HCCD Report Colorado 80016

Healthcare Community Discussion
Colorado
12/31/2008

Meeting Date: 12/29/08
Facilitator: Carolyn
Attendance: Carolyn; Colleen; Barbara; Sherri; Kim; Marla; Terry; Ed; Yenni; Marie; Steve.

Questions:

1. Briefly, from your experience, what do you perceive is the biggest problems in the health system?

Timing of correct billing / accountability (who is responsible? The provider? The hospital? The patient?). 1.5 year-long process from patient visit to actual bill-in-hand). Medicare has a 90-day process that seems more efficient.
- Comment: United States lack healthcare billing standards and communication those standards to the general population.
- Comment: Example: Ideally, we need a simplified billing system – but with secure access to assure HIPAA rules are met.
Exchange of healthcare information
- Comment: Patient healthcare information from doctor’s office to hospital back to doctor’s office.
- Comment: Patient healthcare information shared between doctor’s office and pharmacy to assure the ‘best’ possible direction for medication, etc.
Lack of healthcare for population (1 in 7 people are presently not insured for health-care coverage in the United States. With the current and future trends in the economy, that number will rise).
- Increase in uninsured population
- Increase in underinsured population
Cost shifting
- If the government does not pay the cost of medical care, the cost is shifted to the payer (the employer) which drives up premiums, etc.
- Currently, there is a misalignment payment and who is keeping the patient healthcare.
  - For example, there is a trend currently where the primary care physician is not paid – but the specialists are getting paid. However, it is the primary care physician keeping the patient healthy over the long-term and can promote preventative healthcare measures.
Currently, there is a reduction of medical school enrollment which will eventually demonstrate a decrease in Primary Care Physicians.
Currently, another trend is a reduction in nurses nationwide. On average, physicians see a patient between 4-7 minutes; providing diagnosis, treatment and counseling (for medication, etc). However, it is the nurse that more often provides the hands-on care and counseling.

2. How do you choose a doctor or hospital? What are your sources of information? How should public policy promote quality health care providers?

Health Grades (an organization that grades physicians, hospitals, urgent care organizations, etc).
Word of mouth/reputation
Location/convenience - In Colorado (where a lot of ‘rural’ patients reside), physicians and patients alike depend on the quality and accuracy of Tele-health (Tele-medicine).
- Benefit of using tele-medicine (or video): Rather than flying a patient from a rural area in to a hospital via helicopter, the patient is tethered to healthcare equipment and the data is transmitted to the hospital for decision making.
- The issue with the above is that the technology needs to be accurate and timely. Currently, one of our hospitals in Colorado (Swedish Medical), the neurology team must wait an hour for a patient x-ray to transmit. Obviously, this is ridiculously long if the patient is in dire need of a pertinent healthcare decision.
  - Another issue is that the physician is paid $10.00 to ‘read’ the transmitted x-ray. Ten dollars does not provide a good enough incentive for physicians to practice medicine at a particular health care organization.
- Another obstacle is ‘credentialing’ of physicians. In order to practice medicine at various hospitals, physicians must be credentialed with each and every hospital and/or healthcare center in order to be ‘legal’.
- Alongside ‘credentialing’ from one hospital to another, physicians also need to be credentialed across state lines and across hospitals within the same state.
- Lastly, rural areas in Colorado do not have sufficient and/or appropriate back-up physician coverage
Centers for healthcare excellence

How should public policy promote quality health care providers?

Provide a consistent and realistic hand-off from the physician (physician office) to the ‘rest’ of the healthcare industry. For example, if a patient visits their doctor office and then visits the Emergency Room over the weekend, the physicians office should be notified of the ER visit. The Emergency Room should also have access to the patients medical record – especially if the patient is unable to speak for themselves. This will help alert the ER staff of any allergies, etc. Ideally, there needs to be a standardized way of providing information to various healthcare team member regardless of where they administer the healthcare.
CCR – Continuative Care Record is a ‘standard’ – but not widely adopted due to it being in paper form. Even if it was electronic, it would only be available as a PDF and would not be considered interactive (i.e., would not allow or sustain updates, etc).
Promote ‘patients being part of their healthcare team’ – make them more accountable (they have more time to do research, follow-up, etc., than the over-worked healthcare provider).

3. Have you or your family members ever experienced difficulty paying medical bills? What do you think policy matters can do to address this problem?

Provide standards to the community
Communicate standards to the community
Mandate those standards

* Please see ‘stories’ section for details on paying medical bills.

4. In addition to employer-based coverage, would you like the option to purchase a private plan through an insurance-exchange or a public plan like Medicare?

Regarding Private Plan: For small businesses – it makes no difference whether they have the option to purchase a private plan or a public plan.
Regarding Public Plan: Cost effective (co-pays cost more) – would like the option to purchase a secondary plan.
Vote of 11 participants in this community discussion:
- 8/11 opt to purchase a secondary insurance – via an exchange or to choose what they want (OR provided with $200 the decision to purchase their own supplemental insurance).
- 3/11 opt to not purchase additional insurance because it does not make sense for them as an employer (maximum is hit out-of-pocket).

5. Do you know how much you or your employer pays for health insurance? What should an employer’s role be in a reformed health care system?

How much does your employer pay for health insurance?
- 7 no, 4 yes
What should an employer’s role be in a reformed health care system?
- 80% paid by employer/21% paid by employee
- Employers are looking in to higher deductibles – for small businesses.
What should an employer’s role be in a reformed health care system?
- Standardization across the state
- Standardization if employed by a small vs. large company
- Compensation plan(s) may include/not include health insurance (give the option for one or the other)
- Employer does not have to have a role

6. Below are examples of the types of preventive services Americans should receive. Have you gotten the prevention you should have? If not, how can public policy help?

States should endorse teaching exercises, eating healthy, etc., through the schools.
Employers should be given an incentive or business advantage in making their employee population healthier. Unfortunately, small business can’t really be given an incentive.
- Colorado Health Association has an agreement showing a vested interest in the employee’s healthcare by awarding a $250 gift card (for the patients’ HSA) if they undergo an assessment.
Mandate a physical exam once a year – or make drivers license ineligible.
- Health assessments provided by insurance organizations are considered ‘required’ – but not mandatory. People (clients) are asked whether they smoke or have guns in the house, etc.
Mandate a physical exam once a year – provide a tax rebate.

TYPES OF PREVENTIVE SERVICES

MAMMOGRAPHY:

10/10 underwent a mammogram in their life-time.

9/10 underwent a mammogram within the last year.

FLU SHOTS:

6/10 underwent a flu shot this year

4/10 did not choose to have a flu shot due to already having an immune disorder

CHOLESTEROL SCREENING:

8/10 Performed – within the year (a preventive visit)

How can public policy help?

Educate children (at a young age) on prevention, etc.
Incent children (Presidents’ physical fitness award).
Providing financial incentives to physicians training patients on preventative medicine.

7. How can public policy promote healthier lifestyles?

Through Educating the public
Through lowering the cost of living a healthier lifestyle (organic food costs more than non-organic food).
Through Incentives
Employer incentives:
- Athletic Memberships
- Mandated time-off
- Flu-shots
- Weight watchers
- Discounts on healthier life-styles
- Tax incentives for employers

OTHER IDEAS

Nurse Practioner – expand the scope of practice and/or role (PA, NP), etc.
Provide a standard for doctor’s to implement assessments (using best practices) – (information/electronic health records will help).
Evidence Based Medicine
- Physician/clinician: In order to stay up-to-date on medicine and healthcare, physicians must read more and more – taking away precious time from caring for their patients. These articles/standards should be made available via the internet at no cost.
- Provide a special incentive to physicians that choose general practice.
- EBM is a good starting place – but give the physician permission to go outside the box and be creative with not only the quality care given to patients – but their overall practice.

STORIES

1. During my husband’s 10 year battle with a malignant brain tumor, we experienced multiple breakdowns in the healthcare system. Lack of communication and billing issues were the norm. We would be billed up to 2 years after a procedure was done and it occurred again this year even after notifying them of my husband’s death. After our primary institution implemented a radiology imaging system that allowed the neurosurgeon’s to read the films online, there was a lack of education provided. After an MRI, we met with the neurosurgeon who reviewed the results online and believed that the tumor was not growing. A few days later, he called with the devastating news that in fact he had not read it accurately and there was tumor growth. Allergies alerts did not stay on the EMR from visit to visit, drug interactions were not identified, and anti seizure meds that were required were not given while an inpatient. I know that all of these issues can be fixed with systems, processes, and procedures.

2. I have power of attorney for my 94 year-old relative. When I was out of town Memorial Day week-end in 2007, he was admitted to a local hospital with chest pains – age 92. The ER doctor called me to tell me his heart was fine – the pain was skeletal muscular. But, the hospital’s policy was to keep him in observation for 6 to 12 hours, which could mean an overnight stay.

8 days later the hospital finally released him to a rehab center with pneumonia, a UTI (urinary tract infection) and severe bed sores on his heels– none of which he had when he entered the hospital. It seems that every “doc on duty” wanted to have additional tests run, and in the meanwhile, he was left in bed and neglected – 2 days went by without anything (except infection) happening (Holiday week-end – departments closed). When he was finally discharged a very sick man, the attending physician actually said “Let’s get him out of here before we kill him.” He spent the next 7 days in a rehab center, and has gone downhill ever since. HOSPITALS ARE NOT GOOD PLACES FOR THE ELDERLY!!

My relative was charged the maximum by his insurance company, which we protested through the hospital. The hospital agreed that he should only have spent one day in the hospital, and the charge was reduced accordingly.

WHAT NEEDS TO BE FIXED: 1) accountability passed from one physician/nurse to the next; 2) the current system takes advantage of those with Medicare and supplemental insurance – they are gauged – attending docs ordered whatever tests they wanted to – whether relevant or not, no matter how long the stay was extended, knowing insurance would pay. Both the insurance company and my father were screwed!!

3. I am an RN and I was helping out in my son's classroom. One of the girls in his class was complaining of a terrible ear ache. I had told her that if she is not feeling well to go to the school office and then have your mom take you to the doctor as she may have an ear infection. The next time I helped out in my son's classroom, I asked the girl what the doctor said. She stated that they could not afford to go to the doctor and if they did, then they would have to go without food. I was surprise to hear this because my first thought was this doesn't happen in our middle class neighborhood - this only occurs in low income areas. Needless to say this was an eye opener for me. Even though I took care of sick babies, I never knew who had health coverage and who didn't. I provided the same level of care no matter what their socioeconomic status.