Six medical professionals joined The Topeka Capital-Journal in a roundtable discussion to tackle the complex, challenging and positive things happening in health care. For more than an hour, they wandered through topics that varied from reimbursement to community health initiatives to electronic medical records.

We've pulled portions of the informal discussion.

Participants were Jackie Hyland, chief medical officer at the University of Kansas Health System St. Francis Campus and an anesthesiologist; James Owen, a radiologist affiliated with St. Francis; Eric Voth, vice president of primary care services at Stormont Vail Health and an internal medicine physician; Clifton Jones, Stormont's vice president of subspecialty care and an infectious disease specialist; Doug Iliff, a private practice physician with Iliff Family Practice; and Michelle Meier, chief operating officer for Kansas Medical Clinic PA.

The shift to population health — an approach aimed at improving the health of the entire population — is across the board one of the biggest and most exciting changes occurring in health care nationally and regionally, the group said. But the approach has challenges in and of itself.

Population health, Jones said, is "all well and good" for people who have access to health care, but there is a large group that health professionals aren't reaching.

"The people I work with administratively are mostly doing hospital acute care, and all of us have seen people getting admitted to the hospital (who) are sicker and sicker. It's like there's an inexhaustible supply of very ill people," Jones said. "So that's where community health has to kick in somehow, to reach people who don't have any resources whatsoever. How do we reach them? You can have incentives for people who are employed, who have health care products, health insurance. But I don't know how you reach the other people that come in and are so sick. And then what do you do with them when they're well enough to leave the hospital? Where do they go? There are few resources. A lot of those people don't keep those (follow-up) appointments. If they do keep those appointments, they have a real hard time getting assigned to primary care. That's what I worry about."

Patient responsibility

"One of the problems that I see with health care in general in the United States, and certainly in our area, is there's this assumption that we are responsible for health care," Owen said. "The fact is, if you look at a lot of the health care problems, they're not ones that we can have. They're ones that the patients have to fix. Obesity is a good one. They come and they get bypass surgery or whatever … but the fact is, so many of the problems facing health care right now are really problems the patient has ultimate control of.

"They go home from the hospital, and we can't force them to take their medication. Now, if some of them can't get the medication, that becomes society's problem," he added. "But even the ones who have medication, you can't get 'em to take it. So there has to be some level of personal responsibility."

Physician responsibility

Yes, the physician has a responsibility to educate the patient, but the method has to be approached with careful consideration, Meier said. The Centers for Medicare and Medicaid Services is incentivizing the way physicians are reimbursed and the importance of education to avoid penalties.

"But education turns into a printed sheet that you hand to the patient as they walk out the door, and then you've got your box checked," Meier said. "You know, honestly, if you think about it, it might be the physician who doesn't take the time and check the boxes and print the sheet who's giving a better education to that patient. But when you look at the national surveys online, it's those who check the boxes who are going to look like the physician compare sites' good doctors. I think the education needs to change."

Medicaid and emergency departments

"Nationally, we're seeing more people use the ER rather than fewer," Owen said.

"But interestingly, earlier," Voth added. "Earlier in their illnesses, and that's kind of the whole theory behind expanding Medicaid. You get people to access health care before they're a train wreck and spend maybe $100 or $1,000 on your care rather than these gigantic disasters that roll into the ER and tie up tremendous services, cost hundreds of thousands.

"One of the things I find most disturbing, not just here but nationally, too, is this has become such a political hot potato. Both sides need to come together to say, ‘Let's figure out how in the heck to fix this,' rather than you and you, and good guy and bad guy, and Republican and Democrat. It's just nonsense.

"The whole Medicaid expansion thing is a perfect example. Would we have walked away from $2 billion of Department of Defense money or highway monies or anywhere else? This was $2 billion worth of fairy dust that could have been sprinkled on Kansas, and now it's jeopardized nationally."

Behavioral health needed

In using numerous wrap-around services from social workers, behavioral health, care managers and others to help high-risk patients, Voth said the "toughest crowd" seems to be patients who have psychiatric and behavioral health issues underlying their medical problems.

"They're very hard to get services to and very hard to get to come to services," he said. "They shut down the state hospital, and those people didn't just vanish. Those populations are out there — some being served and a heckuva a lot not being served, getting sicker."

Is behavioral health care a primary consideration in Topeka?

As a group, the six answered, "Absolutely."

"Every Thursday, I get together with the social workers and the case managers to talk about the complex patients, and it's not because of their medical issues that they're staying in the hospital," Hyland said. "It's usually placement and mental health issues, and we have a severe lack of mental health resources in the community."

What's something positive in medicine right now?

Voth: Population health.

Hyland: Telemedicine. "I've used it," she said. "We have been able to make an appointment, be in the waiting room, have the visit and then have my prescription called in and have it at my house in 30 minutes. That's really exciting."

Stormont and St. Francis have been utilizing various forms of telemedicine through different programs. Owen noted radiology certainly uses technology, recalling the days when radiologists would have to drive to Seneca to read an X-ray, then they'd make a report, resulting in delays sometimes of days. Now, the final report is often ready within 20 minutes or so of the X-ray being taken.

Meier said KMC has been able to send a physician assistant or other advanced medical practitioner to communities that need dermatology appointments. If the physician assistant needs to consult with a dermatologist, they're able to quickly access one online to ask a question or talk about a case.

Staffing challenges

Yes, yes and yes. Like most of the country, Topeka medical organizations are challenged to find staff. Voth listed a licensed practical nursing shortage, exacerbated by higher wages at area retirement facilities that draw LPNs away. A medical assistant shortage is also a problem. Jones noted retention of registered nurses can be a problem. Many registered nurses are motivated to get advanced degrees, working in Topeka in intensive care units for a couple of years then going on to become nurse anesthetists or advanced practice registered nurses.

Electronic medical records

"I think what's a frustrating situation for physicians now, but I think will be exciting in the next 10 to 15 years, is the electronic medical record and the amount of information we're going to be able to get from the record on the population health side," Hyland said.

But right now, the EMR is a bit of a pain.

"I had a discharge from the hospital day before yesterday that was 36 pages long, and I couldn't find out what the patient was there for," said Iliff, who uses paper charts in his practices.

"We're in the infancy of EMR, and frankly, so far, personally I think it's been detrimental," Owen said. "It's extremely expensive. It's capable of putting all sorts of information into the chart automatically, but just try and find the part that I care about, which is what we think is really going on with the patient … it's a struggle."

Meier said the KMC EMR system was being looked at by a coder for auditing purposes, and the woman said something that really stuck with Meier.

"She said this is supposed to tell a story, and she was grading down my doctor's notes. As they went through and hit all the points — they'd actually hit all the right points and they could show that — but she's an outsider trying to read it, and she can't find the story," Meier said. "She can't find what's really happening with the patient anymore."

Jones noted, as an infectious disease specialist, he worries about infection control with the keyboards and medical personnel going from room to room, back and forth to keyboards.

He also noted that complaints about physicians who don't have enough eye contact because they're typing into the computer should be handled by the physician. "You do not have to practice that way," he said. "I think that's what a busy primary doctor has to do. Most specialists don't do it that way, I hope."

Voth said Stormont is considering the use of scribes, which has been something of a national trend. This is a person who goes to the room with the doctor, and he or she sits at the computer and takes notes while the doctor focuses on the patient.

"Of course, they work for free," Owen chimed in, drawing laughter from the table.

Hyland rose in defense of EMR and it's potential, even as the system works through the kinks now.

"Right now, I agree with everyone. We're not in a good pace with EMR, but I think it can take off and make things very exciting," she said, explaining that some of the young professionals she works with talk about using Google glasses and other technology and incorporating them with the EMR.

Positives?

Generic drugs, Iliff said. "I think the generic drugs I've got to treat the most common problems of my overweight, under-exercised patients are terrific," he said. "I can get all their numbers in the right place with really cheap stuff."

Iliff, who puts out a newsletter as part of his practice, doesn't usually pull punches about the patient's responsibility to take care of himself or herself. Does he attempt to work with his patients to make changes?

"I used to, but I've thrown up my hands," he said. "Nothing I do makes any difference. It's a waste of time. I give 'em pills and make 'em better. They know what I think. They've heard it over and over and over again, because I've been here for 35 years practicing. They don't do it, and we smile and go on."

It's about education

Multiple times, the conversation came back to education and how to do it efficiently and effectively. Nutrition, diet, smoking — all the factors that feed into the top health issues in the state. More insurance carriers are offering incentives to push people to change habits that affect their health.

During a discussion with a leader at UnitedHealthcare, Hyland said she learned about an app the insurance company has that works on exercise watches. Users are rewarded with up to $3 per day off of their deductible if they hit three criteria: a frequency target — getting up and walking around with at least 300 steps every six to eight hours; intensity — doing a 30-minute 3,000-step walk; and tenacity — doing 10,000 steps a day.

Personal rant

"One thing I'm on a personal rant about is the cost of pharmaceuticals," Voth said. "It's staggering. Staggering. And you know, companies need to make a profit, I understand that. But this is a killing. A hepatitis C cure is $99,000, or rheumatologic drug is $4,000 a month. That's ridiculous. That is absolutely criminal, and nobody's standing in the way of that. There's a lot of things that could be done."

Heads nodded around the table. And aren't there shortages are some of the cheap drugs, sometimes because they aren't as profitable?

"You can't get normal saline right now, 200ccs to a bag — a particular bag, the way it's packaged, that a lot of people use," Jones said.

"It's not like some complex chemotherapy agent," Owen added. "It's sodium bicarbonate. It's saline."

"Narcan for opiates. Narcan used to be dirt cheap. Now, it's terribly expensive," Voth said. "Inexcusable."

"There's a lot of gaming that goes on in big pharma," Iliff said. "All of this stuff could be fixed by our congressmen."

What's on your wish list?

"I would have kept the family practice residency in Topeka," Hyland said immediately. She referred to a residency program supported by Stormont and St. Francis that offered residency slots to interns and helped the hospitals to retain those physicians as they completed their schooling. It closed in 2002.

"I'd find a way for patients to have some skin in the game — responsibility for their own care," Owen said.

Iliff said he'd focus on health savings accounts, which he's personally seen accrue more than $60,000 for his health care.

"I'm nostalgic for the days when I was a young doctor and physicians interacted on a regular basis and worked in the same places and saw each other frequently," Jones said. "The days before things that are huge, like hospitalists taking care of patients efficiently. The primary doctors would come to the hospitals to care for the patients and interact with the specialists. … Everybody is siloed now. The people of my generation know each other, but the people of the younger generation do not. I miss that."

"I'd like to see medical education completely overhauled and a really serious national commitment to it," Voth said. "Right now, it's a mess."