“It’s the Right Thing to Do”
That was the sentiment of 5 healthcare executives who took part in the Kentucky Chamber of Commerce Business Summit on July 23, 2013, in Louisville, when discussing the need for increased access to insurance coverage and care for Kentucky patients.
Bruce D. Broussard, president & CEO, Humana, Inc, began the discussion on The Future of Health Care in America. He was followed by a panel featuring Kentucky’s leading health executives discussing Health Care: ACA and What It May Mean to Kentucky. Panelists were Ruth W. Brinkley, CEO, KentuckyOne Health; Stephen C. Hanson, MPH, FACHE, president and CEO, Baptist Health; Michael Karpf, MD, executive vice president for health affairs, University of Kentucky; and Stephen A. Williams, president & CEO, Norton Healthcare.
Several themes emerged from presentations, including the importance of technology, changing payment structures, integrated delivery models, potential unmet expectations, partnerships, and cancer care.
“It’s the Right Thing to Do” The healthcare executives emphasized that Kentucky organizations need to work together to address issues related to access to care and population health in Kentucky. They also agreed on the importance of expanding Medicaid in Kentucky, which Governor Steve Beshear announced will happen effective January 1, 2014.1 Karpf insisted that “it is morally, ethically, and socially unacceptable to have so many people uninsured; therefore, we must expand the mandate for healthcare and Medicaid.”
Brinkley reminded participants of the impact of health on the economy. “If we want to thrive and be economically successful as a state, we have to have healthy and well-educated employees,” she said. Hanson emphasized, “It’s important; we shouldn’t do it because we have to, we should do it because we are the leading systems in healthcare and we should do it because it’s the right thing to do.”
Humana’s Broussard and the other healthcare executives challenged the participants to consider the use of technology in order to improve the health of populations and to consider healthcare more as “an experience rather than a transaction.” He challenged organizations to make things as simple as possible. Although healthcare is very complex, he proposes that “the world in technology has made things so accessible and so easy to use....This raises the expectation that if you’re not easy and you are complex, you will get penalized over time.”
Broussard also suggests that technology will provide solutions to physician shortages found in rural, remote areas of Kentucky, with particular emphasis on telemedicine. Other solutions outlined by several of the healthcare executives included virtual care, lay providers, and “retail” access points. Although some technology that rely on broadband infrastructure, such as online and mobile devices, can be difficult to access in some rural areas within the state, Broussard suggests that “It’s a problem today but probably won’t be in the future.”
He noted that technology-based companies are watching changes in healthcare closely and are figuring out a way to be involved, which will impact future service areas. Humana provided an example of social network connectivity without the technology. Through partnerships in Bell County, Kentucky—part of rural Appalachian country—Humana created a social-based wellness program designed to address chronic diseases. At the end of the program, he said, 95% of participants have seen health improvements.
Collaboration and Partnerships
All the healthcare executives highlighted the need for partnerships with multiple organizations in order to meet the responsibility for improving population health. These include healthcare providers, government, health departments, schools, members, and employers. Hanson discussed the need for partnerships to address more aspects of wellness, such as mental health, dental health, chemical dependency, and spiritual health, and Brinkley described a program in which hospitals partner with health departments to prevent hospital readmissions.
The changing healthcare system is “driving consolidations, collaborations, and alignments; developing a new world order in Kentucky and beyond,” Williams said. “We all compete, but we need to collaborate at a higher level,” Hanson said.
Changing Payment Structures
Funding healthcare reform, reduced reimbursements, and increased costs were a concern for all the healthcare executives. Two aspects were highlighted during the conference that affect the changing payment structures for healthcare. First is the shift from fee-for-service to a payment structure that rewards better health outcomes, quality, and lower cost. Second, the financial risk has shifted to physicians.
All the healthcare executives recognized challenges in the current system where organizations and physicians are paid and incentivized based on the volume of services rather than improved health outcomes.
“People are getting older, people are unhealthier, and the structure is flawed—the more you do, the more you get paid,” Humana’s Broussard said. “There is an inherent conflict especially if you don’t have transparency and understanding of the cost.” For Humana, 26% of their current members are focused on relationships based on quality and cost of service through their Medicare Advantage program. Of the $40 million Humana makes annually, $26 million is paid on fixed reimbursement, incentivizing the insurer to improve quality and overall health among members. “The better we do, the more we get paid,” Broussard said. “I have a whole team of people whose purpose is to improve quality.”
He gave a specific cancer example to highlight this fixed fee. “If you are in stage III cancer, you are taking the most expensive treatments, and you select Medicare Advantage, we have a responsibility to take you on. Our motivation is to keep people healthy.” Although Humana is required to take on this high-risk patient, there are differences in the rates based on preexisting conditions.
Since the payment structure is moving to promote healthy outcomes, an increased risk has shifted to physicians. Through bundled payments, there is an incentive to do less, be efficient, and focus on quality of care more than quantity of procedures. Broussard highlighted a program from Humana known as “path to risk” in which the company dedicates resources to help primary care physicians make the transition. Humana gradually increases bonus payments for improved quality and reduced cost, and it reduces fee-for-service payments over time.
Integrated Care Delivery Models
Aligning with the changing payment structure, the executives said the healthcare system is moving from a skilled and fragmented delivery system to integrated primary care delivery systems and models. Hanson highlighted the need for coordination of care across the continuum: from prevention, screening, treatment, home health, rehabilitation, to long- term care and hospice.
Broussard attributes the growth and uniqueness of Medicare Advantage to the combination of fixed costs and the integrated care delivery model. The member relationship and experience around health has become a higher priority. Although Medicare Advantage is currently the only plan implementing this model, Humana plans to expand to other benefit plans.
One important aspect of the integrated care model includes the ability to provide education and navigation to patients who will be newly insured under ACA, so that they will understand how to utilize their new coverage. Williams explained that Norton Healthcare will train staff to be navigators who provide support to patients using “decision trees.”
The healthcare executives agreed that concerns about cost and improved outcomes require better cancer prevention. When fewer cancers occur, there are fewer patients who need treatment. In announcing plans to add 308,000 people to Medicaid, Kentucky’s governor said he was “tired of being at the bottom” of the nation’s rankings of cancer deaths.1
When cancer is not prevented and patients must be treated, Karpf, of the University of Kentucky, said he confident that the patients would not receive different care based on the type of health insurance they carried. He believes that there will be increased standardization of treatments and participation in clinical trials, speaking just days after the University’s Markey Center received a National Cancer Institute designation that was years in the making.2 NCI designation allows funding for increased clinical trials.
“The greatest costs of cancer are in the last 30 to 60 days of life. Decisions will need to be made based on value for the cost,” Karpf said. “If treatments are $15,000 per month and it prolongs life 3 months, the treatment may not be covered on a population level. Parameters have to be set based on impact to society.” He also emphasized the need for the best care for families and patients, which may involve hospice care, which can both decrease the cost of care and increase the degree of satisfaction for patients and their families at the end of life. Hanson proposed that genomics and personalized medicine may become more common once populations have a medical home.
He believes this aspect of medicine can impact both the screening and the treatment of cancer in the future.
Although there are many potential benefits for Kentuckians with the increased access to care, there is also potential for disappointment. While Karpf stated his support for healthcare reform and increased access, he also described scenarios that may result in unmet expectations during the implementation process:
;• Kentuckians will have the choice of a plan, but they may not have the choice of a provider or a network. There will be well-defined referral patterns within plans and systems
providing fewer choices for patients.
• Kentuckians may also not have the choice in the types of diagnostics and therapeutics due to increased standardization.
• When Kentuckians sign up for an exchange plan, they may not fully realize the difference between the bronze, silver, gold, or platinum plans and their respective copays or deductibles.
• There will be fewer “Cadillac” plans because taxes on companies are increasing. One way to absorb the tax may be to offer fewer benefits in their health plans.
• When the employer mandate is implemented, some employers may choose to pay the fine and let the employee find his or her own insurance. These personal insurance plans may offer fewer benefits than employer-sponsored plans once did.
• Healthcare, which is already expensive, may become more expensive than anticipated. When Massachusetts implemented health reform, costs exceeded projections. Massachusetts had only 7% to 8% of the population uninsured, compared with Kentucky’s 20%. If Kentucky spends more money than planned, there may be more reform required.
Another area leading to unmet expectations involved the Obama administration’s decision in early July to delay the employer mandate. Brinkley emphasized that the only thing to change in the mandate was the date of implementation; however, both she and Hanson agreed that the delay in the employer mandate will probably not be the only delay in implementation due to the complexity of the ACA.
As Williams reminded the conference attendees at the end of the session, “ACA is a framework. Fix what doesn’t work and accelerate what does work.”
Jennifer Redmond, DrPH, is a research assistant professor at the University of Kentucky College of Public Health. She provides expertise in partnership sustainability, program development, and group facilitation, especially related to cancer prevention and control, health promotion, and overall chronic disease prevention. 1. Gov. Beshear Expands Health Coverage to over 300,000 Kentuckians. May 9, 2013. Governor Steve Beshear’s communications office. Frankfort, Ky. Commonwealth of Kentucky. http://migration.kentucky.gov/Newsroom/governor/20130509medicaid.htm. Accessed July 21, 2013.
2. Perry A. Markey earns prestigious National Cancer Institute designation. Markey Cancer Center, July 12, 2013. University of Kentucky, Lexington, Ky. http://www.ukhealthcare.uky.edu/markey/news/07122013-NCI-designation-press-release/Accessed July 15, 2013.