Randy Jordan - The Value of the Health Safety Net Pt. 2

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Today we continue the discussion between Yates Lennon and community health expert Randy Jordan, about how good health is typically achieved through a good clinical home, which has always been an insurance discussion but now should shift to a discussion about the uninsured who need the knowledge about where to go when sick, to increase savings in the cost of caring for the entire population.

OK, All right, Randy, thank you for sticking around. Our first conversation was fascinating. Looking forward to continuing that. I think you've touched a little bit on the next question I have for you, but we'll maybe expand a little bit more. Tell us about you talked about the health, the safety net and being that term being used pretty widely and you I think listed out free and charitable clinics, FQHCS, rural health clinics as sort of the network. I think I might have left one out. So fill, fill that in for me. But why is it so important? Why? Why is the health safety net so important? And to one of my earlier questions in the first session, why does it not get more attention than it does?

Well, I think added to the list Yates would be public health units and school-based health centers.

There you go.

You know it. It's a fascinating question that you're asking because I think to those who work in the space, it gets all the attention in the world. It's built around mission minded folks who want to see this issue of the uninsured being taken care of. If, if we just pause for a moment and look at all the energy that was brought to North Carolina recently about Medicaid expansion, it brought all kinds of groups together. But it was in that case, it was for the intention of getting a health insurance card in the hand of people in need. That same passion though, exists for those that are in the business of trying to, to provide healthcare services to uninsured patients. And so at one level there's a lot of attention to it, but at another level, there's, a real absence of attention. I don't think it's because people don't care. I think it's because we've not informed them well enough. And it's one of the things I appreciate, appreciate about the chance to be on your podcast today is when the message gets out, people are good hearted, they'll respond in the right way. But we do need to get the the message out. We need to get it out to policy makers. We need to find ways for that voice to be united. And that's, you know, those are some things that I'm also working on in my spare time.

Awesome. So you, you mentioned in the first session the hospital in Jacksonville that worked with the free and charitable clinic. Can you talk to us a little bit about how the Medicaid, the the health safety net can be strengthened? What, what, what needs to happen? What are some ideas and needs for strengthening that safety net?

Well, we mentioned a number of times Medicaid already today. One of the strong ideas that came out of Medicaid transformation was a recognition that social determinants of health are important for good health. And so we're talking about housing, food insecurity, transportation, and basically protections against family violence and other forms of interpersonal violence. So the Healthy Opportunities pilots that have sprung up across the state, three of them now have identified and brought together sort of the safety net of social services. It's a wonderful thing and we celebrate it. But it because it applies only to Medicaid, that access to that network is not organized in a way to also apply to the uninsured. And I think that that's one challenge that that lays ahead for us is finding a way to leverage what's being built in the Medicaid system and apply it to the uninsured. Now here's an interesting thing. If you look at the demographic of, of most Medicaid patients, it's very, very similar if not identical to uninsured patients. The it's all income based. And the levels of income that we're talking about here can be, you know, just sort of on a knife's edge if whether you have insurance or whether you don't. And so that churning of patients in and out of uninsured and insured status is also something that we need to pay attention to because when we do, then we inform the next doctor, the next emergency room, we have the opportunity to make that next provider aware of the prior medical history of the patient that's sitting in front of them right then.

Well, we talked a little bit about funding for the safety net system, whether that be FQHCS, real health clinics, being able to bill payers, Medicare, commercial payers, Medicaid and the the free and charitable clinics, you know, funded largely by grants. Are there other funding sources, other funding resources that are being looked into? And then I'll, I'll have a follow up question on that in just a second but start there.

Yeah, Well, within, you know, the existing system, one of the innovations that we've seen happen is that small businesses which themselves don't have health insurance or, or for whatever reason can't afford to buy it for their employees, have been open to the idea of providing some limited fundings or grants to healthcare providers that are willing to give their employees access to primary care. I'm aware of a boat, a boat building enterprise over on the Outer Banks in Nags Head and the free clinic leader there approached them and said, you know, I understand that your employees don't have health insurance because many of them are showing up in my clinic. But you know, is there a place where the health of your employees could match up with our need for funding to take care of your employees such that there could be a payment made that would allow us to expand our services to include all 200 of your boat building employees and they were able to work something out. So those, that's sort of a one-off innovation, but I think it's a good one. It's a good example of, of small businesses commercial interest showing an interest in the in the uninsured. And we celebrate that.

Right. And it, it just dawned on me though, because the free and charitable clinics don't bill Medicare, don't they automatically have some additional freedom to, to work those kinds of arrangements? Because they're not, you know, they're not restricted by the laws that don't allow it or that prevent a Medicare provider from billing anyone less than what Medicare pays. Right? Does that Am I right about that?

You are, you are right about it. I think where that shows up is not so much of, of a kind of a legal or regulatory calculus, but just an, an understanding that the culture of, of those that take care of the uninsured is, is innovative. It's, it's creative. It's, it's, it's a certain energy about wanting to help the citizens and that, you know, that live within their local community. And so that's where most of that energy comes from. But you're exactly right. You don't get caught up in a bunch of balance billing and, you know, issues like that,

Filing claims, revenue cycle, all the, all the fun stuff.

Yeah, I mean, I, I think that the safety net is a really interesting learning laboratory because imagine if you could parachute into a world where there was no insurance and how would healthcare look there? And that's exactly what the safety net represents. It gives all of us who are interested in policy and care about making big changes an opportunity to look into what is the essence of healthcare? Is it really health insurance? You know, you, you and I are both old enough to know, to maybe remember a time when insurance was not so prominent. But most of today's generation, that's all they know.

That's all they know.

You know it. I I remember one time when I split my head open on the side of the swimming pool when I was growing up. My mother took me to the doctor's office. It was on a Saturday, and he stitched up my head and she pulled $2.00 out of her pocket and paid it. And that's how that was the way healthcare was taken care of. Yeah, back in the day. So, you know, it's a unique place to learn some new, some maybe some old ideas, to relearn some old ideas, but maybe also to innovate on some new ideas.

Yeah, certain. Well, we touched also on the first session on data just a little bit. Let's dig into that a little bit more and talk about the honestly, the richness of the data or at least the potential richness of the data that exists within the health safety net provider milieu.

It's an interesting question, Yates, and I'm going to harken back to an experience that I had in 2019 when I sat on the Healthy North Carolina 2030 panel. That was a study of your audience is probably very well aware of it. But just for the others that aren't in North Carolina, the Institute of Medicine every 10 years does a projection out of what, what can we do to make the next 10 years of healthcare in our state be better? And I was on the 20th the, the group that was looking at 2030 I looked at I was a Co-lead on some clinical care issues and the uninsured was one of the topics that we took on. We could not do anything other than measure whether a person had insurance or whether they didn't have insurance. That was the only target that we could make for the next 10 years to benefit the uninsured. And so our only goal that we could identify as an intervention was to try and get Medicaid expansion to happen in the estate in the state. And I'm thrilled that that did happen. But I was sitting there thinking there's got to be more that could be done to help we. And the problem is we don't have data. We don't have measurable data that can be used and applied to this problem. And so most of the safety net providers have electronic medical records in their offices. So when a patient comes in, that patient encounter is being recorded. But what we don't have is the way to extract it and to compile it and to examine it and to study it. And all the things that insurance companies do with the day that they pull off a claims form, we need to figure out a way to do it off of an encounter form.

Yes. And clinical data is it's a challenge everywhere, but I can imagine especially there the cost involved in trying to extract and normalize that data across disparate EMRs is extremely challenging. I do think the HIE is, is one part of the problem if we can get everyone connected to that. Well, you mentioned the healthy North Carolina 2030. Tell us if anything else there in terms of your role in that and how you see that unfolding over the next. What do we have now six years left in the 10 year window.

Yeah, Well, what one of the things I love about living in North Carolina is the forward thinking, the willingness to explore and learn and to move on issues that need attention. And I mentioned just a moment ago my frustration with some of the limitations that were discovered in that first round of, of intervention setting for healthy North Carolina 2030. But the state has another process called the State Health Improvement Plan. It's an annualized process where the Division of Public Health convenes a group called the Community Council and they then take each of the 22 interventions that have been identified in Healthy North Carolina 20-30 and say, well, what, what advances have we made? What advances do we need to make and what might the future be? And there happens to be one of those 20 plus interventions that's focused on the uninsured. And so we have over the last two years been able to identify two, I think important things. One is that part of the problem with helping the uninsured is that there's not a single agency in the state, either private or governmental that cares about this issue. There's no single agency. It's split across five different providers. As we've talked about, there's other groups that are taking that interest, but maybe we should identify who's going to be in charge of the uninsured. Who owns the uninsured is I think a good question. And once that that identification has been made, then maybe there's some decisions that could be made. One of those decisions is the second big thing and that is the, the funding question that you've asked a time or two here, because the, the safety net is split up in its different parts. If you ask what kinds of funding do you need, you'll get a different answer likely from everyone. But, but the state, which is over the last four years shown a willingness to, to give part of the state appropriation. They're willing to appropriate money to the safety net. They need to have guidance, reliable guidance. They need to have unified guidance. And one of the new targets that's been set out through the state health improvement plan is for the five top priorities for the safety net to be established by this consensus group of the safety net. The person, whichever it whether it be a group or an organization that owns the safety net, they will then take on the challenge of identifying, building consensus around what are the five top funding needs for the state. And that process will be annualized and roll forward. And I think that would be another place where we can make progress on all kinds of issues like the ones we've talked about here today.

Yeah. Yeah. Well, Randy, this has been a great conversation this afternoon. As we wrap up, I just have one final question and and that is in your wealth of experience and background, is there anything I haven't asked you that you think would be meaningful to this conversation?

Well, let me first commend you and your team for caring about this issue. That means a lot. I think that's that is a role, an ongoing role that you might consider is how, how might we continue to elevate these issues? But in terms of, of unanswered questions, I, I really think the, the, the, the role of the medical home has found its way into an insurance discussion, but I think it, it needs to find its way also into an uninsured discussion. I just think there's so much that could be leveraged if those over 1,000,000 uninsured folks in North Carolina all had a answer to the question, what am I? Where am I supposed to go when I get sick? I think it would change dramatically the cost of caring for that population. I think it would change dramatically the health outcomes for that population. I think that's really one of the new challenges. I, I heard someone important in state government say once that we all know the way to good health is through an insurance card. And I'm sitting there saying, I'm not sure that I agree with that. I think though, the way to good health may be through a medical home, through the doorway of a medical home. And I, I hope that that would somehow make its way into the ambition of the state and taking care of the safety net.

Absolutely. I think I agree with you. A medical card does not guarantee that you're going to access high quality, compassionate care. Randy, thank you very much. It's been a great time talking to you this afternoon and I believe we'll need to have you back at some point in time.

Thanks so much. I appreciate it so much, Yates, you’ve got a great team.

You're welcome.