Nevada’s healthcare system has seen a multitude of challenges in recent years including access to care, quality concerns, and doctor burnout, among others. Leaders in healthcare are working hard to address a multitude of issues within the industry. Recently, some of the state’s most prominent leaders met at the Las Vegas offices of City National Bank to discuss those challenges and what the future holds for healthcare.
Connie Brennan, publisher, and CEO of Nevada Business Magazine served as moderator for the event. The magazine’s monthly roundtables bring together industry leaders to discuss relevant issues and solutions.
Do Nevadans have Access to Quality Healthcare?
Heather Korbulic: It depends on your savviness. Healthcare is very complex and to advocate for yourself in a complex system when you’re sick is incredibly challenging. It depends on the resources and your level of expertise to really access that quality care. It’s who you know. In our industry we can probably call the right doctors, right? I think that there’s a level of disparity depending on our knowledge.
Dean Dow: Other issues are the sustainability and access to healthcare in and of itself. I know from our industry, regardless if it’s paramedical or aeromedical services, the industry is under immense pressure. [We’re under] probably more pressure than I’ve ever seen, in the sense of reimbursement. I wake up in the middle of the night worrying about sustainability and what we’re going to be able to provide five to ten years from now. The Affordable Care Act (ACA) didn’t fix the accessibility problem. So 911 systems in this country have become the go-to default safety net. If you can’t access a physician or a clinic, you can’t understand how to get into the healthcare system, what do you do? You call 911, we take you to the emergency department, you’re in the system. Is that cost-effective? Is that the right thing for the patient? Is it sustainable to communities across the country? We have to change a lot of things to make it better.
Donna Miller: Our state has similar issues to many other states. However, I do believe, because of our geography and the way our healthcare access is, it really does make us a bit unique. Access to care in rural communities is barely there in many communities. The only access to healthcare is by air ambulance and ground or EMS (emergency medical services). It’s sustained by volunteers and communities depend on people like that.
Karen Rubel: From our perspective in hospice, because we see those patients right at the very end, our issue is care coordination. I think the social deterrents of health certainly become an issue as you move through your healthcare journey and so trying to find resources in the community and connect patients to those resources [is a challenge].
Does Nevada Have a Shortage of Healthcare Providers?
Mark Price: When you compare us to the rest of the country, we are absolutely shorter in terms of providers per capita, particularly when you look at preventative care. [We’re in the] bottom five in the country for behavioral health providers per capita. The system we have in place right now does not come close to using the resources we have. The fee-for-service system is broken. There are incentives that are the exact opposite of what they should be, in some cases it may actually lead to inefficiencies. So, we’re short [providers] compared to the rest of the country and it’s not by a little, it’s by a lot. By some estimates, we have to have 80 percent more primary care providers to get to [the national] average. At the same time, we certainly do need to get better at using the resources we have and change a system that incentivizes the wrong behaviors. Making some of those changes are difficult here for a variety of reasons. It’s a little bit harder to assign or manage a population where we’ve got such a distributed and fragmented system. We still have to figure out how to do it and manage this population where we’re focused on population health and not focused on delivering as much. The goal should never be delivery of services, it should be to deliver health and do that in the most efficient way possible.
Dr. Sherif Abdou: Seventy percent of 911 calls don’t need to go to 911, I would say the same thing for traditional visits to the doctor. Some percentage of it does not need to be a face to face, time-consuming visit. A lot of the visit can be done by registered nurses, nurse practitioners and physician assistants, by much less expensive, much less limited resources, [such as physicians]. But, because of the fee-for-service system, [those physician visits] still dominate. When we merged with Fremont back in 2009, we reduced their visits by 33 percent and patient satisfaction almost doubled on the outcomes of every category we were able to measure. Before we merged with them, the physicians were getting paid per visit. So, for every patient that comes in, they would say, “Come back next week.” Whether they need to come back next week or not. Once we change the model to a different incentive, the patient comes back in six weeks, or six months. In between, care managers or coordinators will call and check on results. It’s no longer that the physician gets paid only when the patient walks through the threshold of the office. A lot of the pressure and shortage of physicians is self-induced by inflated demand.
How Efficient is the Delivery of Healthcare?
Mason Van Houweling: Many 911 transports that are made don’t end up being a true emergency. Even at UMC, which is the highest level care, less than 15 percent of our patients are admitted from the emergency room (ER). I do see a lot of improvement on the insurance side, in getting patients in much sooner so they’re not having to use emergency rooms. Actually our ER volume is down. Most hospital CEOs will tell you that’s not a good thing, but I’m proud of that. I’m proud that we’re down 4 to 5 percent year-over-year in our ER visits because patients are getting the medications they need, they’re getting the care they deserve and they’ve got a primary care physician so they can be medically managed.
Dow: You actually hit the nail on the head, your focus is managing the patient and helping that patient go through a very complicated health system and navigate that health system, but your philosophy is to steer them into the right direction. Any large hospital today in an urban setting that can say that their census in the ER has gone down needs to be applauded. I can tell you, across this country, that is not the case.
Miller: As ambulances, we only get reimbursed if there is a transport associated with the response to the 911 call. So, when you respond to a call and there’s no transport, there’s no reimbursement. The reality is, we have to perform a certain number of transports to be sustainable. Medicare is trying to implement [a program] where we have the capability of responding to a call and assessing the situation. If there’s reason to believe that this patient really doesn’t need to be taken to an ER, then we either treat the patient onsite, take the patient to another destination or refer the patient to an ER, a quick care, their doctor or, perhaps, a nursing line. This way the patient does not get to overcrowd the emergency rooms and they still get taken care of but in a more financially effective and efficient method. The Medicare program, in a situation like that, would still reimburse for that call even though a transport has not happened.
Is Patient Information being Shared Across Providers?
Miller: ESO is a platform that recently has been put in application here in Las Vegas where there’s sharing information about the patient from pre-hospital to hospital and back to the pre-hospital.
Van Houweling: For UMC we have Epic, which is a great electronic health record system. Every other hospital has a different system so the inter-operability of those to speak to each other is non-existent unless you go through the health information exchange which everybody’s signed up for. I know with the Trump administration it’s a hallmark. In fact, the mandate to provide electronic health information by 2021 in electronic format is coming.
Abdou: The solution to this is patient centricity The medical record belongs to the patient, not UMC, not Healthcare Partners, not P3 Health. The patient owns the record and only the patient has the right and the ability to move that around. Right now it’s my record, if my patient showed up in his group with my record then they have to ask me and maybe I’ll give it to you, maybe not. It’s the patient’s record. If you mandate that in a way that AMR would have access to the patient’s record, the hospital would have the patient record, the patient can choose to go to any urgent care and they will have access to their record.
Van Houweling: Those are the arguments I hear. [People say], “That’s our proprietary information. We don’t want this company to know.” We just need to get over that.
Patty Holden: They did it years ago when they had the imaging and developed the Dixon Method for storage and being able to transmit images wherever you wanted them to go. It should be the same, it should be somebody saying, “This is the format that is has to be in so that anybody getting the patient’s information can have access.”
What are Nevada’s Challenges to Improving Healthcare?
Price: The most important challenge we have is changing our goal. The goal shouldn’t just be great healthcare, it should be great health. We know that medical care only drives about 20 percent of disparities in health outcomes. The other 80 percent is what’s generally called social determinants of health – healthy behaviors, diet, socio-economic factors and environmental factors. Our large, growing industry of healthcare continues to spend most of our resources on what drives 20 percent of the outcomes, as opposed to what drives 80 percent of the outcomes. That’s a national issue, not just a local issue. But, I do think we have local things that make it even more challenging for us to address that here, at least in Southern Nevada. We have a very fragmented delivery system, which makes it hard for any one group to step up and make investments. Another [challenge] is, we do have one of the lowest levels of state and local funding of health of any state in the country.
Miller: It’s surprising that in a state like ours we have one Level One trauma center in the entire state. It’s amazing that we don’t get any transplant services other than kidney. Every single transplant patient has to be transported out of state. It’s unbelievable when you talk with other states and you point that out, most people think that I don’t know and that it isn’t true.
Is Healthcare Underfunded?
Abdou: The biggest not-for-profit company spent $100 million dollars to put their name on the Raiders stadium. One of the problems is, we have so much money in healthcare and we’re so busy collecting it, that we’re not paying attention to the patient. The highest-paid executives on Wall Street are healthcare. To sit here and pretend there is no money in healthcare is totally unfair and unreasonable. We’re not going to go anywhere if you think we just need more money and everything will be okay.
Korbulic: There is a need to profit. Eighteen percent of the GDP is healthcare and that’s constantly growing. We push up against patient needs with the need to grow the bottom line to satisfy stakeholders and that doesn’t ever die. Specific to Nevada, from my perspective one of the biggest, most profound and significant disparities that we have is our lack of investment in public health. In general, we spend $6.75 per person on public health when the national median is $38 per person. That’s kind of telling on what we value in what our investments are in health.
