“Everyone in healthcare is struggling with this,” said Dr. Paul Krakovitz, region president, Intermountain Health. “It’s not just in Nevada where we have a very low number of physicians and advanced providers per capita. It seems to be worse in our state, but it is an issue around the country.”
The question of how to provide quality care to patients given the shortage of doctors, nurses and staff isn’t only about staffing hospitals with medical personnel. It’s also about specialists being available in emergency departments, and it’s about access to healthcare.
“When we talk about quality of care, the question is [are] people able to access healthcare,” said Krakovitz. “That’s really the first part. Providing access to care.” Access can mean having providers in emergency departments, physicians in hospitals and patients accessing transportation to get to appointments.
Access to care covers both those patients who can go see the doctor, and those who can’t, said Dr. Sherif Abdou, CEO, P3 Health Partners. “We support our doctors with physician’s assistants, nurse practitioners, even an RN will sometimes see patients.” Being able to treat patients regularly for ongoing conditions like blood pressure or diabetes can lead to better clinical outcomes quarter after quarter. “Sometimes [when] it’s necessary, we’ll create a profile for the patient with the social determinants. So, for example, if transportation is an issue, we know to address it ahead of time and not wait until the next appointment to see if they’re not showing up because they lack transportation.”
Costs of Living
Escalating medical costs are part of the inequality of healthcare for some populations.
“Everything is increasing in cost everywhere,” said Krakovitz. “Being a not-for-profit, value-based care organization, we look very carefully at quality of care that we’re delivering and what that cost is. A lot of the spend in healthcare right now, particularly in southern Nevada, is around access. A lot of people use higher cost healthcare, going to the emergency department for care. People don’t see another option. That’s where we see how we can help decrease escalation in cost with help of access so people don’t have to go to the emergency room as the first place for care. The first place for care can be in an outpatient environment, which is less expensive.”
One solution is to redefine healthcare expectations. “Expanding the concept of care as we did in our own offices,” said Abdou. Patients with regular appointments for routine checks can be treated by medical staff and only need to see the doctor if there’s in abnormal result, making lower cost visits. “Start bifurcating the element of seeing the doctor to receiving care as a more expanded definition,” he added. “Because if you ask the patient it’s, ‘Did you receive the care when you wanted or needed?’ Not, ‘Did you see the doctor when you wanted?'”
There’s a tendency to treat healthcare as something separate from other industries, but it’s impacted by the same economic pressures as any other field, with the caveat that it doesn’t have the choice to close up shop at the advent of higher prices or pandemics.
“The cost of care is increasing because of labor shortage, labor costs, supply costs, supply chain disruption–like any other industry,” said Abdou. “But if you lead up to that utilization, actually there is an improvement year-over-year.” Organizations like Silver State ACO, an accountable care organization, work to coordinate high quality care for patients using Medicare.
“If you put the macro economics overall healthcare costs against the price of gas and inflation overall, it does not rise the same as real estate costs over the last 24 months, though those are coming down. The cost of cars went up. If you look at economics side by side, compare healthcare to all other industries. The pandemic was not an economic crisis, it was a healthcare crisis. Healthcare is actually the least pressured of all other industries,” said Abdou. “Gas prices went up 28 percent year over year. Healthcare costs did not go up 28 percent.”
But they are rising, and ways to end the escalation are being debated nationwide. “In every state and every city in the United States of America today, the cost of providing care, particularly for inpatient to hospital is extremely expensive,” said Jon Van Boening, president and CEO, Dignity Health, St. Rose Dominican, Siena Campus. “Around 50 percent of our cost of doing business is labor. We are a labor intensive business. The average nursing wage today is $80,000 a year. Nevada is one of the highest paid states in the country, because we have to be. Because there is a shortage of nurses here. Physician call pay is extremely expensive today. So are medical supplies.”
Then there’s the cost of simply needing to run a business that’s open 24/7, 365. “We are a business that cannot close. The pandemic proved that,” said Van Boening. “Other places can shut their doors and tell people ‘We’re not open.’ We can’t do that. We can’t ever do that. By law we cannot turn anyone away that comes to us for help and as part of our mission as a nonprofit, faith-based hospital, we’re never going to turn somebody away.”
Access to Care Givers
Different hospitals find different ways to mitigate the shortage of medical professionals. Healthcare is already a stressful career. The pandemic accelerated burnout of a lot of caregivers, leading healthcare systems to put emphasis on taking care of their people.
Renown Health recently began a partnership with over 7,000 employees, launching a national recruitment campaign on Valentine’s Day to ensure staffing to meet the needs of the growing patient base in northern Nevada. “We’re working with our employees to recruit 500 more dedicated clinicians to Renown and this community,” said Dr. Brian Erling, president and CEO, Renown Health.
At the same time Renown announced enhanced benefit packages for employees with the expansion of 401K retirement fund matches scaled by seniority, enhanced tuition reimbursement to the amount allowable by the IRS for full time employees and expanding to per diem employees.
Intermountain is working with university residency programs, building out their healthcare professional pipeline, as well as finding ways to retain current talent and attract new to the state. They’re also looking to high schools and colleges for new recruits.
“But we’re getting even more obscure than that,” said Krakovitz. Intermountain recently partnered with Discovery Children’s Museum in Las Vegas to open a new exhibit geared toward getting children interested in healthcare careers. Intermountain also partnered with Goodwill of Southern Nevada and NV Careers to create 90 Day MA, a free training program for financially disadvantaged populations to jumpstart careers as medical assistants.
Dignity Health isn’t understaffed. Rather, they’re able to provide specialty care consulting services for other hospitals.
“Nevada has a unique shortage of certain sub-specialists and the physician side one of the large shortages in this community is ear, nose and throat doctors to take calls in emergency rooms,” said Van Boening. Dignity’s Sienna Campus is one of two hospitals in southern Nevada that provide that service.
Telehealth
Another solution for providing access, especially in rural Nevada, is telehealth or telemedicine. Already in use when COVID locked down the state, telemedicine exploded during those months.
“During the pandemic it helped tremendously, there’s no doubt that it’s because of the mandate or because the disease itself was so different,” said Abdou. “Telehealth was almost reintroduced to the patients, the customers,and the providers as a tool of providing care and the percentage was significantly increased during the pandemic.”
Post-pandemic, especially for senior patients, use of telehealth has dropped back to near pre-pandemic levels. People are willing to drive to the doctors office, even from rural areas where it’s a significant commute to access care.
Telehealth can still be a significant boon to rural communities. “We serve over a million people in a 150,000-square-mile radius, so access to healthcare in rural areas of Nevada is a challenge that we face as a state,” said Erling. “It’s a challenge faced everywhere, but we can improve the health disparities for those in remote communities by leveraging telemedicine technology. Telemedicine was a partnership we provided to our rural communities and providers long before the pandemic. For some people they think of telemedicine as something complicated like a facilitated video visit, but it can be as simple as a telephone consult with a specialist that’s coordinated through our Regional Transfer and Operations Center.”
“As awful as COVID was and awful as COVID still has the potential to be from the operational side, it actually improved the way we deliver care,” said Krakovitz. First, it opened more patients to the idea of telemedicine. Second, it made healthcare providers understand the importance of acting as a system, making processes consistent so patients receive the same quality care wherever they’re seen.
Renown met the challenges of COVID head-on, said Erling. “We built an alternate care site in the Mill Street parking garage of Renown Regional, which helped care for hundreds of patients with COVID at the height of the pandemic. At the end of 2020 and well into 2021 Renown began administering thousands of free COVID vaccinations for employees and community members with our drive-through site in South Meadows. We continue to learn many lessons from the COVID pandemic, but one important lesson continues to stand out: our physicians, nurses and healthcare teams are critical to the health of our community.”
Capital Improvements
There are unique challenges to building medical facilities. The keyword for doing it successfully is flexibility.
“As we saw with COVID, the needs of patients can change rapidly,” said Bret Loughridge, president, SR Construction, which specializes in healthcare construction. “How you treat those patients might need to be modified extremely quickly. Before COVID, if you were changing the modality of a floor from rehab to medical med-surg or ICU (intensive care unit), that had a planned process to it. Now we’re planning these things to be able to change, to be universal so they can be adapted quickly.”
With COVID it was because the virus was airborne and air systems had to be changed. Now hospitals are being built to be more flexible so in the event of another outbreak, hospitals can adapt quickly and isolate individual rooms or areas as needed. “We need to accommodate the ever-changing landscape of healthcare,” said Loughridge. “So again, flexibility. How do we do that? We might need more infrastructure up front. A lot of the projects we’re working on have universal rooms that can easily be adapted without major construction to make those modifications.”
Hospitals with upcoming or ongoing capital improvement projects may see delays in those projects from supply chain disruptions and labor shortages. Some major components of construction require significant lead times because specialized medical equipment isn’t necessarily in stock on a shelf, said Loughridge. “Most of them are custom made, so it’s planning ahead and understanding what is going to be needed so you can order early.” Another issue is that equipment sourced today for a hospital opening next year is outdated by the time it’s installed. “You have to plan for what infrastructure those machines will need when you buy the machine that might not be completely designed or built yet,” said Loughridge.
SR Construction built Northern Nevada Sierra Medical Center, an acute care 300,000-square-foot hospital in Reno, completed Centennial Hospital’s 5-story patient tower addition and the Henderson Hospital 6-story patient tower addition. Currently they’re working on a new acute care hospital in West Henderson scheduled to complete at the end of 2024, and a MorningStar Senior Living Facility scheduled to be finished in late 2024.
While there are no new capital improvements planned at Renown, there are several projects in progress that began before the economic downturn. Projects underway include a new neonatal ICU, pediatric ICU and surgical trauma ICU in the Tahoe Tower. The new neonatal intensive care unit (NICU) will increase Renown’s capacity from 39 to 49 bassinets, and the pediatric intensive care unit (PICU) will increase capacity from 11 to 16 private patient rooms. “Our care teams have been instrumental in helping us design and develop the layout of the new floors,” said Erling. The Tahoe Tower opens in April 2023.
Renown’s other large project is at Renown South Meadows Medical Center where construction is underway to build a 120,000-square-foot, 3-story medical office building, a specialty care center with expanded laboratory and diagnostic services and outpatient surgery center. “That facility is projected to open in May [of next year], and will help us meet the increasing demand for healthcare for those living in Carson City and North Lake Tahoe,” said Erling.
At the other end of the state, Dignity Health is adding 38 beds to the Sienna campus in a $40 million addition project. They’re also adding a $5 million pediatric emergency department with a separate entrance, which will be staffed by pediatric board certified emergency physicians and pediatric specialty nurses.
Economics of Healthcare
“In Nevada, 26 percent of our economy is based around the service industry, which is great for the state, but we know we need to be able to diversify,” said Krakovitz, who sits on the Las Vegas Global Economic Alliance (LVGEA) board. “When we think about how to diversify and bring better businesses to the state, we look at the states around us. In Utah, the number one employer is healthcare. California and Arizona are the same. In about 15 states, the biggest employer is healthcare.”
When Nevada spends to bring more healthcare into the state, it both helps diversify the economy, and creates jobs. “It also gives the backbone and support that’s so needed for other industries within the state, particularly around what we do for hospitality. Having that backbone of healthcare is really a force multiplier to have more businesses that we want to come to our state,” said Krakovitz.
“The second largest employer in the country and in our state is healthcare,” said Abdou. “The growth of Nevada’s population and the growth of the senior population puts healthcare more and more into focus and into higher ranking and impact on the economy.” Building the medical school in Southern Nevada will improve the number of medical personnel in the community and shine a spotlight on how healthcare impacts the economy.
“I think the biggest project that challenges Nevada is that we have not developed a fully integrated healthcare system,” said Abdou. “Southern Nevada is the largest metropolitan area in the country that does not have a secular integrated health system. The next big thing to drive the Nevada economy [is for] patients and residents of Nevada that suffer specialized healthcare needs to not go to the airport [or] some other state for care.”
