First National Conference on Primary Health Care Access (1st Plenary Panel, Part 3, Hullett)

Last Updated on April 16, 2022 by Lee Burnett, DO, FAAFP

The archiving and publishing of the  proceedings of the introductory remarks and the first two plenary sessions of the First National Conference on Primary Health Care Access (April 20, 1990) was made possible, in part, through the generous support of the Michigan State University/Sparrow Hospital Family Medicine Residency Program, Lansing.


Sandral Hullett, MD, MPH, Medical Director, West Alabama Health Services, Inc.

Sandral Hullett, MD, MPH; West Alabama Health Services, Selma [Dr Hullett is a Fellow of the Coastal Research Group.]   I work as a Health Services Director in a rural community in Alabama.  The community is called Eutaw, Alabama.

We have a unique problem in dealing with a situation where the service area is about 80% black, is rural, and extremely poor.  And we have many problems that impact on access to care.

The lack of facilities for care and lack of providers are both significant problems.  We have to deal with a low socio-economic population living in an are with poor transportation components.  It’s a real tall task to provide access to care in an area like this.

I am one of those people who Don Weaver was just talking about.  I was a National Health Service Corps provider.  I came there 11 years ago, at the same site where I am now, to fulfill a two-year Corps obligation.  I served the two years obligation and volunteered two years after that.  So I was in the Corps for a total of four years.  I have remained there.

Alabama’s “black belt” counties with high proportions of African-Americans; Eutaw is in Greene County near the Western border; map prepard by the University of Alabama

I have continued to be interested in the concerns of people who need care and in the delivery of rural health care.  This has made me become more interested in program planning and policies; and I have a public health degree in Public Health Policy.  I see patients about 50% of the time now because West Alabama Health Services has grown significantly as I will show a little later.

I came to a site that was a two physician site and a satellite was started in 1979, the same year I got there.  We now have a total of six sites, five satellites, 15 full-time physicians and over 150 employees dealing specifically with the health service component.  So we have grown.  And part of what we have tried to do is to look at new and different ways of delivery and accessing care for the people in our area.

Bill Burnett asked me briefly to talk about the use of a health maintenance organization for Medicaid patients which we created and operated as part of the Robert Wood Johnson Foundation program on prepaid managed care for a couple of years.

We were one of the 13 organizations who received a Community Partnership grant from the Robert Wood Johnson Foundation.  We were to develop a rural health HMO that was primarily supported by Medicaid.  And that was a tall, difficult task.

I want to share with you what our goals and objectives were, the patient population demographics that we had to work with, some of our strengths and weaknesses, our enrollment and utilization, and then some of the conclusions that we found in working with this particular program.

The first question is, why would poor people even look at an HMO?  This is a volunteer HMO which has a lot of problems that we might talk about later.  But the objective of this HMO is to provide adequate health care to a low income, rural, Medicaid clientele and to simultaneously reduce the rate of increase of Alabama health costs.

Alabama has one of the lowest Medicaid reimbursement rates of any state in the union, including Mississippi, and we’re always fighting and trying to to be one step above Mississippi.    But we didn’t beat them when it comes to Medicaid reimbursement and we are really pretty pitiful.  Health care is not one one of our main interests in Alabama.  I hate to say that I think our main interest is highways.

We have a serious problem.  When you look at the state, it is a predominantly rural state.  It was once an industrial state in some respects but now it’s not.  We have one of the lowest property taxes in the nation and we have a very large amount of land and everything is in shambles.  Health care is not one of our emphases.  And especially health care for the underserved is not one of our emphases.

Table I compares the demographics for West Alabama Health Services fee-for-service patients with those who are enrolled in the HMO.

As you can see, we have a predominantly (75%) female population, who’s average age is exceptionally high compared to the average which you will find in most HMO’s, which does present problems.

Most HMO’s have younger people who are supposed to have less health problems, and whom you’re supposed to make some money off of.  We have a larger median age group than most.

The demographics of West Alabama Health Services, comparing those enrolled in HMO to all WAHS clientele

We also see that about 83% of the HMO clientele are separated, divorced, single, or widowed, and that falls in that female group and the average educational level is 7.8 years of school.  As we go on to Table II, we are going to see how the area served by West Alabama Health Services compares with the state.  You can see the state has come serious problems also, if you look at the per capita income, at the number of people receiving public assistance, and the health statistics for the state.

Our service area contains a very large number who are receiving public assistance, and the health statistics for the state.  Our service area contains a very large number who are receiving some type of public assistance.  The poverty level there is very, very high.  We also have a large number of babies who are born to women that are not married and who also have a high teen pregnancy rate.  Alabama as a state has also one of the highest teen pregnancy rates in the nation.  The infant mortality rate is a little bit higher than that.

Our HMO is called the West Alabama Health Plan.  Again, it’s a volunteer program and it’s an open panel, independent practice type HMO.

The demographics of the West Alabama Health Services

The state Medicaid program provides for 30 services, and we had to come up with some things that would make people look at us; because we have in our own community a very large number of people who are on Medicaid and who do not want to give up any of those privileges.  Our “carrots” are services provided HMO members which are not covered by Alabama’s Medicaid program:

  • (a) preventive medical and dental care,
  • (b) unlimited physician visits,
  • (c) transportation for medical and dental services, and
  • (d) 24-hour health consultation by telephone.

These “carrots” may not look like a lot but to many of our people they’re quite a bit.  The patients were particularly attracted by the privilege of unlimited physician visits for the HMO members.  We have no limit on how many visits they complete.  And they liked having access to transportation, which is a significant problem in our area, and preventive dental services.

We feel that there are strengths are in the program.  Primarily, our patients have a high patient satisfaction and that means that they don’t move around a lot.  We do have a 60-day lock-in right now.  We would like to have a longer period of time, not so much that the patients are jumping in and out, but because of the fact that in the state each person’s eligibility for Medicaid is determined monthly.

The person, in 30 days period of time could be ineligible and go off the rolls; when you have to do all the paperwork, and then they com back, and so it’s a real problem.  We have good coordination of our expanded services, good patient-physician relationships, good preventive care programs with utilization improving.

One of the things that most HMO’s are supposed to do is have a good preventive program.  We had people who had 7th and 8th grade educations who had been accustomed to doing anything they wanted to do and they thought Medicaid would pay for it.  And then all of a sudden we got into offering health education, preventive services that people were not accustomed to, that they didn’t want, and that they didn’t accept initially.

We feel that prevention will cut down on the cost of health care, so that was a major focus of our program.  We have been in action now about four years, going on our fifth year, and we’re now finally beginning to make some headway in that respect with things like walking clubs and exercise groups.  The whole community is walking.  I find that very exciting.

We have a significant problem with hypertension, obesity, diabetes, infant mortality, and teenage pregnancy.  We have noted changes in all these particular areas, especially among the HMO group which we can verify, because it is a small group.

One of the weaknesses in the program is management information.  We worked on it, worked on it, and still are working on it.  The capitation rates are very low.  We are capitated by the State of Alabama and we’re at risk for everything, including hospitalization.  We have five counties involved and the capitation rate is different for each county because it’s based on the experience of the county.

The capitation rates go from $60 to $80 a person.  And remembering all the different things I said about the people, that’s really a relatively low rate considering all the things we have to deal with.  They want to give us 90% of that particular rate.  So we don’t get total cost.  The high number of members lost due to loss of eligibility, as I said before, and the high enrollment of older people, the need for more providers, and the distances that our patients have to travel for specialty services constitute real problems.

Table II looks at hospital stays and shows that for our patients, most of the hospital utilization occurs in the group under 65.  The length of stay is about four days which is really not that bad, even over four days.

A graphical comparison of utilization rates

Interestingly enough, the older population – you would think that the stay of the older people would be longer and then you would have a higher utilization of hospitalization of the older group – but we do not have that.

If we look at our total enrollment, we see that we have about 2000 people under 65 right now.  The enrollment fluctuates.  The highest number that we have ever had is about 5000 people.  This is a small group, but you have to look at the fact that we cover an area of 4000 square miles with an average of 20 persons per square mile.  It’s a very sparsely populated area.

We have to remember that a Medicaid population is not homogeneous.  We like to think it is.  And if you think it is and if you approach it with that respect, you’re going to have serious problems in delivering care.  Self-selection is a real problem when you have a volunteer program.

There has to be some way to encourage people to join the plan, so – we market.  You have to look at your marketing.  You have to be competitive with the private practice people.  If you don’t have different things to make it attractive, then we will continue to lag behind the traditional fee-for-service type situation.

And then, finally, if we have some any regulations that are applied to us by the Medicaid people that make it very difficult to deliver this type of program, it won’t succeed.  And if Medicaid does not make it any different, if they don’t help us make a program like this attractive, it won’t succeed.

I’ll state this here now that to allow the fee-for-service group that it has to operate under more stringent rules to control the cost of care is going to make it very difficult for a program like this to succeed.  The Medicaid agency as a whole for the state has to be told about he advantage of a program like this.

Now this is a model program.  It’s the only one in the state.  The state is about to expand it but it’s still not making the commitment needed to make it work over the long term.  Why has this one worked as well as it has?  Because the West Alabama Health Services is basically a community health center that has the philosophies already intact of serving the underserved as its cause.

Cause has always been a part of what we had to do because of our regular federal mandates.  So promoting the cause and delivering care to the underserved had made it easier for us to do this.  But if a group does not have these principles, then it would be very, very difficult to make a Medicaid HMO work.


Dr Hullett’s presentation was preceded by: First National Conference on Primary Health Care Access (1st Plenary Panel, Part 2, Weaver)

Dr Hullett’s presentation was followed by: First National Conference on Primary Health Care Access (1st Plenary Panel, Part 4, Rodos)

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