The Adirondack Park in Upstate New York is a six million acre mountainous area that past generations of Americans had the foresight to limit from overdevelopment. However, the very conditions that maintain this wilderness have created a rural population that rely on service and public sector jobs, many of which are seasonal. The Adirondack Region Medical Home Pilot is an ‘experiment’ that began in January of 2010 to address the low numbers of physicians in the area, and the rising costs of healthcare. Through a series of interviews with those involved in the Pilot, both physicians and administrators, I learned about the changes of the Medical Home model and what it has done for the region’s health care system. Through interviews with seasonal workers and people involved in insurance policy, I learned of the challenges that remain in the area for seasonal workers to secure health insurance coverage.

The fact that many seasonal workers go without insurance or struggle to find coverage brings to light deficiencies in the traditional system of health care and health insurance, a system that is experiencing many changes. One change is the Adirondack Region Medical Home Pilot, which is working to reduce health care costs and establish a more productive system of health care delivery. While the Medical Home Pilot does not directly increase health care access for seasonal workers, it can benefit them indirectly because it is an important step in making health care in the Adirondack region more efficient and affordable.
A Medical Home is not a place, rather it is a model of health care geared specifically toward the patient that provides extra support when necessary and improves efficiency. Financially, a big change has been that insurance companies are paying health care providers an extra $7 each month for each insured patient at their practices. Deciding which patients are considered members of the Medical Home was a difficult back and forth process between the insurance companies and the health care providers, but it has gotten smoother during the two and a half years the Pilot has been running.1, 2 The extra money has funded the start up and/or improvement of care management and electronic medical records (EMR), and while the money is used in different ways in different practices, the same end goal is to provide better quality care, instead of the traditional goal of seeing as many patients as quickly as possible.3,4 This is a big change for the health care system because now it is a “pay for performance model” that insurance companies have agreed to instead of the traditional fee for service model, at least for the duration of the five year Pilot.4 More specifically, Dr. Alison Guile has found “a real change” to be the regular meetings of physicians in the community. Physicians and administrators from different practices now discuss how they want the Medical Home funds to be used and what they want to achieve as a group.5
The Medical Home Pilot began as a collaborative effort between three major health centers in the regionA, as well as their surrounding primary care practices, because they were all experiencing a sharp decline in primary care practitioners. Dr. John Rugge, one of the leading organizers of the Pilot, related that they wanted a model that would make physicians “feel rewarded and satisfied, not just financially” and he believes the Medical Home can draw and keep physicians in the area. Champlain Valley Physician’s Hospital (CVPH) President Stephens Mundy has attested that since the start of the Pilot he has seen better success at recruiting physicians, more physicians staying in the area, and more use of nurse practitioners and physician assistants. One physician currently has a medical student, who knew about the Pilot, shadowing at her practice.6 However, with the high ratio of patients to doctors in the region the efforts of the Pilot have only allowed Dr. Heidi Moore to see more patients and “drown a little less slowly”.
The results of the Pilot are ongoing, and while the jury may still be out on cost savings, there are indications of increased efficiency that could make health care more financially accessible. High users of the system, which drive up costs, receive more care management now, such as extra follow-up and referrals to people such as diabetic educators and nutritionists.2,3,4 Special focus has been made on recently discharged patients in an effort to reduce “preventable” readmissions, which are readmissions to the hospital within 30 days of discharge for the same condition. At CVPH, the preventable readmission rate has decreased from 15% in May 2011 to 7% in April 2012, suggesting a significant cost savings if each readmission runs around $10,000, which is a low-end estimate.4 Emergency Room (ER) visits are also beginning to decrease in some areas, and there has been a huge push to educate patients about appropriate use of the ER, and even call patients who have used it inappropriately.2,3,6 Moving forward the Medical Home administrators are trying to pool together the data collected during the Pilot to show the insurance companies the cost savings.4,2,7 Although the Pilot is a five year agreement, physicians and administrators are confident that insurance companies will continue to work with and fund the health care providers because it is in their “best interest to share savings, share information and encourage better models of care.” 2
Despite the advances in the Adirondacks with the implementation of the Medical Home Pilot, seasonal workers still have limited health insurance options. Erika Walker, a Community Health Advocate, receives calls from many seasonal workers and uninsured people, whom she helps to find low cost health insurance. Her position is not a result of the Pilot but was started with grant money from the Affordable Care Act (ACA), and she covers six counties in the region. Walker related that while seasonal workers can be on Medicaid or state programs in the off season, they often no longer qualify for these plans once they report income from a seasonal job. Other premium-based health insurances exist, such as Healthy NY and the NY State Bridge Program for pre-existing conditions, but these can be expensive with monthly premiums of at least $181 along with a deductible of $1200, which still represents a significant sum of money for someone working seasonally.8 Michelle Be, a young seasonal worker, said that it is “hard for us in the Adirondacks because our income varies so much from week to week, month to month, year to year” and explained that health insurance is simply something she cannot think about when she has a hard time paying rent. When available plans are unrealistic for somebody, Walker looks for health centers that offer discounted payment plans based on income, or even suggests individuals try to pay up front in cash at doctors offices and ask for the lower Medicaid rates. Finally there is buying directly from insurance companies. The individual market typically has higher cost and lower benefit plans, and at over $1000 a month, this is never an option for a seasonal worker.8,9
Additionally, employers of seasonal workers are faced with many reasons not to provide insurance. With the nature of seasonal work being short term and having high turnover rates, it is really not in the best interests of employers or insurance companies to offer plans. There is also lot of “unrealized expense” involved in taking people on and off a health insurance plan, and there is a potential for high use in a short period of time.9 David McKillip, Human Resources Director for ORDA, a large seasonal employer in the Adirondacks, said that as much as 75% of their employees during the peak season do not qualify for the health insurance, and that it would simply be too expensive to offer a seasonal health plan. Another potential concern for some employers is that some seasonal workers may have under the table jobs, and if they were to report all of their income, the burden of paying for health insurance might not be on the seasonal employer who does report earnings. For this and other cost reasons employers will limit the amount of time seasonal workers are hired so they do not qualify for health insurance.
The common financial decision of seasonal workers to forego health insurance brings up the question of accountability in the health care system. Michelle Be believes “insurance could be a great system if it was done with more concern for the individual’s financial cost/benefit” and feels that insurance companies unfairly profit off a contrived system. The current insurance options for seasonal workers are so limited that switching between low cost plans and Medicaid based on the time of year it is and varying income levels is almost like having another job.9,10 Mary Ilacqua, an older seasonal worker, only recently invested in Healthy NY after years without insurance. Clearly some sort of accountability is necessary because the uninsured are still treated in the ER. While some people see no way to cover the uninsured without a government mandate, others see a mandate as an attack on those individuals who already cannot afford insurance. Physicians in the area generally agree it is a tragedy people go without insurance in the U.S. because of cost, and believe people deserve at least some level of basic care.5,2,6,11 A fair amount of health care providers see a solution through the ACA, and while many believe a national approach is not the way to go, we certainly have a “national failure” of high cost and poor result health care.2 According to Dr. Rugge, “we have the least developed primary care system of any nation” and this emphasizes the unbalanced nature of a health care system that financially promotes physician specialization instead of more cost-effective and accessible primary care. It is difficult to say who should be accountable for our country’s uninsured, because as the case of seasonal workers shows, the traditional system of a year-round employer providing insurance coverage is not always adequate.
Any attempt at health care reform that could provide coverage to seasonal workers needs a highly efficient and cost effective health care system, which is what the Medical Home Pilot is beginning to establish in the Adirondacks. The Pilot has seen improved cost efficiency in areas such as ER visits and preventable readmissions, and while its changes have been gradual most health care professionals in the area believe it is a step in the right direction. Although paying for insurance is still the biggest obstacle to seasonal workers, the efforts of the Pilot can hopefully stop the decline of doctors in the area, because this is an obstacle to care for everyone. Unfortunately, under the traditional system of health insurance, seasonal workers do not work enough to get insurance through an employer, and they work too much to qualify for state programs. The United States health care system is currently an issue of serious debate, and the complexities of finding coverage for people who work seasonally hopefully will be not be forgotten.

References
1. Murphy, Megan. Grants and Strategic Planning Manager. Adirondack Medical Center. Saranac Lake, NY. Personal Interview. 1 June 2012.
2. Rugge, John, MD. Hudson Headwaters Health Network. Queensbury, NY. Personal Interview. 17 July 2012.
4. Ashline, Karen. Director of Medical Home. Champlain Valley Physician’s Hospital. Plattsburgh, NY. Personal Interview. 7 June 2012.
3. Taft, Hazel. Care Manager. Lake Placid Health Center. Lake Placid, NY. Personal Interview. 6 June 2012.
5. Guile, Alison, MD. Internist. Great North Woods Medical. Plattsburgh, NY. Personal Interview. 7 June 2012.
6. Moore, Heidi, MD. Pediatrician. Mountain View Pediatrics. Plattsburgh, NY. Personal Interview. 8 June 2012.
7. Mundy, Stephens. President and Chief Executive Officer. Champlain Valley Physician’s Hospital. Plattsburgh, NY. Personal Interview. 8 June 2012.
8. Walker, Erika. Community Health Advocate. Queensbury, NY. Personal Interview. 5 June 2012.
9. Biesemeyer, Tish. Partner and Health Insurance Broker. Burnham Benefit Advisors. Lake Placid, NY. Personal Interview. 8 June 2012.
10. Be, Michelle. Watershed Steward and Ski Instructor. Lake Placid, NY. Personal Interview. 11 June 2012.
11. Anderson, David, MD. Family Practitioner. Plattsburgh, NY. Personal Interview. 13 June 2012.
Ilacqua, Mary. Waitress and Ski Instructor. Jay, NY. Personal Interview 12 June 2012.
McKillip, David. Director of Human Resources. Olympic Regional Development Authority (ORDA). Lake Placid, NY. Personal Interview. 6 June 2012.
Riccio, Joseph. Director of Communication. Adirondack Medical Center. Saranac Lake, NY. Personal Interview. Personal Interview. 1 June 2012.
Riley-Clark, Alison, MSN RN. Lake Placid, NY. Personal Interview. 12 June 2012.

NOTE: The above is a list of all the people I formally interviewed for the project. Those not directly cited in the paper still contributed information that was valuable to me during my research. Additionally important are the views of several anonymous seasonal workers, which helped form my background information on their current situation, and which I was able to learn through my own experience as a seasonal worker ski instructing for the past two winters.