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TAKING THE PULSE
OF ST. LOUIS HEALTHCARE
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By Bill Beggs Jr.
Health System CEOs Take a Look Back,
a Look Ahead
The upside: Glittering new
expansions. Cancer centers, heart care and mental-health units.
Satellite facilities and ambulatory surgery centers. Research
complexes developed via unique partnerships of the public and
private sector.
The downside: Continuing
struggles with insurance carriers over coverage. An uninsured
populace testing the limits of area ERs as a matter of course,
not emergency. Frivolous litigation.
These are just some of the impressive advances being made in
healthcare throughout the region—and some of the challenges.
To be sure, the ups and downs pertain to healthcare nationwide,
and as such, St. Louis is a microcosm. But, the region boasts
one of the most vibrant environments for translational research—from
bench to bed—and in many areas stands shoulder to shoulder with
any medical community on either coast and in between.
We surveyed four CEOs of regional healthcare institutions and
organizations—and a CEO of the State’s largest healthcare foundation—to
get their perspectives on the region’s progress to date, and
the challenges that remain. Each was posed the same six questions,
and responded in writing, to create our “virtual roundtable.”
Participants:
Denny DeNarvaez, president
& CEO, St. John’s Mercy Health Care
Jim Kimmey, M.D., president
& CEO, Missouri Foundation for Health
Steven Lipstein, president
& CEO, BJC HealthCare
Tom Rockers, president &
CEO, St. Anthony’s Medical Center
Jim Sanger, president &
CEO, SSM Health Care St. Louis
1. What did you
see as major trends locally in healthcare in 2007?
DeNarvaez: Due to the aging population, poor health statistics
in our area and the rising number of uninsured and underinsured
people, hospitals have seen an increase in emergency department
visits and high acuity—very sick—inpatient admissions. This
increase, along with the aging of facilities themselves, has
led to many area hospitals renovating space and moving to all
private patient rooms to accommodate more patients.
Recognizing that it’s not always possible or cost-effective
to renovate and upgrade existing facilities, there is a trend
to build new facilities, such as St. John’s Mercy Rehabilitation
Hospital and others.
Another trend is retail clinics. These clinics opening in area
grocery stores and pharmacies are likely to have an impact on
the relationships people have with their primary care physicians,
because it is unknown how or if these clinics will coordinate
care with a patient’s “medical home.”
As part of the overall modernization movement and improvement
to healthcare delivery, many providers are moving toward Electronic
Medical Records (EMRs). While upfront costs are significant,
EMRs clearly benefit the patient by providing quality clinical
care and coordination of care among various providers.
Kimmey: The most disturbing trend in 2007 was the steady
increase in the number of uninsured individuals. Driven by a
combination of government program cuts in prior years and the
continuing erosion of employer provided health coverage, the
number of uninsured in the State and region increased nearly
12 percent in the past year. What has this meant for the community?
An increasing part of our population is sicker and dies earlier
than is the case with the insured. More people are seeking care
in the area’s emergency departments, an expensive and unsatisfactory
alternative to access to primary medical care. Businesses that
do not provide insurance experience more absenteeism and workers
who should be under care trying to continue to work.
At the same time, the public health infrastructure in the area,
and particularly St. Louis City, is financially strapped. One
only needs to look at the data to see something is terribly
wrong—St. Louis leads the nation in gonorrhea and chlamydia
infection rates; it’s ranked as one of the 10 worst American
cities for men’s health; lead poisoning in children is seven
times the national average—and on and on go the dismal statistics.
The costs of the uninsured are in part passed through to business,
in terms of ever-increasing premium costs, as providers recoup
those costs from the insured and those who pay for that insurance.
In the second instance, a reputation as one of the worst cities
in the country in health access and status impacts location
decisions for badly needed new business and those of individuals
considering relocation to the area.
Lipstein: The dialogue around health insurance for all
Americans is capturing the attention of citizens in Missouri
and around the country, now more than ever as voters prepare
to go to the polls in 2008. Some combination of government-sponsored
insurance (Medicare and Medicaid), together with a combination
of employer and individual mandates to provide and procure private
sector health insurance, could emerge.
The trends are clear. Low-income Missourians without health
insurance are twice as likely to be admitted to a hospital for
an avoidable condition than Missourians who have health insurance.
The question is no longer whether health insurance should be
available to all citizens, but rather how to make that insurance
affordable and how to share the cost.
Rockers: Three trends are intensifying, year by year:
1. More personal responsibility for payment of healthcare bills
through higher deductibles and co-pays, fewer people eligible
for Medicaid, and more people with no insurance coverage at
all.
2. Continued transparency regarding hospital outcomes; for example,
quarterly infection rate comparisons, price comparisons and,
in the future, patient satisfaction comparisons.
3. We have seen and will continue to see more private physicians
establishing their own diagnostic and/or treatment facilities
in competition with hospitals.
Sanger: A trend that has been emerging over the last
several years is the issue of transparency. Reporting quality
outcomes, patient satisfaction, and costs publicly will help
consumers make more-informed decisions about where they should
receive their care. More importantly, publicly reporting quality
outcomes positively improves safety. This movement has been
gaining momentum, and I think will have a lasting impact.
A negative trend is the overcrowding of emergency departments.
Unfortunately, this trend is growing and placing great stress
on staff and hospital resources. It is a reflection of the growing
number of the uninsured and underinsured in the region.
A third major trend that should have a positive affect on healthcare
is the upcoming launch of the InsureMissouri initiative for
Missourians who are in need of health insurance.
2. What are the main obstacles the healthcare
industry faces in St. Louis?
DeNarvaez: Providing care to those who are uninsured
or underinsured can be costly because care is often provided
in emergency departments. This is costly and can only provide
intermittent care. The ultimate cost of providing care to these
patients is paid for by those with insurance—through higher
rates—and/or through charity care.
The building and development of limited service facilities that
are not part of an integrated approach to care, such as investor-owned
surgery centers, cancer centers—these tend to fragment care,
reduce coordination and communication.
Rising costs across healthcare—including technology, labor,
insurance and pharmaceuticals—affect all of us. The rising percentage
of healthcare in the gross domestic product has been talked
about for years, yet no one seems to have the answer to turn
it around.
Locally, for the next two years the project for I-64/Hwy. 40
will be a community-wide challenge affecting everyone, especially
hospitals and emergency medical service workers. We all need
to pull back on the gas pedal and have a lot of patience.
An ongoing challenge is the baby-boomer shift that is taking
experienced healthcare providers out of the labor pool, and
there are simply not enough qualified people to replace them.
Kimmey: Obviously, one is meeting the costs of operation
in an adverse payment environment. This leads to the “brinksmanship”
recently seen in negotiations between SSM and Blue Cross, but
that was not the first example. Insurers are motivated to keep
payouts low, premiums competitive and profits high. Providers
generally are motivated to provide quality services to the community,
but need adequate payment to do so. The result is an adversarial
climate that does little for the people who use, and ultimately
pay for, medical care.
The employment-based approach to funding health insurance is
failing, and efforts to find effective alternatives are mired
down in politics. There are some hopeful signs at the State
level, where the Governor has proposed expanded coverage for
the employed uninsured and their families. Although an important
step, there will still be large numbers of uninsured individuals
in our community and region for the foreseeable future in the
absence of a broader attack on the problem.
Lipstein: It is not possible to control the ever-increasing
costs of healthcare by simply being more efficient, or by controlling
access, or by asking employees and consumers to pay a greater
portion of the healthcare bill. We must also confront and come
to terms with the unfortunate truth that Missouri’s health-status
indicators are among the worst in the United States. We have
high incidences of heart disease, cancer, smoking and obesity.
We are taking steps to educate people about the risk factors
associated with poor health and the lifestyle choices that can
actually reduce the possibilities of some diseases such as diabetes
and lung cancer. But, we all must do our part. Your health is
in your hands, and there is much that you can do to improve
it.
Rockers: Meeting the expectations for rapid service and
the highest level of care, when government payers do not pay
their full share of the bill.
Sanger: One of the major obstacles that we face as an industry
is the growing shortage of healthcare providers—including nurses,
pharmacists, respiratory therapists, primary-care physicians,
etc. Given this shortage of healthcare professionals, it is
an increasing challenge to provide a healthcare environment
that is satisfying and affective for the caregivers themselves.
3. What are your thoughts on healthcare
employment in the region?
DeNarvaez: The area offers significant opportunities
for individuals dedicated to a career in healthcare. Our region
has excellent healthcare providers eager to recruit talented
candidates at every employment level. Most hospitals have far
more openings for the professional and technical-level positions
than qualified applicants to fill them. Not surprisingly, this
creates an “employee market” in terms of sign-on bonuses, competitive
salaries, benefit programs and special incentives related to
tuition assistance and loan forgiveness programs.
In response to these co-worker shortages, area hospitals are
collaborating with regional nursing and allied health schools,
along with the Missouri Hospital Association, on ways to increase
enrollment for these education programs. This will help ensure
an adequate number of healthcare professionals to meet the current
and future staffing needs. It’s a serious matter of public health
that affects every citizen, and an issue that both the public
and private sector must work together to address.
Kimmey: The healthcare sector is one of the largest business
sectors in St. Louis, with four of the 10 largest employers
providing healthcare services. Although healthcare is relatively
insensitive to economic downturns, the sheer size of the sector
should elicit caution, lest major shifts occur as a result of
changes in financing of care in the future. The excess cost
generated by the duplication of facilities and services in St.
Louis is unlikely to be supportable in the future because containing
costs will be a high priority under any expanded program of
health coverage involving government action. Whether an employment
“shake-out” related to containing costs—particularly those associated
with high-tech where duplication is greatest—will be offset
by expanded opportunities in the primary care and public health
fields can only be a matter of speculation.
Lipstein: As the population ages, the demand for healthcare
professionals will surely increase. We are very fortunate to
have medical schools, colleges of nursing, universities and
community colleges that provide good opportunities for people
to pursue careers in the health professions. The science and
technology of healthcare is constantly producing new and better
ways to take care of patients.
Rockers: Rapidly changing medical technologies and advanced
patient treatment modalities require ever-increasing competencies
in the nursing profession. At the same time, there are numerous
opportunities for nurses to work in diverse settings and a shortage
of nurse educators in nursing programs. Hospitals must face
these challenges by providing their nursing staffs the education
needed to function at the highest possible level and partner
with nursing programs to provide the best possible clinical
experience.
Sanger: As baby boomers age, there is an increasing demand
for healthcare services, which generates a greater demand for
healthcare professionals. We need to do everything we can, as
an industry, to help fill this void through the promotion of
educational opportunities. One example of this effort is SSM’s
nurse internship program, where we give the student nurse who
is graduating in the next 12 months the opportunity to work
side-by-side with a registered nurse.
4. What methods would you suggest for
attracting and retaining healthcare employees?
DeNarvaez: Most important is creating an environment
in which co-workers take ownership and pride in what they do,
and enabling them to have input in the decisions that affect
their work lives. There’s a long list of benefits and incentives—sign-on
bonuses, competitive salaries and benefits, fellowship training
programs, special pay practices, on-site child care services,
tuition assistance, loan forgiveness programs and others—that
we and other employers use.
What separates healthcare is that it is about serving others
at very meaningful times in their lives. When co-workers feel
and embrace the mission aspect of their work, retention is a
natural outcome to the intrinsic reward of serving others.
Lipstein: St. Louis is already known for world-class
healthcare institutions. Washington University’s School of Medicine
ranks among the nation’s best, and BJC HealthCare’s Barnes-Jewish
and St. Louis Children’s hospitals also command top rankings
in any list of the best hospitals in the United States.
Together with biotechnology investments such as CORTEX and the
Center for Emerging Technologies, and cutting-edge research
at the BJC Institute of Health at Washington University, St.
Louis can emerge as one of the few regions in the U.S. able
to attract the most-talented scientists, biomedical researchers
and clinicians.
Rockers: Attracting and retaining employees begins with
promoting your organization from within and creating awareness
of the services and benefits available to both employees and
the community.
We offer a number of educational opportunities to help our employees
advance in their careers. We have on-campus programs through
Lindenwood University and Central Methodist College, offering
employees the opportunity to earn their BS, MBA or BSN degrees.
Through St. Anthony’s tuition-reimbursement program, employees
can receive up to $5,000 per year to help pay their educational
costs.
Sanger: The key to retaining and attracting quality healthcare
employees is providing work environments that are positive,
supportive and appropriately staffed with professionals. As
part of creating this environment, it is important for us to
offer opportunities for our direct caregivers to help make decisions
in shaping that ideal environment.
5. What changes are you hopeful to see
in healthcare in 2008?
DeNarvaez: I hope the movement toward transparency—both
quality and pricing—continues, so there is a better and deeper
understanding by consumers.
Somehow we need to move people to the prevention side of healthcare
and educate individuals on healthy lifestyles. We are still
far too much on the reactive/acute care side of healthcare,
which also happens to be the most expensive both physically
and financially.
I would like to see existing healthcare resources used more
effectively. I mentioned earlier the mis-use of emergency departments.
If people would utilize primary-care physicians and public health
outreach centers more often, we hopefully would see a decrease
in costs and more satisfying experiences for the patients.
Kimmey: One of the curious aspects of the U.S. healthcare
financing approach is the dependence on employers to provide
what most industrialized countries consider a societal responsibility—providing
access to healthcare for all their citizens. This has created
adverse competitive situations as the global economy has come
into existence, but American business has, curiously, been slow
to support approaches that would restore a level playing field
with their global competitors. It is past time for business
to take leadership in forging effective solutions to the problem
of access and affordability of health coverage.
Although the potential changes will not begin until after 2008,
the importance being accorded the healthcare issue in the presidential
campaigns holds some promise for dealing with the uninsured
nationally. Although each candidate takes a different approach,
at least they each have an approach and are giving the issue
top billing in their campaigns. The reality is that, regardless
of the campaign rhetoric, moving from a politician’s promise
to a functioning program to cover the population will be a difficult
task. The interests invested in the status quo are far better
financed and connected than those seeking universal coverage.
If there is one step that would move Missouri and the region
forward, it is to do as Massachusetts has done—declare that,
as a matter of public policy, every person should have basic
coverage for their health needs. Once that is done, there are
many possible paths toward the goal. Universal coverage is achievable
without a single-payer, government plan, but is not achievable
in the absence of a clear commitment to do so from the political
leadership in the state or in the nation.
Lipstein: I would hope that in 2008, the people of St.
Louis will make healthcare their No. 1 priority. I hope that
we achieve health insurance for everybody in our region; a real
commitment to improving personal health; and a commitment by
employers to help their employees take on whatever health improvement
goal they set for themselves.
Rockers: Legislative approval of the proposed MOHealth
budget.
Sanger: Through programs like Insure Missouri, I am hopeful
that we will start to see more insured patients seeking healthcare
through their primary-care doctor, before they become critically
ill. In addition, I am hopeful that healthcare providers, the
business community, elected officials and the community will
work together to solve the challenges of healthcare that affect
our society.
6. Any tips for employers regarding
the health and wellness of their employees?
DeNarvaez: In health organizations we promote the health
and wellness of our patients, and sometimes forget that our
co-workers and their families are also our patients. We provide
opportunities for community members, including our co-workers,
to live healthy lifestyles. We plan and provide opportunities
to learn how to manage chronic disease, weight or tobacco use,
for example. We offer these to our co-workers at locations and
times convenient to them and then open these same services/classes
to the public.
It is not enough just to educate co-workers about the activities
they need to engage in to improve or maintain health. Rewarding
healthy behaviors can motivate someone toward a healthier lifestyle.
We as health organizations do a great job of caring for our
patients, and we need to remember to take care of our co-workers
as well.
Kimmey: Healthy employees who are not bringing concerns
with their health or their family’s health to the workplace
are an asset. Conversely, an employee who comes in despite being
ill or is distracted by concerns for a loved one and the costs
of their care is a liability. Businesses have taken two approaches
to these factors—providing health insurance benefits and promoting
employee health. Both are necessary, but the former has become
increasingly expensive for employers, thus the erosion of the
employment-based approach to health coverage. The latter—health
promotion and prevention programs in the workplace—is a more
recent development, as employers and employees have recognized
the importance of prevention, both on current health and on
long-term costs associated with preventable illness.
Lipstein: Please get involved. Investing in the health
and well-being of your employees will pay handsome dividends.
Providing employees with information on the key indicators of
good health—knowing and controlling cholesterol, blood sugar,
blood pressure, weight and not smoking—encouraging employees
to be less sedentary on the job, and evaluating and changing,
if necessary, the food choices in company cafeterias and vending
machines are beneficial to employee health and wellness with
minimal costs to the employer.
Rockers: Identify employees who are health-and-wellness-minded
and appoint a wellness coordinator and committee. Promote wellness
using all methods of internal communication—newsletters, flyers,
information boards, intranet postings and ongoing promotion
by public relations, human resources and managers. Reward employees
with wellness gift certificates for massages, classes or fitness
facility memberships.
Sanger: I would suggest that employers consider investing
in preventive medicine. Clinical evidence demonstrates the negative
impact of smoking and obesity on health. Employers who provide
wellness programs, incentives for smoking cessation, or fitness
facilities are making great strides in improving the effectiveness
of their workforce.
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