Few industries have seen as much change as healthcare has in the past decade. From insurance mandates to physician shortages, healthcare faces a multitude of challenges. Recently, executives representing healthcare in Nevada met at the Las Vegas offices of City National Bank to discuss the industry and what is needed to move 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.
How do you define quality healthcare?
Ed Epperson: If we all wrote down our definition of quality, we’d each have a different answer. There would be matches and crossover. What is the definition of quality in healthcare that everybody can sign off on? I don’t think it exists.
Carole Fisher: And, oftentimes the regulatory entities are defining that for us. We’re not defining it for ourselves.
Epperson: Exactly right. Everybody but us has described what quality is.
Dr. Sherif Abdou: The saddest statement about Vegas was from a meeting that I had with the Kaiser Foundation about three or four years ago. Kaiser saw the Vegas market as growing for seniors and [they] wanted to come in. They have a criteria and they determined that they are not going to come to Vegas because they cannot maintain a five-star in their quality measures. They said the environment was not conducive to physicians. There’s a lack of integration.
Todd Sklamberg: From a physician per capita standpoint, we’re 50th in the country in primary care physicians, we’re 48th in pediatricians.
Dr. Michelle McGuire: We are 51st in mental health.
Mark Price: It really is incredible when you look at Nevada compared to [the] five states that border us. We have more hospital beds per capita than the states around us, but we have fewer physicians per capita. We could say the same thing about behavioral health. There’s a lot of areas on the preventative side where we’re really short. So we’re providing care in a way that’s most expensive and not the highest quality for the patients. The right care, at the right time, for the right patient, that’s the biggest challenge. Part of it is the reimbursement model, part of it is social support and it goes well beyond healthcare. How do we support the patients when they’re not in the healthcare system? It all feeds into the same thing.
What can be done to fix healthcare?
Mike Murphy: Everybody’s always looking for the silver bullet or the single thing [to fix healthcare]. The confusion of the consumer about where to get care, how to get care, how to access the system, that creates huge problems. I think the other challenges we have around talent and recruitment and licensure is forcing folks to get care on the wrong side of service. It’s significantly more costly and less connected. We’re not getting things efficiently done. It helps add to suffering of equality, cost and just sheer confusion and frustration. I don’t know that there’s any single place [to fix healthcare]. I think there are a whole host of places and Nevada’s got some different challenges than we do in other parts of the country, but those things also kind of sift through the fabric of healthcare.
Abdou: We can’t blame too many people not in this room, including myself. The reality is, if you’re a leader for a number of years in your community and you’re big, there is nobody to blame but us. We don’t do much between one meeting and the other. It’s not for lack of trying but at some point, we all need to own this.
Heather Korbulic: I agree. And, the state needs to commit to whether or not healthcare is a worthwhile investment. This next legislation session should provide some proof in the pudding on that. It strikes me that Nevada doesn’t have a single advocacy group for healthcare. There are some but there isn’t a unified advocacy voice. That has an impact.
McGuire: It seems like everybody works in silos. There is no integration. Doctors don’t talk to each other. Everybody’s in their silos and nobody wants to have that conversation about what we do. That’s one of the biggest reasons that I wanted to come here. I hear from psychiatrists all the time that there isn’t quality care. There’s not. How do we fix it? When we don’t have the advocacy group because we’re all working in silos, we talk about it and then nothing happens, ten years from now we’re in the same boat. I don’t know how to navigate that when I get resistance from fellow healthcare professionals in quality care.
Epperson: In healthcare we continuously pick out things to fix and make better and it’s never looked at globally. We’ve got this comprehensive ball of string that’s healthcare and we keep pulling at the thread or laying another one on it. I don’t know the answer except it’s got to be comprehensive. It’s got to address all of it, which is huge, but you can’t just keep picking a piece and saying, “That’ll fix it.” If there was a broad-based coalition in the state saying, “We’re gonna make healthcare happen in our state because we care,” that’s going to challenge everybody. Nobody’s gonna come away unscathed and you might actually make a difference.
Fisher: We keep creating the symptom of the larger problem in a very reactive approach, so I’m not sure, totally, how you get there. We’ve sat at this table in other venues, and have talked this through. How do we break down some of these barriers?
Korbulic: I’m curious if you think that regulation plays a role in how to incentivize that integration and if there are opportunities for regulators and statute to encourage innovation. It seems that sometimes the regulation is very forceful in reverse incentives where you’re not really actually helping. You’re just trying to solve a problem to get it to go away instead of trying to solve the problem systematically and holistically.
Abdou: It’s not a money issue, it’s the redistribution of money and, because of lack of integration, it’s a zero sum game. Who advocates for the patients? Does the state need to put more money in? It’s misplaced focus. It’s a lack of integration and focus on the patient. [Las Vegas is] the largest metropolitan area in the United States that does not have a single clinical integrated system of care. In Reno and Tahoe, they have two very respected clinical integrated systems of care that we all can learn from. We have two and a half million people [in Las Vegas] and we don’t. When we get to that level of integration, then we can really become patient-centric; then we can really achieve quality. The reality is, you’d know the quality when you [see it]; it’s not here, I can tell you. As painful as that is.
Sklamberg: I’m gonna push on the investments side. I agree in terms of the redistribution of money and of assets. It’s not solely the reimbursement issue but, if we are able to raise the tide, all the boats float a little higher and then we’re able to attract the physician talent. We’re able to address some of the integration challenges. It’s not about how we profit, it’s how we redistribute dollars to bring talent in, to push the integration and to push the quality agenda. None of us are content where we are. But, until we get the talent, until we get the resources, until we get the technologies, it’s hard to invest to bring in what we need to raise the boats. It’s more than just on the reimbursement and the economic side but that has to be addressed. That’s a community issue. That’s a state issue. It’s a business issue.
Dr. Marwan Sabbagh: We have done a strategic plan and a deep dive on what are opportunities and threats and, clearly, the thing that emerges is reimbursement. Our current estimates are that we’re getting 23 cents on the dollar for Medicare, 11 cents on the dollar for Medicaid and 28 cents on the dollar for commercial. Our breakdown is 47.6 percent Medicare, 38.6 percent commercial and 8.1 percent Medicaid. Our net is 21.7 cents on the dollar for reimbursement all across the board. Because of that, we’re losing money. We can’t recruit physicians, we can’t recruit talent because we have to eat more cost. This is a chronic problem and that’s why you haven’t seen Cleveland Clinic run into town with more service lines and more development. We are trying to be creative.
How does insurance play a role in improving healthcare?
Murphy: There’s a tremendous amount of self-insured employers that are in this community and in the country. Our insured base, for simple numbers, half of it is self-funded. These are employers that are paying their own claims. To solve the problem, you have to start at the bottom and work your way up. The bottom is, “What can the consumer afford? What does the consumer expect?” We’ve got to measure quality as, “Did we do the right thing? Did we provide a better outcome at the best possible cost that we could?” When you go back, before the Affordable Care Act, the biggest crisis on everybody’s hands was affordability. We’re going to reach a point where there’s 35 to 50 million people that are uninsured. A lot of this is push and pull but, the reality is, we’ve got to start from the bottom and work our way up and say, “Who are we serving?” We’re serving the patient. Our intention is to get the best quality outcome we can and do it at the most effective and reasonable cost that we can for them. We’re all in this together. How do we balance visibility and equality, and reimbursement on quality through the continuum? I sat with a physician that said, “I immunize 100 percent of my patients. That’s exactly what we want to do, right? We want to get folks in for immunizations. So, what I do is, I go and I’ve negotiated a deal with the drug company to give me my immunizations at ‘X’ dollars and I give it to all my patients. And, I charge my patients what I paid for that immunization.” The problem was, when he gave that to me, it was three times what we pay for an immunization. When you go back to it, the intentions were good, the intentions were right. The problem is the execution was flawed.
Dr. Anthony Slonim: I think your point is right on. You have to continue on the insurance side of the business. Drive your cost per case down and drive your quality up and that’s the magic formula. The only way you can do that, it seems to me, is by insuring more and more people. It’s a simple problem and it’s a simple formula, it’s probabilities in insurance. It’s all about the sick people in the numerator and the healthy people in the denominator. You want that denominator as big as you can get it because you are collecting premium dollars. Hopefully, you’re running an enterprise that is efficient and organized and making people better all along, living healthier all the way. You can’t do that without integration. Otherwise, you’re just paying for the sick-care, and the sick-care doesn’t let people live a healthier lifestyle and be well. And you’re just driving your expense in the numerator and not in the denominator.
Where are insurance rates headed?
Korbulic: We saw a leveling this year and it came on the heels of a drag. [Rates] increased the year before and that had everything to do with volatility. We all know, insurance relies on a healthy risk-pool. We all benefit from having insured consumers, from Nevadans being insured. Our number of uninsured increasing should be concerning for a variety of reasons, not just that consumers won’t be insured but because there are economic impacts from that. If we can maintain a healthy risk-pool, and we can do our job in keeping Nevadans insured in comprehensive health benefits, not junk plans, then we are likely to see a continuing level-off and a potential drop. But, we forget the elephant in the room in those conversations, which is the cost of medical care.
How big of an issue is the physician shortage?
Sabbagh: We have a massive shortage of physician talent and provider talent. There are only 22 practicing neurologists in Las Vegas outside of the Cleveland Clinic. That’s one quarter of what is actually needed to meet the current demand. You also have 100,000 people a year moving into Las Vegas. We’re trying but we can’t talk about meeting our current demand [and] we haven’t even planned for the growth of the future of this city.
McGuire: There’s less than 400 practicing psychologists in this entire state and we don’t have the infrastructure to retain quality people. That’s a travesty and I can’t get people to come and practice because we don’t have the infrastructure for it. They don’t want the reimbursement rates or it takes them over 120 days to get credentialed.
Jon Bilstein: Burnout clearly [is a challenge]. We’ve had three of our senior physicians retire in the last year. Trying to recruit is difficult because folks are keenly aware of reimbursement in Las Vegas. Between Medicare and Medicaid it’s about 54 percent of our book of business. As prices rise on pharmaceuticals, and the cost of drugs get more expensive, more and more patients can’t pay their 20 percent co-insurance. which, of course, puts us upside down on drugs. Part of our strategic plan is to continue to be proactive in recruiting but we have struggled to bring talent to Las Vegas. It’s [also] a long process to get physicians licensed and credentialed. It can’t go on, it just takes too long.
Is Nevada an attractive place for physicians to work?
Abdou: We are more than competitive as far as compensation goes. The work environment is not competitive. A primary-care board-certified internist in Southern California [will make] $150-180,000 with the ten percent taxes and the state’s cost of living. Here, you pay $250,000 and still can not get good physicians and you’re lucky if you’re able to get them at $200-250,000 in primary care.
Epperson: We’re competitive because we have to be. There’s just no alternative. Hospitals are incredibly unsustainably expensive. We know this and part of that is because we’ve made them the major employer of physicians in the country at a loss and a subsidy for pretty much every physician, at least on average.
What are the bright spots in healthcare?
Sklamberg: One thing I’ve seen community-wide is the growth in GME (general medical education). It’s gonna take another five, seven years until we get through the medical school and residencies but, with the expansion of GME, there may be a light at the end of the tunnel of having a physician-base here to provide accessibility. As we expand the GME opportunities, across all the health systems and the investment, hopefully in five years we’re not 51st.
Price: When I moved here, I was actually pretty amazed at how well Medicare Advantage works in this state. Health Markets just did a study of cost and affordability of Medicare Advantage plans around the country. Nevada is number one in the entire country. The number two state is almost ten percent more expensive than we are. When you look at quality and Medicare Advantage, we’re not five stars, but we’ve got a lot of four-star plans. It feels like a place where we’re doing pretty well and it comes down to coordination. There tends to be more coordination and those plans and networks take tight integration between health plans, providers and hospitals. It comes down to a framework for reimbursement, even a regulatory framework, that allows you to focus more on prevention and wellness. You actually profit when you do those things well. All these things that we’re talking about, you can actually do it in that model and everybody wins when you do. It’s very different than fee-for-service medicaid or fee-for-service medicare.
Slonim: The Northern Nevada market is different. We’re fortunate in that we are small. We have integration. Our board is invested, handsomely, in the health part of that conversation. It’s not sustainable over time without making either the community that you’re serving healthier or trying to drive a different business model. That’s what our new strategic plan is about. We’ve invested all this work on the health side in social determinants, making sure people have access, mental illness and addiction. We found out that our cost per case has gone up in an unsustainable way. We can’t do that anymore. We’ve got to make sure it’s profitable in its own right, independent of the hospitals, and that’s the business model that we’re implementing. That integration that you talk about really does help drive consistency and the issues that we need to address.
Abdou: Absolutely. I would love for hospitals [in Las Vegas] to start leading the charge of how we integrate the community in to a system rather than just [having it] fragmented.