In May 2016, Round table

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North Carolina health care providers are dealing with changes in population and procedures, the latter brought by the Patient Privacy and Affordable Care Act. They also manage growing rates of chronic diseases, one disturbing trend that Minnetonka, Minn.-based United Health Foundation used to determine that North Carolina falls to 31st place on its list of healthiest states. Combined, these factors make providing care more challenging than ever. Business North Carolina assembled a panel of health care experts to examine these issues and prescribe solutions.

The discussion was moderated by Ben Kinney, Business North Carolina publisher. It was hosted and sponsored by High Point University. Additional support was provided by FirstHealth of the Carolinas and High Point Regional Health, part of Chapel Hill-based UNC Health Care. The transcript was edited for brevity and clarity.


How is North Carolina’s health care industry?

SELIGSON: It’s thriving. There are more than 210,000 physicians employed in the state that are responsible for about $30 billion of annual revenue. People are accessing health care services more than ever before. There are challenges with reimbursements and creating a value-driven, rather than fee-based, environment.

ERB: In 1994, 4.5% of North Carolina adults were diagnosed with diabetes, according to the Centers for Disease Control and Prevention. In 2014, that number was 9.8%. As the rate of chronic diseases grows, so does the need for health care providers. When I came to North Carolina five years ago, there were four physician-assistant programs in the state. There are 11 now. The PA class that [High Point University] seated last year had 20 spots, and we reviewed more than 800 applications. The class exceeds the national average for GPA and GRE scores and clinical hours served.

CANFIELD: Demand keeps growing. The move afoot is toward ambulatory care and ambulatory surgery. We have struggled to find medical-surgical beds for adults every day for the past 12 to 15 months.

How is the Affordable Care Act, which became law in 2010, still shaping health care? 

HAND: The dust is still settling. Unlike a traditional business, hospitals can’t close, rebrand or renovate and reopen the next day. There are always patients that need care. We’ve had to make this transition with one foot on the dock and one foot in the boat. As a patient, I like that it focuses providers on creating the best outcome for me. As a hospital, I’m figuring out how we move to that and still work in this world. I do a lot of federal lobbying, so I talk to legislators about ACA effects. It continues to cost hospitals at least $100 million a year industrywide. That’s not just because Medicaid expanded under the ACA. It’s because more money is sent elsewhere — about $75 million to Massachusetts, for example — because of Medicare Wage Index calculations, which determine reimbursements based on regional salary costs. Then there are the audits. Medicare recovery audit contractors are paid on denials. Appeals first go to the auditor and then to the auditor’s supervisor. Two or three years later, a court hears the appeal, and 75% to 80% of denied audits are overturned. We’re spending an enormous amount of money to get what we’ve already earned.

SELIGSON: Medicare and Medicaid reimbursements have been cut. Hospitals have lost money, but so have physicians, maybe more on an individual basis. Four of 20 physicians at Eastern Carolina Internal Medicine near New Bern underwent a Medicare audit. When it was finished, minor errors from about 100 records were extrapolated to the whole practice, and the return of about $1.2 million in overpayments was demanded. It took them three years and about $300,000 to fight the audit. In the end, the administrative-law judge lowered the fine to less than $4,000. The fight was one reason that the practice subsequently disbanded. There’s a strong political will in Washington and Raleigh against higher taxes. That, and the large portion of budgets that fund Medicaid and Medicare, have pushed the government to use the ACA to promote value-driven medicine — better outcomes through cooperation and fewer resources. It pushes us to try harder. We have spent several million dollars educating our doctors about value-based medicine. It’s changing how health care is delivered. It requires you to be innovative and progressive.

GORDON: The ACA is probably the first time that we’ve talked about payment recognizing the bigger picture — the outcome. That puts a high value on nursing care. Studies have shown that the more time nurses spend bedside, the better the outcomes are for patients. We have to make sure that nurses spend the majority of their time providing direct care to patients. The ACA has brought many changes in a short time, and that makes nurses and other professionals anxious because of the uncertainty. The new normal is still unknown. The outcome will be positive if patients remain the focus.

CANFIELD: Aligning dollars with quality outcomes is good for our health care system. In our work, bundling care, such as with local joint-replacement providers, has demonstrated that everyone is in it for the right reasons. As long as the patients are at the forefront, they’re happy and their outcomes are positive, it’s a good thing.

What health care struggles do rural regions face?

GORDON: There are more insured people who want quality health care. That puts us in a good position to respond, but some hospitals and health care entities, especially in rural regions, are struggling to make the dollars match demand. We’re seeing some nursing shortages in rural regions which, if they continue, could be trouble for providers and ultimately local economies.

SELIGSON: Health care is an important economic driver in any community. If it’s not there, folks won’t stay. We started a community practitioner program in the early 1990s. We probably placed more than 400 physicians, PAs and nurse practitioners in the state’s underserved regions. As an enrollment incentive, we would pay off a portion or all of a participant’s tuition loans. Sometimes the local hospital would help with the incentives. It’s difficult to keep physicians in rural regions because of the reality of making a living there. If they want to raise a family, they typically want to be closer to urban regions. It’s a huge challenge.

HAND: Health care access is good in rural regions, but their residents are typically less healthy than those in urban regions. Many are unemployed or retired. That means some of the highest rates of Medicare and Medicaid use in the state. We worry about access in 10 years, when even more baby boomers are retired. We need more providers serving those communities. People come to us for help, so we manage their health and teach them better habits.

ERB: Students want to help the underserved, whether they are rural or urban. High Point has seven food deserts, places where a lack of nearby stores or markets make finding healthy, wholesome food difficult. Residents eat what they can, which might mean cookies and milk for breakfast and hot dogs or some sort of sausage for other meals. High Point University students recently met to consider what would happen if these people had access to low-cost, nutritious food. We discovered that there is a roving farmers market in High Point that visits these food deserts. Making that better known could solve some of these issues.

How do chronic diseases affect health care?

GORDON: I recently heard a story from a family friend that a 7-year-old boy in the family was recently diagnosed with Type 2 diabetes. They live about 60 miles outside of Raleigh. Obviously, he’s not the only one. We have young children with diseases that used to affect only older, sicker and obese people. What is that going to mean 20 or 30 years down the road?

SELIGSON: The ACA gives more health care access, but it doesn’t instill enough self-responsibility. Health care providers must push their patients to eat right and exercise regularly. We need an environment where people want to do that. At the society’s headquarters, for example, I rent a gym to a trainer. My staff has access to it. We’ve created a culture where they can work out anytime — before, during or after work. That squelches time and access excuses for not exercising. We have to drive changes in restaurant meals and grocery-store offerings. There need to be more healthy options at each. No matter how much money you pour into the health care system, people who don’t take care of themselves will use it unnecessarily. The majority of chronic conditions that we’re treating nowadays are preventable. The health care system would be much more efficient if it only treated people who became ill through no fault of their own.

How is technology changing health care?

HAND: Technology has made hospital visits sterile. Doctors have to answer questions on a screen before they can put down their tablet and ask the patient what’s happening. It is hard to get used to, not scanning the chart before walking in, putting it down and talking to the patient.

SELIGSON: A couple years ago, my assistant thought she was having a heart attack. Instead of calling an ambulance, I drove her to the emergency department. The triage team came in, and as they started prepping her for a heart catheter, I called her cardiologist and asked him to speak to the doctor in charge. After they spoke, the emergency-department doctor called off the procedure, and she received the treatment she needed. That is an unusual situation, but its moral is the right information leads to the right decisions and great outcomes. Health-policy journal Health Affairs reported that physicians spend about $15.4 billion in quality parameters and reporting annually. That has to be more efficient, but it’s a challenge to make information systems cooperate. Doctor’s offices have spent millions on computer software. Some of it doesn’t work or sync with the hospital. Hospitals have similar issues. The electronic Health Information Exchange must provide clinical data to all physicians, so they can make the correct decisions about care. We need to collaborate, maximizing limited health care dollars to provide great care.

ERB: It’s no longer only about the patient logging on WebMD.com to explore symptoms or a diagnosis. It’s helping patients comply with orders. You’ve heard the saying, “There’s an app for that.” A patient might tell me he is exercising, but in the background, his wife is shaking her head. So I ask to see his smartphone, which has an app that recorded 4,000 steps in the past three days, not in one morning, which he claimed. I do a lot of work in underserved regions, and those patients go to the public library to use technology, or they might have a smartphone but are unsure how to use it. Millennials embrace it. One might have had arthroscopy on his knee and want to record his exercise, how fast he’s going, etc., to monitor his recovery.

HAND: North Carolina is a national leader in telehealth, which delivers care remotely through technology such as video conferencing. WakeMed recently had a telepsychiatry visit in the emergency department, for example, and the patient didn’t speak English or a language that staff could understand. So they rolled in a tele-interpreter. The patient sat with two machines, which were talking and translating. That’s how technology helps patients and providers. It ensures they receive the correct information. Supplying every rural hospital with telehealth technology is one way that we can give those communities the best health care.

How can businesses help improve the health care system? 

HAND: Health care is unique. The person receiving service doesn’t directly pay for it. That makes it difficult for many to understand rising costs and suddenly having to pay an insurance premium. I own a car, and I take care of it because I pay for it. I also pay for my health care, so I take care of myself. North Carolina businesses need to make sure their employees know their role. Healthy employees save businesses money. Encourage activity, stand-up desks, farmers markets — many of our hospitals have organized them — healthier choices in the cafeteria, if you have one. It may seem expensive now, but it saves plenty later, when you’re not managing chronic diseases. 

GORDON: There’s a huge payoff for businesses that promote health. Mentally and physically healthy employees are more productive. They are in the workplace and not a doctor’s office, dealing with their condition. [Cary-based] SAS Institute Inc., for example, published a study that identified more than $200 of savings per employee when a certain number used its onsite health care clinic. That minimizes time away from work, and they’re saving money because healthier employees keep premiums in check. We need more partnerships like that. It shouldn’t be health care providers or businesses figuring this out. The business and health care communities together can make it a more complete conversation about the future of health care in North Carolina.

What workforce issues does the health care industry face in North Carolina? 

GORDON: The nursing workforce is battling the perfect storm. Baby boomers are retiring in droves, and many nurses are part of that generation. Ironically, that’s happening when we need them to take care of all the baby boomers. It’s a numbers and knowledge gap. A new graduate isn’t an equal exchange for a nurse with 35 years of experience, at least at first. Training is costly and time consuming. We work with employers, finding ways that make it more efficient and effective. Hospital staffing has changed in the past five years. We’re seeing fewer long shifts, for example, because older nurses don’t want them or can’t physically do them. You don’t want to lose their knowledge, so creating flexible workplaces to keep them is important. We can’t afford to lose anybody because they decide nursing is too physically or emotionally demanding. The most creative employers will have the workforce they need.

CANFIELD: We’re working on our hospital and new medical-neurological intensive care unit. It was not a huge additional cost, but we installed structural steel above the ceiling. That will allow the installation of mechanical patient lifts, making it physically easier for our aging nursing workforce to move patients. Those types of additions need to happen as routine, not exception.

HAND: We have a fantastic health care workforce; we need to make sure we have people there to replace them. We have really good medical education in this state. We have phenomenal medical schools, universities and workforce training at community colleges. We need to encourage North Carolinians to become health care providers.

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