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."
"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."
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."
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."
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."
"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'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."
"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."