Transcription of Dr. Noah Nesin and Lisa Lemieux for the show Accessing Health #163
Speaker 1: This segment of the Dr. Lisa Radio Hour is brought to you by the following generous sponsors: Mike LePage and Beth Franklin of RE/MAX Heritage in Yarmouth, Maine. Honesty and integrity can take you home. With RE/MAX Heritage, it’s your move. Learn more at ourheritage.com.
Dr. Lisa: As a family physician for many years, it has been an interesting experience to see how access to healthcare 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. 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 healthcare when we weren’t before and also what that process entails and why it’s important.
Today we have with us Dr. Noah Nesin who is the Chief Medical Officer for Penobscot Community Health Care 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. Nesin: It’s great to be here, thank you.
Lisa L: Thanks for having us.
Dr. Lisa: This is an interesting topic, as I mentioned, for me because as a family doctor, I’ve cared for patients across the spectrum. I have 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 unites all of them is the need for basic healthcare services. This is something that you both have quite a lot of experience with.
Dr. Nesin: Yes, there’s no question. I grew up in a household in rural Maine where my dad was the doctor for the community in the old style family doctor mode and saw that model and then 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 delay it or deferred their care because of the cost. It is very gratifying to have more people covered and able to access care.
Lisa L: Right. My role, it’s a fairly new role here as in many states, is to educate consumers about what their options are. 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 pressure to choose a plan. It’s up to them. That’s my role is to guide them through that.
Dr. Lisa: When we think about healthcare, often we think about things like vaccinations and preventive care, but what I find fascinating is that you are also talking about behavioral healthcare in 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 is making a decision to access services.
Dr. Nesin: One of the catchphrases in healthcare these days is population health. I’ve heard a number of definitions of population health, some of which I understand and some of which I don’t. Fundamentally, it’s about the wellness of the community in which we live, and we can think of a community in a number of ways, but I think that’s much more tangible for people. 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. Until people have the kind of coverage that allows them to participate in that model, there are outsiders who are intermittent users of this system and therefore can’t fully partner with us.
Dr. Lisa: Lisa, as a social worker, I suspect you spend some time with individuals who maybe have financial difficulties, who maybe have problems emotionally. How does healthcare become more important for people who maybe are dealing with issues of unemployment or poverty or grief or loss?
Lisa L: I think that’s 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 had health insurance experience, sales experience. The goal is to get people and who could just sit down and have a conversation and really understand where they’re coming from, what their needs were, and how they were best going to be served. That helped us go through the different plans, to talk to somebody and say, “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. Here in Maine, you need to be between 100 or 400 percent of the federal poverty level in order to qualify for a subsidy and it’s those subsidies that help define affordability. 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. That’s the two bottom inner lines that we’re going to look at when we look at the plans for them.
Dr. Lisa: If I am 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 percent of the federal poverty level.
Lisa L: For a household of one, I usually tell people, “It’s like 11,600 is what you need to claim on your federal income taxes.” In Maine, it’s a little difficult. One of the whole things is that you have to project your income for 2014. People in January are going “I don’t know what I’m going to make in 2014.” Here in Maine, we have a lot of self-employed people, we have a lot of seasonal, part-time, so 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 their subsidy is based on. Again, a person of one, it’d be like 11,600 is what I say.
Dr. Lisa: That’s not a lot of money.
Lisa L: It’s not a lot of money. That’s the 100%.
Dr. Nesin: One hundred, right.
Lisa L: Right.
Dr. Lisa: Okay, so you can make between that amount and four times that amount-
Lisa L: Exactly.
Dr. Lisa: Which is still not a lot of money really.
Lisa L: Right.
Dr. Lisa: If you’re one of the individuals who qualifies in that range, what can you expect to pay for health insurance?
Lisa L: If you’re right at that 100%, the majority of people I saw were paying 3 to 5 dollars right 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. It’s broken down into four districts here in Maine.
Dr. Nesin: Age also factors into it,
Lisa L: Age, yes, thank you, yeah.
Dr. Nesin: A young person who’s single, the only member of the household and low income can get a very significant subsidy and pay very little for insurance whereas a couple who has a combined income that’s at the upper levels of that who might be a little bit older will pay a little bit more. One of the phenomena that I 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 from the marketplace is helpful in aiding people in understanding the value of what they’re getting in that subsidy.
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Dr. Lisa: Lisa, I think it’s interesting that we are now at a place that’s people who in the social work field have arguably been in for generations, the need to marry logistical concerns and priorities with emotional and social concerns and priorities. 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. That’s a broad range of things, but it’s all part of the hierarchy of needs.
Lisa L: It is, absolutely, and I think that was one of the reasons for hiring us to talk to people. Again, the first thing I say to somebody when I meet them is “Hey, I’m just here to show you what your options are.” I’ve had people not even choose a plan because of that, 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. It’s all about education and understanding what their choices are. 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 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. Again, it’s tied into education and trying to meet their needs and what feels good to them.
Dr. 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 healthcare need unmet or having to pay for an emergency healthcare need. 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 L: I think that’s sometimes a cultural thing of growing up maybe. People that have never had insurance, it’s that education piece about what is now offered to you. I do think the word is getting out. 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. Nesin: Especially with the way the marketplace rolled out last fall.
Lisa L: It really was.
Dr. Nesin: Many people hesitate.
Lisa L: Yeah, and a lot of people are like, “Is this going to work?” There’s no guarantees at anything, so some people really step back and they wait but I think they’re talking to people tat took that bold step and said sign me up. I’m sure you probably had the same and you’ve also said you’ve met with patients who are really excited to have health insurance. 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: 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. We know that one of the major problems 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. Nesin: People lose homes, people become homeless, families break up over some of the financial stresses that are caused by medical debt, and they can be devastating. There was a Time magazien article in the last year, I think, that detailed some of the variabilities and 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 of 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 L: 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. Six thousand five hundred, you’re covered at a 100% after that. You talk to somebody and you say, “What happens if you’re in the hospital for 2, 3, 4, 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 reduction. The 100% federal poverty level, typically their out of pocket maximum is $500 and then they’re covered at a 100% for the rest of the year after that. Those are big pieces to talk ton people about.
Dr. Lisa: 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 my self healthier because it will cost me more if I don’t.” 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, let’s say for joint pain, because they’ve become obese or heart attacks because they can’t control their cholesterol levels. 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 what 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. 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 and important ways and they’re constantly refining them. In addition, some of the payers like Maine Community Health Options, one of the 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 to the employer, the cost to the entire healthcare system.
Because, as you know, we’re in a system that spends 40% of the world’s healthcare dollars on 5% of the world’s population and has something like the 35th or the 36th best outcomes. We don’t have an efficient system right now. Part of what’s been missing is exactly that kind of engagement that you just spoke about.
Dr. Lisa: Because I’m thinking about what the healthcare educational system and recruiting system has been and you were describing type A personalities, medical students who are able to put their noses to the grindstone and just plow through all the work, and that really was, I believe, your father’s practice model. I think there are still medical students who go in with that idea in mind. 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. I love working as a team because it makes my job actually much easier.
Dr. 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. You’re exactly right. That transformation from … it 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 in that team for people to act in ways that serve the patient’s best and all of that supported by the kind of data that helps us adjust our work systems so that we really are providing care as efficiently and as effectively as we can to people.
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: 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 L: 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. There’s a 3 month window that … I say to people that it just doesn’t hurt to see what your options are. Give any certified application counselor or navigator, you can find them listed on enroll207 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. It doesn’t cost anything.
Dr. Lisa: How about you Dr. Nesin? Do you have any final thoughts?
Dr. Nesin: I do. Just that I’m so pleased to be able to work in a community health center the way that Lisa does. There’s partnership, there’s team approach that you described. It’s fundamental to what we do and the commitment to serve all of the population of Maine regardless of their ability to pay. I hope that we’ll be able to, at some point, expand Maine Cure because there’s a big population that the marketplace doesn’t serve, and that’s exactly what the expansion of Maine Cure was designed to address. Hopefully someday we’ll get to that so that we really can reach all people in Maine.
Dr. Lisa: That is a lot of a goal and I’m going to put my energy behind that, that intention as well. We’ve been speaking with Dr. Noah Nesin, the Chief Medical Officer for the Penobscot Community Health Care 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. Nesin: Thanks for having us.
Lisa L: Thank you.
Dr. Lisa: 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 Nesin. For more information on our guests and extended interviews, visit doctorlisa.org. 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 @doctorlisa and see my daily running photos as Bountiful One on Instagram.
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Speaker 1: The Dr. Lisa Radio Hour and Podcast is made possible with the support of the following generous sponsors: Maine magazine, Marci Booth of Booth Maine, Apothecary by Design, Mike LePage and Beth Franklin of RE/MAX Heritage, Tom Shepherd of Shepherd Financial, Harding Lee Smith of The Rooms, and Bangor Savings Bank.
Dr. Lisa Belisle is a physician trained in family and preventative medicine, acupuncture, and public health. She offers medical care and acupuncture at Brunswick Family Medicine. Read more about her integrative approach to wellness in Maine magazine.
The Dr. Lisa Radio Hour and Podcast is recorded in the studio of Maine magazine at 75 Market Street, Portland, Maine. Our executive producers are Kevin Thomas, Susan Grisanti, and Dr. Lisa Belisle. Our assistant producer is Leanne Ouimet. Audio production and original music by John C. McCain. Our online producer is Kelly Clinton.
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