Insightful Discussions
Oct 23, 2017

Health Care Changes And Challenges

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In the midst of proposed changes to “Obamacare," patients and medical providers alike continue to feel the impact of federal regulations on the availability of affordable care. But those regulations have prompted those in health care industry to think outside the box and partner with other providers and the community at large. In the following pages, five industry officials offer their thoughts on the changing health care landscape.

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How does the Wilmington area compare to other regions its size in terms of health care services?

KELLY EROLA: My impression, having recently moved here from Savannah, Georgia, is that this area is a big health hub for the region. There are excellent hospitals, outpatient care sites and some very well coordinated services. The community cares about meeting the needs of its population and strives to have services locally.

ELLEN TUCKER: The Wilmington area is very fortunate to have superior health care providers and facilities versus similarly sized areas. Strong physician practices and a well-respected hospital enable most care to be provided locally. Care that must go out of the area can be provided at Duke or UNC, only a couple of hours away. This is an important factor in attracting employers and their employees to the Wilmington area.

LEZA WAINWRIGHT: Trillium Health Resources manages services for mental health, intellectual/developmental disabilities and substance abuse for those who receive Medicaid or are uninsured throughout 25 counties in eastern North Carolina. The majority of our counties experience economic difficulties, as well. The N.C. Department of Commerce recognizes Tier 1, Tier 2 and Tier 3 counties, ranked according to population growth, unemployment and median household income. Only four counties in the Trillium catchment area - New Hanover, Pender, Brunswick and Carteret - are considered Tier 3.

Trillium - and all MCOs - must ensure residents have a choice of at least two providers within 30 miles of their home in urban areas, and within 45 miles in rural areas. While we have experienced no shortage of providers in our more populated areas, such as Wilmington and Greenville, the difficulties mentioned above make it harder to find qualified, experienced clinicians in some of our lower populated areas.

Although access to higher-level, licensed professionals is easier in the Wilmington area, the availability of direct-support professionals is more challenging, since the more diverse job market provides those workers with more options. Direct support professionals are critical for the people we serve, since they provide much of the hands-on care with activities of daily living and supervision.

Wilmington’s higher cost of living also makes it more difficult to obtain safe, affordable housing for people with disabilities living on Supplemental Social Security or disability payments.

JOHN GIZDIC: This region is blessed to be served by a medical staff whose size and range of specialties far exceed what you would expect for a community this size. The New Hanover Regional Medical Center [NHRMC] Physician Group now includes 262 providers, and there are hundreds more in the region that practice within our system.

The range of specialists includes huge advances in specialty pediatric care - including two pediatric surgeons who perform minimally invasive procedures - and in cardiology, gastrointestinal, endocrinology and pulmonary care.
Cape Fear Cancer Specialists, which has moved to our newly renovated and expanded Zimmer Cancer Center, includes providers specializing in different types of cancer and supporting a lung clinic. A head and neck cancer clinic is in the planning stage, in partnership with our maxillofacial surgeons.

We have added several neurologists, including specialists in interventional neurology and Parkinson’s Disease. Other medical disciplines work together in effective clinical teams in areas such as orthopedics and pulmonary disorders.

When I first came to Wilmington, many patients left the area for specialty treatment. While we do have tremendous academic hospitals in our state, our own medical staff has grown in size and scope, which means patients seldom have to travel elsewhere to find the care they need.

JEFF JAMES: Wilmington is becoming a stronger health care leader in the state and across the country. Every day, providers from our area are building new relationships and sharing data with groups across the country. Within the past two years, Wilmington Health has deepened our efforts with health care groups in Texas, Iowa, Illinois, and right here in North Carolina.

In addition, we are providing leadership in creating new models for delivering care and innovating within the industry. Innovo Research, our recently announced venture with Christie Clinic in Illinois, is an example of how we are reaching out and driving change to increase the quality of care at a lower cost.

What additional services and facilities will Wilmington need as its population continues to grow?

WAINWRIGHT: Each year, Trillium conducts a Gaps and Needs Analysis so we can accurately assess any shortages in our communities. The 2016 results will be published on our website soon, and in the coming months we will start soliciting responses for our next survey.

Substance abuse continues to be a huge priority in eastern North Carolina. Although attention has focused on a recent study that named Wilmington and Jacksonville as two of the top locations for opioid overdoses, this study only focused on prescription opioid abuse among individuals with insurance. The issue extends beyond opioids and other prescription drugs.

Trillium will receive state and federal funding, and participates in many local efforts. However, recent budget cuts by the N.C. General Assembly drastically reduce Trillium’s funding for ongoing programs. Trillium had announced plans to bring two long-term recovery facilities to Wilmington and Greenville, but we must now explore more creative sources of funding with community partners to complete this work.

Trillium has dedicated a page on our website to the opioid and substance use epidemic that shares data, resources and treatment programs with any groups involved in this fight.

Higher utilization of the Emergency Department [ED] also occurs in the Wilmington area. Trillium worked with NHRMC, RI International - the provider that operates the Wellness City program in Wilmington - and other stakeholders to develop a proposal for “system navigators” that will help people currently going to the ED to connect with providers who can better meet their behavioral health needs. We are thrilled that through the efforts of Sen. Michael Lee, the N.C. General Assembly appropriated $250,000 to pilot this program.

JAMES: Primary care providers are still going to be the number-one need as the population continues to grow. This group of providers is essential to managing overall health and will be the driving force in facilitating the industry’s movement toward population health management.

The U.S. still ranks near the top in diagnosing, treating and saving lives for acute conditions. However, we also rank highest in the disease states that cause many of these acute issues, such as diabetes and heart disease. Shouldn’t we be trying to solve these problems through the efforts of primary care and patient engagement, rather than pushing for more technology and facilities to treat the acute issues?

In addition, there is a need for more access to same-day care outside of the ER. Everyone knows that ERs are extremely expensive to the health care system and patients. Having more options for non-emergent health issues, then educating patients on the appropriate use of those facilities, is imperative to reducing cost.

GIZDIC: In the short term, our community needs mental health services, particularly in the outpatient setting as well as rehabilitation facilities for patients addicted to opioids.

This crisis has brought the community together to respond in a way that is encouraging, but the problem is rapidly becoming a serious drain on our employees and resources, on our law enforcement, courts and social services, in addition to the toll it takes on those addicted and their families.

State legislators have been wonderfully responsive in terms of bringing resources back to our community to address some of these issues, but we all must remain committed to working together to solve this problem.

In the longer term, we need to change the way we approach health care. Instead of adding services and facilities, the community should look at collaborative programs and initiatives that address keeping people well and removing the barriers to their health.

Our collective challenge going forward is providing everyone access to health care that has value to them and meets their needs. Access, value and health equity are the primary pillars of our new strategic plan that will enable us to lead our community to outstanding health.

EROLA: The population is aging. There is no question there is going to be a larger elderly population here. This area draws a significant group of retirees. I have encountered many people from the northeast and other parts of the country who have come here to retire. The health care system has to be ready to address the needs of an older population while providing services for all ages.

I really hope to see aging in place, which means people age at home with more available and affordable home care services. This means more funding for home care services, adaptable equipment, and trying to plan and design housing to accommodate an older population.

Primary care providers are essential for managing our growing aging population and overall growth. We need to focus on healthy lifestyles and preventative care, not just on episodic hospital or ED visits or more technology.

How has the shift to value-based care impacted patients and medical providers?

GIZDIC: We have started participation in a Medicare “shared savings program,” in which we are incentivized to control the costs of more than 17,000 Medicare patients. In 2019, our state is expected to convert its Medicaid program to a fully capitated system, which means providers like NHRMC will be paid a certain amount per Medicaid enrollee, then challenged to maintain that enrollee’s healthcare costs within that cap.

Physicians are just starting to be paid under MACRA, a federal program to incentivize physicians to control costs and meet quality standards of care. In collaboration with our physicians, both hospital- and community-based, we have undertaken a number of initiatives to help patients find the right level of care at the right cost.

These include:
• A Patient Assistance Center in our ED to help patients find timely follow-up care
• Chronic Care Management programs
• Pharmacists embedded in physician practices to review patients’ medications and educate them on adherence
• Expanding access to children in our Coastal Family Medicine clinic
• Connecting patients to primary care physicians
• Providing more opportunities for virtual visits
• Increasing and improving the process for annual wellness visits
• Home through the Family Medicine Residency Program

WAINWRIGHT: MACRA started the move to value-based reimbursement in the Medicare program. The Medicaid system in North Carolina will begin the transition to value-based reimbursement through the proposed plan for N.C. Medicaid Transformation. Trillium is already experimenting with some alternative payment methodologies, such as case rates, to begin the move to value-based reimbursements. We believe these changes will improve member outcomes, incorporate population health data, and require integrative care between behavioral and physical health providers.

One challenge in implementing value-based purchasing in behavioral health care is the lack of robust outcome data. A simple x-ray can demonstrate if a broken arm has healed successfully; it is not that easy to demonstrate the effectiveness of a behavioral health intervention. Trillium is actively working in partnership with our providers to identify and collect the outcome data that will be necessary to fully implement value-based purchasing.

EROLA: Presently, health care is reimbursed on a fee-for-service basis which promotes doing more expensive tests and procedures, which in turn increases the overall cost. Fee-for-service no longer makes sense.
We should be doing value-based care. If you’re doing the appropriate things for patients - keeping them healthy and out of the hospital - that’s what you should be reimbursed for instead of the opposite.

The shift to value-based care is excellent, and this is really important in palliative care and hospice because palliative care is all about helping patients and families understand goals of treatment, like quality of life.

However, the issue is how it is being implemented by the government. Under MACRA, you are supposed to have quality measures, but those current measures were never designed for palliative care. An example of a current measure of quality is managing blood sugar. When someone has years to live, you want tight control of blood sugar but when somebody is towards the end of life, keeping their blood sugar is under too tight a control can have worse consequences.

Getting penalized because you’re not doing something because you’re in palliative care doesn’t make sense. The whole idea of quality-based health care is wonderful but how it is being implemented is extremely burdensome to providers. And it’s also impacting patients because more time is spent on entering, and the patient ends up with less one-on-one time with the provider.

How important is collaboration between health care providers in making that shift?

JAMES: It is imperative that health care providers work more closely together and utilize communication tools, including the electronic medical record, to improve the quality of care. Primary care, specialists and hospitalists need to not only know what the other is doing, but also work together to provide real value throughout the entire health care delivery cycle. Everyone wants to retain patients but, when necessary, we must set aside our concerns for profits and market share in the best interest of the patient.

EROLA: The AMA [American Medical Association], the American Academy of Family Physicians, the American Academy of Hospice and Palliative Medicine… all the big organizations have come out and said, wait, yes we want quality measures but they cannot be burdensome to providers and patients. CMS [Centers for Medicare and Medicaid Services] has listened (a little bit) but more work needs to be done. There has been much more collaboration in terms of health care organizations saying what are we really doing here? And what you’re finding in communities is, to improve the quality of health care, there are now many more partnerships.

I’ll give you an example: A patient is in a hospital and the patient transfers to a skilled nursing facility. If that patient re-admits to the hospital in the next 30 days, that hospital is going to be penalized. That hospital now cares about the quality of care delivered at the skilled nursing facility, so they begin looking at partners in the community that can provide quality care. The same thing applies with hospice. If patients are referred to hospice care, you need to refer a patient to a quality program.

I think organizations, in general, are looking for more collaboration and partnerships on the whole continuum of care so that patients are getting the proper care at the proper place.

GIZDIC: To make the new “value” payment models work, collaboration between our health system, physicians and the community will be needed. Fortunately, all these components are already working on this path.

The best method of controlling costs is to provide the highest-quality care. Organizations that standardize processes – and reduce hospital readmissions or other care that is often unnecessary – are the ones that succeed in a “value” environment.

This care entails more than just a physician or a hospital visit. We are working with our physicians to ensure patients have easier access to primary care, engage with care managers on social and environmental barriers, are screened for mental health, substance abuse or other impediments to health, are able to purchase and understand their medications, and receive a follow-up visit at home to ensure their aftercare is going well.

All these steps require collaboration, and we are grateful that our community is stepping up to help us meet this challenge.

WAINWRIGHT: Integrative care is vital to improving overall population health. About 31.5 percent of all Americans live with multiple chronic conditions. Patients with chronic depression, dementia or psychotic disorder are at a high risk of developing long-term physical conditions, and the risk of mental health problems increases substantially in those with long term physical conditions. In addition, rates of mental health problems also increase noticeably as the number of long-term physical conditions increases and as socioeconomic deprivation worsens.
Integrative care between behavioral health and physical primary care providers is crucial to addressing the needs of the whole individual so that all issues are treated at once, rather than in isolation.

Is consolidation the key to growth under the value-based care system and, if so, how does this affect small providers?

GIZDIC: Small practices and health care providers continue to have a role in the health care of this community, more along the lines of collaboration than consolidation. These providers often know their patients and can best communicate their needs that may go beyond medical care.

Health care entities may appear to be getting bigger through consolidation, but the most basic component of health care, which is the relationship with the patient and the community, has not changed.

Some providers may wish to consolidate with larger entities because it helps them with overhead and administrative costs. Others may wish to continue as small groups. Either way, they are vital to our community.

JAMES: We don’t believe that consolidation is necessarily the key to growth. It is however, a result of the health care system, being driven to reduce cost, improve outcomes, and enhance the patient experience. Unfortunately, the small family practice, while often providing some of the best care available, is unable to manage the back and front-of-office items that are now required. We have welcomed several practices to our group that have been looking for an organization that can provide them the tools and support to allow them to do what they do best, deliver high-quality care to their longstanding patients.

WAINWRIGHT: The question is really about the infrastructure that providers will need to collect, analyze and manage the data that will drive value-based purchasing reimbursements. Small providers will face challenges building that infrastructure. Consolidation to form larger organizations is certainly one solution, but there may be other models that permit the sharing of systems by multiple smaller agencies to achieve cost efficiencies and economies of scale without actual merger or consolidation.

EROLA: It’s getting harder for small providers to compete, to do all the regulatory requirements they have to do. It just costs too much for the infrastructure to be able to survive unless you can share these costs.

There is the model of direct primary care, where physicians decide they’re not going to deal with insurance companies. Patients pay a flat fee and the physicians look after all their basic needs. Direct primary care, which is bypassing of all the insurance companies and middlemen, is getting some traction.

How can population health management improve cost and quality of care?

TUCKER: I will speak to population health management within an employer’s health plan. We diagnose cost drivers, stratify risk and identify opportunities for case management, disease management and wellness initiatives.

Historically, wellness has been centered on physical health with strong expectations for a return on investment (ROI) realized through lower benefits costs. While cost management can be a part of the overall goal, employers are realizing that, by narrowly focusing on health as it relates to health care costs, they are not fully capitalizing on the opportunity to demonstrate the impact of total employee wellbeing and culture on the employee value proposition.

We advise our clients on how to develop a holistic strategy for their organization with wellbeing at the center of the employee value proposition to drive employee engagement and high performance in today’s complex, multigenerational workforce.

While cost management and ROI remains an appropriate expectation for an employer’s strategy, there is a shift towards value on investment (VOI) that companies are realizing. By focusing on VOI, employers are examining the bigger picture relating to total wellbeing and a change in culture instead of only focusing on the medical costs.

We think about wellbeing’s impact on an organization through an increase in productivity, decrease in presenteeism, lower absenteeism, lower safety incidents, lower health care costs and a more engaged workforce.

EROLA: We have to educate and have ongoing prevention, particularly in the southeast, where the rates of obesity, hypertension and diabetes are very high. It is really important that people understand the need to exercise and eat a healthy diet and take ownership of caring for themselves.

JAMES: Very simply, it could have a huge impact on both sides of the equation. Pricing for health insurance through the exchanges created via the ACA are directly tied to the health of everyone in your area. So, if your neighbors and coworkers are unhealthy, they are driving up the cost of the insurance that you purchase. Creating a healthier community can directly affect the cost of health insurance, no question.

Secondly, the healthier a population is, the more focused health care providers can be on maintaining that level of wellness, rather than treating preventable health issues. Chronic disease states tend to wear on not only the individual patient, but also family and friends around the, they have worse long-term outcomes, and are costlier.

GIZDIC: The best health outcome for anyone is to be healthy and not require medical treatment. With the concept of “population health,” the goal is to incentivize the healthcare system to focus on people’s health rather than treat them when they are sick.

Many illness and injuries are unavoidable and happen to all of us. We’ll always need a strong clinical team in these cases. But many are quite avoidable. Those who pay the cost of health care – the government, employers, insurance companies and individuals – are determined to find a way to stop paying to treat conditions that could have been avoided.

In the majority of cases, our health has more to do with our environment, social issues and behaviors than our genetics or quality of health care. Researchers estimate that 70 percent of our health care is tied to these “social determinants” of health, such as transportation, housing, education, food and other poverty-related or behavioral issues.

So, many in our field are asking: How do we address social determinants? and How do we eliminate disparities in our health status that are caused by biases based on race, gender, sexual orientation, religion or any number of factors?

These questions are a major part of our strategic push to be a national leader in health equity, starting with our recent hiring of our first director of health equity and human experience.

For the most part, we’re still in research mode, but we have taken some early steps. We have begun a relationship with a firm that will give patients with no transportation a ride home from our ED. Meals on Wheels partners with us to provide temporary assistance to patients who we’re not sure will be able to feed themselves when they go home. We have started community gardens at three facilities within our system.

The primary focus of our early work has been within the Youth Enrichment Zone on the north side of Wilmington. Our employees raised more than $12,000 worth of food to feed school children in the area, and we started a book drive for the area’s elementary schools on Sept. 25. We’re working closely with leadership in the zone to learn residents’ needs and help solve them – with the help of multiple community agencies, faith communities and local government – rather than have patients visit us in the hospital for medical issues caused by lack of a ride to a drug store or inability to eat a proper diet.

We can be better than this as a community, and we look forward to developing more partnerships with others who feel the same way and expanding strategies throughout our community and region.

WAINWRIGHT: Trillium partnered with UNC-Wilmington’s Department of Mathematics and Statistics to develop a data analytics project for population health. A professor and graduate student in the newly formed M.S. in Data Science degree program will participate on the project.

As of summer 2017, Trillium and UNCW are defining and cleaning the data that will be used in the project. Next, UNCW will begin to analyze the data and develop the algorithms that will be necessary to create the predictive analytic model.

Once complete, the model will be able to predict those members who are at highest risk for an untoward outcome or crisis event. This model will assist Trillium to better predict costs and determine the appropriate services and level of care for members.

Is preventative care playing a larger role in employer health care plans?

JAMES: Health care insurance premium expense is often the second highest expense line item, behind salary, on most employers’ income statement. To continue to be competitive as a business and provide the salary and benefits to their most valued asset - their employees - preventative care is definitely taking on a larger role in health care plans. We’ve seen employers affect real change in the health of their employees and their bottom line through four major efforts: 1) creating targeted employee programs; 2) restructuring health care benefits; 3) optimizing the network of providers; and 4) developing incentive programs for healthy living. Each of these items can have a major impact on the resulting health plan utilization and future premium expense to both the employer and the employee.

TUCKER: Preventive care is playing a larger role in employer health care plans. We want to pay for preventive services to avoid higher costs down the road. Obtaining preventive screenings, which are covered at 100 percent under the ACA, identifies issues when they can be treated effectively both from a cost- and quality-of-life standpoint.
Identifying a pre-diabetic, for example, can delay the onset of the disease.

Additionally, our approach to wellbeing is more than just fitness, weight-loss or disease management; rather, we consider an employee’s overall wellbeing, with the understanding that the whole person comes to work each day, and each employee’s physical, emotional, financial, career and community wellbeing will influence their individual performance and, ultimately, the organization’s overall performance.

EROLA: Employers are looking at that. They’ll offer programs and classes because they know if they keep their employees healthy, they’ll decrease health care costs and employees will be much more productive.

We have a palliative care program for this community, which is different than hospice. Palliative care is for anybody with a serious illness. It’s a sub-specialty in which patients see a palliative medicine physician, nurse practitioner and other team members. Palliative care provides pain and symptom management, helps patients and families understand goals of care, and provides that extra layer of support. The cardiologist or the oncologist, for example, is busy managing a patient’s disease, which is important. But the palliative care team works alongside to look at symptoms and figure out how we can make a patient’s life better every day.

GIZDIC: Without question, employers are more concerned with controlling the health costs of their employees, and more are approaching this from the preventive point of view.

At New Hanover Regional Medical Center, we offer the Jack Barto Center for Employee Fitness, diabetes and hypertension management, an employee health clinic, and smoking cessation assistance to reduce employee health costs. Our commitment to this approach has improved the lives of the more than 5,500 members of the fitness center, and several dozen have lost more than 100 pounds. We’re just beginning to see the results of this approach, and we expect employers to explore this more going forward.

How can do you strike a balance between safeguards against the abuse of some prescription drugs and ensuring access for patients who need them?

WAINWRIGHT: Trillium supports the newly enforced requirement for physicians and other prescribers to consult the NC Controlled Substances Reporting System (NCCSRS) before issuing prescriptions for opioids and narcotics.

The provision, part of the Strengthen Opioid Misuse Prevent (STOP) Act signed by Gov. Roy Cooper in June, helps to address the fact that North Carolina has one of the highest opioid prescription rates in the country (National Prescription Audit by IMS Health).

On top of that, the NCCSRS shows that certain counties in the coastal region covered by Trillium are among the highest for the state. The STOP Act will also limit initial prescriptions to a five-day supply.
While these measures will not prevent access for patients who truly require these medications, they will help lower the volume of opioids in communities and therefore hopefully reduce the likelihood of addiction.

EROLA: There is a lot of talk about the opioid crisis, and I am not disputing that, of course. However, there are patients who legitimately need opioids. In our palliative and hospice population, it’s getting harder and harder to access opioids. Physicians don’t want to write prescriptions. They’re fearful; they are worried they will get into trouble. The pendulum has swung so far the other way now that getting access is difficult.

With safeguards in place in our palliative care and hospice programs, we want to make sure our patients get opioids as needed and that they are appropriately managed with safe disposal. So, we’re helping that problem, not making it worse. A reputable hospice program takes that very seriously. With palliative care and hospice programs, the nurse is actually in the house, sees the medicine, counts the pills and can provide a lockbox.

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