Quality Access + CostNevada Healthcare Checkup 2024

 

There used to be a joke about healthcare in Nevada that went something like this: Where do you go for the best healthcare in Nevada? The airport.

The joke doesn’t hold up. Today Nevadans don’t need to leave home to access the healthcare they need. That’s not to say the industry isn’t facing challenges, especially in light of ongoing inflation and the lingering results of the pandemic. But healthcare in Nevada has changed.

Healthcare is People

Ask half a dozen healthcare administrators what the number one challenge to the industry is and the majority will answer workforce. Even before COVID, burnout and retirements were plaguing every industry, particularly healthcare, and Nevada has long been short on providers. There are national shortages of radiologists, ultrasound technicians, physician specialties like anesthesiology and pathology, nursing specialties such as critical care and emergency room attendants. Nevada also has an ongoing shortage of doctors, nurses, medical assistants, physicians assistants and technicians of all sorts.

But that situation is actually improving. “Healthcare is always changing,” said Jeff Prater, CEO, Carson Valley Health. “It’s not what’s up and coming; it’s an always kind of a thing. Recently, the healthcare workforce shortage is paramount across [the industry].” In order to make access to healthcare for Nevadans a reality, there’s a lot of necessary recruitment. “We need to ensure that we’re retaining those folks when we do hire them.”

Statewide efforts by healthcare organizations are aimed at not only recruitment, but educating and retaining new care providers. Nursing schools are working to increase enrollment. Hospitals are creating residency programs. The state Legislature is searching the budget for funding for even more programs.

“Some med schools are starting to increase their enrollment and are expanding,” said Prater. “I’m not saying it is pre-COVID from that standpoint, we don’t have people knocking at our doors, but what we’re seeing at my facility is a stabilization of some of our hard to recruit areas.”

Helping recruit medical personnel into our communities is Optum, a care delivery organization with 450 physicians and advanced practice clinicians like nurse practitioners and physicians assistants. Optum is the oldest, largest medical group in southern Nevada.

“Our staffing is going really well right now,” said Dr. John Rhodes, president, Optum. “We were having a hard time bringing in medical assistants (MAs’), so we were able to do a collaborative effort with one of the training schools here in town, to help MA’s train in their facility, graduate from their program, and join us through the recruitment process to fill those needs [in area healthcare].”

Staffing is one current industry challenge. A logically related challenge is access to care, especially in Nevada’s rural counties. “Especially living in Gardnerville and working in a critical access hospital,” said Prater. Nevada has 13 critical access hospitals with a lot of ground to cover. Those hospitals work together through Nevada Rural Health Partners, sharing ideas on how best to deliver healthcare to rural Nevada.

Metro area hospitals face similar access-to-care challenges. “One challenge is really around social determinants of health and how we work with our community partners to try and solve what are major impacts on individual’s health, like homelessness, food insecurity, poverty. Those are the challenges, and they’re difficult things to solve,” said Dr. Brian Erling, CEO, Renown Health in Reno.

Renown partners with community organizations to address those problems. “I’m not a food bank,” said Erling. “But I know how to partner with a food bank who knows how to put effort into trying to solve food insecurity.” In 2023, Renown financially supported and partnered with around 50 community organizations. Every three years they perform a community health needs assessment to identify the biggest needs in the community and create plans to tackle them.

A trend with negative effects on healthcare is private equity firms. “We’re experiencing those challenges firsthand, as some of our long-term key partners that support the hospital have been bought up, purchased by private equity, and subsequently those demands and new contracts have created some exorbitant fees, putting a strain on the financial system and access to patients,” said Mason VanHouweling, CEO, University Medical Center of Southern Nevada (UMC). “Unfortunately, private equity wins, and patients lose.”

Private equity firms are venture capital groups, not publicly traded, formed by wealthy investors with no particular ties to healthcare. They purchase practices, consolidate, and put financial pressure on healthcare providers, limiting access to services.

The Legislative Counsel Bureau’s Interim Finance Committee is expected to look into private equity firms this year. Meanwhile, UMC has created in-house departments of specialties impacted by private equity, like UMC Anesthesia, allowing patients access to necessary procedures.

Rising Costs of Healthcare

With a post-pandemic economy and rising inflation, everything is more expensive, including healthcare. Workforce shortages drive up salaries. During the pandemic, providers could make extraordinary amounts of money by working as traveling nurses. For example, medical-surgical nurses could make $200 an hour as traveling nurses. Those costs are stabilizing. Nurses are returning home. Traveling companies are no longer paying extreme amounts.

Other costs remain high. “Cybersecurity is a major player in the cost of healthcare,” said Prater. The efforts required to keep patient data secure need to be constant and backed up by the most updated technology possible.

New technologies can save lives and improve patient outcomes, but come with high price tags. Rural hospitals with smaller budgets than larger metro centers can experience difficulty acquiring new technology, even when there’s a need for it to help provide access to patients in remote areas.

Technology can also help lower costs. “We’re starting to see the use of artificial intelligence,” said Karla Perez, president, Valley Health System. “Imaging radiology is an example of how artificial intelligence is being used to improve the quality of care by prioritizing patients that are in queue to be read for imaging scans. Artificial intelligence can go through and actually re-prioritize those patients that might have higher acuity, and prioritize those exams be read first.”

Chronic disease management with an aging population is another factor driving up healthcare costs. Access to coordinated, multidisciplinary care is vital; educating patients on the importance of regular checkups and managed care could help slow those costs.

The high cost of pharmaceuticals drives up prices. Carson Valley Health’s infusion center needs everything from cancer drugs to pain meds, and the price is steep.

Is there any relief in sight from the high costs of care? Collaborating and partnering rather than competing could help bring down costs. It’s vital there be, “partnerships between healthcare systems,” said Prater. “We should all have the same goal – to improve the healthcare quality to the people we serve. If we could combine our efforts and look at it from that perspective versus the competition behind it, I believe that would impact some of the cost of care because we can appreciate some of the synergies behind it, which decreases inefficiencies.”

There are efforts to increase reimbursement to hospitals, especially from Medicaid cases, but no specific efforts related to decreasing the cost of care overall, said Perez. “From an industry perspective, it behooves us as an operator to look to ways to reduce those costs. So we’re focused on increasing efficiency, standardizing the approaches we use, optimizing and rightsizing where appropriate. Because we’re not going to get significant reimbursement relief, we have to continue to focus on our cost controls and make sure we are operating as efficiently as possible, reducing waste in the system.”

That waste is of both time and supplies. Because hospitals don’t share information, a patient might get a CAT scan in one hospital, get admitted into another a week later, and receive another CAT scan. Lack of coordination can lead to unnecessary services and duplication of efforts. Which sometimes comes down to the question of access.

How Cost, Access, and Quality Tie in Together

“There is a significant, direct correlation,” said Perez. “Because if you can’t get access to your primary care physician, you may resort to using an emergency room (ER).” Using ER care rather than primary care is quite a bit more expensive.

Workforce shortages can drive up costs in unexpected ways, like delaying discharging a patient from hospital because there’s a shortage of skilled nursing. The patient remains in the hospital because there’s no placement at the next level of care. That not only increases costs but can impact quality of care.

Studies have shown longer hospital stays can result in further complications.

“A patient might be more susceptible to a fall or an infection the longer they’re in a hospital. So our goal is to provide care in the most efficient way possible where patient length of stay is appropriate to the care they receive and the resources they need,” said Perez.

Healthcare is expensive to deliver. The aging population means more Medicare, and Medicare doesn’t cover more than about 85 percent of costs. But it’s important to make certain when trying to lower costs that it’s not at the expense of quality.

So how do cost, access, and quality tie in together? That’s the healthcare value equation: quality, access and service over cost, said Erling.

“They’re all related, they’re all interdependent, and a change to any one of those variables has an effect on the others,” said Erling. “I hope that anybody in healthcare would say quality is expected and not optional. I would hope that you wouldn’t go into healthcare if you’re willing to tolerate anything other than high quality. So when the industry feels costs pressures as we have felt over the past several years, we tend to see an impact on access, customer service. That’s a significant focus for us right now.”

Make it Better

Ask half a dozen healthcare providers how to make Nevada healthcare better and there will be half a dozen wish list answers. There’s a lot already happening to improve healthcare, starting with the basics: recruiting necessary personnel and growing primary care access. Primary care is essential for prevention, early diagnosis and chronic disease management. Once primary care is in place health systems can bring in specialists, expand care, work to keep access local.

“I would like to see a focus on value-based care within the community,” said Rhodes. “Care that encompasses the Quadruple Aim, which is really affordable care, quality care, care that the patient feels good about, and care the physicians are proud to be providing.”

Another way to meet Nevada’s need for more doctors and nurses is through residency programs and fellowships. Graduate medical education programs are offered by many hospitals, with the hope that graduates from programs will stay in the community.

Renown offers four residencies: psychiatry, internal medicine, family practice and a new pediatric residency. Valley Health, which offers residencies in internal medicine and psychiatry, just launched a new program in emergency medicine. Sunrise Health System has the largest medical education program in its three hospitals: 310 residents, and there’s still a need for more residencies. Sunrise’s anesthesia program received 1,000 applications for the eight slots available.

“We had our first graduate in the internal medicine and rehab residency program, and that graduate chose to stay right here in Las Vegas,” said Hiral Patel, CEO, MountainView Hospital. Sunrise partners with nursing schools for their clinical rotations; the first in-person cohort starts this fall. They’re also the only hospital-based paramedic institute in Nevada.

Residencies are funded by Medicare, but only up to a certain amount. Renown currently has 74 residents, and will add two more with the pediatrics program. That’s 20 residents over Renown’s cap, meaning Renown doesn’t get reimbursed for those: they pay out of pocket. Their goal is to launch five more programs by 2030 to bring more clinicians to Northern Nevada.

“That requires funding, so we’re working with the state,” said Erling. During the last legislative session a bill passed for a one-time $8 million grant for graduate medical education programs. It’s appreciated, but it’s not enough. It might cover three new programs for the first year, for the entire state.

Coordinated care systems can lower costs. Based on the Kaiser model, Valley Health is creating a clinically integrated system of coordinated care that assigns doctors to patients and guides those patients through medical processes seamlessly. Coordinated care limits personal choice, but a clinically integrated system of care can improve access, quality, and cost of care.

Make it More Efficient

The more efficient providers can be, the better they can provide care and decrease costs. One step is to find ways to incorporate AI into the industry. The idea isn’t to replace humans but to augment their efforts and deliver healthcare in an efficient, cost-effective way.

Renown intends to pilot AI-assisted technologies like virtual nursing, providing support like ambient listening, which monitors patient rooms to determine things like is the patient simply rolling over, or trying to stand when they’re not capable.

“We’re seeing a lot of technology being used in our academic centers,” said Rhodes. “When I went through school they had a cadaver lab. Now much of what they’re doing is on models and technology in a way that outlines it really well for new learning physicians. There’s a lot coming ahead with technology and how it incorporates into healthcare, it is really exciting.”

So where do you go if you get sick in Las Vegas? Not to the airport. “I really believe we have a very good medical community with a lot of really good doctors. I just hope we continue to build it with great quality physicians and people can feel good about the care that they’re getting in our community,” said Rhodes.