Policy Research: How the Georgia Health Policy Center Benefits You
at the Andrew Young School of Policy Studies

The Georgia Health Policy Center (GHPC) develops health policy recommendations and implementation strategies to improve health care quality, access and costs. The center moved into the Andrew Young School in 1998 and houses a team of health care policy experts led by James Cooney, Monica Herk and Karen Minyard, GHPC director, whose current work in the areas of long-term care and end-of-life improvements, children's health and well-being, and networks for rural health, respectively, are making a difference in Georgia.

Where is grandma today - nursing home or hospital? Is this decision made as much by her health status as by what her insurer will pay for - and how does that impact her health? What changes must state agencies make to better meet the multiple needs of children in its care? How can Georgia's rural communities improve access to insurance, physicians and other health care providers? These are the types of issues the GHPC addresses.

"We anticipate using the GHPC long-term care study to get broader support in the legislature for continued improvements to Medicaid," said Mark Trail, director of the Division of Medical Assistance in Georgia's Department of Community Health. His hope is echoed in a variety of ways by state and local policy leaders in elder care, children's services and rural health who have similar expectations for the center's research and recommendations in their areas.

As long as changing demographics and rising pressure on public resources dictate the need for greater improvements and efficiencies in health care, the Georgia Health Policy Center will aid governing authorities in developing recommendations and strategies to improve services and costs for all affected populations, ensuring that those who Ambassador Young calls "the least of these, God's children," do not fall through the cracks.

Long-Term Care: Health Insurance Is Not Enough

Health insurance itself is not always sufficient to provide economical access to appropriate health care services, and this is especially the case with long-term care services," said James Cooney, professor of Health Administration and associate director of the Georgia Health Policy Center.

"Most people who use long-term care services are eligible for both federal Medicare and state Medicaid. But the policies and administration of these public insurers are not integrated, so care patterns can lack continuity, negatively affect quality and be unnecessarily expensive." He warned that given the rapid growth of the elderly population, the problems in Medicare and Medicaid long-term care policy would seriously accelerate.

Under Cooney's direction, the GHPC in 1996 began a series of studies to better understand the problems inherent in existing long-term care insurance financing and to identify effective options for the state. In 1999 Cooney and his associates discovered an unusual pattern of frequent and rapid nursing facility-to-hospital transfers of the frail elderly they labeled "the churning effect." They speculated the transfers were related to conflicting incentives between the Medicare and Medicaid programs. Cooney interested both the state and federal government in this finding, and obtained support for expanded work to understand the problem and identify public policy solutions.

"This churning phenomenon needs to be understood and its problems dealt with," said Bill Clark, with the Centers for Medicare and Medicaid Services (CMS) in the U.S. Department of Health and Human Services. He noted Cooney's latest research would link Medicaid data from the state and Medicare data from CMS. "Only when you bring these two pieces together do you see the full cost and consequences of care. I think it's a very good approach - and it is also timely."

"Look at the demographics of our society," said Clark. "When baby boomers begin to retire, in 10 to 11 years, long-term care issues will become even more important, their cost to society far greater. These issues can perhaps be looked at and solved more easily now than in 15 to 20 years."

Cost issues are critical to care. Georgia's Medicaid payments were nearly two-thirds of the state's Department of Community Health expenditures in 2000. "The Medicaid 'fact' all too frequently missed," said Cooney, "is that although this program's aged, blind and disabled population is the smallest proportion of Medicaid-eligible - 27 percent in Georgia - it consumes 65 percent of Medicaid's resources annually.

"What we face, given a growing elderly population, is an alarming increase in long-term care costs that could, unchecked, eventually consume the total Medicaid budget," said Cooney, "unless there are serious and coordinated policy revisions between Medicaid and Medicare."

The Center's current study focuses on more than 45,000 Georgians admitted to long-term care service in 1999; their care and costs will be tracked for the year before and the year after their 1999 admission. The goal is twofold: to get a more complete look at the churning effect and its cost and quality consequences to nursing facilities, their patients and insurers, and to evaluate home and community-based alternatives to nursing facilities. The study team includes Glenn Landers, associate long-term care project director at GHPC, faculty from GSU's Robinson College of Business and researchers from the Kerr L. White Institute for Health Services Research.

"We pay a lot of money for long-term care," said Trail, who runs Georgia's Medicaid program, "but without having comprehensive access to Medicare records, we have not been able to truly measure the costs of serving these patients or their quality of care. Cooney's research will facilitate such access."

Trail continued, "Improved cost understanding will instruct us on how to improve our policy and consider the most efficient use of resources. It will instruct various long-term care providers, as well as the state, on quality-of-care improvements. Finally, it should help open conversations with Medicare on ways to improve care and share savings."

"It is critical to understand the patterns of use in long-term care, and how policy decisions affect the quality of life and quality of health care in our state and nation," said Clark. "Ultimately, in a rapidly aging society, we must know where the inefficiencies are and find ways to avoid placing patients in settings where they may not need to be."

Dr. James P. Cooney, Jr., principal investigator for the long-term care studies, has researched, taught and administered programs at Georgia State University for 12 years. Before serving as associate director of the Health Policy Center and professor of health administration, he was dean of Health Sciences at GSU. While dean, Cooney facilitated the creation of the GHPC on the Georgia State campus. Glenn M. Landers, a health policy analyst and associate project director at the GHPC, is also researching access to care for the uninsured with a study of the Indigent Care Trust Fund in Georgia.

Child Policy Initiative Supports Governor's Action Group

GHPC's Child Policy Initiative received a major gift from United Parcel Service in 2001 that enabled it to expand its scope beyond child health into a broader range of child policy issues. Its early findings got the attention of Governor Roy Barnes, who asked the initiative to provide research support for his Action Group for Safe Children, formed in January to recommend policies to improve the state's child protective services.

The Action Group will present policy recommendations on how to improve Georgia's placement system for children going into state custody. With these findings, the state plans to develop a more effective and compassionate model to replace its current system. The initiative's new director, Monica Herk, and her staff are collaborating with the Governor's Office of Planning and Budget to provide key technical support, background research and information to help shape discussions.

"The Child Policy Initiative's role in supporting this group will be instrumental in focusing the array of public, private and nonprofit service providers on solutions that work. It will help them improve quality, facilitate access and improve efficiency by coordinating all services provided to children and families," said Sally Rosser, member of the Governor's Action Group for Safe Children and an AYSPS Advisory Board member.

"The issues the state is facing are very complex. In the past our approach has focused on narrow pieces of the child and has failed to interconnect the multiple agencies and private providers that all have an impact on children and families," said Rosser. "The initiative's multidisciplinary approach, supported by rigorous academic research, will allow greater opportunity for successful outcomes."

Herk agrees. "Even if a child initially has only one problem in his or her life, that problem can ultimately affect the child along multiple dimensions - emotional, physical, educational and so on. Many of the children the state encounters are facing more than one issue in their lives. A multidisciplinary approach allows us to examine all effects more fully and view the child as a whole.

"In addition to our work with the Governor's Action Group, the Child Policy Initiative provides broad policy research that is relevant to the state," said Herk. "To improve outcomes for Georgia's children, we must look systematically at what has worked, what doesn't work and promising options for the future. We're looking at positive programs within Georgia and nationally at other models that hold promise for the state."

Monica Herk joined the Child Policy Initiative in November with nine years of child policy and advocacy experience in Georgia. Most recently she served as the executive director of Healthy Mothers, Healthy Babies of Georgia, a nonprofit organization devoted to promoting maternal and child health.

Networks for Rural Health a National Model

Rural Georgians want better access to insurance, physicians and other health care providers. GHPC's Networks for Rural Health has found that this population recognizes the linkages that exist among their health systems, health status and the economic viability of their communities, yet many fear their health care systems are crumbling.

Networks for Rural Health (NRH) was contracted by the state's Office of Rural Health Services to provide intensive technical assistance to Georgia communities with fragile health care systems. "With the first project we helped communities develop some great planning ideas, but they often lacked the resources to implement them," said Tina Anderson Smith, interim director for NRH.

So NRH began building relationships with foundations in Georgia that led to a new round of programs including the Access Georgia Rural Health Matching Grants Initiative, a partnership of the Philanthropic Collaborative for a Healthy Georgia and the Georgia Department of Community Health.
Access Georgia couples technical assistance with grants. In January, nine rural health care collaboratives serving 37 counties were awarded nearly $1.8 million by the Department of Community Health, the Robert Wood Johnson Foundation and the Philanthropic Collaborative to improve service access and eliminate health disparities in rural Georgia. NRH directs the initiative and provides a broad range of technical assistance to help ensure the grantees' success. "These collaboratives are community-based," said Anderson Smith, "and have expanded beyond health care providers to include local governments, business leaders, faith-based organizations and other civic groups."

In addition to working at the community level, NRH is advancing state-level initiatives that will build community capacity and strengthen rural Georgia's health care infrastructure. For instance, rural physicians are critical to successful collaborations, yet it has been difficult to get them involved. In response, the NRH is working with the Fanning Leadership Institute at the University of Georgia and all state medical schools to tap into this core of rural physician champions. NRH expects to launch the first "Rural Physician Leadership Institute" in the fall to grow this essential leadership base.

"Georgia has emerged as a leader in the community health system development arena because of investments that have been made to improve access to health care and health status throughout the state. State government, foundations, communities and the Georgia Health Policy Center at AYSPS have all made major investments, and the results are getting recognized," said Anderson Smith.

She said a lot of people are looking to Georgia to learn what to do. With the Community Health Systems Development Institute, "We are helping other states develop the infrastructure to do this work statewide, as we have done here." Its second annual conference is in June.

Karen Minyard in May agreed to serve as director of the Georgia Health Policy Center. She has worked for years with rural Georgia communities to help design systems that provide access to health care as private, state and federal revenue streams decrease. Tina Anderson Smith, rural health systems developer for the GHPC, travels the state helping rural communities assess systems, collect and evaluate data, plan and implement strategies for building viable local health systems and regional partnerships.

For more information go to the Georgia Health Policy Center, to Georgia Kids.com, and to the Networks for Rural Health.

Photos from top: 1) Monica Herk; 2) James Cooney; 3) Sally Rosser; 4) Karen Minyard, GHPC director, and Dean Bahl