An industry that remains in the throes of transition and reform, healthcare has been in the spotlight for the past several years. Between healthcare reform and changing practices, healthcare professionals have had to learn to jump with the times. Executives representing healthcare in Nevada recently met at the law offices of Holland & Hart in Las Vegas to discuss this changing industry and what the future holds.
Connie Brennan, publisher of Nevada Business Magazine, served as moderator for the monthly event that brings leaders together to discuss issues pertinent to their professions. Following is a condensed version of the roundtable discussion.
In regards to the healthcare reform bill, do you think the state’s rights lawsuit will succeed?
Dr. Sherif Abdou: I don’t think so. I believe that the Supreme Court will look at the healthcare reform as a whole as a beneficiary for the country and that will supersede any State interests or individual interests according to the Commerce Clause and the 14th Amendment. I believe they will uphold the healthcare reform and it will continue. Not only is it the right thing legally to do, but I believe it is the right thing to do for the country.
Howard Baron: I believe they won’t uphold it legally but it won’t tremendously affect healthcare reform going forward. We are fooling ourselves if we believe that striking out the mandate for everybody to have insurance, which is unconstitutional, is somehow going to overturn the entire Affordable Care Act. I don’t think that is a big portion of it. I don’t think that is the killing point of healthcare reform.
Abdou: Do you disagree that healthcare reform itself is the right thing to do?
Baron: No, I don’t disagree. That is why, even if they don’t uphold it, I don’t think it will be a stake in the heart of healthcare reform.
How will healthcare reform and insurance costs affect business owners?
Baron: Despite the voiceover in the whole thing that if you like your insurance, you can keep it, there are some very practical issues associated with that. I am a small business owner. My practice employs about a dozen people. It is getting to the point where I can no longer afford to insure my employees because of the rapidly increasing rates. When you have the insurers around the table and ask why the rates are going up so rapidly, they say because of the uncertainty in healthcare reimbursements and the fact that we don’t know from year to year at this point what is going to happen. We are trying to guard ourselves against all possibilities. They see their expenses are going to substantially go up and so they are trying to plan for that. For the small business owner, it’s going to give them an inability to afford third-party insurance for their employees.
Brian Brannman: It is an ongoing battle for reimbursement rates. I have family members that have had premiums go up 25 or 30 percent. If the premiums are going up that much and reimbursements on my end is five or six percent, where’s the difference. There is no visibility and that is the thing missing in our current system. I have to be totally transparent. Any taxpayer can know exactly where all of my money is going, but any of the people that I am paying huge amounts to for a medical device or pharmaceutical, who knows where that money is?
How long before healthcare practitioners have to be completely compliant with healthcare reform?
Abdou: It depends on who you’re talking to. I don’t think we will see the full-fledged impact of healthcare reform until 2017. The rules and regulations are really going to impact more the payers than they will impact the providers in a direct fashion.
Brannman: There are some aspects affecting us now. For example, we recently signed a contract for electronic health records so I can beat the windows for reimbursement. I think that was expedited because of the pressure of the bonus money. The carrot was out there so I can access that but also there were penalties if I didn’t adopt it; to see my already meager reimbursement I get decline even further. Having an automated healthcare system proliferate throughout healthcare is going to be a positive influence for everyone. It is out there and we are not going to roll back from it no matter what else happens with the constitutionality. We are already there now.
James Kilber: We have seen the results of a true EMR (electronic medical records) working throughout our practice from our surgeons to our radiation oncologists to our medical oncologists and how affective that is. I only see that continuing to improve for the future, and that’s very positive.
Are you seeing more departmental collaboration and why is that important?
Kilber: What is happening now is we have recently formed multi-disciplinary groups to take care of patients. For example, if I have a breast cancer patient, now we have breast surgeons, medical oncologists for breast cancer and radiation oncologists. We meet every Thursday morning in a roundtable tumor board to discuss every breast cancer patient. There are a number of positive things in this that affect the patient and patient outcomes. If you can get faster, more efficient care and have people at the same table collaborating together, I only see a positive outcome. It saves the patients money because they don’t have to be bounced around town. It saves the insurance companies money because they don’t have to send patients out of network. Multi-disciplinary groups are the way of the future and we have to be accountable to ourselves and the community. We can now prove to the insurance companies that we are saving them money by having a multi-disciplinary approach.
Dr. Carolyn Yucha: Do you see involving a nurse clinical specialist or physical therapist? You are talking about the group as multi-disciplinary but it sounds like it’s all MD’s.
Kilber: We have oncology certified nurses and social workers involved.
Brannman: That’s how it is with the accountable care organizations. If you start looking at healthcare from a more scientific and evidence-based perspective, it is a really smart approach. You see the same thing in our transplant program. We sit down once a week with the surgeons, the internist, the advanced practice folks and the dieticians to take a 360-view of the patient. That is how to properly manage some of the complex illnesses. The areas where you don’t see that take place is where the costs really take off. The earlier you can bring all of the resources to bear, the better chance you have of keeping that situation contained and keeping costs under control. It challenges our traditional open-shop mentality and it is going to be a real transition for the physicians on how to deal with that, whether they go to an employee model or some other kind of affiliation. We seem to be pushed in that direction by the way healthcare is changing.
Have patients had to become more responsible for their own healthcare in recent years?
Yucha: I think they should. They should be the center of this.
Brannman: They have to advocate for themselves.
Yucha: I do think that the patient should be more involved. Whether they have the knowledge to be more involved is another issue. I fight this at the university. We have students who get out of the university without any idea of how their body works, how can you understand what anyone is telling you?
Zulma Munos: I agree that once the patient is given the right tools, it is truly in their best interest that they take responsibility for their healthcare. That is one of the models of Access to Healthcare. It’s a shared responsibility model. The patient has an invested responsibility in keeping their appointments, doing what they are supposed to do and paying at the time of service. It has proven to be successful in Washoe County where the uninsured are taking a lot more responsibility for their healthcare and making a difference being healthier.
Brannman: Rather than having a relationship established with your physician, a partner in your care and someone you can work with, now the physician has to contend with [patients] watching a football game and some guy saying they ought to ask their doctor about this, that and the other. Buying medication is not like buying a soda. That ought to be something that is left to someone who really understands you and makes that decision.
Are we still experiencing a shortage of qualified nurses?
Yucha: It swings back and forth. According to national reports, we still have a nursing shortage. If you look at Southern Nevada, nurses who were retired went back to work and people who were working part-time are now working full-time. We don’t have a nursing shortage right now, but the prediction is that we will as soon as the recession ends and people get back, their spouses get to work, they will leave the workforce again and we will have a shortage.
Brannman: I have a very senior nursing staff at UMC. They are stable and very experienced. I am also concerned at some point, we will have this block of retirement where I am not sure there are all the young people coming up the pipeline to take their place. That is troubling to me. You can’t replace those years of experience, that makes a difference. The longer you are in the business, the more seasoned you are, the better decisions you make for the patients. You can’t replace that experience overnight.
Kilber: We are seeing a shortage in specialized oncology research nurses. It is very difficult for us to find.
How is Nevada’s healthcare system ranking compared to other states?
Baron: The problem is that it is made up of so many different factors. We are probably in the middle of the pack in some and low in others and we are surprisingly high in yet others. For example, if you look at specific areas, we have a children’s heart center here in Nevada that is the premier pediatric cardiac interventional practice in the Western United States and nobody knows that. People literally get referred from Idaho for special interventional baby heart procedures here, but people don’t know that. On the other hand, we have a huge problem in terms of an insufficient amount of primary care physicians. If you ask the average Southern Nevada who their primary care doctor is, they can’t name who that is.
Brannman: I think our facilities here would stand up well against anybody else around the country by and large. I think we need to do a better job on tooting our horns. The idea of transparency, of being able to, if we can decide on some relevant quality indicators, have them out there for everybody to be able to compare is a good thing. We do have some pockets of excellence that we ought to tout and we don’t. By and large for healthcare consumers here, it is a pretty good market. Baron: I think our local media is particularly cruel to the medical community here. You hardly ever hear about good stories. It used to be that there truly were services that were not available here. It has morphed into [people saying] the services that came here in the last 25 years can’t be that good or they wouldn’t be here. It is very frustrating to hear about patients that go to Southern California for care. That is why I came here, so they don’t have to go to Southern California anymore. I think the new motto for Nevada healthcare should be what gets sick in Vegas, stays in Vegas.
Abdou: We can believe our own shenanigans, but the fact is, every indicator points to a substantial lack of quality in Southern Nevada’s healthcare industry. I practiced here for a period of time. We can talk about the media, the reality is every single matrix that measured out of Vegas for the last five or ten years indicated that we suck. We have not emphasized quality of care for the longest period of time. People came here because they made more money here than anywhere else, people gravitated here and we promoted fragmented dysfunctional groups. You can find pockets of good care but there is no delivery system. Unless you put the issues on the table, you will never fix it. I think we have a unique opportunity. We have good people and we have good doctors but they are not integrated in a system.
Brannman: There has been progress and we recognized it. I think it is important to start educating people about the data. It is our responsibility to educate people about the things that really ought to be looked at. We need to hold ourselves accountable for meeting those standards. You get what you expect. As long as we all recognize we are willing to be out there and have those quality indicators be how we are judged; I think you are going to see some changes.
Abdou: We are on the right track. We are looking in the right directions. It will take more than gimmicks and thinking and hope to change the image. You’ve got to do it and you’ve got to do it for a while and consistently, then people are going to come and say, “Yeah, you know what? The image has changed.”
Will Nevada ever have an academic medical center?
Brannman: We have a great system of education. We have to pull together the wealth of resources we have at UNLV and the University of Nevada School of Medicine and capitalize on that. We had this movement trying to get some sort of truly academic medical center. Not just a big hospital where there is teaching going on but where you have research and other scholarly activity so that we have people publishing. That raises the bar in the community because then the standard of care is not just good enough that the patient gets out of here and we didn’t end up in litigation. I think it’s moving that way.
Abdou: I fully agree with you. It is time to build the system, it needs to be a system. It needs to be integrated, coordinated. The County needs to get out of the business of running a hospital. The School of Medicine should coordinate with the community and cooperate and become a true teaching hospital. It’s time for us to invest in the community and into a full-time teaching staff.
Brannman: We need to reach out and overcome some of the fear in the community that somehow the medical school is going to come in and sweep up everybody’s business. It needs to be collaborated. We need to create a system that takes advantage of the strengths of the medical community we already have and incorporate them as partners. Some of it will be full-time academic people. We have a lot of talent out there in the community, let’s bring them into the discussion and help them work with so we grow great physicians and nurses that want to stay here in the community.
Baron: That is underscored by little things that have already happened in the last few years. The Cleveland Clinic venture with Lou Ruvo has been successful so far and I think they are doing the right thing. They are adding things to the community rather than finding a niche and competing against people. They brought in people from the medical school initially. They are doing it the right way.
