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Friday, Sep 22, 2023

Health Care: A Roundtable Discussion


What is your outlook for the future of the healthcare system as we move into the second half of 2022?

Mayes: The outlook for the future of the healthcare system has many opportunities for growth and expansion of service lines. One of the clinical areas of need within the patient community includes services to support mental health issues from the acute hospital to outpatient and community-based programs.

Diaz: Emerging from the worst of the pandemic, our focus has been to help our communities make a return to health—encouraging patients and families to resume their routine healthcare and screenings, to stay up to date with recommended vaccines and boosters, and to seek essential care. Building on lessons learned from the COVID-19 pandemic, our healthcare system continues to work on streamlining processes, embracing digital innovation, implementing other technological advancements and updating our infrastructure in order to provide healthcare that is more effective, efficient, and equitable. Additionally, PIH Health has continued to expand its network of physicians and medical offices with the acquisition of local primary and specialty care groups and the opening of a new urgent care center. We look to the future with hope and continued commitment to improving healthcare access and patient outcomes.

Kalkat: The outlook for the second half is cautious. We will continue to see lingering effects of COVID-19. With approximately 25% of our community not fully vaccinated, we will continue to have to deploy our resources for providing medical care for new COVID-19 infections. We also expect our census to stay low, as many vulnerable patients who required frequent hospitalizations have passed away from COVID-19 infection.

Mone: The challenges of peaks and valleys of COVID+ patient loads will continue to burden the system with staffing demands while simultaneously reducing healthcare staffing as caregivers are infected. While the infection rates are far less often frequently serious than was the case two years ago, the operational impacts remain critical.

Telehealth is transforming care delivery. Are there specific practices, protocols or innovations developing that can eliminate barriers to care?

Manemann: Providence has transformed care delivery through the use of digital innovation and technology by offering a safe and easy way for patients to speak with their primary or specialty health care provider via smart phone, tablet or computer. Between 20-30% of our office visits are virtual. When COVID-19 hit, Providence quickly transitioned to telehealth to provide continued care from the safety of patients’ homes. Outside of the pandemic, telehealth continues to eliminate barriers to care such as transportation or the inability to take time off of work for a doctor’s visit. And, for the same cost as a standard office visit co-pay, many patients enjoy the convenience telehealth provides.

Yamaguchi: Cigna was an early leader in telehealth, starting with coverage for “virtual house calls” in 2007. Since then, we have developed, refined, and expanded our model. Last year, Cigna’s Evernorth division acquired MDLIVE, a national telehealth provider, which enables us to bring telehealth services to more of our customers. For many years, telehealth utilization had been low, but the pandemic changed that. Customers tried telehealth, liked it, and then stuck with it. Sixty percent of our behavioral health customers now use telehealth. Cigna now covers virtual wellness screenings, which are especially popular among customers who don’t have a primary care doctor. Virtual health services are also available for healthy lifestyle coaching, primary care, urgent care, dental care, and dermatology.

How dramatically have the healthcare business and operational landscapes changed in the wake of the COVID-19 pandemic?

Kalkat: The biggest challenge is the increase in operational costs. The majority of the increase in costs comes from the dramatic rise in spend on wages. We are mitigating this by aggressively hiring more nurses, surgical technicians and other essential employees. We are also experiencing approximately 15% drop in our inpatient census, which will affect the bottom line.

Diaz: Staffing shortages, frontline burnout and supply chain disruptions have made the most significant impact to operations and finances. As a result, healthcare businesses have been facing higher costs to recruit and retain frontline staff and have also had to navigate tight allocation restrictions and price hikes to maintain ample ongoing supplies. Due to delayed care and cancelled or postponed outpatient procedures, healthcare organizations are seeing a rise in patients presenting with more serious illnesses and a corresponding rise in healthcare costs. These changes in the landscape have prompted healthcare organizations such as PIH Health to adapt and innovate—opening additional lines to care, through the expanded use of telemedicine, maximizing digital healthcare tools to minimize burden on clinical staff, and optimizing non-clinical operations such as supply chain to sustain organizational-wide functions during a very critical time.

Mone: Hospitals clinics, and physician offices have seen unprecedented negative impacts on their finances as routine care and treatments have in many cases remained below traditional levels, while the cost of staffing has risen dramatically due to the COVID-related burdens faced by healthcare workers and as many have left the field as a result. In our own world of organ, eye, and tissue donation, one third of our staff resign last year – some left the healthcare field all together, some followed spouses or partners to jobs in other regions and some took jobs with higher wages and reduced demands in other areas of healthcare. We are catching up now, but we and most healthcare providers are still short-handed and paying far more to recruit and retain talented employees than we were pre-COVID.

Mayes: Hospitals are still in recovery mode from the height of the pandemic. The most significant operational and financial impact is the staffing shortage. During the pandemic, 84% of our staff was out sick. Temporary staffing agencies increased their rates up to 300-400%. Many agencies still have their temporary staffing rates as high as they were during 2020-2021. Because of the pandemic, many healthcare workers resigned from nursing, which is causing a decrease in the staffing pool.

Yamaguchi: One of the biggest changes we’ve seen during the pandemic is the exponential increase in virtual care. Our customers really appreciate the convenience of accessing care via video or phone wherever they are- at home, at work, on the go- without spending time driving to an appointment or waiting to be seen in the doctor’s office. To meet this need, Cigna significantly expanded our virtual care network by acquiring MD Live, one of the country’s largest telehealth networks. Millions of our customers now have access to digital-first primary, behavioral and urgent care as well as dermatology. We expect that moving forward one in three visits will be virtual.

How does California’s healthcare outlook differ from other parts of the country?

Mone: California’s healthcare landscape continues to be far more impacted than the rest of the country due to more than 30 years of capitated and provider risk bearing. This has led to smaller margins than have been experienced by many hospitals across the country. Simultaneously, the continued impact of being one of the few corporate practice of medicine (CPM) states has made managing physician practices within hospitals and capitated/risk plans more challenging than the vast majority of states without CPM. These challenges are exacerbated by our relatively large proportion of community and small-to-mid-sized hospitals and fewer large, tertiary and quaternary medical centers as compared to many area of the country.

How about the insurance landscape?
What changes are you seeing there?

Kalkat: I am concerned that with the passage of “Medical Injury Compensation Reform Act (MICRA) modernization legislation,” physicians and hospitals will likely face increased claims and premiums. The provision in the new act providing up to three caps in each case is worrisome. This stacking up will most likely result in increased number of claims. The resulting increase in premiums could result in many solo practitioners closing down their practices.

How is consumerism impacting the healthcare industry and how are hospitals and health systems responding?

Diaz: Now more than ever, patients are seeking convenience in addition to trust in their relationship with their healthcare provider. The availability of online reviews, the ability to compare and shop around for services, and all the offerings of the latest advancements in healthcare technology have contributed to the impact of consumerism in the healthcare industry. Many procedures that used to require in-hospital stays can now be safely and effectively performed in outpatient surgical centers, meaning shorter recovery time, less pain, and reduced risk for infection. In addition, home monitoring technology enables providers to care for patients virtually once discharged. To meet consumers’ needs, health systems have to work to ensure patients they can provide the “best” healthcare that’s not only high quality, yet also convenient and affordable.

Manemann: Consumers want convenient, accessible and low-cost care, and Providence is committed to delivering high-quality, affordable care close to where people work and live. In fact, we are growing our network with the goal of being 15 minutes from 15 million people in the communities we serve. We understand that many people can’t take time off from work to focus on their health. This is when a urinary tract infection can progress to a painful kidney infection and an ER visit. Through our Express Care neighborhood clinics, urgent care centers, and virtually through telehealth, we can meet consumer health needs wherever, however and whenever it’s convenient for them. And, for continuity of care, we provide referrals to primary care providers and specialists who seamlessly continue the patient’s care journey.

Mone: Clearly there are many efforts on the part of providers to create consumer-friendly care services, such as pharmacies with clinics and immunization centers, plus the continued growing reliance on urgent care centers. This growth is spurred by rising insurance deductibles that make paying for a convenience worthwhile. Whether these consumer-focused providers can routinely negotiate contracts with insurance company payers so that patients don’t routinely have to pay out of pocket for more complex services may be a limiting force on their expansion.

Kalkat: Consumerism will continue to advance in the coming years. Patients demand accountability, transparency, satisfying online experience and improved outcomes. Here, technology will play the most important part. We continue to increase our investment in technology, including hardware and software solutions. We also have increased our support staff to help navigate this journey for our patients.

How is digital innovation revolutionizing health care?

Yamaguchi: Innovation, particularly through technology, is key to improving the healthcare experience and making healthcare simpler and more affordable. Several years ago we established Cigna Ventures as the investment arm of Cigna. It researches and invests in technology companies in three broad areas: insights and analytics, digital health, and care delivery and enablement. Cigna Ventures has invested in companies such as Omada (diabetes prevention) Buoy Health (COVID-19 symptom checker), Ginger (behavioral health and coaching), Cricket Health (kidney care), and many more, all with the goal of harnessing technology to make it easier for people to access care and more effectively manage their health.

Manemann: Consumerism is changing the way healthcare is delivered. Consumers are becoming increasingly active and engaged in their care. They want to track their health conditions online, see test results on their electronic devices, connect with their doctor online and schedule appointments with a click of a button. The innovative Providence app is a patient’s personal connection to great care. The app enables patients to access health information and receive great care wherever they are, including same day care with Providence ExpressCare clinics, Urgent Care and some primary care physicians. In addition, patients can see a qualified provider in minutes with ExpressCare Virtual. Consumerism has forced healthcare to deliver an exceptional care experience when and where patients want to receive it.

Diaz: Growing technological advancements have brought about the development of numerous apps, devices, and other digital health solutions for healthcare. With the implementation of such technologies, healthcare organizations can offer many more services for patients and encourage timely access to care, potentially reducing hospitalization. When the pandemic placed limits on in-person interactions, digital health tools such as telemedicine and remote patient monitoring opened additional communication pathways across service lines between patients and providers. Additionally, digital innovations that support remote work and speed reporting capabilities have contributed to more adaptable care teams, better workflows, and reduced burnout in clinical staff so they can provide more attentive patient care.

Mone: The tremendous number of independent care providers and the still-emerging standardization of data exchanges and interfaces have limited the potential of digital innovation in California healthcare. The federal focus on interoperability is improving health care data sharing across providers and platforms, but too often we remain limited by a reluctance to share data across provider entities. In our organ donation work we have seen tremendous value in the rare cases where we have full remote electronic access to referred potential donors. However, access is limited by hospital priorities and too often by hospital limitations on our access, despite the fact that federal law requires hospital provide it. This remains a work in progress.

Now that we know what we know, what can the health care sector do to better prepare for a potential future crisis?

Diaz: Healthcare will need to shift towards new models of care that focus on acting earlier to prevent, diagnose and treat diseases and including COVID-19 vaccines in routine immunization packages. Strengthening logistics and supply chains, harnessing transformative innovations to improve patient outcomes; supporting recruitment and training of healthcare workers to prioritizing their physical, mental, and emotional well-being—these are ways that we in the healthcare sector can better prepare ourselves and ensure the resilience of our health systems against future crisis. As we navigated through uncharted territory brought on by the COVID-19 pandemic, the guidance, ingenuity, and dedication of our PIH Health leaders, physicians, clinicians, staff, and volunteers has never been stronger—or more vital. If these last couple of years taught us anything, it has taught us that, together, we can overcome challenges and learn from them as we face the future ahead.

Mayes: Now that we have survived through the heart of the pandemic, hospitals now have mitigation plans in place that promote early preparation and immediate implementation of strategies to be prepared for the next COVID-19 surge or other types of disaster/pandemic situation.

Yamaguchi: One of the things we learned is the importance of being flexible, nimble and quick to pivot. Large companies don’t generally move quickly, but practically overnight we shifted from a largely office-based business to a mostly work-at-home one. It became clear in the early days of the pandemic that if we were going to protect the health of our employees and still serve our clients and customers, we needed to get equipment to people very rapidly so they could work at home. And we did that. That sense of urgency and rapid response infused virtually every business activity that followed. Knowledge about the coronavirus kept evolving and guidance from the CDC kept changing, and that affected virtually every aspect of our business – from coverage policies to clinical guidance to regulatory compliance. So flexibility and agility quickly became embedded in our culture. We also learned how important it was to be seen as a trusted partner and source of credible information for our clients. We routinely shared information and clinical guidance with our clients throughout the pandemic, through email communications and webinars. Once vaccination made it possible to consider returning to the workplace, we provided expert guidance about doing that safely. So the key takeaways are: communicate early and often in a rapidly changing environment; and be credible, flexible, quick to pivot, because everything can turn on a dime.

Will outpatient care continue to trend upwards?

Diaz: Throughout the pandemic, the use of telemedicine greatly increased lines of access for timely healthcare delivery. Because of its convenience and effectiveness, virtual visits will likely remain higher than before COVID-19, supporting the upward trend of outpatient care services. However, due to a rise in the number of patients presenting with more serious conditions after delaying care during the pandemic, hospitals are now seeing greater demand for inpatient services in order to treat more advanced stages in disease and address significant health complications from prolonged illness. The need for inpatient care may also continue to grow due to an aging population.

Southern California has a critical shortage of inpatient psychiatric and behavioral health care, and a rising need. How do we move forward to meet that demand?

Kalkat: There is a crisis in psychiatric and behavioral care in California, as demand continues to increase. Unfortunately, we will continue to not able to make inroads here until drastic changes are made at many levels in health care. Many health plans provide subpar coverage for psychiatric and behavioral care. The shortage of psychiatric and behavioral healthcare providers, coupled with low reimbursement for this care, leaves many patients unsupported in society. There is a much higher number of patients with psychiatric and behavioral issues in our country when compared to those of equally-developed Western societies, and we must address these underlying causes.

Yamaguchi: After years and years of relatively little consumer uptake, virtual care exploded during the pandemic, particularly for mental health, when anxiety and depression and other behavioral health issues became practically a pandemic of their own. And once people started to use virtual care they realized it’s a great option, because it’s so convenient, and it provides a certain degree of anonymity, especially for mental health. Due to the stigma that still, unfortunately, surrounds mental health, many people are reluctant to go to a doctor’s office. Virtual visits provide a great alternative because the patient doesn’t have to worry about who might see them in the waiting room. So we see virtual care as absolutely part of the health care delivery mix, particularly as technological capabilities continue to advance, which is one of the reasons behind our decision to acquire MDLive last year.

How are organizations successfully implementing value-based delivery to reduce the cost of care while also improving quality?

Manemann: Providence is focused on keeping our community healthy by providing comprehensive, coordinated and highly effective team-based care in the primary care setting. This patient-centric model meets the important health and wellness needs of our patients. When specialized care is needed, we provide high-quality, evidence-based medicine at every access point in our network. As we transition to value-based care post COVID-19, one of the biggest challenges all health systems face is patients returning to their pre-pandemic cadence of annual physical exams, important health screenings such as mammograms and colonoscopies, and follow-up care. Many patients avoided care during COVID-19, which is why we’re seeing avoidable complications in patients with chronic disease and higher acuity patients in our hospitals. Many of these conditions necessitate invasive treatment and lengthy hospital stays, which strain all health systems focused on post-pandemic recovery.

Are wellness programs worthwhile investments for employers in 2022?

Yamaguchi: Wellness programs are absolutely a smart investment for companies. Pre-pandemic, most businesses considered health benefits a cost to be managed, and little more. But those attitudes changed over the past few years. Our recent Healthy Workforce survey of executives and employees found they agree that worker wellbeing is essential to business success. More than 90% of executives see investments in employee health and wellness having a direct impact on financial performance, and feel that prioritizing employee health will help their business recover faster. The survey highlighted the importance of mental health- the combination of fatigue, burnout and stress were recognized as the top barriers to business growth. Employers play a key role in addressing this need- it’s more than providing health benefits and wellness programs, it’s also about building a culture of health from the top down to encourage employees to engage in those programs.

What are some of the issues you feel may have been overlooked while we were battling the pandemic over the last two years?

Mayes: The federal stimulus funding for the small to medium size hospital providers did not receive the same level of financial support compared to larger hospitals and health systems. The calculations used to determine distribution of available stimulus funds for the small to medium size hospitals did not receive a fair allotment – especially the safety net hospitals. The safety net hospitals are widely needed by the surrounding communities of the underserved population. As president/CEO at Pacifica Hospital of the Valley, I have been active in communications with our local legislators in the City Council, assembly, senate and congress. We have strong support from our local officials to advocate for hospital providers and public healthcare needs and priorities. These relations have played a significant role in the support of our safety net hospital.

Mone: We all miscalculated how long the pandemic would continue to impact all of us and I believe we also underestimated the level of frustration and sometimes anger felt among patients and families who have had their own understandable struggles to access care and be with their loved ones.

Yamaguchi: Exhaustion and pandemic fatigue are certainly big challenges, but an even bigger challenge is the uncertainty we all face from the constant threats posed by new virus variants and a seemingly never-ending pandemic. Employers need to continue to remind people to be kind to themselves and to one another. It’s critically important to create a workplace where people feel valued, respected, appreciated, and connected to one another. Cigna’s research on resilience shows how important it is to have meaningful connections in the workplace. Above all, employers need to help destigmatize mental health, because it remains a significant barrier to people accessing care. The more we talk about whole-person health and the mind/body connection, the more we can normalize mental health and destigmatize it.

Diaz: The toll social isolation took on the mental health of both young and old during long periods of lockdown and uncertainty and concerns about health equity and lack of access to care for vulnerable populations, are all issues that were not immediately foreseen at the onset of the pandemic. Deepening our understanding of the needs in the communities we serve is critical to improving patient care. Knowing the issues that impact our communities can better focus our health improvement efforts and guide our strategic partnerships.

What is your organization doing to ensure we close the health equity gap in our communities?

Mone: OneLegacy serves a region that is 70% persons of color and 50% first and second generation immigrant households. Simultaneously 80% of our organ transplant waitlists are persons of color, and 72% of the transplants in this region are to persons of color. As a result, addressing diversity in every aspect of our work is paramount. We start by assembling a staff who mirrors our communities and are equipped with common cultural experiences and language capabilities which is so important when they are meeting with families at one of the most challenging times of their lives. Simultaneously, OneLegacy invests heavily on establishing and building on relationships with community leaders while participating in grassroots community activities across our major ethnic communities in order earn and maintain the trust that is necessary for a family or individual to choose to give the gift of life to a stranger…who might be someone from their very own neighborhood.

Yamaguchi: Diversity, equity and inclusion aren’t talking points for our company – it’s part of what we do. Through our DEI efforts, we aim to advance an inclusive culture that is powerfully diverse, strives for equity, and values the unique differences and talents we each bring in service to our mission. We created our Enterprise DEI Council to oversee Cigna’s DEI strategy, track and report on progress and strengthen our efforts internally and externally. The council, chaired by our chairman and CEO David Cordani, includes senior leaders across Cigna and reflects our company’s diverse workforce. A key focus for the Council is health equity, including addressing critical social determinants of health such as access to health care, digital literacy, food insecurity for customers and communities we serve, and more. Just a few examples: 1) In 2016 we launched the Cigna Health Improvement Tour, a mobile clinic that travels the country to provide free health screenings and coaching to underserved communities; 2) During the pandemic, we repurposed the Tour to focus on COVID-19 prevention, vaccination and education. We partnered with trusted community faith leaders, food banks and other local organizations to reach communities of color hardest hit by the pandemic; and 3) We partnered with Magic Johnson to launch a new initiative in Los Angeles to support women and minority owned businesses.

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