Medicine has made so many advances in the past few decades. Yet, we have yet to find cures for the big health problems –cancer, heart disease, and diabetes. What will it take to get us to a cure for these health concerns?
Caligiuri: 30 years ago, many people died of cancer. Today, most people know a cancer survivor, i.e., someone cured or living successfully with cancer. This is true for lung cancer, colon cancer, breast cancer, prostate cancer as well as many blood cancers. This is remarkable, and this number increases every year as mortality from cancer decreases. Furthermore, we now have a vaccine to prevent cervical cancer and the majority of head and neck cancers. We know so much more about cancer, as well as the intersection between cancer and diabetes, as our medical knowledge on how to treat and eventually cure these diseases increase exponentially every year. Coupled with our expansive knowledge on genomics and the use of big data and artificial intelligence (AI), precision medicine (giving the right treatment to the right patient at the right time) will further increase the number of people who will either not get cancer in the first place or will be cured. Finally, our increased collaboration with cancer centers around the country and the world moves our collective progress toward the best outcomes.
What are the current trends impacting health care? What major trends do you expect in the next 3-5 years? How will the landscape be different?
Morgan: The health care industry is always evolving, and the trends affecting care delivery today are manifold. They include:
- Increasing competition, which is driving consolidation;
- A shift to outpatient care;
- Persistent reimbursement pressures from private and government payors; and
- The rapid evolution of technology (including the expected speed of its adoption).
The investments required to keep up with technology are challenging for acute care providers taking care of very sick patients – and getting reimbursed very little to do so. For example, with some payers, we are reimbursed only one dollar for every three we spend providing care. Looking to the future, it will be critical to establish how we care for (and manage the cost of caring for) an aging population that — thankfully — is living longer because of improvements in medicine. As a clinician, I’d also like to advocate for my fellow doctors – we need to find a way to allow physicians to spend more time practicing medicine and less time dealing with paperwork.
Caligiuri: The current trends impacting healthcare, I believe, are related to health care consolidation, which ultimately leads to fewer and fewer choices for consumers. There is a potential danger with this trend in that it may create an environment where patients are given lower cost options with less attention to the best clinical outcomes. We will need to be careful that we don’t start to define healthcare value only around cost. We should ensure that we are always looking for the best clinical outcome for the best price. Those two variables should always be linked in order to deliver the best affordable care. Another, more exciting trend is the harmonization of cancer patients’ genomic data with cancer patients’ clinical data in larger systems. The utilization of this resource will enable us to better predict who will get cancer and what treatment will likely cure the patient, but it will likely take upwards of a decade to move this into routine practice. Nonetheless, the promise of this level of precision medicine will have great impact on outcomes for many diseases.
Simpson: In this technical era, we must focus on impacting misbilling and claims management, making care easier for the user. Managing claims today is horrific. Members suffer, and doctors are not getting paid what they deserve in this old school tradition. I call it “pen to knife.” Doctors get paid by treating symptoms through radiology, surgeries, and prescriptions. In the Accountable Care models, doctors get rewarded for treating the whole person, through quality of care, disease prevention and management through diets and exercise. Acupuncture, Chiropractic, massage therapy for stress, and promoting wellness are all crucial in the United States today. Suicide rates have been increasing. The CDC claims that although suicide prevention efforts largely focus on identifying and providing treatment for people with mental health conditions there many additional opportunities for prevention. Sitting is the new smoking. Drugs prescribed and/or street drugs are causing a massive health care crisis and this is where we need to focus our attention. We must ask ourselves, “Why are we, the people of the United States now the unhealthiest population on the planet?” Wellness is a $4.2 trillion global industry and growing.
Health insurers and delivery systems are often seen as adversaries. Can the relationship be redefined? Is it possible for them to work together?
Rapisardi: Yes, absolutely, the relationship can and must be redefined if we expect to create a better health care delivery system that produces better outcomes for all stakeholders, including employers, individuals, providers and payers. That’s been Cigna’s mission for years in Southern California, starting right here in Orange County, where we launched an alliance with St. Joseph Hoag Health in 2015. Our relationship is based on deep collaboration and integration. Each party – the provider and the payer – brings its unique abilities and assets to the table to best meet the needs of employers and individuals. We extended this model to San Diego with Scripps Health and to Los Angeles with HealthCare Partners. The result has been robust solutions that enable employers to offer benefit plans that provide affordable in-network access throughout the region, with greater flexibility for employees to obtain quality care that’s convenient to their homes or offices.
Morgan: This relationship can be absolutely redefined – and it will have to be as our population ages and the nature of health care evolves. And we’re already starting to do it. An example of the way this can work – and is working in our region and beyond – is Vivity. Anthem and seven of the top-rated health systems in Southern California (Huntington included) joined together to create Vivity. Under this model, providers and insurers work together to ensure patients have access to high-quality preventative and acute care. Moving forward, there is an opportunity for increased pricing transparency, which is to the benefit of patients, providers and payors. Potential patients should know what their hospital procedure will cost them before they get a bill – and our goal is to help everyone understand that cost is established through contracts with our payors (the insurance companies). Sharing this information clearly and upfront serves everyone’s needs. We should all be rowing in the same direction – in service to the patient.
Simpson: As a broker who manages claims all the time, I see PET scans costing $3k denied due to a lack of a referral. Who pays? The patient does, if they don’t know better. If an in-network doctor does not properly refer, he or she doesn’t get paid. I myself have almost been overcharged many times. I’ve had pharmacies try to charge me $300 for an antibiotic. I say, “No! Call the doctor.” They call and then change the cost to $15. All must use technology for better claims processing so providers get paid properly and patients are properly charged. Referrals are necessary for carriers to control costs and manage care through in-network providers, and these providers deserve to be paid, on time and fairly, for their years of education. There is much waste in incorrect billings by doctors on their laptops — inputting data while trying to speak to their patients. Carriers hold out payments for a variety of reasons, yet data-driven resources with algorithms can find common errors to be eliminated, so doctors get paid faster and patients do not go into collections.
With Millennials changing jobs so often, why should employers invest in employee health and wellness?
Simpson: Employers cannot afford not to invest in employee health and wellness for all generations. Today the main challenge surrounding Millennials is to understand how to keep them on staff. This is a challenge for all of us, yet it is imperative we build a culture that appeals to the generation that is here today and making huge contributions to our organizations. Millennials love connectedness — if even by text — and opportunity. They care about their health and enjoy using apps and data driven resources measuring how much water they drink, how many steps they have taken and where to find the closest gym. We, as leaders must inspire this generation to be the ones who help us evolve our own health care and create resources for the future. Cease high cost presentism through employee engagement. Our Millennials love technology, work hard when challenged and engaged, and truly want to save the planet. So let the ones who don’t fit go – and then keep the great ones and let’s see what change they inspire.
Are wellness programs worthwhile investments for employers?
Rapisardi: Yes, they’re absolutely worthwhile if employers really do view them as investments and not simply as an expense. An expense is just money out the door, while an investment is spending that is expected to provide a payback over time. In the case of wellness programs, the payback is lower absenteeism, better productivity, and improved health care costs. Cigna’s experience is that when our employer clients take the time to assess and understand the health profile of their workforce, then tailor their wellness programs to meet their employees’ specific needs, implement meaningful incentives to encourage participation, and then promote the program, there is greater employee engagement and better payback. The results depend entirely on how well the program is designed, implemented and communicated, but we see time and again that wellness programs provide great value for employers and employees alike.
Simpson: Employers must connect their incentive programs and “wellness & safety” initiatives to their carriers. I can sit down with any employer and carrier rep and explain what we have done at Montage for our employer groups and it is astounding. Our book of business has had an overall renewal rate of 3% over the past five years. Since opening our doors, we have done biometric screenings, massage therapy, promoted wellness and focused on educating the employee on health and wellness. One client when I first met them had a 52% renewal. We drove down through plan designs and properly aligned their carriers and programs. They are headed for their third flat renewal as their employees do 5ks often and have monthly wellness programs. Others have chefs and learn about healthy eating and stress reduction. With proper focus on the health and safety of employees, employers have more engaged staffers and lower premiums in benefits and workers compensation. Employers are seeing results and many of our clients are on the “Best Places to Work” list for many of these very things.
What does the future look like for the viability of small or independent hospital systems?
Caligiuri: I think the future can be quite bright for small or independent hospital systems, especially if their clinical outcomes are good and we as a society prioritize those outcomes. We should not be convinced that mergers into larger systems is the best way to deliver care, especially if the data do not support that position. Value in healthcare should pertain to many factors – getting to the right treatment faster and delivering better clinical outcomes with less side effects and at the best cost. Small or independent hospital systems can focus on high quality care in a way that larger systems may not be able to, which can lead to better outcomes and a better patient experience. To me, all of this points to a very bright future for small or independent hospital systems.
Governor Newsom’s initiatives to revamp and reform health care are ambitious, particularly relating to introducing the individual mandate and extending subsidies for more Californians. How do you view these proposed changes, and how might they impact your business?
Simpson: There are 39.2 million in California, and 32% are low-income earners, while 25% are covered by Medicaid/CHIP. $83 billion was spent on California Medicaid (Kaiser Family Foundation). Covered California states that 1.5 million enrolled for 2019, with a 23.7% drop in new consumers, commenting that “the Federal removal of the individual mandate penalty appears to have had a substantial impact on the number of new consumers.” Any family member offered health insurance, subsided by an employer, may not receive subsidies from Covered California, so this will not impact many employers who want to offer quality healthcare for their employees. The employer mandate for employers with 50 or more ‘Full Time Eligible(s)’ is still in place, causing low impact. In August 2018, 2.9 million Californians remained uninsured, despite the individual mandate. Of the uninsured workers in California, 47% worked for companies with less than 50 workers. One in three of California uninsured had annual incomes of less than $25k, possibly qualifying them for Medi-Cal. Today, 3.5 million are uninsured and 1.5 million are undocumented. Governor Newsom’s goal “is to use revenues from the penalties to fund subsidies.”
How are hospitals adjusting to recently passed SB 1152 requirements regarding conditions for the release of homeless patients?
Morgan: Homelessness is a growing problem – and one that is not going away. As a leading hospital with the last remaining emergency room in Pasadena (and the largest trauma center in the region), we have a legal and moral responsibility to care for all patients, including homeless ones. In addition to providing compassionate care, we follow the law by screening for diseases, providing vaccination plans and working with individuals to get affordable health coverage. Every homeless patient leaves our hospital with clean, weather-appropriate clothing, necessary prescriptions and a post-discharge follow-up appointment, if appropriate. Furthermore, many homeless individuals have a history of trauma in their lives, either as a cause or effect of homelessness. To ensure we are a part of their healing process, I initiated Trauma Informed Care training for all employees and physicians to ensure the way we care for traumatized individuals provides physical and emotional safety. We also screen for mental health issues and provide appropriate services to support whole-person wellness. And whenever possible, we work with available community resources, shelters and supportive services in our region.
Providing affordable health insurance and employee benefits are challenging anywhere. How are we able to meet or serve those challenges and best serve the small businesses of Los Angeles?
Simpson: Government, providers and carriers need to focus on the whole person and accountability care models. Many businesses are sponsoring wellness initiatives in-house. We are tired of going to the doctor only to have prescriptions as the first method of care. The amount spent on pharmacy ads should go to funding labs that truly are focused on disease control and preventive measures. So much money is spent on managing government mandates. According to the Los Angeles Times, the “errors in Medi-Cal roles may have cost the state $4 billion. California spent $4 billion on Medi-Cal coverage from 2014-2017 for people who may not have been eligible for the government funded health plan.” Education is key in serving business owners and their employees. One of our clients, a national company with just under 200 employees, our firm was able to save $1 million in pharmaceutical costs by just informing employees about generics vs. brand name prescriptions. This translated into two flat renewals in the years after taking this educational show on the road.
What role does patient experience play as it pertains to the delivery of healthcare services?
Morgan: It plays a HUGE role! My personal philosophy – as a trauma surgeon and a hospital administrator – is that when you place the patient at the center of all decision-making, you ensure the right outcome. Patient experience at our hospital is enhanced in myriad ways. Not only do we have a gorgeous facility (it’s been mistaken more than once for a hotel), we have 1,400 volunteers who help provide patient support services like snack carts, pet therapy, music therapy and more. Our staff is trained to provide compassionate care that honors each individual, and involves appropriate decision making with patient and family members. At manager meetings, I make sure to read aloud (with permission) the letters our patients write us. And the first change I made when I arrived at Huntington Hospital was to institute regular scheduled rounding for me and my entire executive team. When we make rounds throughout the hospital, we can hear directly from those who are receiving care (and those providing it) what we are doing well – and what we can do even better.
Caligiuri: One thing we know is true. Patients are always waiting – for an appointment, for a diagnosis, for a viable treatment option, for a time when their life can get “back to normal.” It is up to us, at every level of a healthcare organization, to reduce that waiting and hasten the cures – through the delivery of innovative discoveries in our research labs, through shortening our initiation times for life-saving clinical research trials, and through viable treatment options that offer few side effects, so patients can get back to living as normal as possible the life they want to live. These are our goals when delivering healthcare services and this is how we ensure the best possible patient experience.
Mental health continues to be an issue for many people. What are health care organizations doing to proactively address this need and provide the required resources?
Rapisardi: Cigna’s longtime position is that mental health is just as important as physical health, and we are very strong proponents of the mind/body connection. In fact, we have launched a national campaign that addresses the importance of talking to your doctor about how you’re feeling emotionally as well as physically. There’s nothing wrong with admitting that you’re depressed or anxious, but the stigma associated with mental health is often a barrier to people seeking effective treatment. That’s why Cigna works with Shatterproof and other organizations to help stamp out the stigma. One of the most important things Cigna can do is encourage our employer clients to offer integrated medical, pharmacy, and behavioral health benefits. Our studies show that when these benefits are integrated, individuals get more preventive care screenings and are better engaged in managing their health. It’s all about seeing the entire person and emphasizing whole person health.
Morgan: This is such an important issue. Health organizations need to help ensure proper access to mental health services and prioritize mental health at all points of a patient’s health journey. A recent study suggests that more than half of US adults with mental health problems fail to receive treatment, despite availability of effective treatments. While appropriate treatment for all in need should be a goal, even having only a small percentage of individuals receive proper treatment would greatly benefit public health. A widely cited barrier to treatment is stigma. We are working to de-stigmatize mental health issues, and one important example is related to post-partum depression. Our Maternal Child Wellness Program provides new moms with access to caring professionals to help them adjust to the significant change parenthood brings. We are also proud to be one of the last remaining hospitals in our region with an inpatient psychiatric program, which allows us to incorporate this important area of care with our full clinical program.
People are accessing health care in a variety of ways – digital, inpatient, outpatient, etc. How do health organizations ensure that a consistent and high quality patient experience is delivered?
Caligiuri: For us at City of Hope, the patient experience is paramount and we recognize that people access information in different ways and at different times, which can influence their overall experience, including their level of anxiety. We generally discourage internet searches regarding disease and treatment because the information is unfiltered and often is not relevant to a particular cancer patient’s diagnosis. Our physicians always follow national guidelines for cancer treatment to be certain we have an approach to cancer treatment across the City of Hope with the intent to achieve superior outcomes. For example, having an expert in every specific cancer at City of Hope, who in turn works with every doctor in our system helps us achieve consistency in care, a better outcome and leads to an exemplary patient experience.
How is your organization leveraging technology, old and new, to improve the patient experience and patient outcomes across ambulatory and in-patient settings?
Caligiuri: In today’s world, technology is a very important aspect of anyone’s day-to-day experience. Perhaps the single most important technological advance with regard to the patient experience at City of Hope has been a unified electronic medical record across all of our sites throughout Los Angeles. This allows doctors and staff at one site to immediately know the results for a patient test or visit at another site. Equally important, our technology allows the patient to access their entire medical record from anywhere in the world should they need it. We have also recently improved our survey tool that allows patients to anonymously provide us feedback about their experience with a specific physician and other caregivers. Finally, with our acquisition of TGen (Translational Genomics Research Institute) in Phoenix, AZ, we have the capability to leverage unique genetic data to better provide the right treatment to the right patient at the right time. We are also using this information to determine who is at highest risk to get cancer in the first place.
External market issues such as the political upheaval in Washington, D.C. have disrupted the industry in many ways for the last two years. How have you met the challenges of policy changes?
Simpson: Political changes have happened for years. Employers have gone thorough backbreaking changes complying with the many laws they face with ACA compliance, reporting, HIPAA, and paying for outrageous premiums. Employees who used to complain about the rich PPOs are no more. Now all stand quiet in the room to see if deductibles have risen or the rates will take little Johnny off the plan. Through proper education, employees learn to manage through Health Saving Account plans that pay for medical, dental, vision, etc. The learning curve for our industry has been profound — and educating clients on compliance is critical. ACA reduced brokerage firms by half, and many threw in the towel. Some changes are good. There are no more denials for those who have medical conditions. The employer mandate took away the pride for employers who offered healthcare, yet held others accountable to do so. If these changes could settle down, the carriers and industry experts could create with their providers new horizons for us all. Money must be spent on development, rather than complying with the next new law.
Morgan: Healthcare providers have become acrobats to meet the challenges brought on by ongoing policy changes. In my experience, successful execution of any new policy comes from having the right team in place to anticipate the change, plan for it, and be ready when the final orders come down. Changing policy related to healthcare delivery can be problematic even when the idea is great, but the execution is unrealistic. For example, at the beginning of this year, guidelines for prescribing controlled substances changed. This addresses a critical need: making it harder to forge prescriptions for dangerous substances. In practice, the policy was enacted so fast that few prescription pad printers had obtained the necessary components from the FDA to create the new, compliant prescription pads. The result was that providers scrambled to ensure physicians could dispense necessary medication to their patients. In short, a great – and important – plan with flawed execution.
Employers are becoming a more important stakeholder in the health care delivery system. How does your organization engage with corporate entities and what results do those have on patient care, costs and access?
Rapisardi: Consulting with employers is an important part of the work we do every day. For example, we advise employer clients on how to create a culture of health within their organization and how to implement a successful wellness program. We also help them determine what type of funding arrangement to choose, and evaluate different health benefits plans that will best meet their needs and the needs of their employees, such as HMO, open access, high-deductible plans, etc. Do they want to offer a very broad network at a higher cost or do they prefer a high-performing network that’s smaller but offers access to quality care at a better price? There are dozens of decisions that employers need to make that affect their health benefits budget as well as the health, well-being and productivity of their employees. It’s our job to help them make choices that are right for them.
The opioid crisis continues to make headlines as health systems, pharmacy chains, congress and others in the healthcare industry seek solutions. How has your organization addressed this crisis?
Morgan: We need to carefully balance pain management – an important part of the healing process for many of our patients – with an opioid crisis that has taken hold of many communities across the country. Huntington Hospital has formed a committee to help address safe and effective pain management as it relates to opioid use and abuse. This committee uses data to analyze and measure overall opioid safety, quality of care as it relates to opioid utilization, and report any potential misuse of the drug. We have a responsibility to ensure the safety and health of our community, so we also have developed protocols for alternatives to opioids (ALTO) programs, which are becoming increasing popular to combat the opioid misuse epidemic. These programs emphasize the use of nonopioids as a first line for pain management. Hospitals that have implemented these ALTO protocols have seen a significant decrease in opioid use without a decrease in patient satisfaction scores. And of course, we continue to educate our physician partners and nurses about the dangers of this epidemic and how we can address it.
Rapisardi: The opioid crisis has been heartbreaking and it has shattered families throughout California and across the nation. In 2016, Cigna established an ambitious goal to reduce prescribed opioid use among our commercial customers by 25% within three years. Through outreach to prescribing clinicians to gain their commitment to follow CDC prescribing guidelines, sharing best practices among physician groups, education, and using predictive analytics to identify at-risk individuals, we were able to achieve this goal in just two years. While we have not dropped these approaches, we have also established another ambitious goal: reduce opioid overdose by 25% by the end of 2021 in certain communities with higher-than-average overdose rates. What’s most important is that we acknowledge opioid misuse as a chronic condition, and recognize that people who suffer from this disease need treatment without stigma or judgment. Cigna continues to increase access to evidence-based treatments, such as medication assisted treatment.
Outpatient care is still trending upwards as both a convenience and cost-saving focus for consumers, employers and health plans. How have you addressed this transition and how has the growth of outpatient care advanced value in health care?
Caligiuri: Core to our belief is that we can deliver premier cancer care no matter where a patient may live, and yes, outpatient cancer care is growing rapidly. Practically, City of Hope has realized this through acquiring more than 30 community practice sites around Los Angeles and Southern California, with a fully integrated electronic medical record to maintain consistency no matter where you are seen in our health system. In addition, we are bringing our cancer care model to the work place via our partnerships with employers throughout the United States who utilize our expert cancer services to enable employees to receive the right care at the right time in the right place, which is usually close to home near friends and family. As treatments become safer, outpatient cancer care has become more the norm and as technology has become more sophisticated, we can now enable access to cancer experts regardless of geography. This is true value in health care.
Morgan: Since my arrival in Fall 2017, I’ve been particularly focused on enhancing care across the continuum in support of our vision to be a leader in creating community wellbeing. Huntington Hospital has always been dedicated to the right care, in the right place at the right time. Delivering on this promise requires strong partners and the right affiliations. For example, we have a new affiliation with Exer Urgent Care at two locations in our region (Pasadena and La Cañada). They offer advanced urgent care delivered by the very same physicians that provide care in our Emergency and Trauma Center. Another valued partner is Huntington Hill Imaging, and our work with them ensures access to high-quality imaging services (MRI’s, CT scans, mammograms etc.) throughout our region.
