Despite an Uncertain Pathway, Local Administrators Navigate a Positive Course

With the future of the Affordable Care Act (ACA) unresolved, healthcare continues to face major challenges. While reforms have been proposed, what shape or direction the system will take remains unclear. However, despite the uncertainty, healthcare leaders and providers remain focused on providing quality care.

Managing change has become the norm in the industry, but despite this challenge leaders and providers are finding innovative ways to improve the current system. From healthcare executives to practice administrators to legal eagles to physicians, these Memphis healthcare leaders are offering effective and wise direction on how best to proceed into an unpredictable future.

Bill Breen

Bill Breen, Senior VP for Physician Alignment with Methodist Le Bonheur Healthcare, sees reform as providing increasing incentives to improve the way we operate and is compelling us to look at what we can afford as a country and a health system.

"Reform was and is inevitable, but it can force us to rethink the way we operate," he said. "It is a necessary catalyst to a new way to operate healthcare entities with a theme of accountability on both sides as a provider and patient."

While reform is stalled in the legislative process, John Lewis, CEO of Semmes Murphey Clinic, sees one key driving force to reform as those who are living it every day.

"Practices and hospitals have to be the drivers behind reforming the system," he said. "A lot of the reform initiatives have put the burden on practices and hospitals to work together to improve cost and outcomes. A part of that will be to educate patients on their accountability for taking responsibility in their care plan."

Reform is ongoing regardless of what stalemate politicians are in.

John Lewis

"We are in the middle of reform and having to do it right now," said Lewis. "All practices are focused on overhead, costs and how to provide cost-effective patient centered care. In our practice, we are measuring quality and outcomes while also focusing a great deal on the care coordination between providers inside and outside the clinic. We are working with hospital partners in different ways than in the past that allow us to work toward improving outcomes, lowering costs and better coordination in care."

As the administrator of Mid-South Pulmonary Specialists - a specialty that utilizes medications that can be extremely expensive, Kim Avery's perspective on reform is to address what is creating the most issues. "There was no need to reinvent the wheel," she said. "The system was in place, it just needed to be utilized rather than overhauled on a large scale."

With a focus on containing costs, which can be especially pertinent to clinics, Avery says reform should include looking where the expenses are in the system and address them.

"For instance, if drug costs are high, then look at what you can do to fix that. When a drug company routinely subsidizes patients to allow them to be able to afford their medication, why not just reduce the cost of the drug," she said. "Look at mandatory requirements and see who the actually apply to and if age appropriate. For instance, does a 60-year-old woman really need maternity care included in her policy? Why not pay for services and medications you need rather than paying for everything in a policy that makes it unaffordable."

Kim Avery

While preventative care is a huge part of reform, there is no incentive for patients to take better care of themselves yet physicians are often penalized for something beyond their control.

"The system needs to give patients more of a reason to take care of themselves," said Avery. "Payment models based on quality and cost of care does not factor in patient compliance or the vast disparity in wellness across regions and associated cost of care. The South contains some of the sickest and poorest among the population yet none of that is taken into consideration under the current system."

In order for reform efforts to move forward, Baptist Memorial Health Care's Senior VP and Chief Legal Officer, Gregory Duckett, says partisanship has to take a backseat.

"No single individual has a silver bullet to solve the problems we have in current system," he said. "We have got to have degree of compromise to reach true solutions. It is going to take the best and the brightest to coming together to address the rising cost of healthcare and decrease the rising amount of charity/uncompensated care that providers are currently providing."

To address some of the underlying issues, Duckett sees achieving the original goals of the Affordable Care Act to decrease growth in healthcare spending and to extend coverage to as many individuals as possible by providing subsidies or expanding Medicaid are keys for healthcare to be reformed.

"Especially when you look at one of major vehicles of funding for the ACA was a reduction in Medicaid payments to providers. A $340M decrease over a ten-year timetable. Those reductions would be offset by the increase in individuals receiving Medicaid. Theoretically, that sounded great. In reality, Baptist provides care in three states, two of which did not expand their Medicaid programs. We still incurred reductions with no corresponding increase in Medicaid payments. All the while, those who did not have access to care still came to the hospital via the costliest point of access, the emergency department. It is not a long term sustainable process."

Gregory Duckett

Outside of politics, Duckett sees some offshoots of the reform effort having a positive impact.

"The alignment of incentives between hospitals and physicians which is being driven by more physicians becoming either under contract or employed by hospitals and systems," he said. "Historically hospitals were paid on a per visit basis as opposed to physicians who were being paid per encounter. The hospital's incentive to treat appropriately and get the patient out while the doctor's reimbursement provided no incentive for efficiency. Now with the two working more closely through contracts or employment, the incentives are more in line with the same goal of better quality of care."

As incoming President of the Memphis Medical Society, Autry Parker, M.D. wants to see physician groups to be a collective voice on the issue of reform. "Physicians have to be at the table when it comes to healthcare reform," he said. "Medical societies over the last few decades have lost relevance among the current generation of physicians. We are the only collective voice physicians have and we need to speak with one voice as we are fighting the same problem. We all want to do what is right for our patients but we also have to consider the business side of the equation and so far, there has been a double digit rise in healthcare costs."
Duckett sees physicians as being in an excellent position to be an advocate for change and agrees with Dr. Parker that medical associations can play a key role in having that voice heard.

"Individual physicians or small group practices have a full plate dealing with the day to day needs of their practice, which doesn't always leave much time to put toward advocacy and education of elected officials," he said. "Medical Associations can help fill that void and that is an appropriate vehicle for physicians to work through to ensure their voice is heard on the political side."

Autry Parker

One of the most important factors in reform has become the trend of accountability and transparency brought about by the changes in healthcare.

"We are finding the vocabulary changing and physicians are not as averse to talking accountability as before because they have a better understanding of it," said Breen. "There has been lot of good come from transparency as there is nothing hidden under the rug anymore. It shows where your commitment is and how well you are performing. It incentivizes us to take ownership to staff practices to engage patients in totally different way than have before while lowering costs with greater patient satisfaction."

Semmes Murphy Clinic was a bit ahead of the accountability and transparency curve. The clinic is one of the lead sites for a clinical outcome database that tracks the quality of care for common neurosurgeries that was formed in 2012.

"Our physicians took the lead in our joining this database and it allowed us to get ahead of the game. We knew reform was coming and this let us start gathering data to begin to develop benchmarks," said Lewis. "This database has established risk-adjusted national benchmarks for cost and quality of neuro procedures. It can also demonstrate comparative effectiveness of procedures we do. We have then been able to present data to insurance companies and the public on how the practice is performing."

"Patients must be at the center of things, it will fail if not," said Breen, "What do we want for ourselves and families, it is a journey. Every generation comes at healthcare needing something different and with very different expectations and demands. I think in 200 years to will not be like it is today across all lines. Transformation isn't immediate, it is a process."

Fortunately, Memphis has an abundance of leaders who have taken on an intimidating challenge and are making important strides in overcoming major hurdles as well as settling into the norm of change. While we all may be pining for relief from regulation, it is probably a fruitless endeavor. As Breen says, the parade is marching down the street, we may change our position in the procession, but we are not stopping it.