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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.”

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.