cc  >> Jeanan Yasiri: I have the  privilege of serving as the  executive director of the  center.  As we begin today, I'd like to  extend thanks to the partners  who support our communiversity  series, the UW Division of  Continuing Studies, the Oscar  Rennebohm Foundation, the  Alliant Energy Foundation, the  Morgridge Center for Public  Service Challenge Grant, and the  Brittingham Fund.  Additionally, we'd like to thank  our media partners, Wisconsin  Public Television and their  University Place Crew for taping  tonight's lecture.  I'm very pleased to introduce  our special guest tonight, and a  good friend to us, Barbara  Snell.  Barb began her career in health  care as a hospital social worker  in the early 1980s, and over the  next 15 years she managed  behavioral health hospitals and  clinics for large health care  institutions.  After completing her Master's  degree in management, she  started a career leading  non-profit organizations,  including a maternal and child  health center in Rock County,  Wisconsin and Access Community  Health Center here in Madison.  During her 11 years at ACHC, the  organization became a federally  qualified health care center, an  FQHC, she'll reference that  during her talk, and grew from  7500 medical visits a year to  over 60,000 medical, dental, and  behavioral health visits  annually.  Last year Barb was named CEO of  University Community Health  Services, located in Nashville,  Tennessee.  The UCHS is an independent, not  for profit organization, which  in partnership with Vanderbilt  University operates four FQHC  community health clinics and 11  employer-based clinics  throughout middle Tennessee and  southern Kentucky.  Barbara also serves on the  faculty of Vanderbilt  University's School of Nursing. 

 We are, of course, delighted to  include Barbara as an affiliate  of our UW Center for Nonprofits,  and tonight she returns home to  Madison from Nashville to share  details with us about how two  different communities approached  health care access in  interesting ways, both at the  same point in history over the  course of the last decade.  It's a practical example of how  community based and private  organizations work together in  building civil society  solutions.  Please join me in welcoming home  Barbara Snell.  (applause)  >> Barbara Snell: Thank you,  Jeanan.  Thank you all, it's so terrific  and so much fun to be back in  Madison and to see so many  friends, it's really fun.  I left Madison just about a year  ago and moving to Nashville,  Tennessee is a bit of a culture  shock, I will acknowledge that.  And so what I want to talk about  this evening is really how, as  Jeanan said, how two different  communities, very similar  timing, recognized a need to  serve under-served, uninsured  people in their communities.  They came at it from very  different perspectives, they  came at it with different  approaches.  I am not here really to say, oh,  this was better than the other  because I think you'll see as we  go through the evening that  there was both success and  failure for both programs.  So just, I want to start out by  doing a brief discussion about  what Madison is and then  comparing it to, I think... 

 There.  Let's start with the definitions  first.  Little glitch here.  This is my nightmare,  a PowerPoint glitch.  Health care, like every other  institution, has lingo and I am  going to give you a 30-second  rendition of some key points and  verbage, because otherwise  you're going to wonder, what is  she talking about?  Understand that health care is  really broken into two  categories.  For-profit and not for profit.  In the for-profit sector, you  can have private hospitals, you  can have physician practice  groups.  Those physician practice groups  may be two doctors, it may be  2,000 doctors.  It really isn't defined by the  tax structure.  In the nonprofit health system,  you can also have hospitals. 

 You can have what I call "public  hospitals," and public hospitals  are those that are typically  funded by public funds, tax  dollars, and they're to serve  the indigent populations.  There are physician practice  groups in the nonprofit world.  Here in Madison you've got a  great example.  Dean Health System, those  physicians are for-profit.  Group Health Cooperative is a  not-for-profit.  So from a consumer point of view  and getting care, there's not a  lot of difference, but in a tax  structure there is.  Then there are federally  qualified health care centers.  Those are clinics that are  designated by the federal  government to serve under-served  populations.  They're given special status,  they are given some funding, and  there are lots of requirements  that are placed on FQHCs.  Not the least of which is that  51% of their board of directors  must be consumers of the  services of that health center,  and of the remaining 49%, no  more than half can get their  income from a health care  institution. 

 So think about that.  They are placing, they truly  want these FQHCs to be community  clinics.  They do not want them to be a  front of a large health care  institution.  There are safety net clinics.  Safety net clinics are those  clinics that in many ways look  like an FQHC, but they're not  federally funded, and they  oftentimes have very unique  rules attached to accessing  services.  They can be volunteer run  clinics, they may be public  health clinics, they could be  faith based clinics, those types  of things.  Then you have public health,  school health clinics, which  again serve a very important  segment of the society in  getting care and access to care.  So quick and dirty definitions.  Let's take a look at the two  communities, Madison and  Nashville.  On first blush, you would  probably not think that they  have a lot in common, and I'm  here to tell you that there is a  lot in common. 

 Now, granted, you probably can't  find shrimp and grits on the  menu of most restaurants here,  but there are a lot of things  that are in common, one of which  is, certainly the population is  about a quarter million in the  city and almost a half million  in the county.  Madison is the second largest  city in the state.  It's the state capital,  and it's 85 square miles.  In Nashville, we're bigger.  The city itself is just over  600,000 and the metro area is  just under 1.7 million people.  But we are the second largest  city to Memphis.  We are the state capital, and in  this situation, we actually have  473 square miles.  In preparing for this, I learned  that Nashville is the second  largest geographic city, second  only to LA in terms of scope.  This comes to play, and I'm  going to talk about this a  little later when we're talking  about transportation, when you  have this much spread out area.  We also, obviously, in Madison  you appreciate culture, you have  the Overture Center. 

 We appreciate culture, it's  called the Grand Ole Opry.  In looking at the two  communities, this is where you  start to see some divergent, and  I want to share with you, I  spent 21 years in Madison, 11 at  the Access Community Health  Center.  I spent most of my life here,  except for a stint in the  Northeast.  But this is where you start to  see some real differences.  In Madison we have four  hospitals.  Meriter, St. Mary's, UW,  and the VA hospital.  For purposes of tonight's  discussion, I'm really not going  to be talking about the VA and  their services, however.  You have one FQHC.  I can modestly say, it is a  spectacular FQHC and I am a big  fan.  In Nashville, we have three. 

 In Nashville, we have 14  hospitals.  One is a public hospital.  It is staffed by Meharry Medical  College.  It is for the uninsured and  indigent populations of  Nashville.  Here, actually, that's probably  wrong.  I think you have two safety net  clinics, because you have the  student run medic clinic, and  then you have a group of retired  specialists called the  Benevolent Specialists that  provide care as well.  They provide consultative  services for specialty care.  In Nashville, we have 19.  We have three FQHCs and then an  additional 19 safety clinics.  Some of those safety clinics are  very small. 

 They may operate every Saturday  by a bunch of volunteer  physicians.  They may be very large.  Faith Family Medical operates  about 60 hours a week, and they  have a large staff.  Interesting enough, they're a  faith based clinic.  They have very specific  requirements, one of which is,  you must be employed.  So if you're uninsured and don't  have a job, you can't go to  Faith Family Medical.  It's one of those things where,  as an FQHC, we would never be  able to have a rule like that,  but a faith based clinic can do  that.  Some clinics have requirements  of beliefs.  Some faith based clinics say,  you have to accept God and Jesus  as your savior, and then we'll  see you.  Others do not. 

 There are 9% uninsured here in  Dane County and as you can see,  we're almost double that,  16.5%.  Now, I don't know how much is  that the South, or is that a  large urban area?  I can't really tell you and know  why the significant difference.  This last section, though, is  where I started to have "aha  moments" right away when I moved  to Nashville, because here in  Madison, if you go to Dean, if  you see a Dean physician and you  need a specialist, where do you  go?  A Dean specialist.  And if you're seeing a primary  care physician and you need to  see an OB, you go to a Dean OB.  If you need ear, nose, and  throat, you go to a Dean ear,  nose, and throat guy.  If you need the hospital, you go  to St. Mary's.  It's a very large system.  The physicians work for practice  groups.  The physicians work for Group  Health or they work for the  university, UW Health, they work  for Dean.  You don't find a lot of  independent practitioners. 

 In Nashville, that's just the  opposite.  There is one large practice  group, it's Vanderbilt, so I'm  fairly familiar with that group,  but then everybody else, it's a  one or two doc clinic.  It's storefront clinics.  You don't see these big giant  clinics everywhere.  It's two or three doctors here.  It's maybe, grandpa was a doctor  and daddy's a doctor, and now  you're a doctor and you all have  the family practice.  Literally and figuratively.  So it's a very unintegrated,  segregated system.  That will create, this is an  important point.  This creates an avenue to how  the communities approach care to  the uninsured. 

 Long about 2000, actually it was  in 1999, I went to Kathleen  Falk, who is the County  Executive here, and I asked her  for money for the health center.  I said, we're struggling  financially, we were caring for  a lot of the community's  uninsured, and in my infinite  wisdom I thought it was really  important that Dane County  started helping pay for care to  the uninsured.  Kathleen, who is a delightful  human being and very, very  gracious, very sweetly turned me  down.  And just said, the county is  just not in a position that they  can fund this.  Now, for those of you, I got to  meet some students before the  lecture this evening, and for  those of you that are pursuing  degrees in nonprofit management  and nonprofit work, listen to my  next line because I'm going to  tell you something that will  carry you very far in your  careers in the nonprofit world.  When somebody says no to giving  you money, you ask their help to  get you money.  So if they're not going to give  you money, that's the first ask,  you always ask for money.  And then when they say no, they  can't do that, don't go away.  Just say, "Well, can you help me  get some other money?"  What I did was, I asked  Kathleen Falk in 1999 if she  could help raise awareness in  this community.  This community was too  committed, and I really believed  if they understood the plight of  the under-served and the  uninsured that they would come  forward and help. 

 So Kathleen pulled together a  health care summit.  She invited all the business  leaders, she invited the mayors  of every community, it was held  at the Expo Center, we had about  200 people.  We had an entire day where we  talked about this community's  uninsured and what we needed to  do to address this issue.  People left absolutely committed  to changing how Dane County as a  community and Madison as a  community served under-served  populations.  Out of that came the Dane County  Health Council.  The Dane County Health Council  was appointed by Kathleen Falk,  the members were appointed.  And it was the CEOs of all the  health care institutions,  including myself at the time.  And it was coordinated by United  Way and Mayor Dave as well as  Kathleen Falk served on that  council.  That was a very important  council, and that was really the  first time in this community  that all the big dogs came to  the table to say, we need to do  something as a community and as  a group.  What was interesting to me, when  I went to Nashville, is in 2000  they had the same kind of  awakening and reckoning of, we  need to do something. 

 But again, remember, it's all a  bunch of individual, private  practice physicians all over.  There weren't any big groups to  go to, so there weren't any big  CEOs to get involved.  So what they did is, they took  the 22 safety net clinics, the  19 safety net clinics and the  three FQHCs, and they created  the Safety Net Consortium of  Middle Tennessee.  And that comprises safety net  leadership, the metro health  department, and there's an  organization called the  Vanderbilt/Meharry Alliance,  which is an organization that  works for partnerships between  the Vanderbilt medical school  and the Meharry medical school.  Both of these two groups, and  this is the part that I found  fascinating, and I know I'm kind  of geeky about this, but I  thought it was fascinating, went  to Buncombe County, North  Carolina within three months of  each other.  And Buncombe County, you can see  on the map, is on the northwest  corner, it's around Asheville.  It is in the Appalachian  mountains.  So one would say, isn't it  interesting that Nashville, this  major metropolitan area,  Madison, from the Midwest, to  send to learn from Buncombe  County, North Carolina what  they're doing?  What Buncombe County had figured  out is, if they got together as  a community and worked  collaboratively to assign health  care homes, they could divert  patients out of the emergency  room, give them a primary care  home to get their care, and use  the funds saved in emergency  room costs to fund this.  The county put in money, the  state put in money, and all the  health care institutions put in  money.  After the trip to Buncombe  County, Dane County came back  and started to design what  eventually became the health  access pilot. 

 In Nashville they went back  home, now, I have to confess, in  Madison they had to fly, in  Davidson County they took a bus,  because we were close enough.  They came back and they actually  told me that they actually  started to create Bridges to  Care on the bus ride home.  They had similar goals for these  two groups.  They wanted to create a  community wide effort to deploy  resources to care for the  uninsured.  They wanted to reduce  utilizations of emergency room  for primary care, because we all  know that's the most expensive  place to get care, and there's  no consistency.  So there's no continuity of  care, and it's very expensive to  get care that way.  They wanted to improve access to  pharmaceuticals.  They wanted to remove  transportation barriers, and  they wanted to create this  health care home.  So, this was about 2000.  In Madison... 

 I love Madison.  But we can debate anything.  So it took five years to create  the health access pilot.  And I want to talk about some of  the challenges.  What they did was, they got all  the health care CEOs together  through the Dane County Health  Council, and they decided that  they were going to have a six  month pilot.  And the goal of that pilot was  to measure whether or not this  would be a sustainable program.  Not in terms of would people use  it, but more in terms of, could  this community really afford  this type of program?  So what they decided was, they'd  target 600 enrollees.  They decided it was going to be  really important that everyone  be screened for health benefits.  So make sure that they were  truly uninsured and not, maybe,  eligible for medical assistance  or insurance or workers' comp or  something like that.  They assigned what they called  family health navigators to help  recipients or enrollees navigate  the health care system. 

 This is really important.  They decided that what they  would do is, they would assign a  health care home and that every  enrollee would get primary care,  hospitalization,  pharmaceuticals, at either a low  or no cost.  And I say "a low or no" because  the original intent was that  everyone would pay $10 for a  visit.  Some health care institutions  decided it would cost them more  to try to bill a patient for $10  than it was, so they just waived  the fee.  They would provide prescriptions  and transportation, and every  single health care organization,  Dean, UW, St. Mary's, Meriter,  Group Health Cooperative,  Unity,  Access Community Health Center,  everybody came to the table.  They brought not only a  commitment to participate, but  they brought hard, cold dollars  to the table to fund this  program.  In middle Tennessee, remember  it's safety nets.  There's no big health care  institutions to get involved.  Vanderbilt had made the decision  that they would really not be  participating in this.  Understand that it was around  this time, maybe a little bit  later, that Vanderbilt  University medical center made  the decision that they could no  longer afford to care for those  with what we call TennCare,  which is their Medicaid program  in their primary care setting. 

 So currently at Vanderbilt  medical clinics around the city,  they do not accept patients who  have TennCare or Medicaid.  That would be the equivalent of,  if UW suddenly decided that they  were not going to accept  Medicaid in their clinics.  It had a profound effect.  So this was a group of safety  net clinics.  So it was small, nonprofits  coming together to try to solve  this massive health care  problem.  So the first thing they did is,  they started designing Bridges  to Care on the bus home and they  looked around and there were no  deep pockets and they didn't  have a lot of money.  So the first thing they did is  start writing grants.  And they amassed about a million  dollars in grants.  It took them about a year and a  half.  So they were a little bit ahead  of the game to get off, start. 

 They kicked off Bridges to Care  in 2002.  They hired staff to enroll  patients at the emergency room,  so very much like the HAP  program, and later they added an  online component.  They assigned patients to health  care homes, but the health care  homes were the safety net  clinics.  So every safety net clinic  already had a sliding discount  program or a charity care  program, so they didn't spend a  year debating on what the fee  should be.  Should it be $10, $20, $50, $5?  They just said, whatever your  program is now, we're just going  to get people to you.  The kicker was, for the  enrollees, the benefit or the  care to get involved was free  pharmaceuticals and  transportation assistance.  Again, all the safety net  clinics participated, virtually,  I don't think any individual  providers did and Vanderbilt did  not participate at this time.  At the end of the six months,  the health access pilot had 693  applicants and they actually  ended up enrolling 388 people.  Part of the reason for that  significant drop off is, they  found that their system was  incredibly cumbersome because it  required a lot of visits to do  the health benefits screening  and a couple agencies were  involved in that and it took a  lot of time and people dropped  out.  They provided about $2.5 million  of care in the six months. 

 It was interesting,  I pulled out the data.  The cost per participant ranged  between $20 and $231,000 for one  participant.  40% of the participants had one  or more emergency room visits.  Now, think about it, the  original goal was to reduce the  number of emergency room visits.  And in that respect, the health  access pilot didn't have a  significant impact.  45 participants were  hospitalized, like I said, one  ended up with a bill of over  $200,000.  189 people received, about half,  received prescriptions, but they  only spent $33,000.  And as I recall, we had set  aside $175,000 to pay for  pharmaceuticals.  Again, why the significant  difference?  Well, again, we took a lot of  time creating a formulary and it  was very, very restrictive, the  number of drugs that were on  this list.  What was most surprising, I  think, to many people, was  transportation was not an issue  in Dane County. 

 Only 13 participants required  transportation assistance.  Bridges to Care served, since  February '02 to the present,  over 50,000 people.  33,846 actually got linked to a  health care home.  188,000 prescriptions were  provided, equal to about  $2 million.  But this is over eight years,  where remember, the health  access pilot, it cost  $2.5 million for six months.  In 2005, they branched out and  added a component called Bridges  to Care Plus.  And what that was, is an effort  to link uninsured to  specialists.  Since its inception in March of  '05, 771 physician specialists  have participated.  That's cumulative.  That's not the number that are  participating now. 

 And 2800 people received about  $13.5 million in care.  I thought this was a really  interesting slide, because  remember, the patients that were  being assigned to the safety net  clinics were already eligible to  go there.  They may just not have known  about them, or they just hadn't  really bothered to connect to  them.  The real hope for the Bridges to  Care was the prescriptions.  And they really had no  formulary.  If you had a prescription, they  would fund and fill it.  And look at what happened.  Up until 2006, it was just  growing by leaps and bounds.  In 2007 it started to drop, and  then it's really dropped off  since then.  Now, I know I'm supposed to wait  till the end to ask questions,  but does anyone want to take a  venture as a guess what happened  in 2007?  No?  No, not Medicare Part D,  but that's a really good guess,  a very good guess. 

 In July of 2007, Wal-Mart  offered $4 drugs.  So look at the impact on, here  is a community wide effort and  Wal-Mart, which some people  think is the big bad guy...  It was a really interesting  dilemma.  And of course, when Wal-Mart  started it, then at least in  Nashville all the grocery stores  have it.  So every grocery store has a  pharmacy and they have $4 drugs.  So the incentive to participate  in Bridges to Care dropped  dramatically when they could,  for $4, get their medications.  The emergency room visits really  again, you can see, Bridges to  Care and linking people to  health care homes did not really  impact emergency room visits.  Neither one of these studies,  neither the HAP program nor the  safety net assessment in  Tennessee, neither one was able  to measure, what was the use  beforehand?  But there wasn't a dramatic drop  that everybody expected.  So, what happened?  What's the rest of the story?  Some of the challenges in  Madison in creating this health  access pilot, and I should take  ownership.  This is from my observation,  this is not a scientific study,  this is Barbara Snell,  peanut gallery seat 101. 

 First of all, there was almost  no, very limited outside  funding.  United Way stepped forward to  fund the pharmaceutical piece.  But other than that, it was the  health care community that was  expected to fund this.  And so there were obviously, in  Madison you can't get three  people together without having  four opinions.  And so what happened is, you had  lots and lots of opinions about  what service should be included  in health access pilot.  We probably debated almost a  year as to whether or not dental  services should be involved.  And then there was a group that  felt very strongly that mental  health services should be  involved.  We had the very interesting  debate about, do you take and  pilot a program that is fairly  narrow in scope?  Meaning, maybe we do annual  physicals and cholesterol  screenings and mammograms for  5,000 people, or do we do from  primary care to specialty  services to hospitalization for  a smaller group?  And I'm not saying one is better  than the other, but it was a  really interesting debate in  this community.  And so at times, I think it is  safe to say there was a push  pull, because the people who  were advocating for this wide  breadth of services were not the  ones that were going to fund it.  And let me tell you, I can  really do some wonderful  shopping if I can have your  credit card. 

 So the whole idea was marrying  the fiscal realities with the  desires of some very strong  advocates in the community.  There was, the goal was to have  uniformity.  We spent hours and there are  those of you in the room that  sat with me in some of these  meetings, and there were times  when I literally and  figuratively beat my head  against the table.  Because we were so intent on  making everything exactly the  same, it was just...  It took forever to get that  all worked out.  Consensus building always takes  time.  I'm not saying that's good or  bad, it just is a reality.  And because this was a multiple  system approach, from different  angles, different emergency  rooms, different health care  systems, different hospitals,  tracking the data was  significant.  In Nashville, it was a different  set of problems.  In Nashville, the more  traditional health care  community viewed, and some would  probably say still view, the  care of the uninsured as the job  of the safety net clinics and  the public hospital. 

 And, we don't have to get  involved with that.  And many of the large hospitals  have their own little safety net  clinic, so again, I run an FQHC  that's affiliated with  Vanderbilt.  Vanderbilt doesn't take Medicaid  in their primary care clinics,  but we do obviously in ours.  So moving beyond the perception.  Here in Madison, I have to  say from the very first health  summit, no one ever said,  "Care to the uninsured  is not my problem."  And in fact, everybody pretty  said right from the get-go, and  it's part of why I love Madison  so much, is that right from the  beginning, business, health  care, public, everybody said,  "This is our problem to solve."  In Nashville it's more  "go forth and do good."  Now, I will say that the  hospitals are profoundly  charitable, and Vanderbilt  Medical gives almost a half a  billion dollars away of care a  year through their hospitals.  So I don't ever want to imply  that they're not charitable.  But primary care access and  managing the uninsured is kind  of viewed as the safety net  clinic.  The lack of group practice made  engaging the local medical  community extremely difficult  and it does to this day.  So when I needed to improve care  for pregnant, undocumented  women, I called Jeanan Yasiri,  who was at Dean Health System at  that time, and I called the  folks at UW, and I called the  folks at Group Health  Cooperative, and we all got in a  room, and I said, "Here's the  issue, here's the problem, can  you help?"  And within two weeks,  we orchestrated that.  If I would've had to go to every  OB office in the city and  convince every OB physician to  open up their practice, it  would've taken years. 

 So there's an efficiency when  you have large group practices  because Dean Health System can  make a decision, or UW Health  can make a decision.  And it just, it's the law of the  land in that organization then.  So it isn't up to individual  physicians.  And then the hard fact of life  is, all of us that are in the  safety net community are  scrambling for the same dollars.  And so there were times in the  history of the Bridges to Care  and the Bridges to Care Plus  program where there may have  been funding opportunities for  that program, but individual  safety net clinics were also  seeking that same funding and  they were competing for that  same funding.  And because the safety net  consortium's board was made up  of all the leaders of the safety    net, guess what?  I'm not going to vote, and I  wasn't there at the time, but it  is reasonable to say that if my  job is to take care of my  organization and there's a  funding opportunity that I think  I can get funding from and I'm a  voting member of whether the  consortium should go after the  same dollars, I'm going to vote  no, I don't think it's a good  idea.  And that's exactly what happened  here.  So there have been a number of  challenges with both models.  So one model comes from the CEOs  and oftentimes, I have a degree  in management, my philosophy is  very much bottom-up involvement,  but when it came to moving a  health care system and designing  a health care system for this  community, having the big dogs,  having the top down say, this is  where Dr Jeff Grossman  and Dr Craig Salmon  and the physicians at UW  and GHC and Dean,  and all the hospitals  came together and said,  this is the right thing to do  and we're going to do it.  Bam, it happened like that. 

 And that's the best part  of Madison.  The fact that we had to debate  whether it was going to be $10  or $20, that's a whole other  story.  So what happens next?  So in 2005, they did this six  month pilot called HAP, then  they commissioned a study to  say, what happened to HAP?  And that took about a year or  year and a half, and then came  the question, what next?  Now, for people like me who tend  to be a little impatient, the  timing is very frustrating  sometimes here.  However, I have learned over the  years to truly, truly appreciate  that in the end, good people  always come up with good  solutions.  And here in Dane County, while  they languished a bit for a  while, the Dane County health  council decided, you know what?  Trying to provide this wide  breadth of care to a group of  people, and define the X,  is that 1,000, 5,000, 10,000,  was beyond the system's capacity  to do that.  So what they said was, what can  we do really well to have a huge  impact?  And what they decided, which I  think is profound, and you are  very unique in this community,  is right now, today, it's  already started, you have what's  called Primary Access for Kids,  PAK.  And it provides primary care for  all uninsured children in the  Madison School District.  That's huge.  That's huge.  Every single health care  institution stepped forward and  said yes. 

 So you have different health  systems adopting different  schools and providing all the  care those children need in the  primary care setting.  There's also some limited  pharmaceuticals and some  transportation assistance  associated with it.  It's a cool program, I got to  tell you.  Bridges to Care?  Well, the first question,  Bridges to Care itself really  kind of has, it's outlived  itself.  With the pharmaceutical access  being what it is today, it's  really not viewed as necessary.  The debate that's going on in  Nashville is expansion or demise  on Bridges to Care Plus?  There is a sense that if more  specialists don't step forward,  then Bridges to Care Plus can't  really survive, because the  demand far exceeds the current  capacity.  And for very strong, legitimate  reasons, some groups, Vanderbilt  has decided not to participate,  and individual practitioners are  not participating.  So what they did do is say,  okay, maybe that isn't the way  to go.  In advent of health care reform,  maybe that isn't the way to go.  So what they are now kicking off  is again, I think, another  really cool program that's going  to have a profound impact on  health, and that is, they are  taking on chronic disease  management. 

 The first disease that they're  tackling as a community is  diabetes.  And true form for the safety net  consortium, we're in the process  of writing for millions of  dollars in grants.  Lord help us if we were trying  to write millions of grants, but  millions of dollars in grants.  And we're starting, we've got  some grants already, and here's  the goal.  Again, I was shocked to learn  that in Nashville, there is one  amputation a day due to  diabetes.  So the first goal's pretty  simple.  We want to stop that, we're  going to reduce the number of  amputations related to diabetes,  and we're going to improve  health outcomes.  So we've already got some  funding put together where we  can provide free diabetic  supplies for every uninsured  low-income diabetic in the city.  Again, remember, we're talking  1.67 million.  That's a lot of diabetics  in that population base. 

 I think they said it was about  12% are diabetics.  We are going to have them have  regular, no less than quarterly  medical visits.  So it's going to have a profound  impact on people's lives and  well being.  Again, a very different  approach, but a realistic one  that that community can come  together with.  So I am not here to say one  program is better than the  other.  One started with the top-down  and kind of languished for a  while after their pilot.  And one steadily rose and the  environment around them changed  and they've regrouped and  they're going in another  direction.  Both of these programs, I think,  certainly Bridges to Care Plus  and HAP will probably be reduced  in the future as the health care  reform initiatives begin, and  more and more people have  coverage.  But chronic disease management  is going to be there, because  health care reform doesn't  eliminate poverty.  And here, no matter what you do  in terms of health care reform,  there is always going to be  children that slip through the  net and are not eligible for the  public programs. 

 So it's an interesting  kind of...  comparison.  It's been really fun to be a  part of it and to have those aha  moments.  And I've learned a lot.  I've learned that there are some  things in Nashville I really  miss.  Not the least of which is that  community mindedness of,  we're in this together.  So, with that, I will take  some questions.  >> Yasiri: And for those of you  who are new to our series, I  pass the mic around so that we  can capture who you are and what  your question is of Barb and I'd  be happy to do that if you just  give me a quick wave on the  questions that you have.  I'm going to go ahead -  do you have a question?  Go ahead?  >> My name is Lee Wong.  My first question has to do with  the PAK. 

 Who funds the PAK?  And the second question is, who  manages the chronic disease  management program?  Because now presumably you will  have the grant, then who handles  how that program works?  >> Snell: Actually, thank you,  the questions were,  who's funding PAK?  And as I understand it, again,  it is the resources of each  individual health care system.  So when Dean Health System takes  on 500 children, and I'm making  this up, but XYZ school has 500  kids in it and Dean Health  System is providing it, they're  absorbing all the costs of that  care.  If Group Health Cooperative  takes this school, they're  absorbing all the costs of that  care.  So as I understand it, there is  very limited public funding.  I do believe that Kathleen Falk  did put some public funding in  to help with transportation and  some pharmaceuticals, but it  really is the community health  care system.  And in terms of who's managing,  the other question was, who's  managing the chronic disease  management?  That is actually being run  through, right now, it's  probably going to be run through  the Vanderbilt-Meharry Alliance.  The Vanderbilt-Meharry Alliance  is a not-for-profit that works  to link the two medical schools  together, and there's a research  component to all of this, so  they would probably be  administering it.  The individual safety net  clinics will be providing the  care.  And I should mention, under the  Bridges to Care and Bridges to  Care Plus, that was actually  managed through the National  Academy of Medicine, which is  the equivalent to Dane County's  Medical Society.  The HAP program was managed  through United Way. 

 So again, a different approach.  A more health care based  organization and a more social  service based here in Madison.  >> Yasiri: Barb, I'm going to  ask kind of a two-part question.  We've been watching, of course,  as national health care reform  has been debated and eventually  a measure passed.  And really the story that you're  telling has to do with  communities that were coming up  with individual solutions for  health care access.  The question is two-part in  that, I'm curious, given what  we're looking at coming down the  pike, how that's going to impact  access to care through FQHCs, in  particular, those federally  qualified health clinics.  And I'm also curious if you see  individual community solutions  still having a role in the  future of health care access for  vulnerable populations?  >> Snell: Can I answer that one  first and then the FQHC one?  So, with health care reform,  does that eliminate the need for  community solutions, or what's  the impact on community  solutions?  I think that it's really  important to recognize that  communities are best positioned  to solve their own issues.  And I think that community  solutions have to be a part of  anything.  Giving everybody a card doesn't  get you in the door at a medical  facility.  And it doesn't eliminate  poverty, and it doesn't  eliminate the challenges that go  along with providing medicine to  under-served populations. 

 And with the primary access  issues that we have and  shortages that we have in  providers, it's going to take  community solutions.  The big unknown, it's being  debated in Nashville all the  time, I'm sure it's being  debated here, is, what's going  to happen?  Nobody really knows what going  to happen when everyone, or most  people, have "access to health  care," when they have coverage.  Because there's the primary care  shortage.  So instead of waiting six months  for a mammogram, it may be 18  months.  And for people who tend to be  disenfranchised from general  society and maybe have a  distrust and maybe not have the  most sophisticated problem  solving, navigating the health  care system on a good day is a  very difficult job.  If you have any other additional  challenges, to that.  So I think the community  solutions may not be so much in  the provision of care, but in  improving access to care that's  there.  And managing it better to get  people out of the emergency  rooms.  In terms of the impact on FQHCs,  this is a really exciting time  for FQHCs, I have to tell you.  And the thing that makes me  really excited about health care  reform on multiple levels is  that there is finally a  recognition at the national  level that giving everybody an  insurance card isn't going to  solve the access to health care  problem in our communities. 

 So the first thing that's  happening is, there's a lot of  money going in to training  people to become health care  providers.  Nurse practitioners, physicians'  assistants, physicians, all of  that.  We need more primary care  providers and nurses and we're  recognizing all of that.  So there's monies attached to  all of that to be able to meet  the need.  In terms of FQHCs, the federal  government has recognized that  the FQHCs do a tremendous job,  they're the most efficient  deliverers of health care in  this country.  The return on investment for the  federal government is  significant.  Our overhead costs are very low,  our patient satisfaction is very  high, our patient outcome for  disease management is very high.  And trust me, the federal  government, when they make you  an FQHC, they measure everything  you do.  And so there's a lot of data to  indicate that.  As a result, the health care  reform act included $2 billion,  that's a "B," for community  health centers. 

 And we are still waiting, what  is that really going to mean?  How are they going to divvy up  that $2 billion?  What we anticipate and what  we're being told is, some will  go to expand the number of FQHCs  in the country.  There's currently 1200, there's  talk that that may actually go  up to 2400 nationally.  The goal is to have one in every  congressional district, we're  not even there yet, let alone  more than one in a congressional  district.  The second thing is, there is  money set aside for bricks and  mortar, because there's a  recognition there's not enough  clinics out there, particularly  in rural, under-served areas.  So there's going to be monies  set aside so that we can go out  and put clinics out in the rural  areas.  And then lastly, there's a  recognition that people who have  not had access to care for a  long time oftentimes have  complex medical needs, and so  there's funding to be able to  support the cost of care of  these complex medical needs.  So it's a really exciting time  for FQHCs.  >> My name is Mitch and I had a  question in regards to your  initiative to improve the health  outcomes of the diabetics.  And because of the large scale  of the population of people with  diabetes and how big that  movement will be, what kind of  ripple effects, if any, do you  anticipate in the hospitals or  in the organizations that you  said will provide those free  supplies and the increase in  people that will be doing  quarterly visits?  >> Snell: Exactly, that's a  great question.  I think that, like I said, one  of the goals right off the bat  is to reduce the number of  amputations, so that will be a  significant cost savings in  terms of health care and  hospitalization dollars, let  alone quality-of-life issues. 

 What we haven't - what we're  currently in the process of  developing base data on is, how  many diabetics end up in the  emergency room?  In diabetic comas, how many  emergency room visits, how many  ambulance visits because of  poorly managed diabetes?  And we think part of we're doing  is trying to create some  baselines so that we can show  that we're actually saving  health care dollars and  improving quality of life.  So we're going to be measuring  everything from amputations to  hospital visits to lost days on  the job, all those sort of  things, to be able to show the  full economic impact that, as a  community - and we chose  diabetes.  But some communities may choose  heart disease, or they may  choose asthma.  Name the chronic condition.  But we've chosen diabetes  because it's so common in  Davidson County.  It's such a huge issue.  So invite me back in about five  years and I'll tell you how much  money we've saved everybody in  health care costs.  >> Yasiri: Well, Barb, we have  one more question.  I was going to say, you're  always welcome back.  >> I'm curious as to whether you  have a preventive component to  that diabetes program. 

 Sort of like teaching better  diet and all that sort of thing.  >> Snell: There is a nutrition  component for the  already-diagnosed diabetics.  I didn't get into it, but there  is a whole Healthy Nashville  initiative that is addressing  obesity and healthy lifestyle  and all the things associated,  that contribute to the creation  of diabetes and it's a lot  targeted to young people, and  better nutrition and all of  that.  So that's one of the reasons  chronic disease management  initiative chose diabetes,  'cause it was a nice partnership  with what was already starting  to happen in Nashville.  But it's a great question.  >> Hi, my name is Matt.  And you talked about the option  of massively expanding FQHCs on  the national level.  I'm curious about it on the  community level, in the case of  these collaborations that you  presented on today.  Was that option discussed and if  not, why not?  And if so, what were the pros  and cons?  >> Snell: Um, it wasn't  discussed, it's the 300-pound  gorilla in the room.  Because again, everybody's after  the same dollars. 

 And so, I'm not proud of that,  I'm not saying that's a good  idea, but right now, until the  funding is defined as how it's  going to go, we all know we want  some of those dollars to be able  to expand our care, but we don't  know what the definition is  going to be so we don't know how  we're going to approach it.  And historically in Nashville,  the three FQHCs have not spent  any time talking together.  Again, I'm from the Midwest, and  for those of you that know me, I  don't sit quietly in a room, so  the first thing I did was, I  just went and visited them.  Started having lunch with them.  Started talking to the other  FQHCs.  I didn't realize that I was,  like, whoo, that's never  happened before.  It just made sense to me that we  should be talking.  So, am I hopeful that it will  happen at some point?  Yeah, we'll talk.  But right now, everybody's  sitting there waiting, nobody's  talking.  >> Yasiri: Well, we certainly  hope it won't be five years  before we see you again, Barb. 

 You're always welcome back to  Madison and I know you join me  in thanking Barbara Snell.  (applause)