More Insured Means That Medical Care Must Change

By Winthrop
Quigley/Journal Staff Writer

It’s a classic problem: How do you carry around 10 pounds of potatoes when all you have is a five-pound bag?

Starting Jan. 1, 2014, an estimated 200,000 or so New Mexicans who have been without health insurance will be required to purchase some, with government help if necessary, or pay a penalty to the Internal Revenue Service.

If state government takes the federal government up on its offer to pay most of the costs, as many as 170,000 more people without health insurance will find themselves with Medicaid coverage.

Not everyone will buy health insurance come 2014, and not everyone who is eligible for Medicaid will apply for it, assuming the state gives them the option. Still, it is reasonable to expect that before long perhaps 200,000 to 300,000 more New Mexicans will have an insurance card in their pockets than have one today.

The newly insured will be trying to access a system that, according to the state Health Policy Commission, is already short up to 600 primary care physicians, needs 1,000 more nurses and ranks 49th out of 50 states in the number of dentists per capita. The federal government has designated all but Bernalillo County as suffering health provider shortages or being medically underserved.

Patients can expect some big changes in the years ahead. Many will see less of their physician and more of nurse practitioners and clinical pharmacists. They will become accustomed to using smart phones and computers to access the health care system. They will spend less time discussing illness with health care providers and more time discussing ways to stay healthy.

“There could be some inconvenience for current users of the system,” Presbyterian Healthcare Services CEO Jim Hinton said. “I don’t think it will be as great (an inconvenience) as people predict. It would be simplistic to think of it as a function of the current supply and current demand. It’s not static. It’s not going to be 300,000 people coming into the system and using it the same way as today.”

Writing on the wall

Some of the state’s larger health-care delivery systems have been preparing for 10 pounds of potatoes for years, not because they knew federal action would increase their patient load, but because the systems they have been running are too expensive and too inefficient to sustain.

The people who run those systems expect to have some problems serving all those newly insured people. They have been expanding the system’s capacity and looking for more professionals to staff it.

But they say the real solution to endless lines and infinite waits is to change the way they deliver health care.

To understand how ABQ Health Partners, First Choice Community Healthcare, Lovelace Health System and Presbyterian plan to serve hundreds of thousands of newly-insured patients, it helps to understand how care is delivered today.

The first thing to understand is that health care providers, like physicians and clinics, get paid when they see “a warm body,” said First Choice medical director Santiago Macias. Physicians like Macias and clinics like First Choice don’t get paid if the patient isn’t in a room with a provider. The provider has to do something Medicare or Medicaid or an insurance company will pay for — listen to the patient’s heart, order a blood test, remove a cyst.

Smarter care

Macias’s wife, Angela Gallegos-Macias, is a physician with Presbyterian. She has found that getting her diabetic patients together for a group visit improves their health because it allows them to share knowledge and encourage one another. It’s more efficient because information, about nutrition, for example, can be dispensed once to several people at a time. The problem is that Medicare, which insures these patients, doesn’t pay for a group visit.

The second thing to understand is that as payment systems currently operate, sick people are an asset to a medical practice and healthy people are a liability, said ABQ Health Partners CEO Harry Magnes.

A medical group and a hospital can bill an insurance company or Medicare thousands of dollars repairing someone’s broken hip, but no one makes money sending people to the patient’s home before she falls and breaks her hip to eliminate fall hazards like unsecured rugs.

Third, the health care system’s use of communications and information technologies is generations behind that of your average auto parts store. A 2009 national survey showed only 8 percent of adults had ever exchanged electronic mail messages with their doctors.

A disconnect

Hinton said that even though providers and payers all dream of a national, integrated health information exchange that allows any health care system anywhere to access a patient’s medical records, the industry has yet to agree on how each patient is to be identified so a computer anywhere in the country knows who he or she is.

Communications systems don’t exist between practices, and sometimes within them, to alert Dr. Smith that Dr. Jones has already ordered your blood test and that it doesn’t need to be done a second time, Magnes said.

Finally, physicians, who are expensive, scarce and take a long time to train, spend too much time doing things other professionals could do as well or better. That is partly because licenses restrict what medical providers who are not doctors can do. Inertia and tradition in the industry is another reason.

Lovelace Health Plan chief medical officer John M. Cruickshank said patients must see a physician every six months to get medication refills when many times a clinical pharmacist or nurse practitioner could do the job.

Local health care systems have known for years that all of those things drive up costs and degrade care, and they have not stood still.

Healthy people

“The real saving is keeping people healthy,” Magnes said. Healthier people need less urgent care and hospitalization. Systems are learning they can keep people healthier by better coordinating care.

“A whole array of social determinants” affect a patient’s health and the care he receives, said First Choice CEO Bob DeFelice. Communities that don’t respond to health department appeals to vaccinate their children will listen to a neighbor hired to go door-to-door. Patients who need so many medications that they become confused need a nurse or a pharmacist to visit their homes to check on them. Obese children might need a behavioral health specialist to help them with an eating disorder, and their parents might need advice from a nutritionist.

Those teams of providers, which First Choice has been operating for years, make people healthier and keep them from using the more expensive pieces of the system, like hospitals, Macias said. That will free up more money for primary care providers. In the near term, DeFelice said, insurance companies and other payers will reward systems that use care coordination teams and penalize those that don’t.

Magnes said ABQ Health Partners is merging with a large California practice primarily to take advantage of its new owner’s care coordination capabilities.

More efficiency

Patients need to be seen in the most efficient way possible. That can often mean they will be seen via web-based video systems, they will remain at home while remote systems monitor their blood pressure and other vital signs, and they will see nurses, physician’s assistants and pharmacists instead of doctors for some care. They will use computer systems to make their own appointments, check on their own lab results and get medical guidance.

“If I had some chronic things going on, need blood-pressure medications or diabetes medications refilled, and I wasn’t having problems, outside of getting a physical, I don’t need to see the doctor,” Cruickshank said. Soon patients will see a nurse practitioner or pharmacist instead, because payers will reimburse for that kind of visit. Cruickshank said that change alone could double the capacity of the primary care system.

Just like emergency rooms, primary care clinics are clogged with people who don’t need to be there, Hinton said. Health delivery systems are installing web-based products that will allow patients to handle many of their needs from home. Other technologies allow Presbyterian to let patients recover at home who once had to stay in the hospital.

Tech improvements

More specialists will consult with patients and other physicians using telehealth technology, Cruickshank said. Such systems, in particular the University of New Mexico’s Project ECHO, are already in use around the state.

Tests and prescriptions will be ordered online. Patients will communicate with physicians using smart phones, email and Web systems. The industry will figure out how to create a patient record that all health care systems can use, because Medicare and other big payers will require it. When those records exist, duplication and waste should decline. Supply and demand for health care are not static. Standards of care change. Colonoscopies and prostate surgeries are done less frequently than in the past, because practitioners now know they aren’t as necessary as was once thought, for example.

Government and private efforts revolve around improving efficiency and thereby increase the supply of primary care. More primary care means less demand for emergency care, Macias said. It means fewer diabetics have to be treated for eye problems. “There will be fewer patients showing up with acute events in urgent care,” he said. “How do you lower hospitalizations? You increase primary care.”

Cruickshank looks at the next few years as just another shock to a health care system that requires the occasional shock.

“That’s what medicine does,” he said. “Unless we get a threat — a lack of reimbursement, a penalty — change wouldn’t occur quickly enough. We see change occurring because folks understand we can’t be successful operating the way we are today. Chaos for me always creates opportunity.”

To view the story click here for the cover page and here to continue reading.

ABQ Journal

News and Events

FREE Seminar! Financial Boot Camp for Growing Families
Are you a new parent or expecting a child?
Lovelace nurse manager reflects on career that inspired growth

Reina Valdez, RN, didn’t expected to one day lead a team of nurses as the manager of Labor and De

Physical therapist graduate finds experienced team and opportunity to build career at Lovelace

“I grew up in Albuquerque,” shares Lovelace Rehabilitation Hospital physical therapist, Lindsey B