Published by Michael L. Diamond of the Asbury Park Press
New Jersey (March 16, 2016) -You’re on the hook to pay for more of your health care. You are being begged when you feel lousy to call a doctor instead of visiting an emergency room. Your doctor asks if you feel depressed, even if you made the appointment because you had a cold.
Health care is changing fast. Doctors are losing their autonomy. Hospitals are under pressure to keep you away. Insurance companies are under fire in Trenton. Even mayors are being prodded to come up with a program to get their constituents walking and eating healthy.
“There’s constant confusion,” said Toby Stark, an insurance broker with Stark Associates in Tinton Falls and president-elect of the New Jersey Health Underwriters Association trade group. He spends his time walking clients through the pros and cons of health insurance plans.
Stark was one of nine health care leaders who came together at the Asbury Park Press Tuesday night for the APP Business Roundtable – Making Health Care More Affordable edition.
It offered a chance to take stock of the Shore’s health care landscape, six years after the Patient Protection and Affordable Care Act, or Obamacare, went into effect in a bid to provide health insurance to more Americans, improve quality and slow down an industry that has grown so fast it makes up 17 percent of the nation’s economy.
And they spotlighted several steps they are taking that, if they work, would help the law serve its goal.
On the panel: Stark; Marta Silverberg, executive director of the Monmouth Family Health Center in Long Branch; Diann Johnston, chief nursing officer and vice president of patient care services for Monmouth Medical Center in Long Branch; Linda Schwimmer, president and chief executive officer of the New Jersey Health Care Quality Institute, a research group; Sarah Adelman, vice president of the New Jersey Association of Health Plans, a trade group.
Also: James Matera, an internal medicine and nephrology doctor at CentraState Medical Center in Freehold Township; Marc Feingold, a primary care physician, Manalapan; Marty Scott, senior vice president, chief quality officer at Wall-based Meridian Health; and Steve Landers, chief executive officer of the Visiting Nurse Association Health Group based in Red Bank.
The law remains embroiled in a political fight between those who think it goes too far and those who don’t think it goes far enough.
But behind the scenes, the panelists painted a picture of a seismic shift. And health care providers are scrambling to keep up.
The key: Everyone needs to paddle in the same direction.
“We’re not talking about da Vinci robot arms and things like that,” Schwimmer said. “We’re talking about shared decision making, having real conversations between the doctor, the nurse and the patient about what their life goals are.”
How to make health care more affordable? Here are six steps.
1. Stop paying for volume
Medicare and insurance companies are testing new programs reward providers not for the number of services they provide, but for the outcome of their work.
It hasn’t been universally embraced. Lawmakers in Trenton, for example, have been trying to stop a new insurance plan offered by Horizon Blue Cross Blue Shield of New Jersey that leaves some doctors and hospitals out of its preferred network. But some of those in the top network are working more closely with the insurance company to lower costs.
“The goal of all these programs is partnership,” Adelman said. “It’s getting at increasing quality, lowering cost, moving towards better outcomes for patients and overall better continuity of care.”
2. Keep patients out of the hospital
Hospitals face penalties from Medicare if their patients return within 30 days after they were discharged. They face penalties from Medicare if their patients get infections or slip and fall once they are in the hospital. And Medicare and watchdog groups report their performance online for the public to see.
The reason: Hospitals are expensive.
“It’s kind of like two boats in a river,” Meridian’s Scott said. “Right now, we’re still on (the boat that says) put people in the hospital and (treat) them. That’s how hospitals make money, that’s how doctors make money. The boat that’s coming up behind us is, keep people healthy.”
Monmouth Medical Center has honed in on who is likely to visit the hospital multiple times, making sure they see not only doctors but also nurses, social workers and pharmacists.
“If they’re at high risk for readmission, you’re going to get the benefit of our entire interdisciplinary team is going to descend on you,” Johnston said.
Once out of the hospital, health care providers need to communicate better with each other.
“This is a team sport,” Landers from the Visiting Nurse Association said. “The transition coordination has to be right…so we start to work more like an orchestra instead of one-man bands.”
3. Get doctors and patients to buy in
Doctors who once prized their autonomy now work with administrators, insurers and other health care providers to treat a patient. Meanwhile, they need patients to take advantage of all of the exercise programs, healthy eating lessons and smoking cessation classes that are available.
“I think you have to pick the right doctor for each patient,” Feingold said. “I’m not going to get through to some patients and I’m going to get through to other patients.”
CentraState’s Matera said: “The two things that make this very successful is, you have to have doctor engagement and you have to have patient engagement. Those two things must go hand in hand. You can tell a patient to stop smoking every single time you see them, you can refer them to smoking cessation classes, but unless they’re engaged to do this, they’re not going to. You can tell them that it’s going to impact their health. They’re not going to buy in if the doctor is not engaged in this.”
4. Emergency rooms are for emergencies
Newly insured consumers, who previously went to expensive hospital emergency rooms when they got sick, are learning to see a primary care doctor instead.
Health care advocates have had to get creative to change their habits.
“If somebody goes to the emergency room for an earache, and you give them the antibiotics they need for a week, by the time they get better, they’re not going to go back to primary care,” Silverberg from Monmouth Family Health Center, said. Now emergency room doctors “give them two or three days’ dose, (refer) them to the health center, make an appointment with the health center and have the (primary care) doctor follow up.
5. Die with dignity
New Jersey has among the highest costs of treating patients in the last six months of life. It’s prompted health care advocates to encourage doctors to talk to their patients about alternatives to expensive, life-saving measures that are performed in hospitals. An example? Using hospice care and allowing people to die more peacefully at home.
“We in New Jersey get so much care at the end of life, which is so expensive, and no one asks us if it’s anything we want,” Schwimmer said.
6. Rein in prescription drug costs
Pharmaceutical drug prices are growing fast. Half a million Americans take more than $50,000 a year in medication, Adelman said.
One bill that has passed the New Jersey state Senate would ensure hospitals test baby boomers for Hepatitis C, a liver infection. If the test comes back positive, there’s a cure. But the price is upwards of $100,000.
“As a system, you can’t sustain that,” Adelman said. “That’s what we’re seeing across the board with specialty drugs, even drugs on the market 30 or 40 years.”