Executive Summary

 Fairfax County Health Status and Health Resources

The Fairfax Community Health Status Assessment (CHSA) provided information on community health needs and selected aspects of health care access, resource availability and utilization in Fairfax County and the cities of Fairfax and Falls Church (Fairfax CHSA, 2011). Key findings from the 2011 CHSA and data supplied by the county provide context for George Mason University’s (GMU) report and recommendations to the Fairfax County Health Reform Implementation Task Force.

The Fairfax community is an asset-rich, racially and ethnically diverse, well-educated community that has high per capita income and abundant community resources (social, cultural, and intellectual).  However, segments of the population have low socioeconomic status, low educational attainment, high unemployment, low health status, lack health insurance coverage, and have lower life expectancy.  There are differences in availability and access to health services and significant contrasts in health status found across different geographic areas and population groups throughout the community.  These contrasts present challenges in planning and providing services to improve public health and address health and quality-of-life needs of all residents. Additionally, there is evidence of disparities in health and access to health services indicating vulnerable groups in the community have a disproportionate burden of disease.

 

• Despite the Fairfax area’s wealth, more than 1 out of every 10 residents in the county lacked health insurance in 2010; among children age 5 and under, 8.2% live in poverty.
• The overuse of costly, acute care services could be reduced.  Approximately 26 % of the region’s Emergency Department (ED) visits in 2009 were found to have conditions that did not require ED care.  A large percentage of these were by residents with low socio- economic status, who lack health insurance coverage.  Primary care offices or clinics are more appropriate and a less costly setting to address non-acute medical conditions.
• Fairfax County’s primary care capacity is increasingly insufficient to meet projected service demand.  In 2010, 39 % of all primary care physicians in the area were age 60 or older.  New physicians entering the medical profession are less likely to elect primary care, and those who do choose a primary care practice specialty are not entering at a rate fast enough to replace those who are leaving.  Moreover, the number of primary care providers who accept Medicare and Medicaid in the Fairfax community is expected to be insufficient in the future.
• Increased health insurance coverage and the requirements of insurers to improve health care value and assure quality underscore the importance and need for primary care providers and expanded medical home capacity.

Utilizing a robust safety net optimally is increasingly important as resource availability becomes more problematic.  In a region that continues to have population growth and increasing racial/ethnic diversity, integrated, efficient,   and cross-agency approaches will be needed to manage resources for vulnerable populations, especially those with more than one chronic disease and the disabled.

Even as the demand for services provided by the safety net will change as more residents obtain health insurance coverage, a variety of factors including availability of primary care providers and individuals care seeking behavior will continue to support the need for safety net providers.

Federal Health Reform Legislation

Enacted in March 2010, the Patient Protection and Affordable Care Act, (PPACA) is designed to increase the number of people in the United States with health insurance and make health insurance and care more affordable.  The law also provides a variety of avenues for developing and testing innovation in service delivery and payment models.  This report summarizes the provisions of PPACA designed to increase access to affordable health insurance and provide funding opportunities for local public health departments, statewide Medicaid grants and programs, and other state provisions.

Among the major provisions in PPACA include: expansion of Medicaid eligibility, private health insurance premium and cost-sharing subsidies, creation of state health insurance exchanges, new rules for health insurance companies and plans, an individual requirement to maintain creditable coverage, and employer responsibilities.   In 2014, individuals and families with incomes up to 133% of the Federal Poverty Guidelines will be eligible for Medicaid, which will open up Medicaid to many uninsured adults.  For those with incomes above 133% but not exceeding 400% of poverty, the Federal Government will offer health insurance premium tax credits to those who purchase in the new health insurance exchange.  Also available will be cost sharing credits that are designed to lower out of pocket health expenses for individuals with incomes up to 250% of poverty.  Both these credits are available to those who do not have access to qualified, affordable employer sponsored health insurance, nor to public coverage such as Medicare.^[1] Health insurance exchanges will be consumer friendly and transparent marketplaces for individuals and small groups to purchase health insurance.  Insurance companies will be required to provide insurance with a minimum benefits package known as the essential health benefits. A portion of the benefit structure, beyond the minimal federal requirements, could be defined by each state.  In 2014, health plans may no longer determine coverage decisions and or prices based on an individual’s current or past health status.  Premiums will be allowed to vary only for age, smoking status, location, and family size.  All individuals, with a few exceptions, will be required to maintain health insurance or be subject to penalty taxes.  Companies with more than 50 full time workers will be subject to penalties for not offering insurance or for those employees who choose to seek insurance subsidies in the exchange because their out-of-pocket premium at work is too high a percentage of their income. Public health provisions in PPACA include a new and unprecedented   $15 billion fund for public health programs.  Under this program, Fairfax County was awarded a five year Community Transformation Grant (CTG) of $499, 559 for each year.   This grant will be used to review county policies and services in order to strengthen programs and improve the health of the community in priority areas. In so doing, the goal is to reduce health disparities, promote healthier eating and lifestyles, reduce tobacco use, lower the rate of hypertension, and create a healthy and safe environment in Fairfax.

In addition to public health, PPACA has provisions designed to encourage both insurance plans and employers to provide wellness programs.  The legislation also has provisions to promote health and prevent disease.  For example, regulations have been promulgated to require published nutritional information on the offerings from the largest restaurant chains and vending machines.

 Virginia Health Reform Initiative

In August 2010, Governor McDonnell appointed 24 high profile stakeholders and office holders from around the state to the Advisory Council of the Virginia Health Reform Initiative (VHRI), an effort spearheaded by the Secretary of Health and Human Resources, William A. Hazel Jr.,  MD.  After numerous meetings, briefings, expert analyses and debates, in December of 2010 they issued a report to the Governor and General Assembly (GA), with 28 substantive recommendations.  The most important recommendations with implications for Fairfax were: Virginia should make its own insurance market exchange to prevent federal takeover of the small group and individual insurance markets; Virginia should prepare Medicaid for coverage expansion with improved information systems, care coordination pilots, and value based benefit redesign; and the Secretary should be as catalytic and proactive as possible in order to promote delivery system reform across the Commonwealth.

The General Assembly followed the first recommendation of the VHRI when it passed HB 2434 early in 2011.  This law directed the Secretary to consult stakeholders and report back with a plan to implement a health benefits exchange that will work for Virginia and satisfy PPACA requirements.  A subsequent report and recommendations, delivered to the GA by the Governor in November of 2011, again recommended a Virginia-run exchange with the caveat that it not be more demanding of health plans than what is specified in federal law.  It also recommended that a future exchange in Virginia be governed by an independent board much like the Virginia Housing Development Authority, thus giving the exchange some independence from the legislature and governor. However, frustration over delays in receiving federal guidance on various aspects of the exchange, the impending Supreme Court decision (in June or July 2012) on the constitutionality of the law, and the general politics of polarization that plague our nation have raised serious doubts about whether Virginia will create an exchange in the 2012 legislative session.  As such, it risks a federal takeover, for at least 2014.  Developments on this front should be closely watched.  Meanwhile, the Secretary was successful in working with key stakeholders such as the Medical Society of Virginia, the Virginia Health and Hospitals Association, and the state Chamber of Commerce to jointly sponsor a new Virginia Center for Health Innovation in order to stimulate payment and delivery system reforms and promote gains in population health and wellness.

 Quantitative Analysis of Health Insurance Coverage

Even though Fairfax County is one of the richest counties in the nation, the most recent data (American Community Survey (ACS), 2010) indicates that over 144,000 or 12.9% of residents are now uninsured.  George Mason University consultants used advanced estimation and micro-simulation techniques, and credible data from a variety of federal sources, along with Fairfax ACS data, to develop a PPACA implementation model to predict how many and which residents in Fairfax will either purchase insurance or enroll in Medicaid or stay uninsured based upon expected prices and/or insurance program eligibility.  Because of the robust nature of  the analytic methods, the results of sensitivity analyses and the credibility of the data, we are confident the models developed predict insurance choice behavior post-reform, when new eligibility rules, subsidies and insurance market exchanges will drastically change access to health insurance and health insurance prices for so many.  Our best estimates are as follows:  About half of Fairfax’s uninsured will gain coverage and slightly more than half of these will get private coverage instead of Medicaid.  Furthermore, the remaining uninsured are less likely to be children or very low income.  Ordinarily, this development would suggest a commensurate reduction in county-provided and financed safety net health services. However, it will take time for new enrollment to occur and for the healthcare marketplace to adjust to the large-scale changes in insurance coverage among local residents.  Therefore, county services will be needed to ensure continued access to services while newly insured residents and health service providers adjust over time.

 

At present, the county is unable to provide systematic unduplicated counts and lacks uniform demographic data on service users across all of its programs. Therefore, it is impossible to precisely estimate the share of the uninsured the county serves now.  Our best estimate (based on nationally representative survey data and aggregate county service rolls) is that the county serves a large majority of the uninsured who currently seek health care.  Another serious complication of PPACA’s implementation is that not all those who will become eligible for insurance will enroll immediately; thus the model’s quantitative estimates should be interpreted as closer to a “fully phased in” estimate, not an estimate for calendar year 2014.  Also, Medicaid payment rates are low compared to private payment rates in northern Virginia, so that it is likely that many new Medicaid enrollees will face difficulties finding willing private sector providers to serve them.  Low provider reimbursement rates are compounded by shortages in specific health specialties and lack of information about primary care and medical home capacity. For example, there is already a profound shortage of mental health providers in northern Virginia, especially for the seriously mentally ill, regardless of insurance coverage.  Finally, the scale of the Commonwealth’s anticipated Medicaid expansion is very large, and for that reason alone may be slowed from the pace anticipated in the federal reform law, regardless of how the Supreme Court   decision and elections turn out. For these reasons, we caution against precipitous decisions to reduce county support for local safety net capacity until more is known about both PPACA implementation and the effects of reform on residents and health care providers is clearer.

 Peer Counties Review

Understanding what similar counties offer in terms of safety net supports and how they organize their system(s) to deliver those services is useful as Fairfax County explores its own options.  After a detailed selection process, six counties were chosen for the peer county review:  Montgomery County, Maryland, Hennepin County, Minnesota, Travis County, Texas, Cobb County, Georgia, Wake County, North Carolina, and Jefferson County, Colorado.  Findings from the review of these counties show similar challenges as those found in Fairfax, but selective adoption of different approaches to addressing local needs.  The array of interventions used ranged from offerings focused on disease prevention (Jefferson County, CO), to establishing a separate political subdivision with taxation authority to fund comprehensive services to low income uninsured (Travis County, TX).  Others jurisdictions such as Hennepin County, Minnesota and Montgomery County, Maryland were found to be strengthening already robust health care services for county residents. Many of these counties are working to support service integration within Federally Qualified Community Health Centers and their county social-service partners.   Among these peers, we found reinforcement for the importance of information technology as critical infrastructure needed to assure effective, efficient public health and social service systems.

Cobb County, GA and Travis County, TX have strong public mental health divisions that operate similarly to the Fairfax-Falls Church Community Services Board.  Both counties promote efforts to integrate mental health and primary care services. Travis County program efforts are very much like those provided collaboratively by the Fairfax-Falls Church CSB and the local Community Health Care Network (CHCN).

The efforts and programs found in the peer counties assessment provided examples of alternative service delivery programs and methods for Fairfax County to consider.  This included efforts that focus on distinct governance models, comprehensive intake models, public-private partnerships and service delivery cooperation.

 Recommendations

In total, George Mason University consultants identified six major challenges and offered twelve recommendations for the County’s consideration in the future.

Recommendation #1: Work collaboratively with INOVA to develop its first Community Health Needs Assessment (CHNA) required by PPACA and collaborate indentifying priorities and potential solutions for population health improvement.  These efforts should build on and extend the Health Department’s MAPP Strategic Planning process and Community Transformation Grant efforts.

Recommendation #2: Develop explicit agreements or requirements (non-statutory), in collaboration with private providers (nonprofit or not) for sharing the burden of caring for the uninsured and safety net patients.  Information about care gaps (health needs not being met) will help county and Commonwealth officials assess the wisdom or need for more formal requirements for private health providers in the future.

 

Recommendation #3:  Develop a strategic and operating plan for centralizing county contracts with all health care and service providers (especially medical sub-specialists).  Develop an evidence- based model for integrated service delivery across all county agencies and a system to support the coordination of county financed and/or provided health care and service referrals.

Recommendation #4: Continue to pursue “medically underserved population or area” (MUP/A)” Exceptional MUP Designation (also known as a “Governor’s Special Designation”) concurrent with efforts to establish a “New Access Point (NAP)” or expansion of existing Community Health Centers (CHC) in Fairfax, that enhances Medicaid and Medicare reimbursement under the “federally qualified health centers” (FQHC) benefit.

Recommendation #5: Expand the use of existing streamlined eligibility systems. Support current efforts to expedite utilization of the new cross-program integrated eligibility system that the Virginia Department of Health and Human Resources is currently developing to combine eligibility for multiple programs across the secretariat.

 

Recommendation #6: Invest in integrated information technology that supports uniform or standardized data collection and enables a comprehensive array of clinical care and administrative functions (including client information, billing and information exchange) across all county health and human service agencies and programs.

Recommendation #7:  Continue to include dental care as a part of the safety net services and expand access to local dental service programs for more adults.  Work with other safety net and community providers to achieve this expansion.

Recommendation #8:  Prepare the CHCN to accept an array of payer sources including self-pay, Medicaid, Medicare and private insurance, especially in preparation for expansion of public and private coverage in 2014.   The ability to collect money from newly eligible and enrolled Medicaid patients will be particularly important, as many patients who use CHCN now will likely become Medicaid eligible.

 

Recommendation #9: Develop an outreach campaign in 2013 to inform the diverse community about new coverage options and Medicaid expansion coming in 2014.  Expand self-sufficiency services to support future Medicaid expansion.

 

Recommendation #10: Plan for some safety net reduction and/or consolidation, since the scale of the insurance coverage expansion under PPACA could be substantial eventually.  But since expansion will not be immediate and Medicaid payment rates are likely to remain low, it is important to anticipate newly eligible beneficiaries (maybe most) having trouble finding private clinicians, especially those patients with behavioral health needs. For these reasons, we recommend keeping the CSB at its current scale until after 2016 and reducing CHCN capacity only after reductions in need can be demonstrated.

Recommendation #11:  Create a new government entity and structure which will enable cross sector, cross agency integration, coordination, and planning in order to reorganize access to services through an authority that will manage and/or leverage resources and coordinate services and programs.  The statutory authority to take action is available to the County Executive under 15.2-5200 to establish a Fairfax County Health Commission or 32.1 to establish a Fairfax Health Partnership Authority (herein referred to as the Entity).  This Entity would report to the Board of Supervisors but would have operational autonomy assuming Supervisor-determined objectives and priorities were being met.

Recommendation #12:  Develop a privately-funded evaluation program for the proposed Entity, wherein independent contractors conduct a gross and net impact analysis and report to the Board of Supervisors (BOS) every five years (however, the first evaluation should be initiated following the first three years of implementation). Evaluate the program by the priorities determined by the BOS.

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