The state of health care in N.H.: a roundtable

NHBR’s editors recently met with New Hampshire health and wellness leaders at the Greater Manchester Chamber of Commerce to take the temperature of the Granite State’s health-care system and to find out what they believe the future holds for the industry.

Participants were:
• Mary DeVeau, president and chief executive, Concord Regional Visiting Nurse Association, Concord• Ned Helms, director, New Hampshire Institute for Health Policy and Practice, Durham• Dr. Richard Lafleur, medical director, Anthem Blue Cross and Blue Shield in New Hampshire, Manchester• Scott Lawson, president, Scott Lawson Group Ltd., Concord• Ann Peters, chief executive, Lamprey Health Care, Newmarket• Heather Staples, consultant, New Hampshire Citizens Health Initiative, Bow• Susan Tenney, manager of network contracting, Harvard Pilgrim Health Care, Bedford• Dr. Barbara Walters, senior medical director, Dartmouth-Hitchcock Regional Practices
Q. What are some of the health-care challenges faced in New Hampshire today?

Ned Helms: I think one of the biggest challenges is getting people’s attention on the right issues. I just saw a poll that came out that said jobs and the economy were on 50 percent of people’s minds, balancing the budget was on 18 percent of people’s minds, and health care was on about 4 percent of people’s minds. I think from a business perspective, they’re using the wrong definition. I don’t think businesses care about health care – they care about the premiums.

The reality is, if we’re serious about improving the health of our population, and doing something about it, businesses are going to have to start doing things and take ownership.

Barbara Walters: From the provider point of view, I would say every provider every day wakes up and wants to provide the best care that they possibly can, but the administrative hoops that we have to go through in order to practice medicine in a way that is affordable to our patients, that complies with all the rules and regulations, then make sure I to pay attention to Harvard’s rules or I pay attention to Anthem’s rules. And I haven’t even seen my patient yet.

If there is anything we can do to make administrative things simpler to allow me to take care of the patient the way that I want to take care of the patient, which is using my clinical knowledge and to practice the best medicine I can as efficiently as I can, that’s quality medicine.

Scott Lawson: About six or seven years ago we started a wellness company, Workforce Wellness. We can’t give away employee wellness programs. I’ve had people sit there and tell me face to face, “We can’t afford an employee wellness program because our insurance premiums just went up $300,000 this year.” And when I say wellness programs, it’s everything from health risk assessments to lectures on any health-care topics.

Our own personal experience is we’ve been doing a fairly comprehensive wellness program for about five years now. For two years running, our insurance premium went down by 8 percent, almost 9 percent the next year and almost flat this year and going forward.

Susan Tenney: One of our biggest challenges within the health insurance side is trying to keep our premiums down for our employers. We’re looking at different ways in order to do that. We’re looking at the state level, at ACO (accountable care organization) pilots, getting employers to offer wellness to their programs. We have management programs in house. We have wellness programs where we go out to the employers.

Mary DeVeau: We need to fix the system of care in order for us to really look at the patient and what are the patient’s goals and needs. How do we help educate and empower those patients to improve themselves? We aren’t going to do it for everyone, but I think we can help a lot of people with health literacy when we work with people and coach them on how to improve their health.

Another challenge we have in the home, health and hospice side, or the end-of-life side, we want to save everybody today. We want to make sure everyone gets everything right up until the end of life. And is that what someone really wants in their life? We see many patients come in to hospice in the very last day or week of their life. How do we help to have that conversation with the families and patients sooner?

Richard Lafleur: I read an article last week that talked about terminal illness, that support was as valid as doing two more rounds of chemotherapy. The patient actually lived longer and had a better quality of life. It’s a lot easier to run a test than to sit down for an extra 15 minutes and go over the pros and cons of that test. We see that on the insurance side and the costs are going up.

The bottom line of all of this is it is a cost. Until everyone is on the same page with that issue, we won’t solve that problem.
Heather Staples: I think the accountable care project we have been working on tries to get at some of that issue. We don’t pay or pay adequately for the conversation; we pay really well for the test and the treatment. You’re seeing the cost increase despite the fact that they might have a wellness program or they may even have a high-deductible plan. It’s still not enough to keep up with the use of services and more advanced services that are costly.

Ann Peters: At the community health center, a lot of our patients are uninsured. For us, it’s a case of addressing their needs when they come in and establishing a relationship. Many times, it’s addressing the social determinate of health as much as it is, or to the degree that you can, which may be partnering with other entities to help them address their health-care needs. In the hierarchy of needs, health care may be on there, but housing or food may be number one.

I would have to say it takes a team, it takes engagement, it takes enthusiasm, and we are oftentimes stretching resources over the population to cover it.

Q. How do you plan for or work toward the provisions mandated in the federal Affordable Care Act when that law appears to be changing?

Walters: Health-care reform ended up mostly being insurance reform. We’re strong proponents of using the medical home as a cornerstone for our delivery system and then expanding that into a medical community. That’s the right thing to do clinically no matter what happens with health insurance reform.

As providers, we do have some responsibility for taking some of the cost out of the health-care system. We have the power of the pen – something like 80 percent – because of the prescription I write out with my pen.

Helms: I think the debate that we are having today about health-care reform is so far from the reality of what’s going on today. When you strip it all down, the health-care reform act did three things. Number one, even though the dollars are small, it encouraged two systems – the public health and the medical system – to try and work together. It’s the largest single investment in the history of the country, $15 billion, starting next year to try and do that.

I appreciate what Barbara said, but the reality is the provider community doesn’t act like a model. A group of providers in Concord spent a year really improving the way they care for patients with diabetes, which is a huge cost, as we know. They don’t get paid a dime more because they are so good, than some schlep down the street who does a lousy job managing his patients with diabetes. Not a dime.

I think what the act does is try to encourage (pay for performance) through the accountable care organization coming on in 2012 for Medicare. That’s number two.

The third thing it does is let everyone in over time. We spent twice as much as any other industrialized nation and left 20 percent of the population out. So I think we have to get serious about reforming the system we have and creating a healthy population.

Lawson: We find a real lack of information coming from the broker community, both on the health insurance side and certainly on the workers’ comp side.

I would love to sit here and tell you we have the healthiest group of people, but that’s not the case. What we have is a bunch of people who, when they have their skin in the game, they pay attention to what they’re paying. So now when they go in and they hear they are being charged this amount, they ask why, and the doctors fall out of their chairs. Why do I need an MRI? Is there something else I can do? And if I do need an MRI, where’s the cheapest place in the state I can go because that’s coming out of my pocket? They’ve gone and done their research to stretch their dollars.

I was on my way home and listened to a debate on health reform on the radio, and I kept thinking, when are you going to talk about people having some individual responsibility for their health?

I have no information the way you folks do in your system, but I think the health-care system is totally broken.

Tenney: From our perspective, to prepare for health-care reform, we follow as closely as we can and we adapt to the changing environment and respond as quickly as we can. To be compliant with the health-care reform, we’re working with organizations like the Citizens Health Initiative on the ACO pilot.

Lafleur: Like Barbara said, it’s not health-care reform, it’s health-care insurance reform. A lot of these things were already happening by insurers because they recognize the issues that were important.
Processes that were in place years before health-care reform to get rid of co-pays for preventative care. We had the age 26 dependent in New Hampshire before it became federal law.

It’s also really getting at the issues that drive behavior, personal behavior that you had mentioned, about individual responsibility.
It’s also what drives physician behavior. I’m also a practicing physician, and I hold myself accountable to making sure I give that patient every detail of the pros and cons of what do to. It’s so much easier to order a test than to go over that. That’s partly because the incentives are you don’t get reimbursed for that and that’s the difficulty.

Staples: We’re seeing, in terms of effectiveness of the programs, they’re really reliant on good information about the cost of care, about the cost of drugs, to both the consumer and the provider. It also needs to go back to the systems and the providers in terms of whether they are doing the right things. We haven’t been particularly effective with data about overall costs to providers. They think they are doing all the right things, but they don’t really know if they are or not. Are they prescribing the wrong drug, are they keeping people out of the emergency room?

Peters: We’ve increased the sophistication of electronic medical records, but we don’t really pass data in an exchange back and forth. So the clinicians at Lamprey don’t really know if their patients are ending up in the ER all the time if they don’t get the data back. And they need to know that in order to manage the patient effectively.

Q. There have been several high-profile cases of contract disputes being played out in newspapers, social media and the like. Has the media become a new tool in negotiating contracts between businesses and insurance providers?

Lafleur: We certainly don’t negotiate in the media per se in terms of contracts. I think what you are seeing is representative of what everyone is talking about – we have costs out of control that can’t be sustained.
I think we will see more of this. There is going to be a reality check as to where these costs are going. As Ned said, we are two times the amount of anyone else.

Staples: Contract disputes aren’t anything new. I think we had a pause, where we sustained increases year after year. So quietly contracts were renewed at a 10 percent increase and then people stood back and said, “How did this happen? I can’t sustain this.” I don’t know that’s necessarily the case with all providers, but this isn’t anything new that’s been going on.

Helms: I was over at Blue Cross and Blue Shield 10 years ago, and we had contract fights with the people in Laconia, in Exeter, in Nashua at St. Joseph’s Hospital. It was at a time when people were saying, “This is not sustainable.” Then we had a huge bubble and everyone forgot about it. Premiums went up 100 percent in the last year and they turned around.

The unfortunate part is the conversation that is taking place now is, “How much money am I going to get for doing this procedure?” There’s no argument on when are you going to start delivering the quality of care in this region that is equal to the best quality of care in the country.

Peters: I live in the middle of this right now (with contract disputes). We’re getting a lot of people coming to us and asking, “Can we get care?” There are people that are paying the price in changing the long-term relationship they have with their providers. We’re still part of the Anthem network, but it still concerns me with what I see in the area.

I understand what both sides are trying to do, but I would hope that both sides would try to come together for an end, thinking of the people that are served and the communities that are served, sooner rather than later.

Q. What are some of the key best practices you’ve seen here or elsewhere that you think should be rolled out across New Hampshire?

Walters: There are some well-done, well-researched, well-respected clinical pathways – step-by-step protocols – that are evidence-based. Diabetes is the one that is more commonly thought of.

Others are for congestive heart failure, coronary artery disease, hypertension, COPD (chronic obstructive pulmonary disease), asthma for children, epilepsy, ADHD (attention deficit hyperactivity disorder) for children, and low back pain. If you follow these 80 percent of the time, and everyone does that, the variation decreases in any kind of complicated situation.

Peters: You can build a lot of it in with the electronic medical records. You’re also capturing those unique pieces of data and you can give a report to the individual provider by month.

Helms: I was also thinking of the whole notion of informed decision-making. There was a hospital in Chicago that had developed a protocol that said, for women with breast disease, it’s mandatory that they engage in the informed decision-making process before they go through the procedure. What they found is that those people who were involved, regardless of which procedure they chose, had 60 percent less depression following the procedure than folks who had not engaged. So there are ways we can do that.

Staples: We’re saying, “Be a good shopper and go out and look.” If it’s between a $2,800 MRI and a $600 MRI with the same quality, go for the $600 one. That $600 goes back to saving us in the long run in terms of premiums. But when they’re at the checkout desk and the health system says to go to their own MRI, the hospital-owned MRI, they are put in the position of having to debate that because the providers need to refer them back in to their own system. Not just for financial incentives, but because they also want the data to come back.

There’s a continuity of care reason, but because we set up the payment system so that they are incented to keep them in.

Q. What are some other things that providers need to be doing to keep budgets and costs in check and still provide their services beyond simple cost cutting?

DeVeau: I think that we have way too many home health agencies in the state. How do we come together to support each other without having to have our own little organization that needs high-level administrative support and clinical support systems in order to operate in today’s world? There are opportunities to collaborate and connect.

Lawson: You are never going to get people who have built their business up to come to the table and give away some of their business because they have the overhead and can’t write off that machine. You have all these conflicting motives and profit motives.

I have no idea how to fix it, but I have no problem sitting down with a blank piece of paper and saying how we would like this to work. And get everyone to take off their own hat, and put on a team hat.

Peters: One of the things the community health center did early on – and, again, it was because of resource restraints – we were able to work with the Concord Family Practice residency to start the use of the EHR (electronic health records). Right at the start, we decided to pool resources. So we established a network, and that network now serves, I think, 21 different sites in a couple of different states. But I know the time is coming when we’re going to need to be part of that larger system as well, both vertically and horizontally.

Lafleur: That is one thing when you talk about communication. The banking industry figured this out many years ago. You can take your ATM card and be in France, stick it in and get money out. All that information gets transferred and for some reason health care has not been able to step across that line. Why do we have such difficulty in doing that?

Helms: We know that about 25 percent of our radiology studies are repeats because the person shows up and the study’s not there. So just run down the hall and get it done again. They’ve just done it twice. I just go back to it is not that the solutions aren’t there and very clear, it’s just we find ourselves in a system that doesn’t, by and large, consent you to do the right thing.

To go back to what Mary said in the very beginning about advanced directives and end-of-life care, the stunning thing to me is that we are so unsophisticated as a political culture that, two summers ago when the notion of end-of-life care came up, we had two-and-a-half months of screaming about death panels. We aren’t even mature enough as a political culture to treat that seriously. I think that’s a shame, a real shame.

Q. Where do you see New Hampshire’s health care in five years?

Walters: I see pay-for-performance. We’ve been starting now. I think the Citizens Health Initiative is trying to keep us organized to become a medical home cornerstone. Once you get enough of the willing, maybe that will hold those people in the middle because we are, hopefully, going to be incentivized. Other provider groups will come along and that 2 percent on the other end will be out of business perhaps.

Staples: I think that you’re going to see an increase in the amount of team-based care. I think with clinicians in this new system and new form of care, talking more about their positive experience, I think you will see more practices and physicians around the state doing that because they’ll believe it.

There is still very high skepticism that it’s real, and I think this would do that, and I think there will be a payment system there to support it.

Peters: I also see information-sharing across with medical care that is absolutely essential to medicine.

One thing we haven’t talked about is workforce shortages. They are very real and out there, specifically in the area of primary care. When you look to the future, you’re going to see a lot more nurse practitioners, physician assistants and nurse midwives providing care.

DeVeau: I think there are two changes that will happen. Less care will be done in an institutional setting. There will be more outpatient procedures and more community health center management of patients and their needs.

I think you will have a much more educated consumer of health care. They will look for the MRI that is more cost-effective and they’ll know. They’ll also want to take the MRI with them and be carrying their own records. I really hope they do, because they keep the provider a lot more engaged in the practice, not just the “I want to do it my way.”

Tenney: As for me, being a health insurer, I need to continue more with pay-for-performance, working with each provider community to be doing what fits best for them.

Not every provider community will get there at the same time, and we need to be flexible enough to recognize that.

We also need to be flexible enough to let go. We at Harvard Pilgrim have a lot of disease management programs, and we pride ourselves on our diabetes management programs. But if we are going to be working with Dartmouth-Hitchcock Medical Center and they have their own diabetes management program, does it make sense to be managing that same patient with two different programs? We need to be able to say we’re going to step back and turn it over to Dartmouth.

I think that’s how we need to partner more with our provider partners and work with them more closely so we can eliminate the inefficiencies in health care.