Hospitals

Betting on Reno(Editor’s Note: This is the second of a series of articles on the Athens uninsured initiative, produced by graduate students in the Health and Medical Journalism Program at the University of Georgia. Visit the previous article by clicking on the red button to the left.)

In Athens, a city where 35 percent of residents live in poverty, many people can neither afford health insurance premiums nor pay out of pocket for services.

As a result, hospital emergency rooms may be the only option that uninsured people see for themselves – even though they may have chronic diseases and not the sudden illnesses or injuries that emergency rooms are meant to handle.

Such misuse of emergency rooms is expensive for hospitals and bad for the nation’s soaring health care costs.

A local coalition of health care providers called the Athens Health Network is seeking relief by looking far beyond Georgia. It’s following the example of Reno, Nev.

Reno is very different from any Georgia city. Lying in the high desert at the foot of the Sierra Nevada, it has long been a center of gambling and tourism. Today, the city is becoming known for an innovative health program.

The Reno program, called Access to Healthcare Network, links hospitals, doctors and patients in what the founders call “shared responsibility.” Hospitals and doctors provide services at a reduced fee. Though the fee is relatively low, patients are required to pay it up front, eliminating delays and extra paperwork for caregivers.

“The hospital’s role in the shared responsibility model is that they offer our discounted rate to our members,” said Niki King of Access to Healthcare Network. “The return is that we put our members into a primary care home and get them out of the emergency room.”

For network members, in-patient hospital care at a participating hospital costs $400 a day, all-inclusive, with a $3,000 cap for each stay. According to King, the $3,000 limit protects members against medical bankruptcy.

Outpatient visits and surgical procedures are also discounted, which motivates members to get care from doctors and hospitals instead of the emergency department.

An uninsured woman who comes into an emergency room with pelvic pain may ultimately need a hysterectomy. That’s major surgery. King notes that while ERs are legally required to stabilize all patients, regardless of ability to pay, they don’t have to provide full-scale medical treatment. “They can give you pain pills and send you on your way,” she said.

With the outpatient discounts provided through Access to Healthcare, members can afford the full level of care they need.

A hysterectomy “that might have cost $20,000 to $50,000 [for an uninsured person] . . . is $2,500 to $5,000” for a program member, King said.

Seven years ago, when Access to Healthcare Network began, it contracted with two Reno hospitals willing to treat members at reduced rates: Renown Regional Medical Center and Saint Mary’s Regional Medical Center. The organization now works with seven hospitals across the state.

“Over the past six years, we’ve enrolled 20,000 members statewide, and we have a hospital ER utilization rate of .05 percent,” King said. That means one in every 200 members goes to the ER each year. By contrast, 9 percent to 12 percent of insured Nevadans seek ER care each year.

Reno’s network for the uninsured contracts with seven hospitals to provide care at discounted rates, including Renown Regional Medical Center (above)

Patients share responsibility

Partnering with Access to Healthcare Network was a weighty decision for the Nevada hospitals, according to Chris Bosse, vice president of government relations at Renown Health, a nonprofit health system that includes Renown Regional Medical Center.

“Initially when we sat down with Access to Health and looked at contracting, I think the piece we all had to remember was the rates were not going to be rates that covered costs,” Bosse said.

For this reason, Renown views the plan as a part of the hospital’s charity work, but with a twist. Bosse says network members are engaged with their own care in a way that other charity patients are not: They pay fees for every service they receive and are required to show up for appointments.

If a member misses an appointment without canceling 24 hours ahead of time, the member pays a $25 no-show fee. After two no-shows, the member is removed from the program.

“I believe strongly that it’s been a good thing in the Reno area, primarily because doctors have come to the table, hospitals have come to the table, and the patients have come to the table, and we all have to give something,” said Bosse. “[Members] now have access to primary care earlier, and I believe frequently don’t have to go to the emergency room as their primary care home,” she said.

Like Reno hospitals, Athens hospitals treat many patients who don’t have insurance or a regular health care provider. “The emergency departments in Athens are full, at Athens Regional about 75,000 visits a year and growing,” said Grant Tribble, senior vice president of operations at Athens Regional Medical Center.

A medical discount plan would provide approximately 5,000 Athenians with affordable care outside the ER, according to an Athens Health Network board member, Sister Patricia Loome.

This number is similar to the 4,700 members that Access to Healthcare serves from Nevada’s Washoe County, where Reno is located.

ACA may bring changes

Both Athens hospitals have expressed interest in the discount program, which is not an insurance plan.

It’s a way of buying discounted care through a club membership (like buying discounted products through a warehouse club). As the Affordable Care Act, the 2010 federal health care law, moves forward, many Athens-area residents will still be in need of this nonprofit medical discount network, especially if Georgia does not expand its Medicaid program under the act.

The member pool of the Nevada discount plan may change in 2014. That’s when the ACA’s insurance mandate – the requirement that most Americans have health insurance or pay a penalty – takes effect. Since the medical discount plan doesn’t count as health insurance, some patients may actually buy coverage.

The plan also will still serve individuals choosing to pay the penalty, and those who are not required to buy insurance under the ACA, such as those who would have to pay more than 8 percent of their income for an insurance plan.

Athens Health Network hopes to be able to enroll uninsured Athenians in a similar medical discount plan beginning in early 2014.

Reducing inappropriate, expensive ER visits could save Athens hospitals a lot of money. But Loome, who is also vice president for mission services at St. Mary’s Health Care System, said saving money would not be the primary motivation for the hospital to join a discount plan.

“Our first motivation is how can we care for the community,” she said. “And certainly if more people can come for care, to the right level of care, and there’s some payment, then that’s a help to the hospital.”

Julianne Wyrick is a freelance science and health writer currently completing the health and medical journalism graduate program at the University of Georgia.

This story is also appearing in GHN’s partner Kaiser Health News

Stewart-Webster Hospital last week suspended operations

In the small Georgia town of Demorest, Habersham Medical Center, like many rural hospitals, has seen its patient base change in a way that hurts its bottom line.

As unemployment in the northeast Georgia mountains remains stubbornly high, more of the hospital’s patients have no health insurance.

Among those patients with private coverage, an increasing number have high-deductible policies, which means that patients must pay all or a large portion of the bills out of pocket. And a large share of patients have Medicaid, the federal-state program for low-income people that often doesn’t reimburse enough to cover the cost of services, hospital officials say.

The hospital has enough cash to meet its payroll and service its debt, but that’s about it, says Jack Fulbright, the acting CEO.

Still, Fulbright and hospital authority board member Rick Austin assert that Habersham Medical will survive these tough times. “Habersham Countians are resilient,” Austin says. “We’re tough as a boot up here. We’re not going anywhere.”

Its financial squeeze reflects trends facing rural health care providers, both in Georgia and nationally.

Financial problems recently led Calhoun Memorial Hospital in Arlington in southwest Georgia to close its doors. Earl Whiteley, the hospital’s CEO, cited as a major reason the increase in charity care that the 25-bed facility incurred. “You just can’t continue to give away free care,” Whiteley said in a recent interview.

Stewart-Webster Hospital, 50 miles north of Calhoun Memorial, announced that it, too, was halting operations effective last Friday.

The closure of a hospital can have broad repercussions for a rural area, including:

* Deteriorating health care. People in rural areas tend to have poorer health than elsewhere. Patients’ health outcomes in Stewart County, where Stewart-Webster Hospital is located, were ranked next to last among Georgia counties, according to new 2013 county health rankings produced by the University of Wisconsin and the Robert Wood Johnson Foundation. The bottom 10 Georgia counties in the rankings are mainly rural.

* Recruiting doctors to the community. “Rural hospitals are struggling to produce an economic quality of life for young physicians,” says Jimmy Lewis, CEO of  HomeTown Health, an organization of rural hospitals in Georgia.

* Maintaining economic stability. The availability of health care is vital for a rural area’s economy. A hospital itself is often the top or No. 2 employer in a rural county. Habersham Medical, for example, employs more than 500 people, and the closing of Calhoun Memorial will result in a loss of 100 jobs. Stewart-Webster Hospital is the largest employer in the town of Richland. In addition, a rural area’s ability to attract businesses is partly tied to the availability of a hospital and other health care services.

* Losing important services. In a sign of the overall predicament of rural hospitals in Georgia, at least 40 of them have given up delivering babies. The hospitals blame high costs and low reimbursements. Another big factor is the shortage of rural obstetricians.

A thin margin

Rural hospitals generally operate on a very thin margin, even in the best of times.

Brock Slabach of the National Rural Health Association says the latest figures available show rural hospitals nationally have a negative profit margin of 5.68 percent.

That negative trend will be aggravated by sequestration, the automatic federal spending cuts that went into effect this month. It will reduce Medicare payments by 2 percent and could result in the loss of 12,000 rural hospital jobs, from nurses to support staff, according to Slabach.

Rural health care is accustomed to tough times, but this period appears especially tough, he says.

The Georgia legislature moved quickly this year to help rural hospitals, passing a bill that will speed renewal of a fee hospitals pay allowing the state to draw down an extra $400 million in federal Medicaid funding.

But Georgia hospitals will also lose $400 million in federal indigent care funds under the Affordable Care Act, which has many hospital industry officials concerned. The law cut back payments, called Disproportionate Share Hospital funding or DSH, that had helped cover care for uninsured patients.

The law assumes that most of these uninsured patients would get coverage through an expansion of the Medicaid program. The U.S. Supreme Court ruled last year, however, that states don’t have to expand Medicaid to cover such people, and Republican Gov. Nathan Deal says Georgia won’t do it because it’s too costly.

Medicaid expansion is necessary to add more paying customers for hospitals, Lewis says. “We don’t have a choice’” in order to save rural providers.

Fulbright of Habersham Medical Center says Medicaid expansion “would certainly help us.” Meanwhile, the hospital is seeking a partnership or affiliation with a bigger hospital, perhaps Northeast Georgia Medical Center in Gainesville.

“We’re looking at everything we’re doing [to find] the best way forward,” Fulbright says. Recently the hospital sought to be annexed by the city of Demorest, which would lower its utility bills and security costs.

No more deliveries

For many rural hospitals, a key way to cut costs is to eliminate childbirth services.

Last year, Burke Medical Center, south of Augusta, gave up obstetrics, saying it was losing more than $1 million on the services.

Unless a birth is considered so imminent that it’s an emergency — in which case the delivery is performed in Burke’s emergency room — pregnant women must travel 25 miles or so to Augusta to have their babies.

Among Georgia’s “critical access” hospitals — rural facilities with no more than 25 inpatient beds — 32 of 34 have given up maternity services, according to Lewis of HomeTown Health.

One reason is that it’s difficult to maintain a high-cost service with low reimbursement rate.

About 60 percent of births in Georgia every year are covered by Medicaid, and Georgia physicians and hospitals say the government insurance program generally does not pay them enough to make up for the costs of the care. Georgia obstetricians have not had a Medicaid pay increase in more than a decade.

“Payments don’t cover deliveries and follow-up care,” says Lewis. And if there’s only one OB in an area, that doctor is always “on call,” he adds.

Pat Cota, executive director of the Georgia OBGyn Society, says roughly 40 counties in Georgia — one in every four — has no OB/GYN. “Between Athens and Augusta, there’s no delivery hospital.” Cota says. “It continues to get worse and worse.”

Pregnant women in Burke County get prenatal care through family medicine physicians and nurse practitioners in the area.

Infant mortality is improving in the state, though Georgia still ranks among the bottom 10 states on that measure, says Dr. Paul Browne, director of maternal-fetal medicine at Georgia Regents University in Augusta, which is helping Burke County with its prenatal care. He adds that the maternal death rate in the state is actually getting worse.

Increased reimbursement for physicians is a critical need, Browne says. But he acknowledges that it’s hard to persuade budget makers to include such funds given the state’s financial crunch.

The big question, he says, is: “Will the state subsidize rural health care in Georgia?”

Choosing an urgent care facility over an ER can save both money and time

A sudden ache or illness is troubling at the best of times. And if you can’t get in to see your primary care provider — or don’t have one — the situation can be worse still.

At such times, many people turn to the emergency department (ED) at the nearest hospital. Often known as the emergency room or ER, it can be the first place that comes to mind in an unexpected medical situation.

But unless a patient’s condition appears life-threatening — with symptoms such as severe chest pain, inability to breathe, or signs of stroke, for example — the hospital emergency department is often not the best choice.

People who go to hospital emergency departments when there’s no real emergency are inconveniencing themselves and hurting the system. Misuse of EDs accounts for $4.4 billion in waste annually and contributes to the high cost of American health care.

Patients with insurance are often unaware of the actual costs of the medical care they receive at an ED, because they pay little or nothing out of pocket. But that is changing. Nowadays more hospitals are charging upfront fees for non-urgent ED visits, and more individuals are buying insurance plans with high deductibles. Health consumers may be forced to start paying more attention.

If a person has an illness or an injury that warrants immediate attention but isn’t likely to be life-threatening, an urgent care center may be the best bet. These clinics, which take walk-in patients and are open fairly long hours (though generally not around the clock), are usually cheaper than EDs. Perhaps more importantly, they are often quicker, too.

The wait can be painful

One of the biggest misconceptions among patients who come to the ED is that they will be seen on a first-come, first-served basis, said Kathleen Kriebel, a registered nurse in the emergency department at Athens Regional.

But the very nature of emergency care makes such routine customer service impossible. When patients arrive at Athens Regional Medical Center for emergency care, a triage nurse uses the emergency severity index, or ESI, to decide which of them will get priority. The majority of U.S. hospitals use it.

Based on the ESI, the nurse determines the severity of each patient’s condition, what kind of care the person needs, and how long the person can wait for it.

For instance, a patient experiencing severe chest pain or other heart attack symptoms will be seen immediately. A patient with a sore throat, who may have arrived earlier, will have to wait for an indefinite period, possibly a long time, depending on the hospital and the circumstances.
Patients have other misconceptions about hospital emergency departments, Kriebel said. Some believe that being transported to the ED by ambulance will automatically get them admitted to the hospital and assigned a bed. That is not true.

She said some patients actually believe they can get the same kind of routine care through the ED that they would from a primary care physician. That is definitely incorrect.

Urgent care centers are increasingly numerous and conveniently located. Reddy Medical Group in Athens operates one in the same building as its primary care facility, though the two function separately.

In many cities and towns, retail stores contain small clinics that handle urgent care patients. Two examples are the Little Clinic in Walmart and CVS’s MinuteClinic, where nurse practitioners or physician assistants treat minor aches and illnesses from earaches and strep throat to poison ivy and bladder infections. Prices vary by service, but insurance may be accepted at certain locations, and the clinics are open longer than a typical doctor’s office.

Sunita Singh, vice president of business development at Reddy, said although urgent care is not meant to replace primary care, it is a beneficial option for patients.

“It’s a good alternative, where you can get stabilized until you’re able to see your doctor,” Singh said, adding that urgent care is more or less like a doctor’s appointment.

At Reddy Urgent Care, walk-in patients are not triaged. They are seen in the order in which they arrive, unless there is an extreme case in which the patient may be at risk. Singh said a patient generally spends about an hour in the urgent care facility, and that time includes treatment and discharge.

Urgent care is more economical

Choosing an urgent care facility over a hospital emergency department can be just as much a money-saver as a time-saver.

Take, for example, an uninsured person who has a headache, a fever, and a sore throat with pus around the tonsil area. At Reddy Urgent Care, the bill would come to about $140 for a first-time visitor, which includes a strep test and a 25 percent discount because the patient is uninsured. That’s all the patient would have to pay, aside from getting a prescription filled if necessary.

In the emergency department at Athens Regional, the same patient would be charged about $413 and would not receive a strep test. This includes the pain medicine that would be given at the time of the visit, the ED visit itself, and a 40 percent discount because the patient is uninsured. However, the bill does not include charges from the independently contracted doctor who examines the patient, or any prescriptions the patient may need.

Singh said many individuals are not educated about the respective uses of urgent care centers and EDs. Occasionally — in a reversal of what usually occurs — patients come to Reddy Urgent Care when they should have gone to the ED.

When that happens, and the patient needs hospital-level care, the staff at Reddy will send records, such as X-rays, to the hospital and call ahead to help cut the patient’s waiting time, Singh said.

“It is our job to take care of the patient,” she said, “If we can’t do it, someone has to.”

April Bailey is in her first year of a master’s degree in telecommunications at Grady College of Journalism and Mass Communications.

Georgia's Attorney General

From his opposition to the Affordable Care Act to his prosecutions of Medicaid fraud, Georgia Attorney General Sam Olens has been very involved in health care issues in the state.

Georgia Health News recently sat down with Olens in an exclusive interview regarding his views on health care.

He discusses his fight against “pill mills,’’ his views on health reform and its regulations, and his office’s anti-fraud work, including a current case involving abortion.

Olens also touches on rural hospitals’ challenges, tort reform, and his campaign for lawyers to collect food for poor children in the state.

Q: Fighting against ‘‘pill mills’’ is a legislative priority of yours. Talk about what needs to be done with the problem of these prescription drug sales.

A: Florida had a huge problem, and about two years ago, they passed legislation that significantly reduced the number of medical providers who were selling large quantities of oxycodone.

Ever since Florida’s improvement, many of those bad actors have moved into our state. It is expected that once Georgia passes legislation, those bad actors will move into the next state.

We have the blessing and the curse of such a great [transportation] infrastructure here, between Hartsfield-Jackson [Atlanta's international airport] and I-75 and I-85 and I-20. So it’s easy to transport Class II and Class III drugs [controlled substances].

The legislation seeks to provide the medical board and pharmacy board the necessary authority to wipe out those bad actors.

We’re not trying to stop reputable doctors who treat intractable pain from doing so. We want those patients to have the appropriate medical and pharmacy care.

But when you see a place that’s renting by the month, [where cars in the parking lot have] predominantly out-of-state plates, when the doctors are not really issuing many prescriptions, they’re having a cash business inside the building – we want those actors out of our state.

Q: There’s legislation on this currently introduced in the Georgia House.

A: House Bill 178. The chief sponsor in the House is Tom Weldon, and it has approximately 45 co-sponsors. The bill specifically provides for the medical board to license and regulate providers [of pain management clinics].
Q: Last year, a similar bill failed to pass. What’s different this time?

A: [Last year’s] bill was ready for passage, but it was the last week of the [legislative] session. There was an education component and it was necessary to hold meetings to bring everyone together – the medical community, the pharmacy community.

And the rush is not to pass a bad bill. The push is to pass a good bill.

We frankly ran short of days to accomplish that. It wasn’t for lack of effort. It was for lack of time.

The bill, as filed this year, is exceedingly similar to the last version from the session. We certainly have very optimistic expectations that the bill will pass this year.

Q Is it similar to the pill mill law in Florida?

A: Yes. There are differences in our states’ constitutions that mandate differences in the legislation. But as a general statement, yes.

Q: Your administration seems to place a high priority on fighting Medicaid fraud, based on the number of press releases on prosecutions we get from your office.

A: I would suggest to you that some of that is simply the difference in [information policy] of administrations. By that I mean our office puts a lot out on the website. When I was running for AG, one of the typical questions was, ‘‘What does the AG do?’’ I think part of the way I respond to what the AG does is through these press releases, on pleas, trials, convictions.

From a process perspective, I think we have placed a higher emphasis on the Medicaid fraud unit. But that should in no way, shape or form say that prior Attorney General Thurbert Baker did not put an emphasis on it, too. We’re putting more out there because we think the public learns from that information.

I think frankly it also has a deterrent effect on bad actors, in telling them we’re going to take [their offenses] seriously and we’re going to take appropriate action, whether it’s a civil recoupment or criminal conviction.

Q: Do you think fraud is currently being contained, or are the prosecutions uncovering just the tip of the iceberg?

A: I think it’s the tip of the iceberg. And I think it’s the case nationally. You can get many quotes from the Department of Justice and HHS on the massive amounts of Medicare fraud. I think the same can be said for Medicaid fraud. We work closely with our three U.S. attorneys in the state, with our federal and state law enforcement partners, and I think there’s more we can and should do.

Q: There’s a Medicaid fraud case involving abortion that’s getting headlines. You’re prosecuting that case, even though a state administrative law judge found the physician had not committed fraud. Why are you pursuing that case?

A: Let me answer in general, because it’s a pending matter.

There are two prosecutions, not one. [Also,] we didn’t represent DCH [the Department of Community Health, the state’s Medicaid agency] in the administrative hearings referred to in these cases. We are involved in the criminal context, not the administrative context.

This is not a political case in any way, shape or form. It’s a Medicaid fraud case. The Hyde Amendment is very clear on the use of Medicaid dollars [prohibiting the use of federal dollars for abortion].

These cases didn’t originate in my office. They didn’t originate at the Medicaid fraud unit. They originated at DCH, the state agency …

These cases are generally referred from the state agency or other sources, and moved to the Medicaid fraud unit.
Q: In your mind, there were Medicaid funds spent for abortion?

A: Let me rephrase the question. We allege that Medicaid funds were spent in violation of federal law.

The issue is not abortions. The issue is compliance with federal law relating to Medicaid.

Q: So it could have been anything – Medicaid funds being used to pave roads, for example?

A: We’re treating this case as we would treat any Medicaid fraud case. There’s nothing special or different about this matter than anything else in the Medicaid fraud unit. It’s not a higher priority or a lesser priority.

Q: You were very much out front in your opposition to the Affordable Care Act, the health reform law of 2010, and led the state’s legal fight against it. Talk about the legal reasons for your opposition.

A: When the country was first founded, the first constitution was the Articles of Confederation, which was very weak on national power and gave predominant power to the states.

Thereafter came our current Constitution. And there was a dispute at that time about whether the federal government had paramount power, or the states, which led to the Bill of Rights.

Never before had Article 1, Section 9, of the Constitution, the Commerce Clause, been used regarding failure to buy a product, and call it commerce [the ACA’s mandate for most individuals to obtain health insurance or face a financial penalty].

So I would suggest to you that while your interest area is health care, and that’s the purpose of your publication, the objection from the [state] attorneys general was not specifically about health care, it was federal overreach of the Commerce Clause.

Now we were told we were going to lose on the Commerce Clause and lose on the spending clause about the expansion of Medicaid and that we would win on the tax clause because the president and Democratic leadership in Congress denied it was a tax because they wouldn’t have the 60 votes in the Senate.

Of course the exact opposite transpired. We won on the Commerce Clause and the spending clause but lost on the tax clause when Chief Justice Roberts opined, because principally [he reasoned] if the individual mandate did not carry with it criminal penalties, it could still be viewed as a tax.

We were involved in the case not due to health care, but due to the fact that we felt the president and Congress had exceeded the powers given to them in the federal Constitution.

And many of us think for decades that states have looked the other way and not maintained or sought to maintain state sovereignty.

Having said that, there are still numerous issues. There are thousands of pages of forthcoming regulations still due to the Affordable Care Act. There are significant issues related to the default federal health insurance exchange in regard to the state. There are significant issues on how HHS will deal with the ability of states to not accept expansion on their terms . . .

You have had Governors Jindal [of Louisiana} and Perry [of Texas] opine that if [Medicaid] was given as a block grant, they would be much more inclined to take the expansion.

Q: Governor Deal has also supported Medicaid block grants.

A; That’s true. There are numerous legal issues remaining both on the employer mandate as well as the expansion of Medicaid. As we read forthcoming regulations, it will determine how many if any additional lawsuits [will be filed] by the same states that filed the initial lawsuit against the Affordable Care Act.

Q: So this issue is not going away?

A: Look, the majority of the court held it was constitutional. The president was re-elected. So the Affordable Care Act is a reality. I believe strongly in the rule of law. It is a law in our country, one that I need to follow, like all other laws.

At the same time, there are other elements of that law where federal regulations are still forthcoming. Depending on those regulations, there may be additional disagreements with HHS that merit litigation.

Q: Your position appears to be one of monitoring the [health reform] law.

A: We’re closely monitoring all of the regulations. We frankly did not agree with HHS on the religious liberty issue [mandating most employers to offer free contraception].

. . . I was recently at Clayton State University, and former Gov. Roy Barnes and I were on a panel, and Barnes [a Democrat] disagreed with how [the Obama] administration was handling that issue, too. Folks of very different backgrounds had large concerns with the regulations on the issue.

Q: Will you join in the lawsuits against the employer requirement on birth control?

A: Potentially in the form of amicus briefs.

Q: Did the president’s recent compromise on the contraception issue change anything?

A: It was a little broader than the first version, and I think many folks are now trying to chew on it, and to decide whether further action is necessary. Clearly from a perspective of a business such as Hobby Lobby, the change did not affect them at all. So I expect their appeals to continue.

Q: Certificate of Need — the state regulatory process of health care facilities — has been controversial at the very least. The Republican Party stands for less government regulation. What are your thoughts about CON?

A: To be honest, I’m reluctant [to discuss it] because there’s pending legislation across the street [at the Capitol], and depending on what they pass, I’m there to defend it, whether I like it or not.

Clearly there’s a lot of litigation between various providers at the moment that we can all agree isn’t healthy.

We can also agree that we have too many hospitals in danger of closing. And I think there is a very valid concern that the increased cost of the president’s health care act is adversely affecting those rural hospitals and their ability to stay in business.

And one of the things that concerns me as the state’s lawyer is the fact that we have areas of the state that have insufficient trauma and labor and delivery services now. An unintended consequence of the ACA [may] make it worse.

Q: If the state doesn’t expand Medicaid?

A: We’re in a state where we’re 45th in the country in number of doctors per 100,000 people. We’re in a state where only 42 percent of our doctors accept Medicaid now. There are already estimates of an additional 100,000 enrollees to Medicaid due to the Affordable Care Act — separate and apart from the expansion — [which will have] an estimated cost, according to the governor’s office, , in excess of 1billion over the next decade.

And many state budgets are being cut to balance this year’s Medicaid budget.

I don’t think the public understands how much money Medicaid costs.

One of the reasons we won on the spending clause in the U.S. Supreme Court was that on average, Medicaid is 10 percent of a state’s revenues.

When you talk about K-12 [education], technical colleges, colleges and universities, and Medicaid, it’s really tough for states before you even get to law enforcement on balancing a budget. We don’t get to do what Washington unfortunately does – give massive amounts of debt to our children and grandchildren. I think we’re getting to a crucial point where the states are having trouble funding the essentials.

Q: What are your thoughts about having special arbitration panels resolve medical malpractice allegations?

A: I think it would be very interesting to seek to do that in the form of a pilot [project]. Where everyone would have the benefit to see how it worked on a voluntary basis, before it was potentially made mandatory. By doing so, you may get a buy-in from both sides during that pilot project.

Q: You’ve taken an interest in food donations to the poor. How did your drive to get lawyers to collect food for the poor come about?

A: At the national attorneys general meetings, we try to cover best practices, and best practices may not be limited to how to win a lawsuit, [but also] what’s worked well for your community.

At one of the first meetings I attended, the attorney general for Virginia talked about how his predecessor, now the governor of Virginia, started this food drive. As a result the lawyers in Virginia collect approximately 1.2 million pounds of food every year.

Georgia’s now about the fourth state to do it. Since we’ve done it, one or two other states are now doing it.

The first year we collected the equivalent of 620,000 pounds. The goal this year is 750,000 pounds.

It’s a great way for lawyers to use their contacts in their local communities to collect food and money that goes straight to the local food bank. The food and money don’t come to Atlanta, and are thereafter spread throughout the state. They immediately go to one of the seven regional food banks where [people] live.

The scary fact for me is that 60 percent of our public school children are eligible for free or reduced lunch. That number is alarming. We have specifically timed our two-week food drive so that those children who get free or reduced lunch during the school year may have a healthy lunch over the summer. The food banks are using these donations to help them in neighborhoods where they know there are many poor children over the summer months.

Q: Many kids go hungry during the summer.

A: No one really thinks of what they do in the 10 to 12 weeks over the summer. We overtly encourage them to reach out to the Rotary, Civitan, Kiwanis, Chambers [of Commerce], bring a box and get food from everyone in their community.

With this recession, the demand is only greater, the state’s poverty rate is only higher. It’s a great opportunity for lawyers to provide additional value to their community. ..

And the winners are the children. . . . If part of the bully pulpit that comes with being the state’s lawyer is providing healthy food to our schoolchildren, so much the better.

The U.S. Supreme Court had a major effect on Georgia health care in 2012. Photo by Chris Phan

Here is the GHN list of the Top 10 stories in Georgia health care in 2012.

Disagree with our choices? Let us know with a comment or email.

10. Grover Norquist’s letter to lawmakers on the Georgia provider fee.

The national anti-tax leader stirred up the debate on the hospital fee before the 2013 General Assembly session.

 9.  Consolidation continues among hospital systems and insurers.

Examples of the cost-cutting combinations were WellPoint buying Amerigroup, Mayo Clinic taking over a Waycross hospital, and Emory partnering with Southern Regional.

 8. Gov. Nathan Deal announces a public-private partnership to fight obesity.

Georgia’s rate of child obesity is the second-highest in the nation.

7. The U.S. Supreme Court hears arguments against Phoebe Putney’s merger with Palmyra.

The FTC challenges the Albany deal, saying it will lead to a monopoly and higher prices.

6. Baxter International announces it will build a manufacturing facility in Georgia.

The biopharmaceutical plant will bring 1,500 jobs to Stanton Springs.

5. A young Snellville woman survives a battle with a rare flesh-eating bacteria.

Doctors gave a grim prognosis for Aimee Copeland, 24, who lost parts of limbs, but her courage made her a national inspiration.

4. Piedmont Healthcare and WellStar Health System form an alliance.

The metro Atlanta hospital superpowers announce they will create a health insurance plan.

3. Two famous Georgia centenarians die.

Besse Cooper, 116, was listed as the world’s oldest person; Leila Denmark, 114, was a renowned  pediatrician and author.

2. Gov. Nathan Deal’s makes his choices under the Affordable Care Act.

The governor declines to build a state insurance exchange, and rejects expanding Medicaid as it’s currently outlined.

1. The U.S. Supreme Court upholds the Affordable Care Act, which Georgia and several other states had fought.

In a surprising ruling, the justices say the 2010 health reform law’s individual mandate is constitutional, but they put the choice on Medicaid expansion back in the hands of the states. (With President Barack Obama’s re-election, the law is safe from repeal and will go forward.)