Accessing Health #163

Dr. Wendy Wolf:

We have to have a health system that works better for people, where we take care of individuals no matter what the need is and no matter what their payment source is.

Vanessa Santarelli:

Who's counting on you to stay healthy? Is it your family? Is it your friends? Is it your co workers? Or is it much larger than that? What is your role in this state? So I think that that's a message that we're trying to get out there and I hope as people are weighing the decisions about what plan to sign up for or whether to sign up at all, I think they should take that into consideration. I certain am going to be I

Lisa Lemieux:

say to people it just doesn't hurt to see what your options are and they'd be happy to go over some plans with you and at least you know what your options are, what your choices are and then you can make an informed decision so it doesn't cost anything.

Dr. Noah Nesin:

I hope that we'll be able to at some point expand main care because there's a big population that the marketplace doesn't serve and that's exactly what the expansion of Maine care was designed to address. Hopefully someday we'll get to that so that we really can reach all people in Maine Care.

Dr. Lisa Belisle:

bank this is Dr. Lisa Belisle and you are listening to the Dr. Lisa Radio Hour and Podcast Show Number 163, Accessing Health, airing for the first time on Sunday, October 26, 2014. It is critical for people to have access to health care. Far too many families become devastated by unexpected health care costs, and far too many individuals are unable to seek the medical assistance they need, often delaying diagnosis and treatment for serious problems. Today we address this issue with Dr. Wendy Wolf, founding President of the Maine Health Access Foundation Vanessa Santarelli, CEO of the Maine Primary Care association, patient outreach and Enrollment Specialist and licensed social Worker Lisa Lemieux and Penobscot Community Healthcare Chief Medical Officer, Dr. Noah Nessen. If you or someone you know does not currently have access to healthcare, listen in and learn how you can remedy this situation. Thank you for joining us. Today on the Dr. Lisa Radio Hour podcast, we have the opportunity to speak about something that I think many people would love to learn more about. And it's something that influences all of us, really. We have as guests Dr. Wendy Wolf, who is the Maine Health Access Foundation's founding president and CEO, and also Vanessa Santarelli, who is the main primary care association's chief executive officer. A couple of big names coming in and spending time with. Obviously this is a pretty important topic that you want to discuss. So thanks for coming in.

Dr. Wendy Wolf:

Yeah, it's our pleasure.

Vanessa Santarelli:

Thank you for having us.

Dr. Lisa Belisle:

First, for people who are listening, what is the Maine health access foundation? Dr. Wolf?

Dr. Wendy Wolf:

We're the largest private healthcare foundation in the state of Maine. People may have heard of the Robert Wood Johnson foundation, which is the largest health foundation in the United States. We actually are a statewide organization. We have a mission to provide access to high quality care and improve the health of everyone in Maine. And fortunately we have an endowment that helps fund our work and we give out grants and other program support to organizations across the state, including the Maine Primary Care association, to really try and make sure that everyone in Maine has the health care that they need so they can have better health.

Dr. Lisa Belisle:

Well then I guess we would also like to know what is the Maine Primary Care association and why do people need to know this?

Vanessa Santarelli:

The Maine Primary Care association is also a statewide nonprofit organization. We have the pleasure of representing and having among our members all of the state's federally qualified health centers. So Federally qualified Health center is a community health center. We have 19 FQHCs in the state. They serve approximately 200,000 individuals for their primary care needs, primary and preventive care, and they integrate behavioral health and oral health services. The community health centers have over 71 sites throughout the state and are really integral in providing patient directed primary care services. So when I say patient directed, each one of our health centers boards have a requirement to have at least 51% of their governing boards represented by patients of the health center. And so it's a really unique model in which health center patients have a direct say and direct influence on the healthcare that's provided not just to them, but to several other services available in their community.

Dr. Lisa Belisle:

And tell me where some of the sites are.

Vanessa Santarelli:

Sure. Our member sites range all over the state from up in Aroostook county and places like Eagle Lake Presque Isle, Caribou down to Eastport, Lubeck, Harrington in Washington county, through to Bangor and across the state over to Bethel. We have sites all the way as far down as Springvale and cities like Portland. But we are recognized for being primary care providers in some of the most medically underserved communities throughout the state. And we, in fact, have sites and pioneer designations or destinations, I apologize, like on Vinyl Haven out in the Islands. So we are in almost every single county in the state and are proud to be serving people locally in their communities.

Dr. Lisa Belisle:

So there is a chance that people who are at one of these centers may not realize that they're actually at one of these centers. They just may be thinking, I'm going to my family doctor, I'm going to my nurse practitioner, or maybe I'm getting some counseling, or I'm going to see a dental hygienist. And they may be going to one of these sites you're talking about.

Vanessa Santarelli:

Exactly right, yes.

Dr. Lisa Belisle:

Dr. Wolf, why do we care about health access? What's the biggest what is this that we've been talking about for such a long time and the Affordable Care act has been addressing, and what is the public health impact of not having access to care?

Dr. Wendy Wolf:

Well, let's have your listeners think for a moment. Of all the things that we have in our life, probably the most valuable thing is our health. If you ask people, what do you value most? Probably my health and my family. One of the things that helps keep us healthy and makes us feel more secure about our health is having health insurance. We know this for seniors. They really value their Medicare coverage, and it has really introduced for seniors a degree of security and support that didn't exist before the 1960s when the Medicare program started. For you and me, we probably have health insurance through our employer. And I know a lot of people in Maine who are of working age. Health insurance is a very important benefit because it really helps you feel secure to be cushioned from, say, any medical illness, hospitalization, things that basically people are afraid might really, frankly bankrupt them or really cost more than they could afford to spend to remain healthy. So when you talk about access to health care, there are two things that we need to think about. First of all is everyone in Maine should have access to affordable health insurance, whether it's through public health insurance like Medicare or Medicaid or private insurance like you and I may have through one of the local insurers here in town. Then the second component of that is when you have health insurance is, can I get in and see A primary care doctor and have a relationship with someone who I trust, who listens to me, who takes care of everything that's going on in my life, not just my physical issues, but mental health, hopefully your oral health also. And really wants to take care of me, me and my family. I know you're a physician. I'm a physician. So I think one of the things that we know is that people really want to have a relationship with their health care provider, because we ought to be in a partnership to make sure people are staying healthy or if they have an issue, they can return to health as quickly as possible. So the access equation is two things. Coverage and then being able to get into the healthcare setting, whether you live in rural Maine, Portland, Lewiston, whatever. And that's why the primary care association is a really important partner, because they are the backbone of healthcare providers, particularly in rural areas in our state where a lot of people still continue to live.

Vanessa Santarelli:

And the beauty of the community health centers, just to play on what Dr. Wolf was saying, serve anyone who walks through their doors. So we don't discriminate based on different types of insurance status or ability to pay. We essentially are there to provide care to everyone. So not only are we providers of choice for people who have health insurance, because they recognize that the community health centers provide some of the highest quality primary and preventive care services, but we also serve a very high percentage of folks on Medicare, Medicare actually one of the highest percentages in the country, and folks on main care, but also for folks who don't have health insurance. We provide those health care services just as equally to them, and we try to tear down barriers to access. We provide transportation and interpretation services if individuals need those services, as well as chronic disease management and care management services. So it's really like going to. To your doctor's office, but a whole host of things more. And we're really proud of our model of care.

Dr. Lisa Belisle:

One of the things that has gained recognition is this idea of the patient Centered Medical Home. And this is something that we wrote about for our Maine magazine article in which we interviewed Bill Karen and Maine Health. But this is something that you've been doing and the Maine Primary Care association has been doing for a very long time.

Vanessa Santarelli:

Yes, thank you for bringing it up. Actually, we're really proud because nationally, if you look at federally qualified health centers throughout the country, Patient centered Medical home recognized sites nationally are about 54% of all FQHCs. And in Maine, I think we're at 95%. And we'll likely Be higher than that probably next year. Almost every single one of our federally qualified health centers has at least one, and most have more than one site that's been designated by the National Centers on Quality Assurance, which is a nationally recognized designation for sites that are providing some of the highest quality integrated primary care services. And I think that's a huge. I think it's a huge honor that our members are way outpacing sort of what's going on nationally as it relates to patients in medical home recognition. So. So it's something that Maine should be very proud of, and we wouldn't be able to do that without the support of organizations like the Maine Health Access Foundation, Maine Quality Counts, and others. So it's really been a partnership and also with the state and federal government.

Dr. Wendy Wolf:

Yeah. In fact, one thing you may not know is that Maine is a real leader in the patient centered medical home in one very important aspect. We have actually a statewide effort to bring patient centered medical care to every place in Maine that's being spearheaded by a group called Quality Counts. And as one of the core attributes of Maine's patient centered Medical home is the fact that mental and behavioral health services and physical health care services, or primary care health services are brought together to work hand in hand so that patients receive all the care that they need. And this is so important because if you think about taking care of people with chronic illnesses, say with diabetes, many times people with diabetes feel overwhelmed and they may feel depressed about their illness. If you just try to help them get better, insulin, take care of their diet, but don't address the underlying issues that they may have suffering from depression, then probably they won't get the optimal diabetes care. So in Maine's patient centered medical home, we try and bring and join the mind and the body so that optimal health is really achieved. And we aren't ignoring the really powerful thing that stress, depression, and mental health plays in optimizing health. And it's unique among the nation. Others actually are now catching up in the national standards for patient centered medical Home are now saying, oops, we need to include integrating mental and behavioral health as part of our core competencies for this sort of model. So Maine's a real leader in that regard. And I think we need to acknowledge that

Dr. Lisa Belisle:

here on the Dr. Lisa Radio Hour and podcast, we've long recognized the link between health and wealth. Here to speak more on the topic is Tom Shepard of Shepherd Financial.

Dr. Noah Nesin:

Sometimes I meet with married or partnered clients, and when we get to talking about their financial lives, a cultural divide bubbles to the surface. One person feels one way about their money and the other seems to be on their own financial island with a set of beliefs and rules that have created unnecessary borders and boundaries. It's not an uncommon thing and when I hit those situations, I do my best to help both people understand that neither is 100% right or wrong, that they simply have to take a step back and look at their own financial life in a new light. It is also true in politics and economics. What we need to do is see money as a living thing that can be used to grow our lives together without disagreement or so called border issues. It's a great feeling for me. It's like I'm helping people negotiate peace treaties with their money. Be in touch if you want to know more. Tom at Shepherd Financial Maine will help you evolve with your money.

Dr. Lisa Belisle:

in my practice in Brunswick we see a lot of patients who are self employed. We see patients who are lobstermen, fishermen, people who work in the woods, people who are craftspeople, entrepreneurs and I think this is TR around the state being self employed that offers its own unique challenges as far as health care access and insurance is concerned.

Dr. Wendy Wolf:

Yes, and actually the Affordable Care act or Obamacare, some of your listeners may know it better by that name. Provides a real opportunity for folks who are self employed, say also young entrepreneurs, sole proprietors to finally have the availability of affordable health insurance probably for the first time in their career. Through the way that the health insurance marketplace is structured. One of the things that people may not know is that part of the Affordable Care act is to make health insurance not only available, but also make it affordable based on your income. And when you apply for health insurance through the marketplace, they will ask you for information about your income and if your income, if you're a young person starting off or a sole proprietor or a self employed person, you probably meet the income eligibility to receive a lot of assistance that can lower your monthly premiums and finally make health insurance affordable for lots of people in Maine in fact, last year, in the first signup period for the health insurance Marketplace, out of 44,000 people that signed up, 90% of people, nine out of 10 people, receive financial help that lowered their monthly premiums. And Vanessa can tell you, at the health centers where they were helping people sign up, people would break into tears. They would say, I've never been able to afford health insurance in 20 years. This will be the first time I've ever been able to feel insured and have that security that knowing if I get sick, I can be taken care of. So. So it's really a tremendous game changer for people in Maine, particularly who are working really, really hard, sometimes at multiple jobs, to have that security and have affordable health insurance finally for the first time.

Vanessa Santarelli:

Absolutely. And our health centers, through grants through the federal government, through the Health Resources and Services Administration, we're fortunate enough to get outreach and enrollment grants to hire certified application counselors. So each one of our community health center members has on staff a certified application counselor to help individuals. Our open enrollment next open enrollment period is starting November 15th, and all of our health centers have these folks ready to go to sign people up. And as Dr. Wolf said, Maine was one of the leading states in the nation during the last period. We well exceeded the expectations for Maine in terms of the number of folks that we enrolled. Our health centers alone assisted over 25,000 people and enrolled well over, I think it was 4,000 people. So even some of those folks that we assisted, the 25,000, they might have asked some questions, but then were able to sort of successfully apply and get an insurance plan in their own home. But I would say that for your listeners, if they know anyone who's interested in signing up or re enrolling this time, they don't have to be a patient of their community health center. They can be anyone. Come in, set up an appointment, call one of our federally qualified health centers, and we can set up an appointment and that our folks are ready to help, walk them through the process and answer any questions at any stage in that process that they have. So there's staff at the health centers, but there are also navigators that are out at the community action program agencies. The Lobstermen's association has folks ready to assist people as well. And Dr. Wolf, I'm sure, can tell you about their wonderful website, Enroll207, which has been a tremendous resource for folks here.

Dr. Wendy Wolf:

Yeah. And in fact, I would say if you need help and you want to find out where somebody in your local community can help you sign up for Health insurance or just review your options, not necessarily even sign you up. Go to enroll207.com There's a little place that says need help? And you can click on that. The map of Maine will come up. Just enter your zip code and it will pull up who is in your local area, who is a certified assistor or an application assistor who can sit down with you and really walk you through your options. And we think it's this neighbor helping neighbor and people in your own community helping others, who I think really helped us achieve the enrollment numbers that we got last year with really extraordinary enrollment of 44,000 people. So enroll207.com check it out. And again, I will say, I don't know about you, but I run a small business. I know Vanessa does too. And when we come to our annual health insurance enrollment, I'm a doctor and this stuff is complicated. I have to sit down with my insurance broker and go over all our options. I ask lots of questions. I know for individuals who are thinking about health insurance, these are complicated issues to try and work out. Figure out what's the best plan for you. So it really is great to sit down with somebody and just say, you know, I just need to understand my options. Can we walk through this and help me understand the best plan, what I need to do for me or my family? And these folks are ready and trained to be able to do this. And in fact, when we talk to the assistors, they really enjoy doing this. They really feel that this is helping their neighbors and friends in their community. And it is a great feeling, again, to provide that sense of security to your friends and neighbors that they won't have to worry about a catastrophic illness or an event that might wipe them out financially. So check it out.

Vanessa Santarelli:

I would like to mention that despite the fact that our health centers and other organizations had a great deal of success in enrolling people, I think we had a missed opportunity in not passing the allowing Maine to accept the federal funds to expand main care coverage for approximately 70,000 individuals in our state. A number of them are actually served by community health centers and other types of practices throughout the state, but they're just not. They just don't have the insurance coverage. And so those providers are not getting reimbursement for the full cost to care for their. To cover their services. We found that a number of our assisters, the folks that were helping people sort of fill out applications, would either find there was sort of a gap, there was this hole so that in the Affordable Care act, it was envisioned that the states would expand Medicaid coverage. And so either you would, because of your income, be deemed eligible for coverage under Medicaid, which in Maine is called the main care program, or that you might be eligible for subsidies through the health insurance marketplace. And because Maine, and Maine is the only state in the entire Northeast that did not choose to expand, we fell short by a couple of votes in the legislature to expand Maine care coverage. We found that a number of people would go to try to sign up and either couldn't afford it, didn't have any ability to get the subsidies, and weren't eligible for main care. In addition, we had about 25,000 people dropped from main care eligibility on January 1st. So. So the good thing is that we've stayed connected to these folks, and if they don't have a medical home or a health home, they don't have a primary care provider and that relationship established. Our health centers wouldn't just sort of say, geez, we're sorry, we can't help you out this time. They would offer to provide healthcare services to them through the health centers. And so for folks who are uninsured, they could sign up to be patients at the health centers. But I think that we really need to pass this coverage so that more people can have the access that Dr. Wolf spoke eloquently about earlier in the program.

Dr. Lisa Belisle:

Dr. Wolf, your background is in pediatric cardiology?

Dr. Wendy Wolf:

Yes.

Dr. Lisa Belisle:

So I guess I'm wondering, and I'm sure other people might be wondering too, why is this so important to you? Why is Health access the thing that you have chosen to focus on?

Dr. Wendy Wolf:

Okay, I'll tell you a quick story. I used to practice down in the Texas medical school system, and as a pediatric cardiologist, I took care of children with inborn heart problems mostly. And I had a child who had a heart valve replacement and was doing very well, went home and I got a call a couple weeks later and she was not feeling well. She was feverish. She came in to see me, and the long and short of it is she had developed a toothache. Her mother had tried to get her in to see a dentist. The dentist did not take Medicaid, and her toothache went on to become a tooth abscess. And the bacteria in the abscess got in her bloodstream and infected her brand new heart valve. And she was deathly ill, all because she could not get dental care. And that just frankly enraged me both morally and personally. And I said, you know, we have to have a health system that works Better for people where we take care of individuals no matter what the need is and no matter what their payment source is. I know you as a physician and me, when you see someone who is uninsured, it is one of the hardest things in the world to try and take care of someone when you know they are weighing every potential test, every therapy, every prescription of saying, can I afford this? Maybe I can cut these pills in half. You and I know we can't provide the care that we want to provide because when someone does not have health insurance, they are hamstrung financially from getting the care that you and I know they deserve, and that's just wrong. So I changed my orientation to go into health policy and end up running the foundation. So there's a short version of it.

Dr. Lisa Belisle:

And we were lucky enough too to have Dr. Lisa Letourneau from Maine, Quality Counts, and my sister, Dr. Amy Belisle, who also works with Quality Counts. And Dr. Letourneau is an emergency room physician with public health training, and my sister is a pediatrician. So I think that there are physicians around the state who are working with individuals like Vanessa because we know that this is an issue. This is a bigger issue that we can't just deal with one on one in the doctor patient relationship setting.

Vanessa Santarelli:

Yeah. And the example of the story, the really heartbreaking story that Dr. Wolf just shared about dental and oral health issues, I mean, those issues are being seen every single day in our health centers and in emergency departments, unfortunately, because we don't have adequate coverage for dental, especially for adults. And so that's one of the issues that our health centers will be trying to push this session as well through the legislature and working collaboratively with a number of other organizations, is to try to get some create main care benefit for adult preventive and restorative services. Our health centers throughout the state, for the ones that provide integrated dental, they don't just provide it to children. They get reimbursed for most children's services, but they also provide it to adults, and that's huge. They do oral health cleanings, they provide fillings, they do the preventive and restorative work to try to keep folks from getting to that stage where they just have to have their teeth pulled in order to get rid of that terrible pain. And we're spending at our health centers hundreds and hundreds of thousands, actually millions of dollars each year in essentially subsidizing the cost of providing the oral health care to those adults because we know it's so important, and we believe that integrated health also Includes the mouth, not just the head and not just the body, but also the mouth. And so I just applaud our health centers for prioritizing that. And the voter approved dental bonds a couple of years ago means that towns like Port or Maine, at Sakopee Valley Healthcare Services, they're going to have four new dental operatories and folks down in the southwestern part of the state will be able to go and sign their kids up and sign themselves up to get some oral health care. And we provide those types of oral health services throughout the state in places like Holton and up at Fish River Rural Health up in Eagle Lake and Fort Kent, and actually at Penobscot Community Healthcare in Bangor. I believe it's the largest dental care practice among federally qualified health centers. Certainly, I think on the east coast, if not in the country.

Dr. Wendy Wolf:

Sometimes doctors and nurses don't realize how potent they are in helping patients understand the importance of health insurance. And why. Why should we care about people having coverage? Many people don't realize that medical illness is one of the leading cause of bankruptcies. When I talk to young people starting off on their careers, particularly in Maine, where we have lots of really entrepreneurial individuals or artists starting off saying, you realize you're just at the point of starting off your business right now, you've put plenty of investments in what would happen if you get appendicitis. Something that could just happen out of the blue and all of a sudden end up with a $15,000 or $20,000 bill because you had to have your appendix out. It would really pretty much functionally wipe out all the investments that you made starting your own business or starting your art career or whatever. So people sometimes don't realize how important it is to have that sort of cushion or safety and security that that keeps you from having a financially catastrophic event. And the benefit is also when you have health insurance. There are plenty of things that are in the health insurance package now that can encourage wellness. Free preventive screening, an annual wellness visit with your doctor. Things that allow us the opportunity not only to deal, say, with an acute problem, but really sit down with patients and say, let's talk about how we keep you healthy and maybe keep you out of my office and, and how can I be a helper in doing that? So I think there are lots of benefits that doctors and nurses can help talk about, that you all can help educate patients about. Why is this a really good thing? You're very trusted and we ought to be telling them the truth about these things.

Dr. Lisa Belisle:

How do people Vanessa, find out about the main primary care association and the work that your centers are doing.

Vanessa Santarelli:

Sure. People can go to our website, www.mpca.org, or Google Maine Primary Care Association. And our organization will show folks how they can locate their local community health center also by going to enroll 207, if they're interested not only in how to find their local community health centers, but assisters and how they can get information to help sign up for the next open enrollment period on the Health Insurance Marketplace. We have information available at our office in Augusta. We're on Winthrop street in Augusta, but we also have community health centers, like I said, in over 71 locations throughout the state. And I think any of our health center sites would be more than happy to help folks get whatever information they need about enrolling and staying healthy. One of the key messages, too, and I know that we have limited time that we're putting out there this session, is, you know, who's counting on you to stay healthy. And that's one of the big messages we're going to be putting out there for this next open enrollment period. For me, it's my dog and it's also my staff at the organization that I work for. But I think that that's a key message for people to keep in mind who's counting on you to stay healthy. So just like Dr. Wolf was referencing a small business owner, you know, and sort of working and staying healthy for purposes of their own employment and business success, I think that folks need to think about that. Who's counting on you to stay healthy? Is it your family? Is it your friends? Is it your co workers? Or is it, you know, much larger than that? What is your role in this state? So I think that that's a message that we're trying to get out there. And I hope as people are weighing the decisions about what plan to sign up for or whether to sign up at all, I think they should take that into consideration. I certainly am going to be.

Dr. Lisa Belisle:

And Dr. Wolfe, how do people find out about the Maine Health Access Foundation?

Dr. Wendy Wolf:

Well, they can go to our website also, and that's www.mehaf. it's called mehaf.org. they can call me. They can visit our office in Augusta and also go to enroll 207. It's not about the foundation, but we're the sponsor for Enroll207 is providing basic information about the Health Insurance Marketplace. And as I said, it has that great help locator where you can put in your zip code, find lots of people in Your area in all different sorts of agencies. Community health centers, community action agencies, brokers. We have brokers who are Affordable Care act certified on our website. So there's really just a host of individuals who are ready and really want to help people get signed up for affordable coverage and go there first. I'd rather you check that out than even come and learn about the foundation. You can learn about us after you get coverage.

Dr. Lisa Belisle:

And the open enrollment period begins November 15th.

Vanessa Santarelli:

Yes. And it's shorter this year, so it's more critical that people make appointments to sign up if they're interested with their health centers or with the navigators. The period runs from November 15th to February 15th.

Dr. Wendy Wolf:

I'm sorry. Yes, but if you want coverage January 1st, you need to sign up by December 15th. But coverage for 2015, you can still enroll up to February 15th. After that, people need to realize you cannot sign up for coverage after February 15th for the year 2015 unless you have sort of a life changing event, you have a baby or you lose a job or things like that. So there is a limited window to sign up and people need to realize now is the time to start thinking about it and review your options.

Vanessa Santarelli:

And there will be fines associated if people don't sign up. And so I think that that's also a factor that folks should consider as they're weighing their options come November.

Dr. Lisa Belisle:

I appreciate the work that you're both doing in this area. We've been speaking with Vanessa Santarelli, who is the main primary care association's chief executive, and also with Dr. Wendy Wolf, who is the Maine Health Access Foundation's founding president and CEO. I encourage people to look into enrollment if this is something that they need. Look into the health centers you've described, Vanessa, and really consider who it is that is counting on you to stay healthy. So thank you so much for coming in today.

Dr. Wendy Wolf:

Oh, thanks. It's a pleasure.

Vanessa Santarelli:

Thank you very much.

Dr. Lisa Belisle:

As a physician and small business owner, I rely on Marcy Booth from Booth Maine to help me with my own business and to help me live my own life fully. Here are a few thoughts from Marcy

Vanessa Santarelli:

when asked, most of my clients say the same thing about what keeps them up at night. Money making. Certain cash flow is there to meet

Dr. Lisa Belisle:

day to day operational needs.

Vanessa Santarelli:

Oh my gosh. Is payroll going to be able to make it? When we dig deeper, we understand that those sleepless nights are symptoms of poor planning and forecasting. And more often than not, the reasons for not doing it are a lack of time and a lack of resources. So here's a suggestion. Instead of living in fear of the numbers and losing sleep over them, make peace with them by paying closer attention to the financials and creating positive cash flow.

Dr. Lisa Belisle:

I'm Marcie Booth. Booth let's talk about the changes you need. Boothmaine.com

Dr. Lisa Belisle:

As a family physician for many years, it has been an interesting experience to see how access to health care has changed. When I have patients who come in who tell me that they now have health insurance after many years of not having had health insurance, it's a good thing. It makes me happy. So today we speak with two individuals who are going to help us understand why it is that we now are able to give patients access to health care when we weren't before, and also what that process entails and why it's important. Today we have with us Dr. Noah Nessen, who is the chief medical officer for Penobscot Community Healthcare, which serves approximately 60,000 patients for their primary medical, behavioral health and dental care needs. We also have with us Lisa Lemieux, who is a licensed social worker and the patient outreach and enrollment specialist at all three Daniel Frank David Russell Medical center facilities. Lisa is a certified application counselor who works with both patients and community members to educate and assist them in knowing the options available to them through the Affordable Care Act. Thank you so much for coming in.

Dr. Noah Nesin:

It's great to be here. Thank you.

Lisa Lemieux:

Thanks for having us.

Dr. Lisa Belisle:

So this is an interesting topic, as I mentioned for me because as a family doctor, I've cared for patients kind of across the spectrum. I've cared for patients who are in jail and patients who are students in college and patients who are living in suburban, urban and rural Maine. I've seen a lot of different people coming through my doors, and the one thing that kind of unites all of them is the need for basic healthcare services. And this is something that you both have quite a lot of experience.

Dr. Noah Nesin:

Yes, there's no question. I grew up in a household in rural Maine where my dad was the doctor for the community and sort of the old style family doctor mode and saw that model. And in my own career as a family doctor like you, I tried to mimic that the best I could. Although as medicine became more sophisticated, with more resources, more tests, more and more, I bumped into the barriers of the Finances of people who are uninsured and couldn't afford some of the care that they needed, or delayed or deferred their care because of the cost. So it is very gratifying to have more people covered and able to access care.

Lisa Lemieux:

Right. And my role has been, it's a fairly new role here, as in many states, is to educate consumers about what their options are. So for the first time, people are really understanding what the healthcare can offer them, what plan is best for them, and know there's no pressure. There's no, you know, pressure to choose a plan. It's up to them. And so that's my role, is to guide them through that.

Dr. Lisa Belisle:

When we think about health care, often we think about things like vaccinations and preventive care. But what I find fascinating is that, that you're also talking about behavioral health care and the work that you do and dental care. And you're also using the word client as opposed to patient. You're actually talking about somebody who has a choice, who's making a decision to access services.

Dr. Noah Nesin:

Well, one of the catchphrases in healthcare these days is population health. And I've heard a number of definitions of population health, some of which I understand and some of which I don't, but fundamentally, it's about the wellness of the community in which we live. And we can think of community in a number of ways, but I think that's much more tangible for people. And really that kind of integrated model, and the patient or consumer or client as a partner in that model is really the best way to approach that. And until people have the kind of coverage that allows them to participate in that model, they're sort of outsiders or intermittent users of the system and therefore can't fully partner with us.

Dr. Lisa Belisle:

Now, Lisa, as a social worker, I suspect you've spent some time with individuals who maybe have financial difficulties, who maybe have problems emotionally. How does health care become more important for people who maybe are dealing with issues of unemployment or poverty or greed, grief or loss?

Lisa Lemieux:

I think that the interesting factor about this position is when health centers look to hire people to talk to consumers about health insurance, they didn't look for people that had health insurance insurance experience, sales experience. The goal was to get people in who could just sit down and have a conversation and really understand where a person, where they were coming from, what their needs were and how they were best going to be served. And so that helped us go through the different plans to talk to somebody and say, you know, what are your needs? And let's Find something that can meet those needs. Financial issues play a big part in this Affordable Care Act. And here in Maine, you need to be between 100 and 400% of the federal poverty level in order to qualify for a subsidy. And it's those subsidies that help define affordability. But there's two things I always say to people is affordable means different things to different people and it's about their own health needs. And that's the two bottom lines that we're going to look at when we look at the plans for them.

Dr. Lisa Belisle:

So if I'm listening to the show and maybe say I'm an entrepreneur and I'm working on a startup or I'm an artist, perhaps define for me what that looks like financially. You said 100 and 400% of the federal poverty level.

Lisa Lemieux:

So for a household of one, I usually tell people it's like 11,600 is what you need to claim on your federal income tax. So in Maine it's a little difficult. One of the whole things is that you have to project your income for 2014. So people in January were going, I don't know what I'm going to make in 2014. You know, here in Maine we have a lot of self employed people, we have a lot of seasonal part time. So, you know, it's helping them figure out what their bottom line is going to be and changing it during the year if we need to, because that's what they're selling subsidy is based on. So yeah. So for again, a person of one, it'd be like $11,600 is what I kind of say.

Dr. Lisa Belisle:

So that's not a lot of money.

Lisa Lemieux:

It's not a lot of money. That's the 100%. Right.

Dr. Lisa Belisle:

Okay. So you can make between that amount and four times that amount.

Lisa Lemieux:

Exactly.

Dr. Lisa Belisle:

Which is still not a lot of money really.

Lisa Lemieux:

Right.

Dr. Lisa Belisle:

So if you're one of the individuals who qualifies in that range, what can you expect to pay for health insurance?

Lisa Lemieux:

Well, if you're right at that 100%, the majority of people I saw were paying 3 to $5 rate at that 100%. And the higher up you go in income, it's based on your income and how many are in your household and where you live. And you know, it's broken down into four districts here in Maine.

Dr. Noah Nesin:

And age also.

Lisa Lemieux:

And age, yes. Thank you. Yeah.

Dr. Noah Nesin:

So a young person who's single, the only member of the household, and low income, could get a very significant subsidy, pay very little for insurance. Whereas, you know, a couple who has a combined income that's at the upper levels of that who might be a little bit older would pay a little bit more. And one of the phenomena that I think have experienced in this is people who haven't accessed the insurance market previously. It takes a little bit for them to understand the value of that purchase because it's still a fair amount of money, especially if you're closer to the 400%. And knowing what that is relative to what they'd pay if they were in the private insurance market as opposed to the marketplace is helpful in aiding people in understanding the value of what they're getting in that subsidy.

Dr. Lisa Belisle:

lisa I think it's interesting that we are now at a place that people who in the social work field have arguably been in for generations. The need to marry sort of logistical concerns and priorities with emotional and social concerns and priorities. And this is something that people who are social workers know. You know that you have to help somebody feed their children as well as help them deal with the loss of a parent. And that's a broad range of things, but it's all part of the hierarchy of needs.

Lisa Lemieux:

It is, absolutely. And I think that was one of the reasons for hiring us to talk to people. And again, the first thing I say to somebody when I meet with them is I'm just here to show you what your options are. I've had people not even choose a plant because of that. You know, what we thought was going to be affordable really isn't affordable when we're looking at them trying to put food on their table and Then we look for other alternatives for them. But it's all about education and understanding what their choices are. And I think for the first time, people are understanding the different plans that are available to them and what the consequence is if they choose not to. To take the plan at this time, because there is. There will be a financial penalty for some people, and for others, we can certainly do a hardship waiver. So it's all, again, it's tied into education and trying to meet their needs and what feels good to them.

Dr. Noah Nesin:

I think also for the previously uninsured. I'd be interested to know if this is your experience as well, but I hear people a lot talking about the cost of whatever their share of their premium is compared to no cost, as opposed to comparing that to the cost of having a health care need unmet or having to pay for an emergency health care need. And that's a discussion I've had with lots of friends and family who are interested in this, but wonder if there's value in it.

Lisa Lemieux:

I think that's sometimes a cultural thing. Growing up, maybe people that have never had insurance. It's that education piece about what is now offered to you. And I do think the word is getting out. You know, people. I think last year I certainly had people say, well, I'm going to wait and see. Because there was a lot of, let's wait and see how this goes.

Dr. Noah Nesin:

Especially with the way the marketplace rolled out last year.

Dr. Lisa Belisle:

It really was.

Dr. Noah Nesin:

People hesitate.

Lisa Lemieux:

Yeah. And a lot of people like, is this going to work? You know, there's no guarantees with anything. So some people really kind of stepped back and they kind of waited. But I think they're talking to people that took that bold step and said, sign me up. And I'm sure you've probably had the same. And you've also said you've met with patients who are really excited to have health insurance. And I think the exciting thing is that they understand it and what they can get for that health insurance as well. So really meeting the need of education.

Dr. Lisa Belisle:

I also think that there is a sense of fear associated with not having health insurance, because it's all fine when you're healthy. When you didn't break a leg or your child didn't have appendicitis, or you haven't had a diagnosis of cancer. If you can stay healthy and you can avoid all accidents, then that's great. But we know that one of the major problems associated with. Associated with financial struggle is medical debt. And this is becoming increasingly challenging because our costs are much higher than they used to be.

Dr. Noah Nesin:

People lose homes, people become homeless people. Families break up over some of the financial stresses that are caused by medical debt, and they can be devastating. And as you know, there was a Time magazine article in the last year, I think that sort of detailed some of the variabilities in cost from facility to facility and state to state, and things that one might not think would cost a tremendous amount, like a simple appendectomy or hip replacement, which are not cheap. But the cost variability is so dramatic that without health insurance and with the requirement that you pay that, it could end your ability to retire, for instance, at a minimum, or make it impossible for you to pay your mortgage or pay off your car payment.

Lisa Lemieux:

I think that's one of the things with this new marketplace plans is that there's actually an out of pocket cap on all of them. And that was really appealing to a lot of people. 6,500, you're covered at 100% after that. So you talk to somebody and you say, you know what happens if you're in the hospital for two, three, four days, that debt is accumulating. But once you hit that out of pocket, and it can actually be actually lower than that, depending on your subsidy and your cost sharing reductions. The 100% federal poverty level, typically they're out of pocket, maximum is $500, and then they're covered at 100% for the rest of the year after that. So those are big pieces to talk to people about.

Dr. Lisa Belisle:

I've also seen in my practice that people will actually verbalize. They will say, well, Dr. Belisle, I know that I need to keep myself healthier because it will cost me more if I don't. And this is something that is relatively new, that people are actually understanding that if they can't lose the weight that they've gained, or if they don't take care of their diet, then they'll have problems, say from joint pain because they've become obese, or heart attacks because they can't control their cholesterol levels. And they're now knowing that there's something I can do about this, like I can take some control over my life so that whatever I can control, I can control, and whatever I can't, it will be covered by insurance, which is, I think, really great. It's really nice to know that people are that engaged.

Dr. Noah Nesin:

I do think there's an increasing level of sophistication, both among patients and providers about exactly that kind of engagement, and certainly among purchasers, especially employers who pay for health insurance for their employees that you see more and more wellness programs, but not just more wellness programs, more involved wellness programs that really do promote health in important ways and they're constantly refining them. In addition, some of the payers like Maine Community Health Options, one of the markets marketplace plans really has been pioneering value based benefits which really do get at trying to motivate people to do the things for themselves that will keep them in better health and therefore limit their cost. The cost to the insurer, the cost of the employer, the cost of the entire health care system. Because as you know, we're in a system that spends 40% of the world's health care dollars on 5% of the world's population and has some something like the 35th or 36th best outcomes. So we don't have an efficient system right now. And part of what's been missing is exactly that kind of engagement that you just spoke about.

Dr. Lisa Belisle:

As I'm thinking about what the healthcare educational system and recruiting system has been and you were describing type A personalities, medical students who were able to put their noses to the grindstone and just kind of plow through all the work. And that really was, I believe, your father's practice model. And I think there are still medical students who go in with that idea in mind. But what I'm understanding is that the ability to be collaborative is so much more critical. And in fact, as a physician I feel better because I now know that there are people with me who can offer some of the things that traditionally I had been asked to do all by myself. There are people who can help me in the areas of behavioral health and dental health. And my team in Brunswick, the nurses do so much more because they're able to do so much more. So I love working as a team because it makes my job actually much easier.

Dr. Noah Nesin:

It is easier and we know it's better care that the more delegation that goes on within the care team, the better the outcomes for the patients that we serve. And you're exactly right. That transformation from relies on my memory, my good intentions, my knowledge base and my energy on a day to day basis and my need to control everything that goes on with the people that I serve. To my team's commitment to this, how elegant the delegation model is, how well people understand their roles and the parameters of their roles, the amount of autonomy within that team for people to act in ways that serve the patients best. And all of that supported by the kind of data that helps us adjust our work system so that we really are providing care as efficiently and as effectively as we can to people. And that is a different mindset for those of us who were trained in the control freak model to be a collaborator team leader, to delegate responsibility and to accept responsibility for that team's performance.

Dr. Lisa Belisle:

Lisa, do you have any final thoughts for people who are in the marketplace now and who are looking for options that are available to them through the Affordable Care Act?

Lisa Lemieux:

Well, Open enrollment starts November 15th and people have from November 15th to February 15th to shop for a plan and purchase a plan and then after that it closes. Except for special enrollment situations like having a baby, getting married, moving, something like that. So there's a three month window that I say to people, it just doesn't hurt to see what your options are. Give any, you know, any certified application, counselor or navigator, you can find them listed on enroll 207 and find one in your area and they'd be happy to go over some plans with you and at least you know what your options are, what your choices are and then you can make an informed decision so it doesn't cost anything.

Dr. Lisa Belisle:

And how about you, Dr. Nessen? Do you have any final thoughts?

Dr. Noah Nesin:

I do, just that I'm so pleased to be able to work in a community health center the way that Lisa does. This kind of partnership, this kind of team approach that you described is fundamental to what we do and the commitment to serve all of the population of Maine regardless of their ability to pay. And I hope that we'll be able to at some point expand main care because there's a big population that the marketplace doesn't serve. And that's exactly what the expansion of Maine care was designed to address. So hopefully someday we'll get to that so that we really can reach all people in Maine.

Dr. Lisa Belisle:

Well, that is a laudable goal and I'm going to put my energy behind that intention as well. We've been speaking with Dr. Noah Nessen, the chief medical officer for the Penobscot Community Healthcare System, and also Lisa Lemieux, a licensed social worker and patient outreach and enrollment specialist with the Daniel Frank David Russell Medical Center Facilities. Thanks so much for coming in and talking to us today.

Dr. Noah Nesin:

Thanks for having us.

Lisa Lemieux:

Thank you.

Dr. Lisa Belisle:

You have been listening to the Dr. Lisa Radio Hour and podcast show number 163, Accessing Health. Our guests have included Dr. Wendy Wolf, Vanessa Santarelli, Lisa Lemieux, and Dr. Noah Nessen. For more information on our guests and extended interviews, visit drlisabelisle.com the Dr. Lisa Radio Hour and Podcast is downloadable for free on itunes. For a preview of each week's show. Sign up for our e Newsletter and like our Dr. Lisa Facebook page. Follow me on Twitter as DrLisa and see my daily running photos as bountiful one on Instagram. We love to hear from you, so please let us know what you think of the Dr. Lisa Radio Hour. We welcome your suggestions for future shows. Also let our sponsors know that you've heard about them here. We are privileged that they enable us to bring the Dr. Lisa Radio Hour to you each week. This is Dr. Lisa Belisle. I hope that you have enjoyed our accessing health show. Thank you for allowing me to be a part of your day. May you have a bountiful life.