HCCD Report New Mexico 87508

Santa Fe, NM, Community Health Discussion

December 30, 2008

Participants:
Nancy, staff certified nurse-midwife (moderator)
Diane, Health Educator & LISW, Dept of Health
Lisa, Coordinator, Maternal Child Health Council
Roberta, Maternal Health Program , Dept of Health
Leah, family practice physician in private practice
Susan, epidemiologist and policy analyst and certified nurse-midwife
Lorrie, staff certified nurse-midwife, Hospital

Santa Fe is the state capital and has a cultural mix of Hispanic, Anglo, and Native American populations, with many uninsured and/or undocumented people. We have one community hospital, which recently merged with Christus, a Catholic health care organization from out of state, and an Indian Hospital, which closed its labor and delivery unit two years ago due to pressure from the IHS administration and is in dire financial straits. We have one FQHC, in addition to private practices and state-run clinics.

Our group members all have a longstanding commitment to public health and health care reform, as well as being experienced health care providers. We decided to dispense with the questions provided and allow each member to share the burning issues that brought her to the meeting. While we addressed broad public policy issues, we also focused specifically on issues that affect women.

We met at a restaurant after work and had a discussion that was both heart felt and intellectually intense. The people who ended up coming (we put up fliers in libraries, the co-op, & other public places) are all experienced as health care providers and public health advocates, so we had plenty of very specific ideas! We didn't get to take a group picture because we closed down the restaurant, so we hope you’ll come out to Santa Fe and meet with us to see what we look like. We are heartened, especially after the last 8 yrs, to have a sense that our experience and our values can make a difference. In our 1 ½ hour session, we developed a combination of paradigmatic bases for reform, examples of issues, and specific proposals for change.

Non-profit-driven health care for everyone:

Everyone felt that universal health care should be a right in this country, just as it is in every other industrialized nation.
Everyone agreed that the for-profit health “system” is inherently flawed and wanted to work toward a single payor system. The profit motive just puts money in the pockets of large companies and corporate executives and prevents effective interdisciplinary teams and full participation of essential providers such as CNMs, NPs, PAs and MDs in the health care system.
Example: Lorry and Nancy invite you to visit us at Santa Fe IHS if you want to see what interdisciplinary collaboration can look like in a non-profit-driven system.
Meanwhile, we want strict regulation of insurance companies’ fees and drug costs; the government should negotiate for best prices from pharmaceutical companies.
We recommend revocation of the law that equates corporations with persons and allows the profits of large companies to trump the needs of the individuals they purport to serve.
Insurance companies and medical practices should not be exempt from antitrust law.

Complete, unified health care:

It is time for parity for both outpatient and inpatient physical, oral and mental health care. We are continually frustrated at the inability to get quality mental health care for people – especially the underserved. Resources constantly shift or disappear altogether.
Resist the temptation to fragment care into “medical,” “dental,” “behavioral health,” etc.
Example: pregnancy-only Medicaid doesn’t include depression, which affects 20% of women during the year after a baby’s birth in New Mexico, and adversely affects her child’s long-term development, as well as the functioning of the entire family..
Extend pregnancy Medicaid for a year & include mental & oral health. Or just abandon categorical programs in favor of universal care.

Eliminate barriers to coverage:

Eliminate the notion of preexisting conditions.
Eliminate the connection between employment and access to health insurance/health care. Health care is a right – for the employed, the unemployed, the self-employed, and the under-employed. Women in particular face discrimination because they tend to have worse jobs or work part-time. They are prevented from starting businesses (which are the only way women can get parity in pay) because they have to get health insurance for their kids.
Eliminate barriers such as complex paperwork or lack of providers and lack of providers who will accept Medicaid/Medicare; you shouldn’t have to be super savvy to get care.
In fact, eliminate the whole system of people preventing people from getting health care.

True reform, not lip service:

Our fear is that we will go through the “reform” process, only to end up with the usual stakeholders (e.g. insurance and drug companies and the AMA) at the table and a system that is just more of the same, with entities like pharmaceutical companies dictating care.

Midwifery is the gold standard for maternity care:

Recognize the inextricable bond between mother and child as a basis of policy formation: in other words, acknowledge the unity of maternal child wellbeing and the symbiotic relationship between mother and child.
We must have midwifery as the standard of care for pregnant women. A healthy pregnancy is the key to health throughout that child’s life, and outcomes in the US are worse than almost every other developed nation, in spite of our astronomical costs. Midwifery must be the basis for maternity care - other care is supplemental.
Women and midwives need access to both in-hospital and out-of-hospital birth without barriers, as they have in the Netherlands and are working toward in Britain. Out-of-hospital birth should be integrated into & supported by the health care system. This will improve outcomes and satisfaction and greatly reduce costs.

Evidence-based practice:

We support evidence-based practice. Example:, use the Cochrane Database and others to establish a basis for health policy. But don’t require just randomized controlled trials (RCTs) for evidence, especially in areas where an RCT isn’t feasible or moral.
Fund the CDC.
Don’t allow manufacturer research as a basis for evidence-based practice.
If you want to detect “eminence-based practice”: follow the money.
Example of other interests trumping the evidence: the lack of access to midwifery care and for midwives to practice at our local hospital. NM has the highest percentage of midwifery births in the country, as well as a population with a tradition of midwifery care. Extensive evidence shows that certified nurse-midwives would cut costs and have stellar outcomes. Yet certified nurse-midwives are prevented from having a practice by hospital bylaws.

Encourage a full range of providers to optimize care:

Remove barriers to practice for professional providers, such as CNMs, NPs, PAs, nutritionists, dental hygienists, and acupuncturists.
Keep expanding the legal scope of professional providers who aren’t physicians to reflect their real training and skills. This would increase access and emphasize prevention.
Artificial restrictions, like those proposed by the AMA in their Scope of Practice Resolution, are self-serving, not health-serving, in this affluent county with many more physicians per capita and higher costs than other counties.

Prevention:

Prevention should form the basis of health policy: fund it, do it, and learn from it!
Enforce this in federal grants. Example: enforce the guidelines for Title V grants so adequate funds are allocated for prevention.
A quick fix for lack of pregnancy care providers: require FQHCs to actually provide prenatal care & birth – don’t allow them to turf this care out. Because of this loophole, some women in New Mexico have to travel 80 miles or more for prenatal care.
Promote wellbeing, not just the absence of disease.
Pay for evidence-based prevention: e.g. nutritionists, physical therapists, personal trainers - to help people develop healthy lifestyles.
Pay for lactation consultation and ongoing support for every new mother – breastfeeding saves babies’ lives and prevents health problems down the road, such as diabetes.
Prevention includes food policy (sustainability & whole local foods), protecting the environment to prevent asthma and cancer; and addressing stress as the major killer it is.
Recognize that prevention isn’t usually a priority for individuals - they’re in survival mode. So provide for intervention (secondary prevention) through access to services for all people.
Pay providers extra when they follow evidence-based guidelines (P4P).
Also pay patients for participation in their care: Examples: give diabetics a break on their premiums if their A1C goes down, have lower premiums for people with normal BMI.
Example: New Mexico’s Premium Assisted Mother insurance program gives a break on the premium if a woman starts prenatal care in the 1^st half of pregnancy.

Access to care requires that we educate enough and the right kinds of providers:

Create programs to educate local people as healthcare providers in underserved areas through affirmative action with a competency baseline. Primary care should be local, so study ways to get providers where they’re needed.
Education funding for other professionals, such as CNMs and NPs, should be on a par with GME.
Recognize the need to educate nurses, who are in the front lines of health care.

Reform malpractice law:

The cost of malpractice insurance threatens practices and health care access all over the US. We recommend a multifaceted approach to malpractice insurance reform.

First, reduce the need for torts by providing resources to care for the suffering so that suits are not required to take care of people with healthcare and caretaking needs.

Consider opening up Federal Tort Claims Act coverage as an intermediate step in tort reform.

Develop a worker’s comp-type no-fault reimbursement system paired with a separate patient-safety system (NM is working on a model). Cover medical costs through universal health care. Malpractice is covered by professional review boards – with recourse to licensing bodies for egregious cases.

Examples of the costs of risk manager-determined care: 1. Forced c-section for breech because the hospital won’t allow the obstetrician to do a vaginal breech. 2. Hospitals that don’t allow VBAC in spite of the right of mothers to have a normal birth and all the evidence of the long term risks of cesarean.

Encourage communication among providers:

Electronic health records are only as good as the communications that link them. EHRs must be compatible and barriers to information sharing eliminated for them to be worth the time and money. This is the only way to avoid the current pervasive duplication of services. Note: Nancy and Lorry work in a system that is fully electronic and know whereof they speak.

Fund IHS:

The United States has a trust obligation to provide health care for Native Americans. Urban Indians are also deserving of the same care.

IHS should not only be fully funded and the Indian Health Care Improvement Act reauthorized, but IHS should become a flagship system for this country.

Enforce the First Amendment:

No state or federal money should go to religious hospitals which dictate and restrict care according to their religious principles.

Thank you very much for soliciting our input. As for next steps: We really thought you should use community & town hall meetings & surveys to inform a White House Health Care Summit and Congressional Hearings – in other words, a multipronged and broad based approach.

Why not send out a series of emails about specific areas or questions to moderators so we can solicit feedback from our groups? And of course feel free to call our group - we would like to help.s