With federal changes looming and challenges at the local level, healthcare is an industry in turmoil. Addressing the challenges and the bright spots, healthcare executives recently met to discuss where the industry is headed and what businesses can expect moving forward.
Connie Brennan, publisher and CEO of Nevada Business Magazine, served as moderator for the event. The magazine’s monthly roundtables bring together leaders to discuss issues relevant to their industries. Those discussions are recorded and a condensed version is published in the following pages.
Does Nevada have an issue with quality healthcare?
Dr. Sherif Abdou: The last Commonwealth Foundation report put us at 42nd. In the first report, in 2007, we were ranked 51st. Over the years, we’ve moved up to 36 or 37. We’ve stepped back the last couple of years, back to 42. We’re not at the bottom, thank goodness, but we’ve taken a step back in the last few years.
Ty Windfeldt: Part of the challenge is, we don’t have a standard system to manage quality. What is quality? There’s all those different ways you look at how to measure quality. How do you develop a system where you can have a centralized, standard system that we all agree to? It would be really hard to do. I think that’s the bad news. The good news is, I see us progressing so far in the last two years of getting people to buy into it. I see a pretty big paradigm shift. A couple years ago, [physicians would say,] “Don’t talk to me about quality. I’m taking care of patients, I’m doing the best that I can.” Now they’re like, “Tell me about my quality. Tell me if it’s good or if it’s not good and what I can do to fix it.” I think we’ve made a lot of progress.
Richard Bodager: Ty makes a really good point; there’s not a definition of quality. That’s been one of the major challenges. Right now, with this lack of clarity, there’s a lot of reverse incentives. I’ll just use a simple example. We have emergency rooms call and scream at all us all the time. “It’s been 15 minutes since we did this report, I have to get this patient out of the house.” Because their quality score is based on how fast they get the patient out of the ER. Is that quality? That’s transactional in my mind. The incentives, sometimes, aren’t really aligned with the path we’re wanting to go.
Dr. Thomas Schwenk: I’ve seen reports and, if I recall correctly, if you added up all the quality measures that all of the systems had thrown out there and all of the measures that a physician or hospital could potentially see, it numbers in the many hundreds. Sometimes conflicting, sometimes more complementary. It will make you crazy if you try to really track all of this.
What is needed to fix this system?
Schwenk: Any one encounter can be very high quality, there’s just no system. When you talk about the US having the best healthcare system in the world, it actually has one of the worst systems. It has some of the most miraculous healthcare on an episodic basis but has no system compared to almost every developed country.
Bodager: There’s a lot of lack of coordination between the providers and that’s creating some of the miscommunication and challenges.
Paul Stowell: I thought under the Affordable Care Act (ACA), the communications gap was supposed to be fixed. As a patient, and going to all these different doctors, I thought the communication and the imaging of records and everything was supposed to be integrated between healthcare professionals to where the communication would be better.
Dr. Bard Coats: It’s an aspirational goal.
Jon Bilstein: None of us, in this room, share an EHR (electronic health record system).
Dr. Michael Gardner: There are places that have done a better job of trying to do that through some kind of integrated central repository. But I haven’t even heard anybody mention that yet in Las Vegas, [having a place] where people can go in and retrieve [records]. That was supposed to happen and it hasn’t happened.
Bodager: Instead of using data as a competitive advantage, by sharing data, you actually get a competitive advantage because you also get data to take care of patients. Your quality scores, not [your competitor’s] quality scores, go up. The problem is, in some markets where there’s heavy competition, like Las Vegas, the players don’t want to play together.
Will insurance costs continue to increase each year?
Valerie Clark: It’s tough to say. I think the cost of care has stabilized to some degree, compared to prior years. I would be shocked if we saw costs go down. The changes in legislation, just very recently, may cause a shift again if people go off the plans that they were previously on because they’re not required to be on them anymore. Those are all things we worry about, how the shifting goes. I think the Medicaid expansion helped stabilize costs; where that will go, I don’t know. If I had to guess, on an average change, I would say probably a trend [upwards] of right around five to nine percent.
Windfeldt: From my main lens, which is from a peer source and the insurance company side, my biggest challenge is cost and affordability and how you keep premiums that are affordable. One of the biggest challenges for us today is on the pharmaceutical side and, most importantly, the specialty side. We continue to see those costs sky rocket. We see it get worse, not better, so we’re really trying to grapple with that whole issue.
Abdou: Hospitals are not getting a five to nine increase. Immunizations are not going up five to nine percent.
Clark: Oh no, I know. Whenever my doctor clients, whenever I bring them renewals, they say, “I’m not getting paid that much more.” A lot of it is pharmacy.
Windfeldt: Every other side of the equation is regulated. The health plan is regulated, the providers are regulated by what Medicare and Medicaid tell them they’re going to get paid. But, when you go to pharmaceuticals, there’s no regulation. There’s no regulation on what the price is set at. When you have these speciality pharmaceuticals, the only pharmaceutical available, there’s no option but for you to cover that. It’s lopsided. Not that I’m a fan of more regulation, but if you’re going to regulate some of it, then why shouldn’t all of it be regulated?
Clark: And the carriers really aren’t allowed to assess their risk anymore. There’s no pre-reqs, there’s no requirement for any kind of underwriting. And the carriers’ argument is, “We can’t assess risk so how do we set rates that are fair and appropriate?” It’s difficult.
How is the doctor shortage being addressed?
Schwenk: One of the better things that’s happened lately is the growth of public medical education, two medical schools and the growth of private GMEs (graduate medical education). All of that expansion, which is very positive, required investment, legislative support, system support and partner support. It still barely gets us into the game. If you look at the numbers, the residents per capita, physicians per capita, retention rates, we were so far off the chart that we didn’t even register in many of those measurements. Now we’re sort of in the chart somewhere but that’s with a massive increase from where we used to be.
Gardner: You can build a hundred new medical schools but, if the students have to leave the state for their graduate medical education [it’s an issue]. Most people tend to settle pretty close to where they did their residency. That’s where they meet doctors in their specialty, that’s where they’re offered jobs. The fact that we’re building graduate medical education is just, if not more, important. We also need to expand fellowships, sub-specialty training, nephrology, cardiology, rheumatology, various radiology specialities, those kinds of things. Those things are going to be just as important over a 20 year period of rightsizing in physician population with an ever growing patient population.
Stowell: The need keeps outstripping the capabilities that we have. I’m just amazed that we can’t find the avenues to fill all of the need that we have in this state. But, you’re right, from a residency standpoint, once they leave the state, coming back is just not in the equation.
Is Nevada competitive when it comes to paying physicians?
Coats: Certainly in the adult primary care area, I think many of us try to thrive and do well. We don’t have any trouble recruiting people from other parts of the country, we don’t struggle to fill positions.
Gardner: On the specialty side, people are not only getting adequate salaries, there are people getting very high salaries.
Bodager: It’s by specialty because I would not make that argument for radiology. We are struggling getting people here because there are mega radiology groups that can pay more than we can pay. I know we’re considered a large group and we have nearly 70 doctors; we cannot pay at the level and offer the incentives that a lot of these one thousand, four thousand [doctor], mega radiology groups can offer.
Windfeldt: It’s one hundred percent by specialty. What we see, north and south, is our hospital reimbursement and our primary care physician reimbursement is relatively equal. The specialties are night and day. Las Vegas has significant competition among sub-specialty and there’s many sub-specialities in Northern Nevada where there’s only one group. It’s hard to have a conversation about what’s a reasonable reimbursement when you’re the only group in town. That provides a struggle. I feel like the cost of care is almost double in Northern Nevada than it is in Southern Nevada and it’s driven by the specialists.
How does physician access play a role?
Abdou: We don’t have a true access problem. The reality is, as a physician, I overfilled my schedule unnecessarily because that’s how I’m going to get paid. That’s what my bonus is based on or that’s what the system has forced on me. We’ve found that 33 to 40 percent of the physician visits were unnecessary. But, it’s the only way they get paid. The physicians, in some previous models, were getting paid per visit. So, we eliminated 33 percent of the visits and the patients, instead of coming back every three weeks, they came back every three months, as needed. There’s a lot that plays into the access. That’s why just producing more physicians is not the solution. [We need to] redefine the word access. The system, or lack thereof, is creating the access problem and creating further burnout in physicians. They feel like they are caught in a wheel and they have no control over the system.
Clark: And, that leads to the patient burnout because they’re paying these co-pays. Whereas it didn’t used to be that bad, before the ACA, they were okay. But now they’ve got these enormous doctor visit co-pay and they’re being told they have to come in, more so than they used to [be told] five or ten years ago. It creates a lot of burnout on the patient side too and financial distress.
Has telehealth been a solution?
Windfeldt: Absolutely. We’re driving telemedicine and we’re seeing more and more adoption everyday. If you look at some of the high-performing organizations, 50 to 60 percent of their primary care visits are done remotely. We’re looking at it from two different aspects. One from a convenience factor and lowering costs and two, the drug and primary side. We’re also using it as an opportunity to get the rural visits, especially in the sub-specialty business. It’s one of our challenges.
Coats: All of us that have any sort of a system to deliver care are participating in telemedicine to some degree. It’s just one more good access point if it’s done well and if it’s coordinated with electronic health records and if it’s the right level of care. So we’re all doing it and it’s one more thing to help. In the rural areas, it’s a whole different world. It’s a hugely more important role.
Boadager: We’ve had telehealth as part of our benefit package for three years now and it is been an incredibly low adoption. We’ve done campaigns, we’ve even offered incentives to our employees to sign up. It’s incredibly low. They would much rather go sit at an urgent care
Clark: Until you use it, you don’t get how easy and positive of an experience it can be. I’ve sat there with my clients with their employees and literally put the app on their phone, showed them how to register for it and next year come open enrollment and they’ve never used it.
Does having physician Alternatives see patients help ease the burden?
Schwenk: With a structured teamwork approach, clear communication and a clear delineation of scope of practice and who does what, it works extremely well. I’ve practiced in that type of setting for my whole career, with both PAs and NPs, but it has to be structured. If you get any battles, turf battles, professional battles, reimbursement battles, it just kind of falls apart.
Bilstein: There has to be a structure. You have to see the physician first and then the mid-levels are very capable for lab follow ups or incident-to-coverage for chemo therapy. There are many things they can provide so there’s continuity of care. It’s critical. Just in the last six months, we’ve hired four mid-levels because we’re probably behind in the times. Some of our senior physicians have always felt it must be physician-led, they’ve not bought into a mid-level because of the complexity of care.
Schwenk: It’s definitely a generational issue.
Bilstein: Yeah. Now the younger physician who are coming onboard, the new fellows, are very accustomed to working with [mid-level providers].