Always a hot topic, healthcare is expected to continue being a controversial issue. Between healthcare reform legislation and the poor economy, many in the healthcare industry find themselves caught in the middle, wondering what the future holds. Recently, executives representing this changing industry met at Holland & Hart’s Las Vegas office to discuss the trends and challenges they expect to see in the future.
Connie Brennan, publisher of Nevada Business Magazine, served as moderator for the event. These monthly meetings are designed to bring leaders together to discuss issues pertinent to their industries. Following is a condensed version of the roundtable discussion.
How has federal funding affected healthcare?
Larry Matheis, Nevada State Medical Association: I point out to physicians the crisis precedes the legislative session and starts in Washington. Congress made a mistake in the law, and since 2002 we’ve gone through an annual ritual of Congress having to do a one-year patch [Medicare], because each time they’ve been unwilling to pay to change the law, to fix the law, and it has a formula that’s simply crazy. It starts with the federal government. After all, the Medicare program is the largest coverage program in the history of the world. It is a huge undertaking, and it is unsustainable because right now they haven’t been able to adequately fund it with the promises they’ve made. Right now, 12 percent of doctors in this state have given up Medicare this year. So doctors have begun to re-look at whether or not they can afford to stay in the Medicare program for the first time since I’ve been around.
Dr. Sherif Abdou, Healthcare Partners of Nevada: Maybe they should. Maybe it’s a good thing for everybody to wake up and say, the current system is not only not working, but it’s not stable. The only disagreement I have with the statement made is that I don’t think there is inadequate funding. There’s plenty of money. If anybody thinks or says that there isn’t enough money in healthcare or being spent on healthcare today, it’s [because] the spending is in the wrong place, it’s misaligned, it’s a lot of waste, a lot of fraud. The reality is we, the doctors, who are complaining today about the 21 percent cut, have not risen up, taken the responsibility and said there is a lot of unnecessary stuff going on here.
Matheis: I think it’s a misalignment of priorities. Congress creates the priorities of what the system is intended to cover and then they fail to adequately fund those priorities. Instead, they shift it to other priorites and we’re stuck with those.
Dr. Jack Ruckdeschel, Nevada Cancer Institute: I don’t think the feds have set any priorities for it. I think physicians have responded in the workplace to something that most people find, that primary care is consummately boring as a specialty and the specialties are better reimbursed. They’re not so much better reimbursed as a Medicare policy because throughout the system we reimburse procedures rather than overall care of the patient. I don’t think Medicare has set those policies and procedures.
Matheis: Medicare did.
Abdou: Medicare is the largest payer. You’re both right. There is misdirection of the funding and funding had driven the outcome. Unfortunately, the industry, healthcare, is financially driven. My point is, there is so much money. It’s misdirected and that’s where we are today.
Charles Perry, Nevada Healthcare Association: I don’t believe it’s Congress that directs it anymore. There’s not enough people in Congress that understand the system and the problems that they’ve created, much less figuring out a way to know how to solve them. They’ve shifted that responsibility over to the bureaucracy, principally the people in the centers for Medicare and Medicaid services. So Congress essentially is just reacting to what’s taken to them by the bureaucracy.
Kara Jenkins, Access to Healthcare Network: I have no input on the reimbursement rate in terms of a physician’s perspective because I’m not a physician. I can say that since we’ve launched Access to Healthcare Network in the South, we have successfully been recruiting doctors who have been more than happy to take cash at the time of service for vastly reduced rates for our low-income population. [The doctors] have said to me, this is better than my reimbursement rate from Medicare or Medicaid. They agree to reduced rates, at the same time they know that our members are coming ready to pay for the service.
Dr. Michael Crovetti, Crovetti Orthopedics and Sports Medicine: One of the problems with Medicare is that you take reimbursement away from physicians, but you don’t regulate any of their activity, really, in terms of whether we pass or perform procedures. Medicare was going to cut physician’s reimbursement 21 percent. What’s the surgeon going to do? How’s he going to respond? He’s going to do more surgery, more procedures and more cases.
Ruckdeschel: It wasn’t Medicare that told the State of Nevada to stop funding medical education for the last two or three decades. That’s what impacts us here on a regular basis. The absence of well-trained specialists who keep feeding each other back and forth in terms of pushing each other. They drive the practitioners in an area to a higher standard because their competing and, in turn, the medical schools are pushed. We don’t have any of that.
What is holding Nevada back in regards to healthcare education?
Matheis: It’s not been a priority. But the priority in any state isn’t just at the grassroots; it isn’t just at the community level. It’s got to be shared and validated by the leadership of the state. The state didn’t decide to have a school of medicine. Howard Hughes decided to have a school of medicine. He completely funded its creation because he wanted doctors trained in the state. So even at the beginning it wasn’t a commitment by the leadership of our community, or state that we need to have a medical school here, it was the largesse, and it was a bag of money from one of the most prominent characters.
Ruckdeschel: I think if you peel away the fundamentals of why we struggle in this Valley, it has to do with the chronic, almost criminal underfunding of the state’s only medical school for all these years. So absent a solid medical school and absent fellowship programs, we don’t get people who have the latest and best training settling in this area. Most fellows settle where they do their training. So everybody just goes out and sort of does their thing, and I think that’s a gaping hole in the center of the medical community we have here.
Crovetti: I couldn’t agree more on the status of fellowship programs in education. It seems that people relocate and move, become part of a community that is supported by education in our school and our healthcare. We’re sitting here in an economy that obviously has lived on its gaming for many years. We saw an amazing 2000’s with the growth in the home market providing jobs and people coming to Nevada. We missed a tremendous opportunity to be a great healthcare community when all of those people and money were coming here because the money wasn’t allotted properly into our medical schools and fellowship programs.
Abdou: It’s a leadership issue. The focus of the leadership in Nevada has always been in the gaming industry. It is a chronic problem here and we have to face it. We’re either going to have to live with it and say, this is Vegas, take it or leave it. Otherwise, we’re going to have to change it so that the most important people are not Steve Wynn, they are the people who are delivering education and healthcare and whatever. To the government, Steve Wynn and these guys are the most important people.
Has the quality of physicians here improved over the last several years?
Kimball Anderson, Southern Hills Hospital/HCA Healthcare: I think so. I think some of the best physicians I’ve ever worked with I’ve met here in Las Vegas. It’s true they’re trained somewhere else, usually, but I think the recent economic downturn is a wake-up call that the economy needs to be diversified here, and I hope that healthcare is a part of that diversification. I believe there is a nucleus here of well-trained physicians that can make a difference, working in concert with all settings of healthcare. We can make a difference and have a positive influence on the future of healthcare in Nevada.
Ruckdeschel: I challenge the view that the quality of physicians here is great. I think they’re good, there’s some good guys in town, there’s a few great people in town, but bottom line, it’s pretty mediocre and you cannot find a lot of high-end procedures, which is why anybody with the resources goes to McCarran and gets out of town. That’s a bad joke, but it’s reality.
Perry: I think you’re all right to a fairly large extent. I’ve been here almost 40 years. Quality of healthcare has improved over the period of time that I’ve been here because back in those days it was absolutely true, you didn’t get good healthcare unless you went to McCarran. However, we’ve had all of this growth and brought in some really good folks and places like the Lou Ruvo Center, the Cleveland Clinic and Dr. Crovetti and his group.
How do we change the culture in Nevada to improve healthcare and healthcare education?
James Kilber, Comprehensive Cancer Centers of Nevada: I am hearing numerous complaints with what is wrong with the healthcare system but no solutions. I believe that physician practices need to work as partners with the insurance companies. In the past, it has been who can fight for the best rate; physician versus insurance company. Physicians need to be accountable, insurance companies need to be accountable therefore, joining, and ACO (Accountable Care Organization) to improve the Healthcare is part of the answer. Being accountable to the patients.
Crovetti: I think if we’re going to rebuild, we’ve got to attract people with great healthcare. In 2005 I opened the Medical Education and Research Institute in Nevada, but we were thwarted by the crisis in the surgical centers. And then of course we have a medical school trying to grow at the same time. So how do we get that great reputation moving? I think we do it through education. We do it through the fellowship programs. We keep great doctors here.
Perry: I don’t know how you change the culture. One of the reasons I decided to run for the legislature was because it occurred to me that there just wasn’t anybody in the legislature that knew anything about healthcare.
Jenkins: One of the things we’re trying to do with our members, who are low income, is change the paradigm of healthcare [for those] who don’t have a lot of money. It’s a shared responsibility model where it’s not an entitlement program, that’s why Washington loves it. The Republicans love it because they have to pay a membership fee, kind of like a Costco card, to get into our program so they can access our network. The Democrats love it because it’s direct service to a population in need.
Matheis: I am seeing a culture shift. I think there are more and more discussions like this on every aspect of healthcare going on and there’s discontent with the status quo. As we make more and more efforts to address aspects of what’s not as good as it should be in the Nevada healthcare system, eventually you do have a cultural shift, you do have a paradigm change, and then the leadership of the state will begin to also participate in that change. They’re not where we turn first, but at some point they must embrace the cultural changes.
Abdou: We sit here and we think the leadership in this state, the government and Medicare did this and Medicaid did that. We must get involved, take responsibility and step up and say, we’re going to fix it. Not them up in Carson City or our government or the Medicare program. We do the same thing that poor people are doing, we’re not taking responsibility for the integration and delivery of healthcare.
Are we still seeing the staffing issues that were so prevalent a few years ago?
Doug Geinzer, Southern Nevada Medical Industry Coalition: We still have the lowest healthcare population ratios in the country. That hasn’t changed. I don’t think Nevada planned for the growth that we’ve experienced in the last 20 years. We’ve never had that strategic plan to handle staffing. We were just awarded a grant from Health and Human Services to look at a ten-year staffing model, a workforce development plan for Nevada in order to take a look at where we are today and what it will require to grow our healthcare professional workforce by 10 to 25 percent. It is important to be sustainable. We need to have the educational infrastructure to be able to produce our own healthcare providers.
Ruckdeschel: Finding oncology skilled nurses is very difficult in the Valley, finding a lab tech is very difficult. We don’t have a pharmaceutical industry or any other group that we can go to. We don’t have a university with a bunch of laboratories that can move people around. We obtained a recovery act grant with College of Southern Nevada and the Nevada workforce. We’re going into our second year of, mostly women, who have just completed their training in nursing. We get them a year of oncology training that’s paid for so they can become certified in that area.
Anderson: The economy has had a lot to do with staffing. We don’t feel the real acute [shortage] of qualified nurses for instance, because a lot of them have returned to the workforce out of economic necessity, whereas before many of them were second-income earners. The economy has given us a brief window of a little bit of space, of relief from the stress that was on the staffing before, but I think that will quickly return as the economy rebounds.