NewsWorks freelancer Erin Cusack sat down with the new CEO of Roxborough Memorial Hospital to talk about what the recent Supreme Court decision on the Patient Protection and Affordable Care Act (ACA) means for his hospital and the community it serves.
In June, 2012 the Supreme Court fully upheld the constitutionality of the ACA in its ruling of the National Federation of Independent Business vs. Sebelius case. The impact of the decision is big – for states, insurers, patients, providers, and hospitals. In 2014, all individuals will be required to purchase health insurance, insurance reforms will guarantee individual’s access to coverage regardless of pre-existing medical conditions, there will be new state health insurance exchanges and tax subsidies, and with some limitations, Medicaid will be expanded to 133-percent of the poverty level. In the aftermath of this ruling, public attention turns to key healthcare players like CEO Pete Adamo and what he and his staff are doing now to move forward.
1) EC: What are some of the unique characteristics of your hospital’s health care model and patient population?
PA: The thing that makes this hospital unique is the community. I would say that had this hospital been anywhere else besides Roxborough, it wouldn’t be here today. It has a 120-year-old history here, and was founded by the church across the street, St. Timothy’s, when they realized that their parish didn’t have local health care. People in Roxborough like to stay in Roxborough to have their needs met. When the hospital was struggling, they continued to support it. The staff stayed here despite difficult and very thin times. I’d say that the most unique aspect is the dedication the community has to this hospital, which is very inspiring to this administrative team because we know that every nickel we spend is appreciated dearly. Now we have an opportunity for this body of people, who have struggled so long to keep this place afloat, to have a second chance at rebuilding.
2) EC: What has Roxborough Memorial Hospital already done to prepare for the implementation of the Patient Protection & Affordable Care Act (ACA) in 2014?
PA: Before I even get into that – I’ve only been here for four months, and the hospital changed hands five months ago. It changed hands because the former organization was struggling financially. In that duration, there wasn’t a whole lot done to prepare for future payment structures. I know that value-based purchasing (VBP) is a big deal in all hospitals, so is patient satisfaction and the ability to do core measures properly. Those are the things that we bring to the table. A lot of work needs to be done at this hospital with the way that we interact with our patients. For the longest time we didn’t have the resources available to deliver the absolute best product we could put forward. The facility had not been maintained the way I would like to see a hospital maintained. In the last several months since I’ve been here, we’ve added staffing to the floors and we’ve added technology throughout the hospital that will make a nurse’s day and a technologist’s day that much easier. Just building the basics back up to where they need to be is the first step. You can’t get fancy if you don’t have a foundation to build on.
3) EC: Are there any provisions in the ACA that specifically address the needs of your hospital?
PA: All hospitals have to do certain things right – core measures for instance: the ability to do things quickly once a patient enters your emergency room, to make sure your doctors are documenting properly what they’ve done and what they’ve not done with the patient. This not only helps us, it helps the entities downstream know what exactly took place. The ACA is causing people to deliver care in a more disciplined, evidence-based way. I’d say that that’s probably the first thing that has happened. Also, some reining in of insurance practices was long overdue. I don’t want to say anything negative about insurance companies, but when you see hospitals closing, doctors are making less than some folks make without college degrees, and employers are having a hard time passing it on to their employees, you have to wonder where this is all going when insurance companies are piling up huge profits. Some reform needed to be made about the way we finance through general insurance companies.
4) EC: The Supreme Court fully upheld the health care reform law, but ruled that the federal government could not penalize states which choose not to expand Medicaid. How will Pennsylvania’s decision to expand Medicaid or not impact your hospital?
PA: Over 80-percent of our patients are on Medicare. It’s just endemic to this community. We have an aging population here, and older folks tend to use hospital services a little more frequently than the younger patients do. Many of our patients not only come from Roxborough, but they also come from many of the skilled nursing facilities in this neighborhood. The Medicaid percent of our total business is rather small. My biggest concern is that as we reapportion the dollars, I suspect that the Medicare payment to hospitals will probably be reduced and begin to pay for the unfunded patient. I could probably be in a lesser position financially three years from now if that’s indeed the way the financing occurs. Although Roxborough’s not an affluent community, it’s a blue collar, salt of the earth, highly employed community. Folks have jobs, they have insurance, and they pay their bills. We’re fortunate in that regard. The real hiccups are going to be at those urban facilities that suffer from tremendous difficulties and have been subsidized (by Medicaid and uncompensated care funds] for years.
5) EC: Because of the health care law, millions of Americans with private health insurance gained preventive service coverage with no cost-sharing, including free cancer screenings, well visits, vaccinations, and counseling. How will access to these new preventive services make it easier to treat patients by the time they get to your hospital’s door?
PA: While it makes great sense to get folks vaccinated early in life and detect things early, let’s not confuse prevention with early detection. I would say that bringing more to the home for people who are homebound makes great sense. If we can do more of that, that would be ideal: checking in on some of these older folks, or folks that can’t get out of the house, whether they be children or someone at a distance from a large clinic who can’t drive in with relative ease. I hear statistics and read about communities where even infants are not getting all of their vaccinations by the time they’re two or three, and that’s just a tragedy. If we can nip that in the bud, I think early intervention is going to pay dividends downstream. But let’s not lose sight of the fact that prevention really is a matter of lifestyle, and if you take care of yourself and don’t engage in dangerous activities, you’ll probably be ok.
6) EC: The ACA requires health organizations to make “meaningful use” of Electronic Medical Records (EMR) systems. While a seemingly small change, this could have huge implications for patients. Can you explain in layman’s terms what EMR is, and how this will change the experience of patient care?
PA: Simply expressed, it’s the transportability of information about your health, illness, or former treatment, so that when you move from venue to venue, as much of the salient information as possible follows you. Understanding what may have happened at the last setting, if not the last three, four, five settings, is helpful. There are a lot of folks who are hospitalized, if not treated, by various caregivers at different points over the course of a year or two, and downstream they don’t know what happened upstream. If we can find a way to share that information, I think it improves the ability to quickly get after what you need to be addressing. There’s a lot of testing, and believe me, not everything is comfortable. I’d hate to have a colonoscopy repeated because someone couldn’t find a record and needed to take a second look. Those are the kinds of things I’d like to see come to an end because there’s no real reason for that kind of redundancy and duplicity.
7) EC: The ACA reforms the Medicare program’s payment and delivery systems to incentivize high-quality care, such as hospital readmission reduction programs, the launch of a physician value-based payment (VBP) system that rewards physicians who deliver better care (not more procedures/tests), and grants for coordinated care models, for example the creation of Accountable Care Organizations. Is your hospital pursuing any of these quality control measures?
PA: We’re focused heavily on the VBPs (value-based payments). Today, I’ll be looking at last week’s discharges to make sure that on a list of all core measures, we’re doing everything we’re supposed to do: was the aspirin delivered early on in the event of chest pain, was the vaccine administered before the patient left, were discharge instructions delivered properly, did the doctor do what he was supposed to do and document everything? I work for a company with 18 going on 19 hospitals that recently won a Thomson Reuters Top 15 Health System ranking. That’s a big deal for us, and how you win those awards is a tremendous emphasis on core measures. Those indicators really are a matter of education and vigilance: you can’t let the patient leave without everything being done. Too many hospitals spend time in committees reviewing data on patients who were discharged a quarter ago, and everyone’s in the room pontificating why it is that the data doesn’t look good. The only way to make those numbers improve is to actually walk alongside the patient every step of the way and guard them against any of the omissions that may occur, and that’s what we do as a hospital.
8) EC: How about Accountable Care Organizations?
PA: When it comes to Accountable Care Organizations (ACO’s) we’ll probably be a late adopter. Those sorts of programs fit well in communities where there may only be a sole provider, or where you’ve got mega systems with facilities clustered very close that have sophisticated information systems and employed physicians. Places like the Mayo Clinic, the Cleveland Clinic, and Geisinger come to mind, where you’ve got 1,000 doctors employed, five hospitals in the county, and a robust information system. For us to come out of a near-bankrupt state and make those kinds of investments would put us right back into the soup. We wouldn’t have a community hospital, but we’d have a $20 million information system. I don’t know how much good that serves. I think in markets where things are fragmented, you’re not going to see ACO development move too rapidly unless “meaningful use” (of Electronic Medical Record systems) ties everyone together, but we’re easily ten years away from something like that.
9) EC: A good portion of the U.S. population has one or more chronic conditions. Various provisions of the ACA encourage chronic disease management by incentivizing active self-management by patients and providing federal support for the development and reimbursement of chronic disease management programs. What opportunities do you see for hospitals like yours in this area?
PA: One of the things we hope to do is model certain behaviors. In the fall of this year, we plan not to hire people who smoke. If you study things, the three greatest contributors to poor health that are indeed controllable are your weight, your smoking, and your exercise – all things that most people can do no matter how debilitated they are. That’s our first step. Not to appear to be unkind to smokers, we plan to offer smoking cessation programs to those individuals who currently smoke and for folks who are smokers that interview with us. If you’re a hospital and your nurses are out on the curb smoking when people drive by, it just signals the wrong message. What I’d like to do is start in our own backyard and take care of our own folks first.
10) EC: What are some other plans or initiatives your hospital is pursuing right now, independent of the ACA?
PA: 2013 will be a big year for us. Next year will be the year that we spend a lot of time in the community. It’s not only important to the community, but it’s good business too. People will feel good about an organization that tries to reach out to them. We’re hoping to spend more time at people’s homes, if they can’t get out, to work with doctors who do home visits, and just become part of the fabric here in Roxborough.