Healthy debate

Mention the Affordable Care Act to a business owner, a health care provider or any of the millions of uninsured people who have struggled to pay medical costs, and you’re likely to stir up a lively conversation.

The Affordable Care Act (ACA), officially named the Patient Protection and Affordable Care Act, was signed into law by President Obama in March 2010. Its aim is to dramatically increase the number of Americans who receive health insurance, in part by streamlining delivery of health care and improving patient outcomes.

Many complain that the word “affordable” has no place in the name of the Act, while reactions from individuals who aren’t covered by employers are mixed.

But most of those involved in providing that health care agree on this: The time for change is now.

Debbie Welle-Powell, vice president of accountable health and payer strategies for SCL Health System, says the future is clear.

“We have to get really good at managing the continuum of care for a patient,” Welle-Powell says. “Our focus is on the population health.”

That means connecting everything from outpatient services to prevention to acute care to home care, she says.

“With the newly insured, the system will break us if we don’t start asking questions like how much care is needed, and what kind of care do we need,” she says.

Bruce Johnson, an attorney with Polsinelli, says many of the changes that have swept the country were in the making for years.

“The Institute of Medicine and other groups have focused on the fact that we spend a lot on health care, but we don’t always get a great value,” said Johnson, who has worked with physician practices for 23 years in Colorado.

“It promotes access to health care and it puts the screws down on some of the fraud,” Johnson said. He adds that health care is an essential ingredient in our economy. “Without doubt, there are crooks, and everyone would agree that we should stop that.”

Administrators at hospitals also agree that one of the biggest benefits to the ACA will be expanded coverage, which means fewer people waiting until they are desperately ill and in need of costly emergency room care. Nobody in the industry would dispute that hospitals treating uninsured clients drives up costs.

Simon Smith, executive vice president of Clinica Family Health Services, says the ACA will benefit many of the nonprofit organization’s clients.

In addition to those who will be newly insured, Colorado has expanded the number of people eligible for Medicaid. Many of Clinica’s clients, who were previously uninsured, will have some degree of coverage.

“For us it’s a tremendous opportunity as a community health center,” Smith said. “Increased revenue will allow us to cover costs and hopefully expand our services.”

It will also allow the organization to help people access specialty care.

While Clinica offers primary care services to low-income clients in five medical clinics, it does not cover specialized care, and uninsured clients may have nowhere to turn if they need specialists such as dermatologists or cardiologists.

“The biggest challenge we face is that there are barriers to accessing specialty care,” he said.

ACCOUNTABLE CARE

“The origin of the term ‘accountable care’ is making health care providers accountable for the care they provide,” said Rulon Stacey, president of University of Colorado Health. “In the past, if the treatment was not good, there was no financial risk for the provider. Now you have a financial incentive to keep people healthy, as opposed to fixing them when they’re sick.”

Grant Wicklund, president and CEO of Exempla Lutheran Medical Center in Wheat Ridge, says factors like readmission rates at hospitals will now be examined. One key, he said, is to work with patients closely to ensure they are taking the steps they need to stay out of emergency rooms.

“We have a very targeted readmission program designed to reduce readmissions,” Wicklund said, noting a drop
in heart failure returns. Exempla Lutheran has also worked with the community on smoking cessation programs and obesity initiatives.”

But with an aging population, the hospital faces challenges, Wicklund said, noting the high percentage of seniors who are noncompliant when it comes to taking their medications and following doctors’ orders.

Stacey agrees that the push to hold hospitals and physicians responsible for patient health does not sit well with everyone.

“If you hold physicians responsible, it leaves providers responsible for the actions of the patients, and some physicians don’t care for that,” he says.

COMBINING RESOURCES

The key to bringing down costs is combining the resources of medical centers and implementing electronic medical record systems, say doctors and hospital administrators.

University of Colorado Hospitals are spending more than $130 million system-wide to implement an electronic medical record system from Epic. UCHealth encompasses five hospitals, a medical group and dozens of clinics. It also manages a hospital in Wyoming and another in Nebraska.

SCL Health System, which encompasses nine hospitals and five clinics, including Exempla Lutheran Medical Center and Exempla St. Joseph’s Hospital, also implemented Epic’s digital record system.

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Wicklund says one of the most positive aspects of the Affordable Care Act is that it presses medical centers to improve communication between providers, and to do so electronic systems are the key.

When a patient has one record that can be accessed throughout the system, cost savings will combine with better care, he says.

Stacey notes that the ACA offered incentives to enable organizations to share records.

“One of the things we’re trying to address is communication between providers,” Stacey said. “We identified years ago that the future is going to be in connecting people in financial and records systems, and we’ve taken those steps.”

Communication recently had a huge impact for a patient who was taken from an emergency room in Greeley to the stroke center at University Hospital, he said.

 “Because we understood our stroke protocol, we got the patient to the right place and we saved the patient’s life,” Stacey said. “We’re looking at best practices which means helping outcomes all over.”

Dr. Steve Cobb, a family physician and chief medical officer for the Exempla Physician Network, says patients welcome the fact that their information is shared across a network of physicians and other medical practitioners.

“It delights the patient when they see that their record is shared across the continuum” said Cobb, an internist who works from Exempla’s EPN Larkridge Family & Occupational Medicine Clinic. “It makes us use our time so much more efficiently.”

Another cost-saving measure – telemedicine – will be stressed more as the need to cut costs continues, Cobb said.

While telemedicine is nothing new, it will play a part in building the care teams that will improve quality and decrease costs.

He notes an example of a primary care physician treating a patient with mental health issues.

“A specialist could watch an interview with the primary care doctor and guide that doctor,” Cobb said. “It’s a way to expand the reach of a specialist into the primary care office.”

THE GREAT UNKNOWN

Stacey notes that while Colorado is ahead of most states when it comes to health insurance exchanges, there’s still plenty of uncertainty about payment.

Exchanges offer a marketplace for small business and individuals to compare policies and purchase insurance, which may be subsidized.

Welle-Powell says the changing climate offers an opportunity to educate people. The exchanges will allow people to make decisions based on prices and quality.

Finding ways to cut costs is pivotal, she says. At SCL Health System, around 35 percent of those walking through the doors are Medicare patients, and 10 percent are Medicaid patients.

Medicare covers around 80 percent of the system’s costs, and Medicaid only around 60 percent, she says.

“The cost shift moves to the private market,” she says.  “We have to find ways to bring costs down.”

In fact, hospitals must rethink the way they run, Wicklund says.

“We have to convince the government and other payers that we need to be paid to keep people from getting sick.”

There will come a day when hospitals will be in trouble, Wicklund said.

“The fee for the service model will not work.”

Some legitimate studies have shown that nearly 33 percent of the care in this country was not necessary, according to Welle-Powell.

“We believe that our patients deserve the best care at the lowest cost,” she said. “We have to start looking at health care another way. This is a call to action.”

Bruce Johnson, an attorney with Polsinelli, along with several hospital CEOs and administrators in the state, points to some of the major changes we’ll see in the health care industry.

•         The main goal of the Affordable Care Act is to insure more Americans and reduce medical costs through mandates, tax credits and subsidies. The challenge of meeting the needs of the approximately 32 million newly insured Americans will be felt throughout the industry.

•         Failure to implement electronic records – which will help medical centers share information – will result in fines. The cost of putting such systems in place may be a burden to the private practitioners who aren’t affiliated with medical centers.

•         A value-based payment modifier will look at how doctors are providing care and examine that quality of care. Physician groups are being measured and the results will impact how much they are reimbursed.