Overburdened with COVID-19 cases, healthcare in Nevada is experiencing one of its most challenging years in history. Leaders in healthcare have been committed to finding solutions to the industry’s most pressing issues and the pandemic has prompted innovation in the field. Recently, healthcare executives across Nevada met in a virtual roundtable, sponsored by City National Bank, to discuss their industry and what the future holds.
Connie Brennan, publisher and CEO of Nevada Business Magazine, served as moderator for the event. These monthly roundtables bring together industry leaders to discuss relevant issues and solutions.
What do you Expect to Happen with COVID-19?
Dr. Tony Slonim: Our projections in northern Nevada look like they are going to continue to rise. Obviously, predictive models are only as good as predictive models. As a community we’ve seen unprecedented collaboration, we are working desperately to continue that. It has been the one shining star that has come out of the pandemic. We are all working together because the community needs us to, frankly. Our biggest struggle here, it’s not beds and supplies, thankfully, its workforce. Our people are tired and they’re more and more fatigued and watching more and more people die every day. Hopefully, the vaccine will start to get in, but even with that it is going to be three months before effectiveness starts to kick in. The first dose starts the immune response and 30 to 45 days later, there’s the second dose then, hopefully, some immunity. We still have a long road ahead of us but there’s some light. Let’s keep it focused on the future.
Richard Bodager: We are planning to have additional COVID expenses [such as] cleaning supplies, required PPE, additional staff and all the things we are supposed to be doing, to the end of 2021. Even though we look at the timeline from an outpatient practice, we have to protect our patients, doctors, and employees. We’re really thinking more towards the end of 2021, first part of 2022, before we start scaling back some of those measures.
Bill Welch: We are certainly seeing a significant surge. We’re higher today (December 2, 2020) than we had ever been since the pandemic was officially recognized back in February or early March. We anticipate that we are going to continue seeing that grow. The good news from the healthcare industry is, we have learned a lot through the COVID pandemic. We learned how to better treat patients. We have refined our response to COVID-19, we are doing a much better job. People are concerned about bed capacity; we have the opportunity for a significant increase in bed capacity. How do we staff those beds as we need them? [We must be] working together and creative. Things are going to have to look a little bit different for us to meet the needs of the patients and the community.
Heather Korbulic: What’s really concerning to me right now is the fact that all of the CARES Act dollars end[ed] on December 30th. We have no funding, no resources, to support our state with continued response. We still have a pandemic to battle. We are going to be even more lacking in those resources in the absence of any more federal action.
What are the Lessons Learned from the Pandemic?
Bodager: Obviously, COVID has been a terrible thing for our city and the nation, but we had a lot of positive lessons out of it. We were able to rapidly respond to the volume changes that happened. We had been talking for years about a work-at-home strategy for people that don’t work in clinical [roles]. Almost all of them [now] work from home. We were able to develop a strategy within days by working with our IT team. We felt like we were keeping our employees safe. We were able to find unique ways to get PPE from vendors we’ve never worked with before, overseas or by [reaching out to] any contact we can. We were able to make sure [our staff was] constantly covered with PPE. It taught us a lot on how resilient our organization is and how quickly we can respond to an issue like that. Now we are still dealing with the ramifications.
Tiffany Coury: It’s amazing when an industry is pressed up against the wall, how much everybody can come together and think about delivering assistance differently. I also have some rose colored glasses. What are the benefits that come out of this pandemic? How will it shift and shape the system a bit different when delivering care at home virtually? I do think it is going to add value to the community down the road so all of those are very positive things.
Dr. Bard Coats: The local work, as problematic as it was starting, has been amazingly effective and the engineering in the hospitals to take care of patients differently [has had a] massive affect. Our biggest challenge is the coordination of information. Hopefully, the roll out of the vaccines will be handled well. It’s going to be fall, maybe end of 2021, before things resume to any sense of normalcy. For those of us doing the ambulatory care and testing and trying to keep people on video visits, it’s a chore. But, it’s not like we’re in a hospital. It is really admirable what the hospitals have learned and adjusted with treatment protocol for the physicians and the administrative leadership. We appreciate that great work.
Slonim: The problem, particularly in the pandemic, is the medical model where we focus on one patient, one family, at a time and advocate for them. What we are confronting with now, in the public health model, is a resource constrained environment. You can’t advocate one patient, one family. You have to advocate at the level of greater good for the population. That disconnect for physicians, like us and others, is really problematic. Don’t try to answer the question, “Where do I get more ventilators?” The reality is there are just not enough ventilators, you need to allocate them. As a nation, we haven’t confronted that scarce resource problem before, except in very limited frames. This was an important [lesson] to make sure we are addressing and learning from.
What Changes should be made to Healthcare Delivery?
Coats: [There is] a lack of public health [programs], oversight, follow through, leadership, funding and a support system. It’s a mess. We knew it was a mess before this happened and now that you see the worst thing that can happen, its worse than we even thought. [This is] what happens when we have no structure through which to manage this kind of care.
Slonim: I’m fortunate to have a doctorate in public health, that has served me well in the middle of the pandemic because prevention, screening and planning are all elements of a public health education. It bothers me to acknowledge how poorly equipped we were. That came through decades of not investing in infrastructure.
Korbulic: The last time we sat down for this roundtable, I said the biggest problem in healthcare is the lack of investment in public health. That was a year ago and look what’s happened.
Welch: [The pandemic] has helped expedite the development and expansion of telehealth in this state. A couple of hospital CEOs, representatives of our hospitals, have developed [programs] were they can take care of inpatient hospital needs in the home setting with telemedicine and other appropriate support. On a national level, we had an emergency declaration that expanded the laws and parameters for telehealth. Nevada, fortunately, was a state that was fairly progressive, but we still need federal regulator relief as well. I think telehealth has been something that has really taken off. It has been a great resource to respond to the pandemic that we are dealing with.
How is the Quality of Care in Nevada?
Coats: I think there is some great healthcare in pockets. We can all see great individual cases and great examples of coordinated care. In particular, many of us are doing real population health. In our patient groups you can see amazing things, but to say we are anywhere near the top 50 percent of the country would be false. There are so many definitions of quality.
Coury: The quality of care we deliver is evolving over time. There is much that goes into what a quality-of-care metric is throughout the whole continuum. At the hospital level, St. Mary’s, is monitoring several different metrics to make sure, when a patient comes into our door the outcome is top notch. We’re performing well in that regard. Where we are not performing as well, and hospitals are starting to take more of a leadership role on, is the prevention side of things. Our payment models are changing to encompass things that are done outside of our four walls. [We are] getting engaged in population health and really understanding how to decrease the cost of care, the duplication and prevent long-term disease. That really is evolving.
Dr. Sherif Abdou: There is no element of public health in most of what we do. Even when we talk about the population, we focus on the population we are responsible for. I have to admit, I have not gone and developed a public health branch or focus on what we do as health professionals. That’s number one, the lack of the public health focus and understanding what that means in a large health system. We are only getting bigger, building larger systems, expanding and merging. Yet, we are imprisoned in the four walls of our companies and groups and not looking at health as a public health issue. Second, it’s time to recognize the nurses as the front line. Clearly the nurses inside the hospitals spend a lot more time with patients, COVID or no COVID, than the doctor that walks in for five, ten, fifteen minutes, and so forth. What’s going to determine the outcome of patients in the hospitals is the nursing care. These are two elements [we need to look at] if we want to innovate. The third [element], of course, is behavioral health. It is shameful, in an embarrassing way. We tried to coordinate some of the behavior and mental health during the pandemic crisis, not only for our patients, but also for our staff and family members. We failed miserably. We couldn’t find anybody to integrate, coordinate or navigate through. These are the three elements. [We need to] focus on public health in a large system and on staffing, residency and the types of doctors that are coming in. The next generation of healthcare needs to focus on nurses. They are the real heroes, front line and leaders of the next generation of healthcare. [Finally, we need to focus on] behavioral health.
Dr. John Rhodes: I am concerned about the cost of care. I remember being an undergrad and taking my bioethics class at UNR. [We talked] about how healthcare was, at that point, about eight and a half percent of the GDP. How could we, as a country, continue to afford eight and a half percent of our GDP going to healthcare? We’ve now accelerated into about 18 and a half percent of the GDP going to healthcare. The inflation curve of healthcare is accelerated compared to the inflation curve of the general economy. Yet we don’t have the outcomes, as we have all discussed, to really justify that increase in care. How do we take the resources we have and try to get that inflation curve back to the same level as what the general economic inflation is showing? [We need to] start bringing in quality and trying to figure out where we’re eliminating waste. Going back at what Dr. Abdou said about quality in our mental health facilities, not just facilities, but [mental health] care in general in our state. It is a huge deficit, trying to coordinate that care. Trying to get our patients to the right people for mental health is difficult at times. There is a major disconnect between sharing the records of information between mental health and physical health providers.
Has the Health Information Exchange Helped in Collaboration?
Coats: We took advantage of a window and hopped into the Health Information Exchange (HIE). We hadn’t done that before. It’s been helpful for getting records, particularly for new patients. The Health Information Exchange is extremely helpful for the hospitals, ER and primary health doctors. It’s been a great part of public health as well. Around the country the information exchange has been much more adaptive. There are all sorts of business models state-to-state about opt-in, opt-out and the financial management of it. Here in Nevada, the HIE has gone through several iterations. We will start contributing information to those records after the first of the year, not just looking at them.
Bodager: We have been contributing data to the Health Information Exchange, so we’re kind of the opposite in that we were contributing but not using. Through the pandemic we started to look at opportunities to utilize that data, to reduce our cost. We’re heading down a path where we are going to be much more integrated with the Health Information Exchange. I was the board chair for the Oregon Health Information Exchange when I lived there. [I’ve seen] that go from a very small HIE in southern Oregon to having over four million patient records, all across the state. You can see what the power of HIE can do. I wish that for Nevada because it really lowered the cost of care. That is only a small piece of the inefficiencies and waste in the system, but it is hugely beneficial to patients, physicians and the people treating patients.
Coats: The Nevada regulations around the HIE is that you can opt-in to it but many states have it where you have no choice, you have to participate. You have to provide information and then you have the insight.
Welch: The challenge is that our state is an opt-in state. A lot of states [require organizations] to opt-out if they do not want to participate. So, you have the option to opt-out, but everybody is automatically in. When we passed legislation to initiate the Health Information Exchange, we attempted to have it be an opt-out situation. We were unsuccessful, obviously. We’ve attempted to amend it twice since and have been unsuccessful those times as well. There’s a lot of legislative resistance; they think it’s taking privacy away from the consumer and the patient. Maybe we haven’t done a well enough job demonstrating the value and benefit from the sharing of information – how that would impact the patient’s outcome and how it could impact the cost of healthcare. It is something we are certainly going to continue push to improve, but it will be a significate legislative challenge.
How can we Increase Nevada’s Healthcare Workforce?
Korbulic: Workforce is a big, significant issue. It’s not new in our state and it’s something we have all experienced.
Coury: [The pandemic] has highlighted one of the larger issues in the state of Nevada, our workforce. It’s been amazing to see the lack of depth we have across multiple specialties, for physicians and nurses, as well as the ancillary staff. We’re trying to pivot and meet the employees and physicians where they are. [We’re trying] to make sure they are restoring to get ready for the next patient or the next day. I think we are going to see the effects of that long term. I know some of my colleagues have done this as well in their hospitals but [we’re looking at] team-based nursing. Essentially, we’re thinking about the number of patients one nurse can support and expanding that but giving them additional resources. This is a workflow we’re not used to. We are finding there is a connection and a teamwork that is coming out of getting around the table and creating that model. [It’s helpful] having supervisors side-by-side with their team to say, “What’s working? What’s not working?” The vast majority of people are connecting with their purpose for why they got into healthcare in the first place. This is boots on the ground delivering care when the community needs us most.
Slonim: In Washoe County the number of licensed nurses has actually gone down year-over-year compared to where it was. I was a nurse before I went to medical school and I know nursing brains pretty well. Our nurses are aging, and this is a physically and emotionally demanding job. If we want to have success in the future, we need to help our nursing leaders think creatively about the role of the professional nurse; it’s not about tasked based bedside care. We should be able to perform that work with technical people, who can take directions from the professional nurse and use the nurses’ license at the highest level of what it was intended to do. You don’t need to, necessarily, understand all the dynamics of physiology and pharmaceutical to change a wound dressing. How are we thinking creatively about each task and allocating them to other team members in a creative way? That’s what we are learning as we go through our team-based models together.
Bodager: We’ve expanded our physician assistants (PAs) who support the physicians. We’ve tripled the number of PAs we have in our organization. We are trying to find unique ways to bridge that gap. We’re still short but it has definitely improved.
Welch: We have talked to our licensing boards in the state. We are going to have to relook at how we are regulating licensed professionals to figure out how they can better collaborate. The example that [Dr. Slonim] gave is a model that we will be moving towards. These teams have to be led by a physician. Nurses can only direct people who are certified by the Nursing Board. As you look at other types of medical professionals like paramedics or medical assistants, these are individuals that nurses are not able to supervise based on the current regulatory environment. The licensing process in many of our licensing healthcare categories is challenging to say the least. Nursing is one of the more affected categories. I don’t say that to be negative to any of our licensing boards, it’s just how the world has evolved over time.
Slonim: I am honored to serve on the Patient Protection Commission for the Governor and workforce is one of the things we’re taking up because we know we’ve got to do better. We’re never going to have enough of a pipeline for Nevadans. The data demonstrates that we are 60 or so [doctors] per 100 thousand [people], too few in the state. That has actually gotten worse over time. We know they’re maldistributed as well in the more urban sites and less in the rural. We have to figure out how we go about [fixing] that too.
Rhodes: I see that shortage. We talked about access and, until we can improve that shortage, it is going to be hard to improve access. Within that, we are also putting a lot of specialist and subspecialist out who do incredible things for patients, but we need to increase our primary care physicians. Those [primary care doctors] can take care of 90 percent of what people go to the doctor for and 25 percent of our medical grads go into primary care. We’ve got to figure out how we can shift that and get that above 50 percent of our grads going into the primary care fields.
Do we have Enough Healthcare Residencies in the State?
Coury: No, we really don’t have enough residency slots. There aren’t enough funded slots in this community. One of the efforts St. Mary’s is doing, and I know Renown has been doing this as well, is trying to get additional funded slots here and partner with UNR (University of Nevada, Reno) in a different way to expand [residencies]. And not only primary care [residencies]. One of the goals is specialist care [residencies], so we’re in a different situation five years from now.
Welch: The Graduate Medical Education Program is a very complex issue. It’s something, I believe, the Patient Protective Commission is going to be looking at and there is going to be a presentation. People don’t understand, Graduate Medical Education is a very costly venture for a hospital, which most residency programs are based out of. They don’t need to be based out of a hospital, they can be based out of other clinical settings, but they are primarily based out of hospitals. It costs the hospital a lot of money to ramp up a program and you only have a certain time period to develop your program and receive the funding. Then, after a period of time, you can grow that program and get financial support for your expansion. You have five years. Once you start a Medical Education Program you need to know where you are going to be in five years because [that’s how long] you have to develop that plan and implement it. After that you are responsible for funding 100 percent of the cost associated with it. In our state, over the last eight years, we have more than quadrupled the residency programs. I am really proud of what the medical community has done in trying to respond to that issue. We could quadruple it again four to eight years out before we ever see relief. We’ve had to think about this [in terms of] short term strategies, as well as long term strategies. We’ve developed a lot of new nursing programs in this state but, again, we are so far behind the eight ball that it is going to take us a significant amount of time to catch up. There are challenges, but there are opportunities.