At this point in the year, the initial stages of the Affordable Care Act (ACA) have already been implemented. The results show that, while the state has moved forward in many healthcare arenas, Nevada still has a long road ahead.
More Nevadans Covered
Data showed that during the recent enrollment period, 72,000 Nevadans applied for and enrolled in health insurance plans through the Silver State Health Insurance Exchange. This figure, however, includes all of the 36,000 previously enrolled people who had to again sign up.
“I was really gratified by this year’s results,” said Bruce Gilbert, executive director for the exchange since August 2014.
Similarly, Anthem Blue Cross Blue Shield of Nevada, which offers individual plans via the exchange, met expectations as far as new customers captured there, said Mike Murphy, president. With individuals and businesses as customers, the insurer serves more than 500,000 Nevadans.
Last year, the state exchange was plagued with technical problems, but two major changes resolved most of them, Gilbert said. The exchange turned over its eligibility, enrollment and application processing function to the federally operated exchange. It also transferred the premium billing, collection and remittance component to the involved insurance carriers.
“I think we made, as a state, the right decision to move to a different administration backroom for the exchange, and it’s much stronger in 2015,” Murphy said.
Since the change took effect, an additional health insurer, Time, has joined the exchange. It’s is a subsidiary of Assurant Health, a national carrier.
“The fact that more people now have insurance is a good thing. The more people who receive healthcare insurance, the healthier our community will be going forward,” said Helen Lidholm, CEO, Reno’s Saint Mary’s Regional Medical Center and Saint Mary’s Medical Group.
The change has been positive for patients, added Mason VanHouweling, CEO, Las Vegas’ University Medical Center of Southern Nevada (UMC), a public, 541-bed, acute care hospital with a children’s hospital and level 1 trauma, burn and transplant centers. More people are able to seek primary and specialist care and obtain medications. They’re having better results and fewer readmissions. Hospitals and providers are more aligned than ever as far as clinical outcomes and goals.
“We’re seeing a transition from the uninsured to Medicaid,” added Dr. Anthony Slonim, president/CEO of Renown Health, a Northern Nevada integrated health system and ACO. “That’s what the ACA was intended to do. It changes your reimbursement, you’re getting paid for things you previously weren’t.”
Facilitating Good Health
The onslaught of new insureds into the system pressured providers to accommodate an increased need for care. Southern Nevada’s Southwest Medical Associates Inc. (SMA) gained about 50,000 Medicaid patients, said Dr. Linda Johnson, senior medical director of primary care. SMA is a multispecialty accountable care organization with 21 locations in Southern Nevada. Although it had prepared for a steep patient increase, the amount was greater than anticipated. To manage the growth, the group added 40 new providers—physicians, nurse practitioners and physician assistants—in the last six months alone. In 2014, it opened five new locations in Las Vegas and plans more for this year.
In general, however, the supply of physicians is bleak throughout the state. Southern Nevada is short on specialists; Northern Nevada is short on primary care physicians (PCP). Consequently, some newly insured people continue to visit local emergency rooms, the most expensive point of care, rather than see a generalist on an outpatient basis. Northern Nevada Medical Center (NNMC), whose parent company is Universal Health Services, had a 20 percent increase in ER visits in 2014 over 2013, 80 percent of which weren’t urgent, said CEO Alan Olive.
“It demonstrates that the ACA provided insurance and not healthcare,” Olive added. “[The ACA] provided insurance, but it didn’t provide the mechanism and an additional amount of PCPs or specialists who have the capacity or who are willing to see Medicaid patients.”
“As we think through what the solution set looks like, we need input from people in regulatory positions to think through innovative models to transition through the challenges the ACA has put out there for us,” said Slonim.
Additionally, many people now with health insurance don’t know how to navigate the system and/or care for themselves healthily. Therefore, a major focus of Nevada’s healthcare industry today is on promoting preventive health and wellness and educating people about the ideal places to pursue care for different circumstances. It aims to manage population health or, in other words, improve the health of defined groups—seniors, cancer patients, children, etc.—in a cost-efficient way.
“The health needs of a community are much broader than the healthcare needs of a community,” said Slonim.
The major goals in Renown Health’s new five-year strategic plan are to be as efficient as possible to achieve ACA goals with respect to population health; utilize community partners for their knowledge and expertise; and continue to build the size, scope and scale of the organization to facilitate effective programming and manage the numbers of newly insured. Among other efforts, Renown is using information from its insurance plan, Hometown Health, and getting more involved in community-based programming to better understand and address the health and needs of individual populations.
Saint Mary’s launched a pilot program to capture and maximize the expertise of the Access to Health Care Network (AHCN) that has one of the lowest ER utilization rates among payers. AHCN-provided case managers will help Saint Mary’s better manage patients who have two or more chronic diseases.
UMC offers eight primary care and quick care locations as part of its community outreach. It’s investing in a minimally invasive da Vinci Xi surgical robot as well as high-definition endoscopy scopes and state-of-the-art pulmonary diagnosis equipment.
The Nevada Business Group on Health (NVBGH) is working to help employers create a healthy Nevada workforce. The nonprofit organization provides its 53 member employers with resources and support.
Services include the research, testing and deployment of healthcare, from chronic disease management to in-depth studies of specific diseases. It provides employers with solutions, such as ACA guidance or a no-cost diabetes screening program that can be branded with their logo.
NVBGH also contracts for healthcare services—hospital, pharmacy benefit management, dental, employee assistance programs, employee health and wellness programs, bariatric services and more—on behalf of its Northern Nevada members.
“Our main objective is to raise the visibility, viability and sophistication of conversations between employers—who are the ultimate payers—and those who deliver and influence the delivery of care,” said Terri Lightfoot, executive director and CEO.
This year, the organization will continue monitoring the ACA, launch several consumer engagement programs that employers can use to engage their employees in their own healthcare and offer targeted programs for sleep deprivation and depression in the workplace. It will continue to participate in the statewide diabetes survey and work with employers and community health advocates on immunizations.
Cumulatively, throughout the Silver State, a lot of work is being done.
“Nevada needs more, and it needs everybody on the same page,” Lidholm said.
Providers Boost Access
Consumers today have more of a role in their healthcare than ever before, from decision making to contributing financially. Major advances in providing varied access for consumers to providers and care have taken place and are underway to meet the current and growing demand. Telehealth services, which Renown Health and NNMC offer, is an emerging trend to meet needs of the community where they live, and where and when they want medical help. Even Anthem, through LiveHealth Online, offers its customers the ability to connect online with a physician any time for a co-pay.
“We have to find innovative ways to partner in the rural communities and make sure they have appropriate access and services available, sometimes in person, sometimes via technology and sometimes by bringing them to Reno,” said Slonim. “We have to be innovative in reaching out into the broader geographic areas that we serve.”
NNMC is increasing its footprint to strengthen its integrated health system. It’s growing its medical group and plans to add new locations as needed, offer corporate medicine and introduce new services, including pharmacy distribution services and expanded telehealth.
“Our model of care increases access, reduces cost and strengthens the quality of care,” Olive said.
Saint Mary’s recently started a women’s health center, an obstetrics/gynecology practice. Already with nine primary care offices, it plans to add several more in addition to a pediatric intensive care unit and a wound care center.
SMA added innovative access points to its existing locations that including an urgent care center that’s always open. One is virtual visits, where commercial consumers can connect with a provider via the Internet for simple medical problems. Through e-visits, patients can ask questions via the group’s Web portal and receive answers within one business day.
“We’re a continuous process improvement type of medical group, always looking at how we’re delivering care and if we can do it in a better and more efficient way to improve access and the health of our patients,” Johnson said.
The industry continues to make health care tools available to consumers. To help them make better decisions about where to access care, Anthem provides a cost estimator, among other resources. SMA is developing a smartphone app that will allow patients on the go to do much of what they can accomplish on the group’s website—virtual check-in at its urgent cares, accessing one’s electronic medical record and more.
In Southern Nevada, numerous and varied providers have agreed to participate in the Health Information Exchange, which allows them to share medical information in real time. Launched by the nonprofit organization HealtHIE Nevada, the program eliminates duplication of tests and procedures, lowers costs, improves diagnosis, quality and safety for patients and is more convenient for all involved.
The Reimbursement Dynamic
The ACA moved numerous individuals from an uninsured, self-pay status to Medicaid coverage. UMC’s uninsured consumers nearly halved, dropping to 8 percent post-ACA from 36 percent pre-ACA, VanHouweling said. For providers, this shift translated into additional revenue that hadn’t existed previously.
“For the hospital, at least we get some payment for those services,” Olive said. “So we fare better because of that.”
A remaining problem, however, is Medicaid reimbursement rates don’t cover costs. Dr. Slonim described this universal challenge as “trying to balance between these two worlds of volume-based and value-based reimbursement.”
“Mandates have come out about providing care broadly, we have ACOs and everybody is talking about healthcare reform, but reimbursement mechanisms haven’t caught up with that,” he added. “We’re still paid by each office visit, by each ER visit, by each surgery.”
For Saint Mary’s, it’s a struggle. In its primary care group alone, the number of Medicaid patients increased to 30 from 7 percent.
“We can’t survive on that,” Lidholm said.
Last year, UMC cut $20 million from its operating budget and closed four of its clinics in anticipation of increased costs and loss of support from Clark County Social Services due to the ACA, VanHouweling said. It continues to practice fiscal discipline and reduce costs when and where possible.
Other insurers, like Anthem, however, are redesigning their payment models to be more value based and are strengthening their relationships with physicians. Anthem launched Enhanced Personal Health Care, a program that offers providers payment that rewards high-quality, efficient care and provides PCPs with tools, resources, information and support to help them do the same.
“The more we help support the PCPs, the quarterbacks of healthcare, the better the system will work,” Murphy said.
Tackling Provider Shortages
Solving the shortage of not only physicians but, also, nurse practitioners, nurses, physician assistants, physical therapists and other allied health professionals is a high priority for the healthcare industry, and multiple efforts are ongoing.
One strategy is recruiting physicians to Nevada, in which numerous entities, including Saint Mary’s, NNMC and SMA, are involved. Another is expanding in-state graduate medical education slots, with which the planned new medical schools and expansions should help. UMC, a teaching hospital located in an area targeted for revitalization as a medical district, is the host campus for UNLV’s new medical school. Already, about 200 residents and fellows train at UMC annually. SMA is helping with the planning and growth of the school and will be involved in the educational process.
“I see our hospitals and communities committed to physician recruitment,” Lightfoot said.
The three major Northern Nevada health systems are collaborating with the University of Nevada School of Medicine in Reno on plans to expand to a four-year school for the 2017 academic year. Renown will be a major teaching affiliate. St. Mary’s is creating a family medicine residency program.
What’s to Come
The ACA requires companies with between 51 and 100 employees, as of January 1, 2016, to purchase health insurance, which means near the end of this year and early next, they’ll need to make decisions about benefits.
The Silver State Health Insurance Exchange in 2015 will continue to deconstruct its past efforts, determining what worked and what didn’t and build on that.
“We’re just going to look for ways to continue to grow, improve and do what we do,” Gilbert said.
The experts said Nevada’s healthcare community, in the near future, will keep addressing the need for providers and growing demand for care, continue to facilitate ease of access and focus on improving outcomes of patients and populations.
“The needs are too great,” said Slonim. “The circumstances that we have to overcome are just too large. We have challenges that need to be informed by a broader constituency – business, government and local, county and statewide officials – if we’re going to be successful. It takes a whole team of people looking though multiple lenses.”
“Nevadans have a deep sense of integrity and community,” Lightfoot said. “We will use those characteristics to build a better system that takes care of every Nevadan.”
