Industry FocusHealthcare

Healthcare in Nevada has seen significant challenges, especially in the past two years. COVID has brought about unprecedented change and hardship for this industry, from patient care to workforce issues. Recently, leaders in healthcare met in a virtual roundtable, sponsored by City National Bank, to discuss the industry and its future.

Connie Brennan, publisher and CEO of Nevada Business Magazine, served as moderator for the event. These monthly roundtables bring together leaders from different industries to discuss relevant issues and solutions.

Are COVID Metrics Improving?

Todd Sklamberg: From a hospital perspective, it’s shifted. We know we’re going to have patients [but] numbers are down significantly from previous waves. Now we need to work on how we operationalize and manage. We know we’re going to have COVID volume and that’s going to be with us for an extended period of time. Last year, at the height of COVID, we had over 200 patients at Sunrise Hospital. Today, we have 57 COVID positive patients. There are 500 COVID patients in hospitals today in Clark County; that’s a fraction of what it was. Of the 57 here at Sunrise, only 17 are on ventilators. We had upwards of over 100 patients on ventilators earlier this year.

Dr. Anthony Slonim: We’re running a census of about 50 or so [COVID patients], and that’s been stable for weeks now. It goes up a little bit, it goes down a little bit. [The numbers have been], essentially, in that space of 45 to 55 for probably eight or ten weeks.

Tiffany Coury: We’re about a fourth of the [patients] COVID-wise that we saw even this time last year. Just this week we had zero patients ventilated, which we have not seen since the pandemic started. So there is definitely an improvement in that regard.

Dr. Marc Kahn: I made a comment a couple of weeks ago for a TV program and I said, “I think we’re on the other side of this.” I hope that statement is true, but the virus is going to continue to mutate as long as people are not vaccinated. We do all that we can to educate people, but there’s still a large group of folks reluctant, so I am very worried this may be with us for much longer than we anticipated.

Sklamberg: Vaccinations keep patients out of our intensive care unit (ICU). We know that they are highly effective. It’s our first line of combat and we cannot encourage enough for [people to get] vaccinations. It keeps you alive, out of the ICU and it keeps you from being ventilated. Walk through our intensive care units and see what happens when you’re not vaccinated.

Dr. Melissa Piasecki: If we can have a high level of vaccinations, not just locally, but globally, that’s going to help us with future variants and mutations. The virus is going to mutate as long as it has a playground to play in; vaccinations are going to close down those playgrounds. That’s one more reason to think about vaccinations.

Do We Have Quality Healthcare in Nevada?

Kahn: Right now, the quality of care here is not what our community deserves. There are pockets where there is quality, but when you look at quality measures, we’re again at the bottom of the pile. One of the exciting things about coming here with a new medical school and with new partnerships is that we can have an impact.

Dr. Paul Krakovitz: We have pockets [of quality care]; it’s quite variable. If we look at our quality outcomes and scores on the acute side, we have a lot of work to do. [We all] want to see it get a lot better on the outpatient side. We have pockets that are doing well, but we certainly have places where we can do better.

Alan Olive: There’s a number of hospitals all across our state that are Leapfrog A-rated. There’s also some exceptional work being done in the ACO (accountable care organization) arena as well. I’ve seen some great improvements. There’s some good work being done out there. Obviously, some of it is hampered by access to mental health, primary care access and the Medicaid reimbursement issue for people to get universal care. We’re 51st [in the nation] still in mental health. That shows you, we are at the very bottom of the barrel for mental health.

How can the State Better Address Behavioral Health?

Olive: Comments about the state valuing healthcare is important, and mental health is one of those key issues. I don’t think we value this piece. [We] adopted some kids with mental health issues, fortunately they have a mom who’s become an expert in mental health. Not everybody has help to guide them through medications and other ways to deal with issues. A lot of children or adults end up [suicidal], we’ve seen an increase, especially with COVID. We need to put a place of value on the human life and that will drive our decisions.

Kahn: And [we need to] care for each other. I was in New Orleans for Katrina. That was a local event, but very much a traumatic event that affected every single person in the region. What worries me is the effects of Katrina lasted well over a decade. We’re just two years into this pandemic. When we talk about the need for behavioral mental health services that’s going to increase as the pandemic continues. We really need to be vigilant.

Coury: At St. Mary’s, the issue has gotten excessively worse. Resources, at least in the north, are slimming. One of our key providers [recently] announced closure because of funding issues. There is pressure on the hospital systems to take care of patients that, perhaps, are better served elsewhere. I know there are a lot of efforts locally as well as statewide to address those issues and advocate for a different system, but the issue still exists.

Sklamberg: Also, so much of it depends upon coverage. If one has a commercial managed care plan, one is able to get from an acute care hospital to a mental health facility to access some services. If you don’t have any type of insurance or are on Medicaid, it becomes a challenge. We are working toward a two-tier system. It’s throughout the entire state.

What Challenges are you Experiencing with Workforce?

Erick Vidmar: We’re losing good people each and every day. Trying to find creative ways to keep them here and recruit new people to come and join us [is very challenging].

Karen Rubel: We’re all competing for the same nurses, the same CNAs. [At the same time we’re] trying to keep up with folks leaving healthcare altogether because of what they experienced in the last 19 months.

Coury: Workforce shortages are preventing us from delivering the kind of care we want. [We are also] trying to support our workforce with the mental health component that the pandemic has [exacerbated] and making sure we’re supporting them through these challenging times.

Alan Garrett: People are not accustomed to dealing with this kind of trauma day-in and day-out. It’s not just resiliency, in some ways it’s PTSD (post-traumatic stress disorder). We’ve got some caregivers who are almost ashamed they can’t muster the compassion [they need]. They shouldn’t feel bad about it, but they do. We’re fortunate to have a behavioral health division, we’ve got counselors available on the floors for people to talk to. That’s helpful but not enough.

Krakovitz: When the pandemic started, the ability to separate home and work became really challenging for a lot of people. We’ve started to focus on helping people unplug. A lot of what we’re seeing is decades of healthcare neglect towards behavioral health. The more we bring this out to the front, the more we’re going to be able to work on this together. It’s got to be all of us in healthcare, recognizing this and working together.

Piasecki: What we’ve learned from the pandemic is that we are all so interconnected. We share the same concerns and burdens. There’s a couple of statewide initiatives that are useful. We have the Nevada Physicians Wellness Coalition, which invites physicians from all hospitals, systems and schools to come together and form a community. There’s also the Physician’s Help Line. One of our physicians at University of Nevada Reno, School of Medicine was one of the founders. [It is] staffed by a volunteer psychiatrist talking to physicians and medical students who need support.

How are Changing Policies Affecting this Industry?

Vidmar: [The] challenge now is adequate reimbursement for the work we do. We’re seeing an increasing in costs, rates and demand for the services in the community.

Garrett: Policymakers look at healthcare and say it’s complicated. So, they come up with policies, whether it be the Affordable Care Act, universal coverage or the public option. The problem is, it’s not changing the way we [deliver] healthcare. We have to fundamentally change how we do healthcare to be able to reduce the overall cost. Telemedicine is part of that, managing chronic illness, keeping people out of ERs and looking at complex algorithms so we can predict outcomes and intervene before things get catastrophic. But, there’s no room for that kind of innovation and investment because there’s not enough reimbursement to fund it. Policymakers believe by reducing reimbursement, they’ve solved the problem. What they’ve really done is made the problem worse.

Slonim: The Patient Protection Commission in the state continues to reduce reimbursement and drive costs down; our unit costs on the other side are going up. We [need to] start investing and get reimbursement where it needs to be. We all agree on access issues and, in order to serve people with appropriate, high-quality, efficient care, we have to be compensated for that. Our costs are changing in the midst of the pandemic, and for years to come.

Krakovitz: We’ve got to get more upstream in healthcare, it’s the only way we’re going to be able to bring costs down to be affordable to the everyday person. I agree reimbursement is an issue, but at the end of the day, people have to be able to afford healthcare, to be able to access it and utilize it.

Kahn: Access to healthcare is critical. Healthcare should not be a privilege in a country with the wealth we have. We are the only country in the world where thirdparty payers can make a margin on healthcare. When you look at the United States, we rank low on every single list of healthcare outcomes. The only list we’re number one in is cost per capita. If a public option can decrease cost per capita and increase quality, it’s something we need to think about.

Sklamberg: Access is a challenge here in the community, [but] there was an incredible rush to pass this [public option]. Hospitals were mandated to participate, however, we don’t believe there was a meaningful review of the impact on Nevada, providers, the hospitals or how this would be carried out. We’re one of the most revenue suppressed communities in the entire country. This has the potential to further push down reimbursement to the point of not being able to cover our cost to provide care.

Olive: Ultimately, the key issue in regard to this public option is access. We want access for everybody. Yes, all our ERs are open and mandated to take all people, which we would do even if we weren’t mandated. It’s some of the other issues of primary care [that we need to address]. We’re still 48th in the United States with reimbursement. We’re at such low levels for [access to] primary care, it forces people to go to inappropriate areas to receive care.

How can Population Health Play a Role?

Krakovitz: When we talk about population health, social determinants of health and how we do partnerships [is critical]. They’re not traditional healthcare partnerships. It’s partnerships with education, food banks and transportation. I’m optimistic about where we’re going, not just with value-based care and our ability to reduce costs, but also how we’re collaborating as a community.

Piasecki: Population health is a long game. What we’re doing with Renown, having an integrated health system, the School of Medicine is bringing our learners in to see what population health should be. We’re creating a new generation of physicians and physician assistants who understand the long game. All the obstacles we’ve heard about in terms of reimbursement and workforce, those will be short term obstacles. In the long term, educating a workforce that understands population health and can embrace those practices and principles is what Nevada really needs.

Slonim: The nuances and details of population health really matter. There are several great organizations where they’ve been successful in pushing the envelope, doing value-based care and population care. [But], mandating it doesn’t work for me. It creates a more cumbersome approach to delivering healthcare and doesn’t move us forward.

Is Nevada’s Healthcare Industry Collaborative?

Krakovitz: We’re seeing a lot of improvement in collaboration in healthcare. At Sunrise, we’ve been able to put a pediatric neurosurgeon at the hospital which was able to prevent a lot of transfers that were leaving the state prior. We’re able to keep [those patients] here in the community.

Vidmar: COVID has limited some of these [collaborative] interactions. Our presence at Cleveland Clinic is fairly small and we’re always looking for new opportunities to partner. I find it to be a very collaborative [community].

Rubel: COVID forced us to try to figure out answers to things together. From a hospice perspective, we’re always trying to be [neutral] because we service the patients in all the hospitals and facilities. With the hospitals in southern Nevada, they’re very collaborative. We do a lot of palliative care in the hospitals and facilities, but the pandemic [made] us come together to figure out solutions to problems.

Does Nevada Offer Enough Residency Opportunities?

Kahn: Not even close. When you look at the numbers our state has, we’re at the very bottom in positions per capita. Compare that to a state like New York that has over 20,000 funded positions. Many of our training hospitals are over-capped. The data says that 70 percent of people stay where they’ve last trained. To fix workforce issues, we have to expand graduate medical education.

Piasecki: We need to expand both the numbers and types of residencies to really develop a more robust fellowship training landscape. So many of our great residents leave Nevada because they want to do a fellowship in an area we can’t provide them. We would love to expand graduate medical education all the way from primary care to subspecialty fellowships.

Rubel: We have a fellowship program for hospitals and palliative care. We have made the commitment to hire those doctors once they finish that program, if they want to stay with us. It’s a small, philanthropically funded program, but certainly helps the hospice industry keep those doctors in town.

Slonim: There are a number of things I am concerned about, but the thing I would love to anchor on is how we quickly adapted during the pandemic to work together and advance what our community needed. How can we do the same thing around medical and nursing education? We still educate nurses and doctors the way we did 50 years ago. How can we use the platform we have, the crisis around workforce challenges and what we need to do to creatively execute a cross discipline? Healthcare is a calling and we want to tap into that sensibility because it allows us to engage people in the work that we do.