Nevada’s healthcare industry strives to focus on high quality care while searching for ways to lower costs for patients. A group of Nevada’s healthcare leaders recently met at the offices of City National Bank to discuss the trends and challenges 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.
How does Nevada Rate in quality of healthcare?
Kimball Anderson: For those of us that are providers and deliverers of care, we think that doing the right procedure and seeing the right patient at the right time is quality. We’re all being forced to change our focus. What we forget is, what is the patient’s experience and impression of the service they received? I always try to have the hospital I’m at run more like a hotel from a service orientation perspective. It saddens me that we have gotten away with bad manners when it comes to dealing with our patients.
Lee Pullan: In business we try and deliver a high quality customer service model by matching our channel of distribution to our desired customer service model. If these don’t match, we either have an unhappy customer or an expensive, burdensome channel of distribution. Waiting two months to see a specialist only to have to wait another two months to schedule an MRI isn’t the best customer service model.
Bard Coats: I see three domains. The first is patient experience. The second, which we work hard on, is metrics. The third is something I don’t think any of us do well and that’s outcome-based quality.
Pamela Egan: It’s about prioritizing resources. We’re all so focused on the business of healthcare delivery that we’ve created a certain complexity that makes it difficult to coordinate and improve patient experience. It becomes all about systems and dollars and contracts, which often can detract from the delivery of healthcare.
Mason Van Houweling: Extraordinary things happen every day. We just need to do a better job, collectively, telling all those stories about the great healthcare that’s delivered here.
David Steinberg: The problem is that quality depends on what you’re looking at. If you’re apatient, quality may be how quickly you see a doctor, how clean the office is or how nice the reception is. When you have a problem, it could be how quickly you get a mammogram. On the other hand, that’s a Healthcare Effectiveness Data and Information Set (HEDIS) requirement. Yet there’s not a HEDIS requirement on how quickly breast cancer gets treated. Are we really looking at the right quality measures? We do more MRI and CT scans in America than any other country but there’s no measures that show that anything we do with those scans have any health benefits. The million dollar question is, are we really changing patient outcomes?
Coats: HEDIS has pretty standardized measures now across the country so you can plug in those numbers and they primarily measure access to preventative care, screening tests, et cetera. They’re extremely valuable, but all of a sudden you have to prove you’re hitting those numbers. If you don’t, you either lose money or you get dinged in your commercial population.
Andrew Eisen: Another step in terms of measuring outcomes that’s really challenging is being able to track individual patients over a long period of time. If you can’t track an individual patient, you can’t track what kind of outcomes there have been. It really has to be built on the outpatient side and on the concept that each patient has a medical home.
Egan: If we’re really going to move the needle there has to be a fundamental change in how the system ends up being structured. That’s really tough with all of these various factors. The federal government has a lot of ideas and a lot of initiatives with regards to making it a more value-based system but really the end goal is that coordination that allows us to help the population.
Mike Murphy: Technology’s come a long way, but it’s still very fragmented. There still is no efficient way to transfer or streamline data so everyone gets the whole picture to manage a patient. Simplifying the system is important because at the center of it is the patient. The patient has to understand how to interact with their physician and the medical community to try and help the physician be effective in treating them.
How has the ACA affected Emergency Room traffic?
Robert Freymuller: With the expansion we’ve experienced a significant increase of traffic to the ER; it’s people wanting access immediately even if it’s for the annual cold. They’re frustrated with trying to navigate the system to begin with, so they use the ER as a primary care base, which is limited in its ability to impact care; it’s a really stressed resource. Capacity-wise, you’re seeing minor urgent care-type visits in a structure that’s really designed for acute, more serious injuries.
Van Houweling: I’m seeing things a bit differently post-ACA with UMC in particular. We’ve seen a decrease in our ER volumes. It could be because [patients] have access now and they’re going to other hospitals, but we’ve also seen an uptick in our quick care and primary care throughout the community. I hope they are seeking out the appropriate level of care but my gut feeling is that patients now have access to some kind of exchange or Medicaid product and are still seeking out the emergency department.
Murphy: There are more people with access to the system but when you look at the number of uninsured people in the state, it’s come down, but it hasn’t come down dramatically. Healthcare has been more in the forefront and there’s been productive discussion in the past few years. There still are those challenges such as the consequence of going to the wrong place. For instance, they don’t get as good of care if it’s episodic as opposed to seeing a primary care physician (PCP) who can track it from beginning to end. People don’t necessarily understand that.
Coats: It’s a huge proportion that ends up paying the Medicare rate at the ER that don’t need to be there.
Freymuller: The Affordable Care Act (ACA) is to provide people coverage under the assumption that you get care, but the care right now is delivered in the emergency room (ER) in an episodic fashion. We fixed the supply side and coverage but we didn’t fix the delivery system in terms of primary care so you’re really not getting that solid case management.
Murphy: One issue is the patient’s ability to identify whether something is an emergency or not and where they should appropriately go. The other is convenience. It’s not that they don’t know they shouldn’t be in the emergency room, it’s about not having access at the right time. We talked to emerging groups and doctors and they are more willing to give more access to their patients via cell phones or video conferencing, yet they told me they don’t get very many calls on their cells. There’s reluctance from the patients to utilize the access to the physicians to help triage the front end of it. It’s the mindset.
Steinberg: The healthcare industry may also be sending out a bad message. If I drive around I can tell exactly how long a wait it is at every ER. If it were really an emergency, would you really care how long the wait was? You would go to the nearest one. If it’s not an emergency, you wouldn’t want to wait so you’d go to the one with the least wait time. Maybe those signs should be changed to advertise access for the urgent and quick care centers.
What staffing challenges does the industry face?
Anderson: Staffing is on life support. And if you look at the future, it doesn’t look all that bright. However, I’m encouraged with the efforts of UNLV, Roseman, Touro and UNSOM to keep putting providers out that will stay in Las Vegas and Southern Nevada to take care of patients. Everyone has a hard time getting critical care nurses. We have programs now where we train in-house nurses; that’s expensive but we’re trying to meet the need in innovative ways.
Brian Lawenda: We have no training here for radiation oncology or medical oncology so all these people have to go elsewhere. Frankly, they don’t have a job when they come back here, which is an interesting problem that’s hard to imagine with so many people here with cancer that have access issues. In terms of staffing for whenever I want a radiation oncologist, I have no problem getting people to move here.
Van Houweling: We’re seeing a lot of our staffing come from the colder weather states. That’s one of the draws that we have because we don’t have [bad weather]. We embrace new graduates coming out of our schools and we try to retain those students as best as we can but there are some very critical specialties where you need years of experience.
What is defensive medicine and how does it affect the system?
Eisen: There’s a difference between defensive medicine and the .001 percent of people [who actually needed a particular test]. Defensive medicine is if I don’t [give the test], I’m going to get dinged either in a quality measure or I’m going to have to answer this question sitting on the stand somewhere about why I didn’t do it. You have to be prepared to defend that. It would be a lot easier for me to say I sent that test which cost several thousand dollars and it was negative. We have to make sure that providers, physicians and hospitals are reassured that they’re not going to be left out to dry when they make decisions based on good information and the best practices that they have. It’s not about not holding people accountable for when they do something wrong, but it’s about not conflating a bad outcome with someone doing something wrong because there are bad outcomes. We have patients who die or suffer bad outcomes, but it doesn’t mean someone did something wrong. That’s not the same as someone who egregiously commits a horrific act.
What’s the outlook for healthcare?
Murphy: We’ve had so much change for employers and for individuals. People have had different experiences: we’ve seen people whose health insurance costs have doubled, and we’ve seen people’s health insurance costs come down. The reality is, ACA has done a couple of things in the exchanges. It’s expanded access to care so we have more Medicaid folks as we expanded Medicaid. We have opened access to healthcare and health insurance through education and programs that have been put in place. But we’ve layered on administrative costs. The question is, as a group and as a community, do we do the things we need to do to manage the cost to deliver better quality? If we can do that, we’ll bring the rate increase down. But everyone wants the best and believes the cutting edge technology is the best whether or not it delivers the best outcomes, and the newest is typically the most expensive. Health insurance is expensive because cost of care in our country is expensive.
Steinberg: The problem is really not the cost of care, you have to define value. We’re a rich country and we spend far more than many countries do. This year we’ll spend $10,000 per citizen, that’s $3.5 trillion, on healthcare and the question is what kind of value are we getting? We live, on average, a year less than other countries, our infant mortality is worse. If you have cancer you do better in America than other places, but as a society we have to define how much money we can dedicate to that. Healthcare makes up 17 percent of the gross domestic product. At what point is it too much money? How are we going to deal with what a life is worth? That may seem like a philosophical question but it’s not when you think about what it costs to keep someone alive on dialysis. We have bigger questions as a society to really understand this.
Lawenda: The cost of drugs is going up nationwide for oncology treatment and the cost of technology in terms of cancer treatment in general is skyrocketing. There are ways we can control these costs. We have some great providers in town who don’t have access to a large number of patients that they could treat if those contracts were not there or were restructured.
Eisen: It’s not simply a matter of what we are and aren’t willing to do or spend. The issue is what are we spending it on. We spend more than twice as much as other countries per capita and our outcomes are not better. There is so much of the money that’s in the healthcare system that goes to things that don’t help patients such as redundant administrative tasks. A huge part of that falls into that bottomless bucket of inefficiency because of a lack of coordination and communication.