Who better to ask about the state of the region’s healthcare than health system executives? So that’s what we did for this special issue of SNJBP…and their thoughtful responses ran the gamut from predictable, to discouraging, to depressing, to exciting.
  Accepting an invitation to participate in our virtual roundtable discussion on what’s happening in healthcare here in South Jersey, as well as what’s on the horizon nationally, were:
  •  Jim Foley, CFO at Shore Memorial Hospital in Somers Point
  •  Martin Bieber, President and CEO at Kennedy Health System in Cherry Hill
  •  Alexander J. Hatala, president and CEO of the Lourdes Health System and Catholic Health East New Jersey in Camden, and
  •  Rich Miller, President and CEO at Virtua in Marlton.
  We asked all four about how the Obama Administration should approach health care reform nationally, whether they support universal coverage, what payer model they feel works best, and what’s on the horizon for both Medicare and Medicaid.
Then we opened it up for their thoughts on a wide variety of topics, ranging from swine flu to the impact of the economic downturn.
Here’s what they had to say.
 
 SNJBP:  The President is making health care reform a cornerstone of his legislative agenda. If you could advise the President regarding the key components of his plan, what five points would you emphasize?
  BIEBER:  1. Healthcare for all must be paid for by all. If healthcare is a right for all Americans, then we all hold the responsibility for supporting it and paying for it. We cannot continue to shift a growing proportion of this burden to healthcare providers.  2. Coverage is important, but access is as well. Too many times we hear of patients who have health coverage but still have trouble finding a doctor – maybe the physician network is inadequate in their area, or perhaps physicians are declining to see patients with certain types of insurance. Even those with insurance can still struggle to access healthcare services.  3. Payment for care must be appropriate. Key government programs – Medicare, Medicaid and charity care – all pay N.J. hospitals less than their costs. We must address that if we expect a future of accessible, quality healthcare services. In addition, payment incentives between physicians and hospitals must be aligned to ensure they are working together to provide efficient, quality care.  4. We must streamline bureaucracy and administration, including standardized paperwork such as insurance claims forms and increased health information technology including compatible electronic medical records.  5. Graduate medical education must be supported – and paid for – by all. These added payments compensate teaching hospitals for the added expense they incur in training the next generation of physicians. But while everyone wants access to a physician when they need one, only government payers contribute to GME reimbursement. All payers should contribute to training the medical professionals of tomorrow. In a similar vein, any successful healthcare reform effort must also address strategies to fill the nation’s ongoing need for nurses and other clinical professionals.
  FOLEY:  1. High quality, safe care should be rewarded; ineffective care and medical errors should be discouraged. 2. Alignment of incentives should be attained amongst all stakeholders,eliminating costly duplication and over-utilization. 3. Fairness should be achieved by balancing the needs and concerns of all stakeholders, starting with the patient.  4. Elements of care, administration and payment systems should be simplified to a national standard.  5. Societal benefit needs to be addressed, including universal access,medical and educational research.
  HATALA:  1. Work with state governments, health-care providers, and insurers to develop affordable options that can improve access to top-quality health care for all Americans, particularly the uninsured and underserved.
2. Explore effective, equitable ways to stem the continued upward spiral of health-care costs.  3. Support changes in Medicare and Medicaid that would encourage a greater emphasis on the provision of affordable, readily accessible primary care.  4. Educate Americans about the importance of preventative care in significantly reducing the need for costly hospitalization.
5. Work with the states to address disparities in health-care outcomes among various populations, including minorities and the working poor. 
  MILLER:  1. The President must build incentives for preventive medicine in support of the primary care physician. Preventative medicine keeps people healthy, limiting their trips to the hospital or emergency room. 2. A plan must be able to cover as many Americans as possible and be affordable.
3. Incentives for physicians and hospitals must be the same, and the economics need to be coordinated between those entities. 4. The plan must also have an outstanding prescription drug program, especially for seniors.
5. A combination of public and private programs will work the best, not simply one or the other.
  SNJBP:  Are you in favor of universal coverage?
  BIEBER:  Yes
  FOLEY:  Yes
  HATALA:  Informed support for universal coverage would require the satisfactory resolution of a variety of significant issues and concerns, which include the following:
  •  How would programs be administered and funded?
  •  What would be the role of and impact on physicians and other health-care professionals?
  •  What would be the responsibility of employers?
  •  What would be responsibility of consumers?
  •  What choices would consumers have in terms of physicians, hospitals, treatment options, etc.?
  •  What would be the role of and the impact on the pharmeceutical industry?
  •  What would be the role of and impact on non-profit hospitals?
  MILLER:  I am in favor of universal health care coverage. Again, plans must be affordable, cover as many Americans as possible and contain built-in incentives for preventive medicine.
  SNJBP:  Do you support a single payer or a continuation of the present third-party payer model, which combines private insurers with government sponsored programs.
  BIEBER:  Yes. The conventional wisdom is that a single payer model is not on the table in DC because there is simply not enough political support for it.  That leaves us with building upon the existing employer-based system.  And that seems to be what is emerging with respect to healthcare reform.  That doesn’t mean there won’t be reforms to the existing system.  Administrative simplification in terms of the insurance system is part of reform.  That is very much on the table, along with coverage for all.
  FOLEY:  I favor a hybrid private/government payer model with a play or pay" mandate set at a realistic cost level to address the employer
provided, or not provided, coverage issue
  MILLER:  I support a hybrid plan that includes combinations of private and public programs.
  SNJBP:  If you favor the continuation of the present public/private hybrid, do you support continuation of private coverage through employers? And what kind of safety net do you favor?
  BIEBER:  Yes, private coverage through employers has been eroding over time, but it is still the core of our health insurance coverage, along with the public plans (Medicare/Medicaid).  The safety net has got to provide access to all, care to all, but all must pay for it.  Everybody has to have an investment in reform, and if we want coverage for all it can’t be paid for on the backs of one segment of society.  Our national association, the American Hospital Association, recognizes this and has been working in a coalition with six other groups in partnership with the White House.  AHA has come together with SEIU (a labor union), the American Medical Association, AviMed (Advanced Medical Technology Association), PHARMA, and AHIP (America’s Health Insurance Plans) to discuss ways that healthcare stakeholders can be part of the solution.
  FOLEY:  There should be a safety net for otherwise uninsured along the lines of Medicare, but funded jointly by the federal and state governments along the lines of Medicaid, which already has the administrative infrastructure to accommodate this.
  MILLER:  I favor the continuation of coverage through employers. But again, good plans must be affordable. As a safety net, there should be a basic public plan that is available to everyone.
  SNJBP:  How would you change Medicare? Will it run out of money? Is the new prescription coverage working?
  BIEBER:  By all accounts, Medicare will run out of the money in the not-too-distant future unless reforms are made. The pressure on the program will only intensify as the Baby Boomers age. We need to use the right amount of care at the right time, for the good of the patient. For example, studies have shown that too many elderly patients receive highly intensive healthcare services in the final days of their life, when palliative or hospice care would have been more appropriate and more sensitive to the patient’s needs. We need to promote that kind of thinking better among physicians and family members alike. We also can make Medicare more efficient by improving the coordination of services among different providers – in the transition from the hospital to a nursing home, for example. 
  FOLEY:  Medicare should be means tested above the cost of a base line safety net level of care.  It will certainly run out of money on the current unsustainable course and will begin running at an annual deficit in 2017 if nothing is done before then to change the situation.  Medicare Part D is working for big pharmaceutical companies, managed care firms and most beneficiaries, but the program is too much of a giveaway without more stringent cost controls and a tighter formulary.
  HATALA:  Any changes in Medicare must strike a balance between improving Americans’ access to needed care, including primary care, and controlling costs.  As part of overall health-care reform, sustainable improvements to Medicare must derive from a collaborative effort involving the states, federal government, the health-care industry, and the public.
  MILLER:   Medicare needs to change to keep it from running out of money. One suggestion is to delay Medicare implementation until citizens are a year or two older, especially as Americans are living longer. The cost of healthcare must also decrease if Medicare is going to survive. The prescription plan is better than in the past, but I would like to see it enhanced to include no co pay for chronic care medications like asthma, diabetes and hypertension. If there is no direct cost involved, older Americans are more likely to take their medications and stay healthier longer. Often times when they become sick, they end up in hospital emergency rooms.
  SNJBP:  How would you change Medicaid?
  BIEBER:  First and foremost, New Jersey’s Medicaid program needs to provide better reimbursement to hospitals and physicians. Hospitals on average receive just 68 percent of their costs when caring for a Medicaid patient. Physicians’ reimbursement is also extremely poor. That is a key contributing factor in the poor financial performance of so many New Jersey hospitals; half of the state’s hospitals are losing money, and nine hospitals have closed just since 2007. And Medicaid beneficiaries often have difficulties finding a doctor – fewer physicians are willing to take on Medicaid patients and receive the dismal payments the program offers.
  FOLEY:  Medicaid should be used as the funding mechanism for an expanded safety net system to cover all uninsured at a basic level of care, funded in part through a "play or pay" employer and private assessment system, in addition to tax revenues generated by taxation of employer provided benefits in excess of that basic coverage level
  HATALA:  The continued viabilty of non-profit hospitals in New Jersey – a state without a public hospital system – depends on prudent Medicaid reforms that will increase reimbursement levels.  If reimbursements continue to fall as the costs of care continue to rise, more New Jersey hospitals will fail, and New Jerseyans – particularly the inner-city poor – will see their access to care greatly diminish.
  MILLER:  In New Jersey, Medicaid is a great example of a program in trouble. It does not reimburse enough, especially for primary and specialty care physicians. We need to find a way to increase reimbursements. People in New Jersey have limited access to physician care because doctors are not accepting Medicaid coverage.
  SNJBP:  How has the economic downturn affected your organization? Has the need to provide charity care expanded...and, if so, to what degree?
  BIEBER:  Hospitals statewide are reporting some dramatic impact from the recession. A survey by the New Jersey Hospital Association earlier this year showed a dramatic decline in hospitals’ overall financial performance and a 27 percent drop in hospitals’ cash reserves. 80 percent of hospitals reported an increase in charity care patients, and 76 percent reported an increase in ER visits – both signs that hospitals are dealing with more uninsured patients as job losses mount. And hospitals likewise were affected on the jobs front, with 45 percent of hospitals reporting layoffs in 2008. That’s grim news for the New Jersey economy, because hospitals are one of the state’s largest employers.
  FOLEY:  The downturn has affected Shore Memorial by an increase in charity care, largely due to rising unemployment and consequent loss of health insurance coverage, compounded by increasing co-pays and deductibles amongst the insured.
  SNJBP: What is your biggest concern about the healthcare system moving forward? If you could address that concern unilaterally, what would you do?
  FOLEY:  Sustainability is my biggest worry, as costs and revenues are on widely divergent paths.  I would establish a basic, minimum coverage level of care and fund that broadly through a "play or pay" system, personal taxation of employer provided benefits above that level, and means testing of all other beneficiaries of publicly provided health care, primarily Medicare.
  MILLER:  A big concern is the ability to attract healthcare practitioners in the future. We face a major shortage of primary care physicians. We need to be in a position where physicians want to be trained and practice in this country. Right now, those who want to become physicians are being discouraged by graduating from medical school with heavy debt load and not a lot of initial financial return. There are also lifestyle issues associated with becoming a physician, not the least of which are long hours and little financial reward. We have to solve this problem. If we can’t, it is going to translate into longer wait times for everything from emergency room visits to scheduling an appointment with your primary care provider.
  SNJPB: Did the recent swine flu scare affect your institution? Can you describe the pandemic contingency plans that you have in place?
  BIEBER:  Hospitals statewide have experienced increased ED activity during the H1N1 flu scare. The good news is that hospitals have been engaged in pandemic flu planning for quite some time and were prepared for the situation. But it raises important considerations for the future: this recent flu scare has been limited in scope and severity. We must remain aware of the potential for a much more serious outbreak that could overwhelm our EDs, our testing facilities and our supplies of pharmaceuticals and supplies. In many ways this spring’s flu experience should be a wake-up call that we must remain vigilant and must ensure that our hospitals have the resources and support they need if and when a more serious outbreak occurs.
  HATALA:  The Lourdes Health System is well prepared to handle pandemic flu and other emergencies affecting the community we serve.  We have comprehensive plans that we test several times each year.  With the most recent outbreak of H1N1 (Swine Flu), we were able to open our command center and put our plan into action.  We have maintained close communications with local, state, and federal agencies and have provided both internal and external updates on the situation.  In addition, we have used the situation as an opportunity to provide education to staff and the general public.  Most experts believe that other, more severe pandemic flu outbreaks are likely to occur in the next several years, and Lourdes Health System will remain prepared by continuing to test and refine our plans.