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Sharon A. Baskerville, Executive Director, District of Columbia Primary Care Association
Testimony to the City Council Committee on Human Services on the
DC Department of Health Proposed FY 2002 Budget
March 29, 2001




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Councilwoman Allen, esteemed members of the Council, I am Sharon Baskerville, Executive Director of the DC Primary Care Association, which represents providers, health systems, Medicaid managed care organizations, community based organizations, and other stakeholders who embrace our organizational mission of facilitating the creation of an integrated system of care which guarantees access and eliminates the shocking health outcome disparities for the citizens of the District of Columbia. We represent as well the HRSA Bureau of Primary Health Care's national vision of 100% access 0% disparity.

Preparing for today's testimony, I must say, was somewhat disheartening. There was the usual difficulty of getting a copy of the budget from the Office of Policy and Budget. Next, looking at the DOH budget, there was the depressing awareness that the information offered is not very useful for policy analysis. We had to "discover" on our own that there was an appendix to the budget where the more detailed information was stored. This layout means that information on program goals is presented without any detailed budget information, and the detailed budget information in the Appendix has no program descriptions Wayne Upshaw, Directory of Policy and Budget, testified before the Council that next year the budget and program information would be offered together. I am looking forward next year to participating more knowledgeably in the development, implementation and monitoring of health care spending in the District.

I don't know about you, but as I looked at the DOH budget I had a strange sense of disconnection between the goals and objectives to be achieved by DOH next year and what is currently going on in the city around transition and transformation of our health care system for the uninsured.

In the Strategic Issues and the FY2002 Initiatives, there is no mention of the upcoming closure of the Public Benefit Corporation, the impact that closure will have on the safety net for the uninsured, and what DOH hopes to achieve with this massive reform effort.

Over the last several years, we have come realize the simple truths that the District's illness prevention programs have not made a measurable impact on the health indices of our people, that Medicaid enrollment has not met expectations despite our enlightened and progressive policies, and that DC doesn't have enough high quality primary and preventive care for the uninsured and medically vulnerable. I won't say that we have grown complacent but our need to develop a healthy sense of outrage and consolidate our voices to a loud and persistent outcry that demands change in our government, our systems, and yes, even our people, is imperative.

With the painful process of the impending closure of our public health system a heightened level of awareness and a growing pool of knowledge about the true scope and plight of our uninsured residents is finally getting the focus it requires. Our test as a community is whether we can move beyond political bickering and defensive point counterpoint to ensure that at the end of the day people can get the care they need.

DOH is set to accept massive responsibility for reorganizing a complex health care safety net. Yet, in the budget document, there is little that reflects this new responsibility and perhaps as things become clearer that will be articulated. We will be watching for it. We are concerned however that the Strategic Issues, FY 2002 Initiatives and Agency Goals and Performance Measures don't seem aligned to this opportunity to build an integrated system.

For those who don't know the health care lingo: an integrated system of care is one where the patient gets the services he or she needs, where he or she needs them, without a ton of hassle. If a patient with drug addiction and cavities goes to the primary care site, he or she should get the physical exam, an appointment for drug treatment, and an appointment at a dentist. DC has been talking about this for years: now we have the chance to make it happen.

So why don't APRA, Maternal and Child Health, Prevention, HIV/AIDS, and MAA all have targeted goals that would contribute to building an integrated system? And why do we have five or six separate planning initiatives -- we are developing a state health plan, and a state HIV/AIDS health plan, and have planning money in most of the Responsibility Centers within DOH health. How will all this planning be coordinated with the $16 million dollar computer upgrade planned for the next few years? If the planners don't talk and include the community in the discussion, you can bet the services won't be integrated

Now I want to comment on the Agency Goals and Performance Measures.

Performance Measure 1 is around improving kids health, and I will take this opportunity to repeat again: DOH must get eligible kids their Healthy Families insurance. 100% enrollment in DC Healthy Families. Alaska achieved 100% enrollment. There is no reason DC can't. Insurance is the most important tool we can give parents so they can help their kids stay out of harms way, yet, in this budget there is NO information on who has been enrolled for the past two years, and the goal in 2002 is to increase the number by 20%. It is hard to measure performance when you have no baseline.

As you know Ms. Allen, Mr. Herb Weldon, Senior Deputy at DOH, has promised to give community groups accurate and timely enrollment information. As of yet, we haven't received it but I am pleased to report that Mr. Weldon has committed to getting us these numbers and has assigned Dr. Altoff to be our liaison for trying to reconcile the numbers reporting. Our understanding is that she will also attend our regular Medicaid Reform Committee meetings which will improve information flow dramatically. We will keep you apprised in the coming months of how well this is working.

I would also urge DOH to place as high priority on KEEPING KIDS enrolled once they get in. Our disenrollment rate, according to the-managed care organization reports, and hotly disputed by MAA and IMA, is neck in neck with our enrollment rate. As I say, I look forward to getting the information from IMA and MAA so we don't have to bicker about this in the future.

Finally, before I leave Medicaid, I think you should ask Medicaid exactly how many NEW people would get insurance because of the $139 million in additional spending. And if they could, explain, the following line items that are in the budget appendix:

  1. Increase of $7 million in Office of the Deputy Director
  2. Decrease of $8 million in hospital outpatient care.
  3. How many people will the $30 million in new Medicaid premiums enroll, or will that be allocated to rate increases for premiums for managed care?
  4. What are $35 million in cost settlements?

And what are we "buying" with the following $30 million?

Medicaid DC Public Schools, $10 million
Medicaid Child and Family Services, $10 million
Medicaid St. Elizabeth's, $10 million

I'd like to discuss another goal, to "enhance" school health programs". Enhance them to achieve what? How does DOH's plan to expand the number of school wellness centers fit into an integrated primary care system? How will these school clinics relate to the new Greater SE contract, with the other primary care clinics, and with Children's National Medical Center, the District's primary provider of kids health care? How is DOH coordinating its activities with DCPS? How will the school nurses be coordinated with the new wellness sites? Does DOH really expect to fund effective programs at $100,000 a year, each? Our understanding is that these clinics so far do not offer actual treatment but do focus on health promotion and education. That is laudable but we must be clear what we're really getting here. I am pleased to say that there is a more extensive planning process being called into being by DOH which includes the community advocates and DCPS among others. We will report to you on this process in the future.

The next performance goal is to increase substance abuse treatment. Again, how will APRA integrate with the new safety net contractor those providers who are currently working with the medically vulnerable to get patients substance abuse treatment?

I don't want to bore you repeating the same observations over and over. In Goal 4, develop a focused program for women's health, there is no mention of integration of care whatsoever, there is no relationship to the school health program, HIV program, APRA, and no mention of Healthy Families -- DC's Medicaid program. There is a list of "service units" to be offered, as though if DC provides enough service units, we will be getting something productive done.

The last performance goal I want to bring up is number 7, improve the quality of the health care facilities.

Here was the place to talk planning site expansions based on need, the need to invest in building medical homes for low income residents by providing both capital and technical assistance to safety net providers who have struggled for years with little help. This is where I would look to discover the plan for DC Qualified Health Centers, a concept and planning process developed by our organization, accepted by the Health System Development Commission, endorsed by the Mayor, further refined by the RWJF "Communities in Charge" project, and finally outfitted with necessary regulatory and legislative language by DOH with assistance from our partnership. It lacks one thing to make this innovative and model program for expanding and strengthening "medical homes". There is not a dime in the budget to make all this fine work and planning a reality. Are we frustrated ...you bet! Are we defeated ...by no means! We look to Council and the Mayor to find a way to make this happen.

In closing, I'd like to quote one of our members in a discussion we had last year;

"Action without vision is a nightmare;
Vision without action is a dream."

It is our responsibility, all of us, to make sure that we never operate in either one of these modes. We have all the ingredients for Vision and Action. Let's not waste this critical window of opportunity for the beginning a new day for the most vulnerable residents of our city.

Thank you as always for this opportunity to testify.

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