Will President-elect Barack Obama be a plus or a minus for rural healthcare?

Medical economist and healthcare "futurist" Jeff Bauer says it's hard to say because the president-elect and product of Chicago doesn't have a history on the issue in his few years in the U.S. Senate.

"I'm not aware that Barack Obama brings any particular expertise or personal ties to rural health with him to the White House. Nothing about Obama tells me anything about what his policies towards rural health will be. He has simply not been seen as a leader in that area like (Sen.) Max Baucus (D-MT)," says Bauer, a consultant and futures practice leader for ACS Healthcare Solutions. "There are a number of members of Congress, you tell me their names and I know where they're going. I know their policies on rural health clinics or money for critical-access hospitals. Obama doesn't bring that level of identification with any rural healthcare policy."

That's not necessarily a bad thing. It's just an unknown. It's not like the president-elect will be "anti-rural health." But the emphasis on funding public health policy in tight budget years might be shifted to other areas, like increasing physician reimbursements or expanding medical schools, rather than specifically toward rural health.

Rather than guessing the future actions of a president-elect with no discernable track record in the area of rural health, Bauer says Obama's possible actions in the rural health arena can be more accurately predicted by examining the people he appoints to key public health positions. "I'm a firm believer that people make as much of a difference as budgets and policies. I'm hearing names of people with strong commitments to HHS and CMS, where the future of rural healthcare will be very much decided," Bauer says.

There have been widespread media reports that former U.S. Sen. Tom Daschle of South Dakota has been leading the Obama transition team's healthcare policy component and will likely be offered a key appointment. There is even talk in some circles of making the former Senate majority leader a "healthcare czar," although it's not really clear what that means. At deadline for this column, high ranking Democrats were saying Daschle had been tapped to lead HHS.

"Barack Obama is going to turn to Tom Daschle for something very significant, whether it's HHS or secretary of education," Bauer says. "If it's Daschle, he authored many of the bills that gave money to rural hospitals and clinics, and he is a pro-rural as they come."

Rural healthcare can also expect continued backing from the powerful Senate Finance Committee chaired by Baucus with ranking member Chuck Grassley, R-IA.

Rural health will need all the friends it can get, Bauer says, because the biggest factor will not be who's in the White House, but the state of the economy. Federal tax dollars will be scarce at least for the next year or two, and the fight for funding is expected to be fierce. "This issue will always come back to the economy and whether there is money to maintain critical-access programs or money to get serious about supporting information infrastructure technology development," Bauer says. "That is going to be really tough in the current budget environment."

Satisfying your customers' and members' needs could be the difference between succeeding in these belt-tightening times or watching your employer market evaporate. It will take more than a flashy marketing campaign to win over employers who are focused on the bottom line and reducing contracts.

Employers want simplicity—and that means bringing services such as disease management, wellness, pharmacy benefit management, and dental in-house. This one-stop solution is a way health plans can set themselves apart from the competition, allowing employers to deal with fewer health companies, and reducing member confusion.

Coordinating services was why Capital BlueCross in Harrisburg, PA, recently bought Dominion Dental Services, a privately held corporation with 400,000 members that is based in Alexandria, VA. Capital offers health benefits to nearly one million people in 21 counties in central Pennsylvania and the Lehigh Valley and is one of four Blues operating in the Keystone State. Once the sale is finalized, Capital will become the only Blue-branded dental plan in central Pennsylvania. Dominion will provide the back office work for BlueCross Dental, such as processing claims, while Capital will brand the dental program with its marketing. (Dominion will continue to provide services to its Mid-Atlantic members in Maryland, Delaware, Virginia, and Washington, DC.)

Sandra Neydl, manager of product implementation for Capital BlueCross, says the purchase of Dominion broadens Capital's portfolio as well as offers administration simplicities and efficiencies to its customers.

Why would a health insurer want to get involved in dental insurance?

Robert Zirkelbach, director of strategic communications at America's Health Insurance Plans, says customers are increasingly demanding dental coverage and health insurers see a connection between oral health and other conditions, including diabetes and cardiovascular disease, he says. There are two others reasons:

• Dental insurance gives health insurers a more predictable offering and lower risk than medical. Dieter Freer, divisional senior vice president for local and consumer markets at Blue Cross and Blue Shield of Illinois in Chicago, says the most costly dental procedure palls in comparison to costs associated with normal medical procedures and hospitalizations. Plus, many health plans have a fairly low cap on dental benefits.
• Bringing dental services in-house allows insurers to have a more rounded view of their individual members. Freer says BCBS of IL integrated medical and dental data in January, which allows the insurer to take a more holistic approach to its members. Through this integrated system, BCBS of IL is able to reach out to members who are at-risk of conditions that could be complicated by dental diseases. The insurer can contact those members and make sure they are getting treatment in the right setting before health issues arise. This leads to better quality of life for its members, he adds.

There is an initial downside. Health plans that offer dental coverage will need to hire new staff with a dental background. "If you are going to be successful in the dental business, you are going to need an entire group of individuals focused solely on dental benefits," says Freer of BCBS of IL, which began offering dental benefits in 1975 and now provides dental PPOs and HMOs to more than one million members.

Adding dental is particularly important for Capital. Two Blues plans in Pennsylvania, Independence Blue Cross and Highmark, have proposed a merger that would create a giant health plan that would stretch across most of the state. The state is expected to decide on the merger in the first quarter of 2009.

Neydl says the Dominion purchase is not in response to the proposed merger. Regardless of the reason, dental does make Capital a more appealing option for potential customers and a way to compete against larger health plans.

Streamlining processes and communications for employers is a way to stay competitive in a shrinking employer market. As health plans forge ahead in a rough economy, they should explore moving services in-house. Bringing in dental coverage in-house will mean adding staff, but dental will produce a steady stream of money and allow your company to have a more rounded view of members.

Employees at Ohio-based MetroHealth System have found out that their numbers will be reduced by 112 to break even financially next year. The job eliminations are primarily in unfilled positions, but about 25 employees will be laid off effective the first of December. The layoffs and job eliminations are expected to save the hospital about $6 million in 2009.