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Participants Richard A. Hammett Strategic Planning and Development Executive Vice Chancellor for Health Affairs The University of Texas System W. Edward Berger Vice President, Advocacy & Government Relations Seton Family of Hospitals Jenny Fowler Regional Manager Government Relations Humana, Inc. Ann Kitchen Executive Director Indigent Care Collaboration Patricia Young President and CEO Travis County Healthcare District Sponsored By:  |
Executive Roundtable Health care in crisis – What’s the answer for Given the topic of health care in crisis, it is not surprising that a handful of the heaviest hitters and most influential players in the It was likely the first time so many of these players had been around the same conference table at the same time, and they seemed to genuinely enjoy the hour-long interface that focused on the problems in local and statewide (and to an extent) nationwide health care, what can be done about it and the manner by which that answer can be best arrived. The facts and figures surrounding the breadth of the plight of the uninsured in The report’s data shows that about 79 percent of the uninsured are people that either work or are with families that work. They work particularly for small businesses – those that employ less that 50 people – and of those businesses, only 37 percent offer health insurance. Of the people that work for such businesses, only 35 percent can afford the health insurance that is offered. So there is a very substantial number of working individuals or family that works, who have neither access nor can afford health insurance. Mind you that for the average family of four, the health insurance would cost $10,000 per year. So if you are at 100 percent of the federal poverty level (which is pushing $20,000 for a family of four), that is half your income and if you are twice the poverty level, that’s 25 percent of your income. A lot of those among the uninsured include a very high proportion of Hispanics (as much as 40 percent) and 24 percent of African Americans do not have health insurance, so there is a disproportionate percentage among the uninsured that are from those ethnic backgrounds. And on the other hand, only about 20 percent of the uninsured are so called undocumented individuals. With Code Red as the group’s guide to the discussion, Business District magazine asked the panel a series of questions ranging from specific queries about the status of health care in Travis County to the role of doctor-owned hospitals in the solution to how did we get in this spot? All agreed that it is high time things change and that something has to be done – and soon. Now it’s just a matter of making those goals a reality. That may be a heck of a lot harder than it sounds. Business District: Dr. Shine, in “Code Red,” the task force reports the uninsured rate in Dr. Shine: There is this notion that a majority of the uninsured are young people that think they are immortal and they don’t have to take health insurance. The reality is that a significant number of the uninsured are middle class individuals that work, and lack of insurance is a major source of personal bankruptcies. In the report, we talk about 25 percent of Texans being uninsured, which translates to approximately 5.6 million at any given time. Business District: What other problems do you see for Shine: The rapidly increasing rate of uninsured is a huge issue, particularly in the growing Hispanic population. Secondly, I see the Central Texas [health care delivery system] being under increased pressure as the population of uninsured grows around the state and more and more patients are referred into larger metropolitan areas for health care. Thirdly, Business District: Here’s a question for our two major health systems—what are your big issues, and what really keeps you awake at night? Berger: What’s happening in the legislature certainly keeps me awake along with treating a rising number of uninsured. Staffing to cover those increasing numbers is a huge issue. There are just not enough trained health care workers, and there are waiting lists for young people to get into nursing schools. Earlier this week, we had almost 300 posted positions for nurses in our hospitals right now. We are competing [Between systems] for a limited pool of talent. There are facilities opening up in We are working with all of the surrounding colleges and universities—in fact, at Another part of our challenge is convincing the legislature, and gaining support throughout the business community, to support education programs in order to get those trained workers that we need. Hammett: That’s well said. I agree that the workforce challenges are great here in Given the future demographics of the State, the problem of the uninsured looms as the largest financial challenge for hospital systems and what we are experiencing now is the tip of the iceberg. The cost of treating the uninsured is the fastest growing expense item for St. David’s, and the same is probably true for Seton. So, full service hospitals are faced with the double-digit growth of an expense item that has no end in sight, while at the same time our largest payor (Medicare) will not keep pace with that growth. Other government payors, like Medicaid, already reimburse hospitals below cost. Compounded, these issues make the burden of the uninsured an unsustainable problem for community hospitals. The third thing that “keeps us up at night,” so to speak, is primary care access. There are obvious social aspects to this problem which eclipse the impact to hospitals, that I am sure others here can speak to better than I. From a community hospital perspective though, the problem of access to basic health care services, creates an enormous challenge for emergency rooms. Rather than receiving routine care in a physician office, basic care is rendered in the most costly environment within the health care system – the ER. The largest reason for lacking primary care access is that government reimbursement for primary care services is abysmal. This is a policy issue that simply must be addressed. Shine: The state clearly finds itself in a crisis around the health care workforce issue. We have huge shortages, and we are going to have to make large investments. We’ve been communicating that message to the legislature for the last two sessions. The point I want to emphasize is that when the “Code Red” task force made recommendations for increasing the number of nurses, and medical residents, it was not only to increase the workforce, but to most efficiently and effectively provide a workforce that would provide care for the uninsured. If we don’t have the physicians, we’re not going to be able to take care of the general population. But if we make a real effort, at least we have a strategy which could help with the issues of treating the uninsured. Medical residents become a very important piece of the solution. Nurses that have been certified as Masters level practitioners could contribute substantially. If properly structured, and residency programs [are adequately] supported by the state, it could involve residents in much more community based ambulatory care. Kitchen: I’d like to comment about primary care access as you are both pointing out, it is a huge issue. The Indigent Care Collaboration (ICC) does a study of emergency department utilization every year in Shine: Resources alone will not solve the problem, unless we become more efficient in the health care system and save money, or at least decrease the rate of rise of cost. There is a prevention aspect to it, but it also means eradicating the duplication of X-rays, lab work, and more that happens on a daily basis in clinics and emergency rooms throughout the system. Berger: One of the things that troubles me is that a lot of our conversation around the cost of health care centers on how we pay for things. But we really haven’t had, in my view, a thorough policy debate about what is socially just and what kinds of health care we as a society should be providing to the insured and the uninsured alike—we seem to be afraid of this discussion. Our society has not decided what happens if we cannot pay for everything. So what should we cover? What should we offer? Other countries around the world have had this discussion and in some cases have better health outcomes and lower costs of care than we have. Kathy Poppitt (of Thompson & Knight): Over the few years, there has been a great debate about the effect of individual specialty hospitals might have on some of these issues, especially emergency room care and the uninsured. And since we have one of the highest numbers of specialty hospitals in the country, what effects if any do the people in this room see these hospitals having in Hammett: Now I understand that physicians face huge economic pressures—rising malpractice premiums, government reimbursement shortfalls, the uninsured patients they see in our emergency departments, and so on. As a result, physicians are seeking new sources of revenue. Physician-owned hospitals are certainly one of those ways. As a whole, physician-owned, limited service hospitals are having a tremendous deleterious effect upon full-service community hospitals. The financial responsibility of the uninsured, that full-service, community hospitals already have, will remain with us, while a proportion of those with insurance are directed to physician owned-limited service hospitals. Why does this matter to community hospitals? Here is a simple example of the uninsured problem. If you go to a restaurant and order dinner, you obviously pay whatever is on the menu. Imagine if 20 percent of the other people in that restaurant just couldn’t pay their bill. The next time you go into the restaurant, what do you think the menu price is going to be? The prices are going to go up, and it’s the same effect within community hospitals. In addition, there are federal laws that require hospital emergency departments to provide patient screening and stabilizing treatment. A restaurant can turn people away, a hospital will not. As a result, we are very focused on our mission to care for all who seek our services, while at the same time make certain we also have paying patients. This is the challenge for all full-service, community hospitals in the country. Physician-owned limited-service hospitals, for a variety of reasons, do not proportionately share the uninsured responsibility, creating significant unintended consequences for the health care system as a whole. As a result, philosophically, I am opposed to the proliferation of physician-owned hospitals. Shine: I’ve been in medicine for 45 years. I believe in medicine as a profession characterized by a body of knowledge, self-regulation and altruism. Physician-owned hospitals, in my view, are a real challenge to the professionalism of medicine. In fact, in trying to produce change, they are not only taking the patients away from full-service hospitals, they are taking only low risk patients who can be taken care of very efficiently, at a low cost. And if they are confronted with a patient who is likely to have complications, that patient is often admitted to an acute-care hospital where they will perform the procedures there. So they are not only selecting the paying patients, they are selecting the low risk patients and leaving the high-risk patients to the general hospitals. On moral grounds, and on practical grounds, I believe physician-owned hospitals are a serious challenge to the economic viability of general and major teaching hospitals in the state. Berger: To add to that further, many of the physicians who move their practices to these facilities remove themselves from the call list from our community hospital emergency rooms. This places a greater burden on the physicians that are still working in the emergency rooms. So it’s actually a triple whammy. Not all physician-owned hospitals behave that way. But some do things that are very damaging to the community infrastructure for health care that affects everybody, and not just the safety net for the uninsured. Business District: How did we get in this spot? How do we get out, and what are the barriers to making that happen? Shine: We got into this situation by accident. After World War II, there were wage and price controls. As a consequence of that, many large companies decided that the way to compete for workers was to offer health benefits. As a result, the We did not take on health insurance as a national requirement. We did move toward the deserving elderly with Medicare, because they were no longer employed. Medicaid was added to it on the grounds that there was a certain amount of other people that also wouldn’t be employed. Any ultimate solution has to involve universal coverage of some kind. Not necessarily a single payor, and not necessarily nationalization. So how do we provide the coverage? There have been a myriad of proposals including everything from expanding Medicare to cover the entire population to expanding things like the federal employees health system to the entire population. |
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