Thus, government has an inevitable and important role."
Voluntary Purchasing Pools­Doing It Right
In preparation for the upcoming discussion in the Wisconsin Assembly re SB 332, to create state health insurance pools for small businesses, it is important that it is remembered that there still are no free lunches when it comes to increasing access and lowering costs. In particular, voluntary purchasing pools won't avoid the need for us to further improve standardizing community rating rules and regions, as well as other market rules, across the entire small group market. The following is from the Voluntary Purchasing Pools, adopted by the American College of Physicians; the full text can be obtained at:

www.acponline.org/hpp/pospaper/vppool.htm

"States and small businesses have been rapidly establishing voluntary health care purchasing pools during the past few years. Purchasing pools can decrease health care costs, improve access for some small businesses and individual persons, allow greater choice among health care plans, and provide continuity of care. Purchasing pools also help to even the balance of power in the health care marketplace, which has come increasingly under the control of huge proprietary managed care corporations. This position paper of the American College of Physicians discusses how a system of well-designed voluntary purchasing pools can help protect the integrity of health care in the emerging managed care marketplace."
"While maintaining its commitment to universal coverage, the American College of Physicians supports the concept of voluntary purchasing pools as an incremental mechanism for 1) expanding access to small groups and individual persons, 2) reducing administrative costs, and 3) maintaining quality in a marketplace increasingly dominated by corporate managed care.."
In order to optimize the success of voluntary pools:
· "Choice of health plans offered through a purchasing pool must be made by individual persons."
·: "To provide the broadest possible choice of health plans, purchasing pools should offer all qualified health plans. If that is not done, the authority of purchasing groups to negotiate price should be limited. As an alternative, states should set a minimum threshold for the number of competing plans that must be offered, in the aggregate and by type of plan."
· "Purchasing pools should be as large as possible and as few in number as possible in a given area."
· "Standardize one or two benefit packages across the entire small group market-in public state-chartered purchasing pools, in private pools and employer purchasing coalitions, and outside of all pools."
· "Standardize community rating rules and regions, as well as other market rules, across the entire small group market. Rating factors must exclude health status and claims experience."
· "Allow participants in public purchasing pools to use an agent's or broker's services for enrollment and employee education but require commissions to be line-itemed separately from the pool premium so that consumers know the cost of the extra administrative service and the cost of the plan."
· "In a system of competing public pools, require state certification and monitoring of the pools' adherence to the same market rules to deter competition among pools based on risk selection."
· "Make purchasing groups accountable to the purchasers they serve-employers and consumers. Minimize political appointments to the boards of state- operated purchasing pools. Create incentives for pools to minimize in-house staff and use performance-based contracting for labor-intensive tasks."
HMOs & Rural Elderly
The following is from Serving Rural Medicare Risk Enrollees: HMOs' Decisions, Experiences And Future Plans (Working Paper #19, 11/97) by Michelle Casey, M.S. at the Rural Health Research Center, Division of Health Services Research and Policy School of Public Health, University of Minnesota
"The HMOs serving rural Medicare risk enrollees report that adjusted average per capita costs (AAPCC) rates are one of several factors they consider in deciding whether to include rural counties in their Medicare risk service areas. Other factors that influence HMOs include experience with commercial HMO products in the rural area; having established provider networks in the area; the presence of significant senior populations; employer demand for retiree coverage; competition from other HMOs or the desire to develop a presence with the Medicare product in rural areas before competitors do; corporate mission; and HCFA's requirement that Medicare risk contractors have a contiguous service area."
"Several HMOs report that rural physicians and hospitals opposed the HMO's initial efforts to offer a Medicare risk product in rural areas. In other cases, rural providers were neutral, or provider response varied from one county to another. A number of HMOs report having difficulty negotiating capitated contracts in rural areas. The HMOs report using a variety of reimbursement methods for their Medicare risk products, depending on the HMO model type, the HMO's ability to negotiate capitated contracts, and/or the volume of Medicare risk patients"
"Several HMOs use a combination of reimbursement methods for physicians and for hospitals. Most frequently, the HMOs report paying urban physicians on a capitated basis and some or all rural physicians on a discounted fee-for-service basis. The majority of HMOs with rural Medicare risk enrollees report that their Medicare risk products are either losing money or breaking even in rural areas. Most indicate that the Medicare risk product is less profitable in the rural portion of their service area than in the urban areas."
"Most rural Medicare beneficiaries currently have traditional supplemental policies. Some indemnity insurers with substantial numbers of rural Medicare beneficiaries in supplemental products, for example, Blue Cross Blue Shield Associations, operate affiliated HMOs and are encouraging their rural commercial populations to move to managed care."
"The future of Medicare risk contracting in rural areas may depend in part on whether these organizations decide to offer Medicare risk products through affiliated HMOs, and the degree to which they encourage their Medicare supplemental subscribers to move to managed care."
"The success of Medicare risk contracting in rural areas also will depend on whether increased AAPCC rates allow HMOs to offer rural enrollees the type of Medicare risk products that have competed successfully with Medicare supplemental products in higher AAPCC urban markets, i.e., products with zero premiums or low premiums compared to supplemental products, as well as additional benefits such as prescription coverage."
Note: As of January 1st, BlueCross & BlueShield United of Wisconsin has approval to market a Medicare risk product in Madison and the surrounding rural communities of Dane County.
Population Health-How Is Wisconsin Doing?
The following is from the Wisconsin Population Health Check-Up, 1997 prepared by University of Wisconsin researchers Don Libby, PhD and David Kindig, MD, PhD along with others associated with the Wisconsin Network for Health Policy Research; more information can be obtained by calling them at 608-263-4886 or at the WNHPR web site:

www.biostat.wisc.edu/prevmed/network

"Population health is a concept of health that includes both the length and quality of life of individuals as well as the over-all condition of all people in a population."
"The determinants of population health are health care services, social and economic services, behavior and life-style, the general environment and genetic endowments."
"The Population Health Check-Up measures Wisconsin's population health according to many indicators of health status and the determinants of health. Regular population health check-ups will monitor our strengths, weaknesses and progress toward better health for all of Wisconsin's population."
"How is Wisconsin doing? Wisconsin ranks mid-way in the distribution of states on most population health indicators. On the positive side, we do an excellent job of providing health insurance with among the lowest percentage of population without health insurance and the highest rates of enrollment in managed care organizations. Unfortunately, Wisconsin also has exceptionally high rates of binge drinking, driving while intoxicated and overweight adults."
"All of these factors interact in complex ways. Additional research is needed to determine the optimal balance of factors to produce the most cost effective improvements in Wisconsin's population health in the future." The Behavioral Factors section of the Check-Up is illustrated in the graph.
Rural Physician Under-Supply
The following is from "Fact Sheet: Rural Physicians," recently distributed by the Federal Office of Rural Health Policy, U.S. Department of Health and Human Services:
"Over 51 million Americans live in areas classified as nonmetropolitan. They comprise one-fifth of the US population. Yet less than 11% of the nation's physicians are practicing in non-metro areas. Over 20 million of those nonmetro residents live in areas that have a shortage of physicians to meet their basic needs."
"A majority of physicians (54%) in nonmetro areas are in the primary care specialties of family medicine or general practice, general internal medicine, pediatrics and obstetrics/gynecology, compared with 38% of metro physicians."
"Two commonly used indicators of physician work load are the number of hours a physician spends in direct patient care each week and the total number of patient visits per week. 1995 data show that nonmetro physicians worked longer hours and had more patient visits per week than their metro colleagues. Nonmetro physicians spent as much as 16 percent more time per week in direct patient care and had 38 percent more patient visits per week than physicians in the largest metro areas."
"Nonmetro physicians derived a larger share of their gross practice revenue from Medicare and Medicaid patients than metro physicians. These public programs pay physicians at lower rates than private insurers."
"The Federal government designates areas with a shortage of practitioners as Health Professional Shortage Areas or HPSAs. The Department's recommended ratio for an "adequately served" population is one primary care physician for 2,000 people. In 1997, more than 2,200 physicians are needed in nonmetro areas to remove all HPSA designations. More than twice that number are needed to achieve the recommended 2,000:1 ratio in those HPSAs."
Is the ADA Working?
The following is from "Is the ADA Working?," InsideMS, Winter 1998:
"Today, the Americans with Disabilities Act (ADA) applies to all non-federal employers who have more than 15 employees. (Federal employees are covered by another law.) Very briefly, the ADA requires employers to provide 'reasonable accommodations' to enable employees to perform the essential functions of their jobs."
"How are we doing? In 1991, 14.26 million people with disabilities were employed; by 1994, the number was up by 1.13 million. A recent study by Sears, Roebuck & Co. reported that of the 436 reasonable accommodations provided by the company between 1978 and 1992, 69% cost nothing, 28% cost less than $1,000 and 3% cost more than $1,000.
For more information about advice on "reasonable accommodations" that work call The Job Accommodation Network at 1-800-ADA-WORK or contact their web site: <www.janweb.icdi.wvu.ed>.
I'll See It When I Believe It
From How We Know What Isn't So--The Fallibility Of Human Reason In Everyday Life by Thomas Gilovich:
"It is a great discredit to humankind that a species as magnificent as the rhinoceros can be so endangered. In the last 15 years, 90% of the rhinos in Africa have been killed by poachers who sell their horns on the black market. The horns fetch a high price in the Far East where they are used , in the powdered form, to reduce fevers, cure headaches, and (less commonly) increase sexual potency. Unhappily, the rhinoceros is not alone in this plight... No area has been more plagued by questionable, erroneous, and often harmful beliefs than the field of medicine and health."
"Part of the reason that erroneous beliefs about health are so rampant is that what they offer is so tempting. Having an untreatable
disease-or the possibility of contracting one-is so threatening that people desperately grasp at claims that the threat is not so severe or so completely beyond their control."
"Many people do not appreciate how much healing is done, not by doctors, drugs, or surgery, but by our bodies themselves. Roughly 50% of all illnesses for which people seek medical help are "self limited"-i.e., they are cured by the body's own healing processes without assistance from medical science."
"As Sir Peter Medawar describes it: 'If a person a) is poorly, b) receives treatment intended to make him better, and c) gets better, then no power of reasoning known to medical science can convince him that it may not have been the treatment that restored his health.' "
"The holistic emphasis on personal responsibility for one's state of health has many meanings and, as a result, has a number of costs and benefits. On one hand, as I noted earlier, it simply means that the individual, and not the individual's doctor, is in the best position to look after his or her health. This can encourage people to adopt healthier lifestyle practices and to become more informed 'consumers' of medical services."
"Alternatively, the holistic emphasis on personal responsibility can refer to the conviction that the proper thoughts and feelings can promote health. The down side, however, is the obvious implication that if the appropriate thoughts and feelings promote health, then a failure to adopt the right attitude looms as a plausible cause of sickness. The sick and disabled are subject to blame, by themselves and others, for their misfortune."
"To be sure, there are many responsible advocates of a holistic approach to medicine who are aware of the potential for blaming the victim and who try to combat it. However, it is not clear whether their efforts can ever be successful."
"Our knowledge of the terrain surrounding the relationship between mental states and illness is nothing if not uncertain. While this uncertainty lasts, perhaps we should err on the side of caution and assume that those who are ill did nothing to contribute psychologically or spiritually to their disease. Their burden is heavy enough already."
Brown Slime On Your Neurons?
The following is from a particularly expensive looking piece of unsolicited, direct mail marketing for "G.H.3" from Gero Vita Laboratories in Ontario, Canada; these quotes wre their headlines and are verbatim:

Scientists Discover

That Age Spots Signal

The Start Of Senility

But There's A Way To Deter Them,

And Dramatically

Improve Your Health

At The Same Time!

Senility Is Growing Rampantly!

Age Spots On Your Skin Signal

That A Brown Slime Is Forming

On The Neurons In Your Brain!

Scientists Say

You Can Be More Active

And Energetic With A Sharper Mind

No Matter How Old You Are!

Tightens Loose Skin Quickly!

6-month Supply (regularly $239.70), now $109.95

Cooperation Works!
Cooperation Works! by E.G. Nadeau & David Thompson (Lone Oak Press) is a must read for anyone trying to gain a better understanding of "how people are using cooperative action to rebuild communities and revitalize the economy." Paperback copies can be obtained for $12 plus $1.50 shipping by calling Cooperative Development Services in Madison, Wisconsin at 608-258-4393. Several quotes from the book jacket are as follows:
"In some parts of the country there is a co-op fever not seen since the 1930s. Cooperative Works! describes these new types of cooperatives and their role in solving both urban and rural problems." Charles Snyder, President, National Cooperative Bank
"The key to sustainability and growth opportunities for rural communities is the development of partnerships where businesses, local governments, key community leaders, agricultural producers pool their resources and pursue common goals-especially across community boundaries." Kathy Beery, Division administrator, Iowa Department of Economic Development
"Cooperative Works! provides interesting and useful examples of how people, drawing on their own abilities to access resources, expertise and opportunities, can accomplish far more working together than separately." Susan Jenkins, W.K. Kellogg Foundation
Working Longer To Pay For Old Age
The following is from "R.I.P., Early Retirement?" by Robert J. Samuelson in Newsweek, 11/17/97:
"You can often glimpse huge social upheavals in tiny shifts. We can now see such a transformation in retirement. For a century Americans have retired earlier and earlier. In 1880 more than 75 percent of men 65 and over worked. In 1997 only 17 percent do. People generally worked until they buckled under the physical burdens of labor. But there are now signs--among those in their late 50's and early 60s--that retirement ages are creeping back up and that the concept of retirement is subtly shifting. These small changes surely herald something larger: as baby boomers age, Americans will work longer and retire later."
"Government policy penalizes mixing work and retirement. Social Security still imposes an earnings test--that is, benefits are reduced for those with wage income--for recipients between 62 and 69. Though the penalties are being eased, their complexity and mere existence signal disapproval of work. It's the wrong message and discourages new work arrangements that many older Americans want and their country needs.
RWHC Passages
Like us all, the Cooperative has the pleasure and regret of key people coming and going (usually but not always in that order). Recent passages include:
Don Easley, retired as of year end from his post as administrator at the Memorial Hospital of Lafayette County. Sherry Kudronowicz has been appointed as Don's replacement.
Steve Nockerts has replaced Al Teal who recently retired as administrator at Adams County Memorial Hospital.
In a separate vein, the RWHC Board is pleased to announce the addition of two new members:
Divine Savior Hospital and Nursing Home in Portage to be represented by Michael Decker, CEO.
The Monroe Clinic (& Hospital) in Monroe to be represented by Kenneth Blount, President & CEO.

 The expressions of sympathy received were very much appreciated; the support of friends and colleagues was absolutely helpful. Thanks. T.S.



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