Nevada’s healthcare industry continues to see an increasing number of challenges. With the rollout of the Affordable Care Act (ACA) and the ongoing issue of physician and specialist shortages, healthcare executives in the Silver State are working to adapt while ensuring quality care for their fellow Nevadans. A group of Nevada’s healthcare leaders recently met at the offices of Gordon Silver to discuss the trends and obstacles facing their industry.
Connie Brennan, publisher and CEO of Nevada Business Magazine, served as moderator for the event. These monthly roundtables are designed to bring together leaders to discuss issues relevant to their industries. Following is a condensed version of the roundtable discussion.
What are the greatest challenges in healthcare?
RANDAL SHELIN: Our industry brings to mind the expressio, “how to do more with less.” Unfortunately, that is more appropriate now than ever before. Everyone in healthcare needs to work collaboratively to find efficient healthcare delivery systems that let us stretch those limited healthcare dollars and provide necessary services for our citizens.
SUSAN REISINGER: There’s not a day that goes by where I don’t see delay of treatment because of uninsured patients. A really big challenge is to educate people on what they need to do now that the ACA is here.
DON GIANCURSIO: The sustainability and the consequences of how the ACA is being funded in terms of cuts to Medicare, the cost that gets passed onto consumers and the impact on job creation. All of those things together are going to be consequences that we’re going to start to see and deal with in 2014.
PUNEET GARG: The further implementation and adoption of the Accountable Care Organizations (ACO) model, seeking to cut costs and focus more on quality metrics. Challenges we face in further implementation of that model are physician integration, data integration and sharing risks amongst the various entities, information mobility and security and how to properly leverage lower level personnel and the technology to achieve comparable quality.
M. DONALD KOWITZ: The industry sees the needs to change the delivery system and to make use of every dollar in the most efficient and quality-effective way. Also, there’s so much information out there for healthcare consumers that is confusing and inaccurate, which causes people to make decision that may not be the right ones.
ROD WOODBURY: In public health we are facing the economic challenges just like everybody else. The ACA is something that we are grappling with trying to figure out the uncertainties that come with it and how that impacts public health. Looking to the future, how can we better partner with other medical providers for medical resources that they may not have.
SHERIF ABDOU: The challenge that we’re facing is rather simple but monumental: to repurpose our moral directions to serve as a patient care industry. The system that we built does not have the patient in it; it’s not about what’s best for the patients. It’s what’s best economically for the orthopedic surgeons or for the publicly-accredited large medical group, etc. The system that we need is about whether it’s good for the patient or not. That should be the first question that we answer.
What’s the status of the aca at this point?
KOWITZ: It’s not like we missed the enrollment projections by 10 to 15 percent; we missed it by 60 to 80 percent. Every week there are improvements but every time we move past those initial problems there’s a whole different series of problems. There’s a task force that the governor has organized that meets three times a week, and it does make incremental changes but it’s still been very disappointing how the rollout occurred.
REISINGER: I have some patients that are very smart that just don’t have health insurance. They don’t understand the need for it until they get sick. It really comes down to education.
GIANCURSIO: The carriers have given the Exchange leadership ideas and direction and suggestions on how to do this as efficiently as possible. Where we are today is not where we need to be. It’s very frustrating. The resources necessary to develop new products, to reconfigure sytems, to be prepared, to handle the onslaught of enrollment just isn’t there. There has to be a more efficient way to do it than the current model; what we’re doing right now is archaic. At the heart of it, we’re trying to get people covered who are eligible and it’s frustrating that we can’t. We’re going to continue working as hard as we have to work, but it’s just disappointing. I have to believe that this time next year we will have had a better result because they will have had enough time to figure out how to do the basic electronic data transfer that we had expected.
KEITH BRILL: Half the country and a lot of the media is opposed to anything that has to do with ObamaCare, even the media that might be more left leaning. There are businessmen and state policymakers trying to work on this but you have the media constantly talking about the negatives of it. The reality is people still think this may not happen yet or it’s not worth their time at this point.
SHELIN: The ACA is bringing back fundamental changes, which probably would have happened with market forces anyway. In the past, we worked with pay-for-volume where providers got paid for each study or test we did. We’re changing that paradigm to pay-for-value or quality and, ultimately, that’s the right decision for the country and we’re moving towards the right direction. As we build these systems to better integrate our delivery system and to become more efficient and better quality, it’s a win for the patient because you can reduce the redundancies and the costs. Ultimately, I think it will prove to be a positive for the country but it will be a very disruptive and difficult process to get there.
How is the quality of healthcare in the Silver State?
ABDOU: The Commonwealth Fund ranks Nevada at 42nd and United Health Foundation ranks us at 46th for quality of healthcare. There’s mediocrity and accepting of mediocrity is hardwired for healthcare in Nevada and we need to grow our way out of this. Patients, doctors, nurses, systems – we settle, we accept and we make a lot of money from mediocrity. We need to change that.
SHELIN: The basic fundamental tools for quality care are here. We’ve got phenomenal physicians successfully recruiting doctors coming out of Duke, John Hopkins, Stanford – these are doctors that can go anywhere in the country but they choose to come to Nevada to practice. Ultimately, it’s how we build the relationships because we can provide great care but it’s how we coordinate the care between the general practitioners and specialists and how that care is delivered.
BRILL: The overall question for quality of care is difficult. There are a lot of excellent doctors here but it takes a certain volume of doctors providing quality care to bring more doctors here. Doctors typically stay where they train and we don’t have a lot of specialty programs. Even those we do have are not going to meet the needs of our state. We need to really focus on the quality of care we already do have.
How severe is the shortage of care providers?
ROBERT FREYMULLER: The shortage will be exacerbated by our success with the ACA. If you enroll 200,000 people in Medicaid, much less private insurance products, there’s not going to be a primary care delivery system to accommodate those patients.
ABDOU: A lot of the shortage is self-induced. If you change the economics, there will be a 20 to 30 percent drop in volume, not in new patients, but in repeat visits. Doctors who have financial incentives in tests are 12 times more likely to order the tests for the same diagnosis than it is for the other group that doesn’t have the financial motive. The economics have impacted our actions for a very long period of time and we have taken it for granted.
SHELIN: One reason for the loss of attrition is the spouses. If they’re not happy then the doctors aren’t happy. We encourage the spouses to come in during the interview process because the last thing we want to do is go through the expense and effort only to have them not be happy and leave. Usually they’ll come here because it’s a good economic opportunity, but then after a while it’s the quality of life that the spouse doesn’t like. But we’re building a better sense of community than we’ve had in the past. We’ve been such a transient city for years and years that now we’re finally becoming a more stable community where people stay here and call it home.
FREYMULLER: [It’s] not just quality of life, but also spousal employment. Our robust business climate where there are spousal employment opportunities as we diversify and grow will be key, along with education for the families.
BRILL: Even at the physician level deciding where you’re going to practice, everything is at the personal level. If you’re not from there or train there, you need to know someone there. Once you get a critical mass of doctors from outside our community, people start to talk. It’s just going to take time for us to build up good doctors from outside the community who will then go talk to their graduating residents to come here.
Has a shift in who delivers patient care Affected perception of the industry?
ERIC OLSEN: Most patients want to see the doctor, not the physician assistant (PA) or nurse practitioner (NP). That’s changing. With the economics, you have to have more PAs and more NPs.
ABDOU: The first mission is the bridge between expectations and reality. What we didn’t do well with the system integration is we didn’t set the expectations for the patient. If you go to hospital committees, they would say to never let the nurse practitioners see the patient because they are lower level. We have built the expectation that seeing the nurse practitioner is a lower level and if you allow patients to be seen by NPs then you’re a bad hospital, medical group, etc., which is not true.
GIANCURSIO: You’re going to have supply and demand constraints. As more people come into the system, if we were hugely successful with Medicaid expansion and the individual exchange, you’re going to put almost 600,000 people in the healthcare system and they’re going to want to see somebody. If an individual has a routine type of care they may be totally fine seeing the PA because they want the easiest and quickest way to get care.
ANDREW CASH: It’s a paradigm shift in the patient’s expectations and perceptions. It’s going to take time and it’s going to be a one-on-one basis as they individually show up to a clinic or hospital and learn what the new expectations are.
BRILL: Clark County Medical Society and Nevada State Medical Association testified saying expanding the roles of NPs is great and it’s what our state needs to expand a team-based approach for collaboration and to allow more access in rural areas. But our state has decided that’s not true, which is a big concern. They’re still defining at the Board of Nursing what the scope of practice is for a nurse practitioner. A lot of the language of the law is still saying you should not have a collaboration. For quality care, physician providers and leadership need to make sure everyone is on a team.
Will individual medical groups survive these changes?
Cash: Private practice primary care doctors are bountiful but quickly diminishing. I don’t think they’ll be here in five years, they just can’t compete.
Abdou: Neither should they. They have saturated the fragmented, dysfunctional system. If you create a system you can hold it accountable, you can measure it. Big metropolitan areas should be dominated by systems. Hospitals should be included in that, integrated with physician groups and others. That system needs to start developing and building. All of the quality data, especially surgical data, is related to a lone practice in one place with the same team for a long period of time. They will produce a better outcome.
What is the future of healthcare?
GIANCURSIO: The healthcare consumer in 10 years is going to be different than the healthcare consumer we’re talking about today. They’re going to be more tech-savvy and technology is going to be more a part of the healthcare delivery system, whether it’s tele-health, tele-medicine, electronic medical records, etc. Education is going to be critical and people’s expectations are going to be different.
SHELIN: The economics are we’re going to have physician extenders. By using technology and leveraging that, we can help them do better jobs as well. We can help the physician extenders do the right thing for our patients the first time. They’re there and we’re going to have to integrate them into our system and make sure we guide them to use the technological services properly.
FREYMULLER: Coordination of care is synonymous with quality of care. If you’re part of a system with a robust IT platform, if the health insurance exchanges come together where the primary care and specialists are getting alerts so they can take preemptive or proactive action with patients, that’s where it’s going to pull together and the quality will come from that.