New York Times starts series that will study Affordable Care Act's implementation and impact in Louisville area

It's the calm before the health-care storm, and amid the uncertainty of how the health-care reform law will be implemented, health-care conditions in Louisville, Ky., seem to make it a good environment for a New York Times series that will study the process and its impact.

Reporter Abby Goodnough writes that Louisville, a city with four hospitals, a medical school and one of the nation's largest health insurers, "embodies both the triumphs and the shortcomings of the medical system in the United States." She notes that despite such resources, Kentucky continues to have dismal health outcomes, including some of the nation’s highest rates of smoking, prescription-drug abuse, and deaths due to cancer, diabetes and heart disease.

To watch the six-minute New York Times video, click here.

The health law is intended to address some of those shortcomings, and the potential health benefits to the state are huge. About 90,000 people could get Medicaid coverage in Louisville alone, and the law could also "create thousands of jobs in Kentucky and, if its aspirations are realized, provide better care at lower cost," notes Goodnough.

However, there are many concerns about the law's implementation among health-care providers and Americans in general, both insured and uninsured. Republican Sen. Mitch McConnell says the 2,700-page bill and more than 20,000 pages of regulation is "a massive bureaucracy" not understood by doctors, hospitals, states, small business and most Americans. Regardless, in January the law will require most Americans to have health insurance, or they or their employers will pay a penalty.

Providers and patients: Challenges to providing and receiving care on the front line

For providers, "This is a period of fevered preparation for the far-reaching changes," and many clinics, practices, and health systems are hiring coaches and consultants to meet the demands of the federal health care overhaul, writes Goodnough.

She focuses on the challenges ahead of one such coach, Danny DuBosque. He was hired by Family Health Centers, one of the many clinics and practices across the state that must prepare to treat thousands more newly insured individuals as a result of the law, while simultaneously converting paper charts to electronic medical records to avoid federal penalties. Many practices, particularly in Kentucky's rural areas, are already struggling to stay open, due partly to resources required for this conversion process and problems associated with Medicaid payments from managed care  companies.

Clinics like Family Health Centers, which provide services to patients regardless of their ability to pay, are at a front line of the health law's changes, writes Goodnough. They represent many obstacles now faced by primary-care providers in Kentucky: They serve Kentuckians who are often unhealthy and tend to put off preventive care; they earn less than most physicians; and they are worried about having the staff and money to treat newly insured patients.

Front-line providers like Alaina Brohm, a nurse practitioner in Louisville's West End, treat "a diverse and challenging population: the unemployed, the chronically depressed, the obese, patients with advanced diabetes and feeble hearts," reports Goodnough. She describes the heartfelt stories about patients trapped in the health care system and investigates anticipation of medical coverage from the patients' perspective. (Click here for more details.)

Brohm's patients are often unable to pay for necessary treatments and medications, and they have a hard time even finding transportation to the clinic. One such diabetic patient, identified only as Ms. Edwards, cannot afford medicine to control her blood sugar, and she is depressed by that and her lack of insurance, writes Goodnough. But she will qualify for Medicaid under expansion next year.

Yet, patients like Ms. Edwards and Mr. Elson, who is unable make health insurance premium payments because his diabetic condition led to a 400 percent cost increase, are still skeptical or fearful of the health care law, writes Goodnough. "I don't see it helping anybody, just making everybody get insurance," he told her. Family Health Centers' providers are worried too. Brohm told Goodnough she is concerned that poor, newly-eligible Kentuckians will be required to pay part of their medical costs and she knows of a business that may be sold because it cannot afford employee insurance. (Many businesses don't know about subsidies available for that.)

On the other hand, Gov. Steve Beshear's decision to expand Medicaid with the law is a historic, long-awaited one for Bill Wagner, director of Family Health Centers, reports Goodnough. It will allow about 308,000 Kentuckians to gain insurance coverage, which is almost half of the state's uninsured population, and it may solve the $3 million budget shortfall faced by the center, she writes. As a Federally Qualified Health Center, it has already received $5.4 million to expand its facilities.

Placing waterproof boots on the ground while Louisville prepares for the storm, Goodnough sets the stage for an interesting and highly complex view of the health law's impact that, rather than focusing on the political debate surrounding the health care law, tells tales of patients and providers in the eye of the storm of change. Stay tuned for more alerts.

Health care providers, employers and patients can click here to contribute to Goodnough's reporting by telling about expectations for the health law and their previous experiences with health care in the Louisville area.

Retailers like Walmart, CVS getting into primary care, eyeing the prize that awaits if health reform takes effect in 2014

Last week, a document leaked showing Walmart's intention to become the country's largest provider of primary health services, but the company's interest is not unique. Drug retailers like CVS Caremark and Walgreens are eyeing the same prize: "the millions of Americans with costly illnesses such as diabetes and heart disease," reports Julie Appleby of Kaiser Health News. CVS already has 550 retail clinics, the most in the country. Walgreens has also set up programs aimed at diabetic customers, which includes counseling with pharmacists.

The retail industry is looking at ways it can use its clout to save money and offer a primary care infrastructure that experts say will be short by 21,000 doctors by 2015, largely because of the 30 million more people becoming insured by 2014 under the federal health-care reform law. "It's sad that the existing health care establishment has not figured out a way to make primary care affordable and accessible," said Jerry Avorn, a professor of medicine at Harvard University. "We should not be surprised if someone outside of our world comes in and does it for us."

Costs at retail clinics are "roughly 30 percent to 40 percent less than similar care at a doctor's office and 80 percent cheaper than at an emergency room," Appleby reports, referring to a study in the American Journal of Managed Care. Those savings appeal to insurers. Retail clinic use by people with health insurance increased tenfold from 2007 to 2009, with clinics accounting for 7 percent of all medical visits for 11 common acute conditions, the study found. "If these trends continue, health plans will see a dramatic increase in retail clinic utilization ... particularly among young, healthy and higher income patients living close to retail clinics," the study concluded.

Patients like the clinics for the predictability, with costs made clear ahead of time. And employers — who under the new health law could get incentives to provide wellness programs for their employees — may partner with the clinics to provide blood testing, nutrition counseling and diabetes management. However, there are still many unknowns. While the clinics have proved useful for acute care, it remains to be seen how they will deal with complicated issues like diabetes management.

Some states prevent clinics from employing physicians, nurse practitioners or physician assistants. "Other states cap the number of nurses each doctor can oversee," Appleby reports. The vast majority of clinics are staffed not by doctors, but physician assistants and nurse practitioners. A report by the Convenient Care Association shows 95 percent of the clinicians are nurse practitioners. With these practitioners able to provide basic care, part of the fear among doctors is they will be left to treat only the sickest patients and won't be reimbursed accordingly.

Most of the clinics are in the South and Midwest. In January, Merchant Medicine listed 40 retail clinics in Kentucky, with more to open in 2011. The clinics "are more likely to be in areas with lower overall poverty and only 12.5 percent were in medically underserved areas," Appleby reports, though 21 percent of the U.S. population lives in those areas.

The clinics have typically offered vaccinations and simple physical exams and treatment for strep throat and ear infections, but plan to expand their services and enlarge retail's foothold in the medical world. "Think about Toyota; they didn't start off by competing with Cadillac and BMW. They started with cheap little cars but got better and better over time," said Mark Smith, president and CEO of the California Healthcare Foundation. (Read more)