Issue link: https://beckershealthcare.uberflip.com/i/197073
10 Sign up for the COMPLIMENTARY Becker's Hospital Review CEO Report & CFO Report E-Weeklies at www.BeckersHospitalReview.com or call (800) 417-2035 Safety-Nets: Can They Go From "Last Resort" to "Hospitals of Choice"? (continued from page 1) Despite this statistic, a decline in America's uninsured is unlikely to relinquish the need for safety-net hospitals, according to experts. Public hospitals for the poor will still have a place in the American landscape, especially since most safety-nets are responsible for training physicians and take on significant patient volumes that would otherwise incapacitate markets. Instead, it's the traditional role and public perception of safety-nets that's poised for the biggest transformation. "These hospitals don't always set out wanting to be the safety-nets, but it's a position they get forced into," says Igor Belokrinitsky, a strategy consultant with Booz & Company in Chicago. "They become a hospital of last resort, but they really want to be a hospital of choice. Do you want to stay a safetynet hospital or find something else that will set you apart?" One safey-net's approach Newspaper editor Henry W. Grady founded Atlanta-based Grady Health more than 120 years ago, concerned about a lack of quality healthcare for Atlanta's poor. Today, Grady's payer mix is roughly 34 percent uninsured, 32 percent Medicaid and 17 percent Medicare, with the rest covered by commercial insurance and workers' compensation. Grady provided roughly $200 million in uncompensated care to 100,000 uninsured patients in fiscal year 2011, and the system also trains roughly one-quarter of Georgia's physicians. Like many safety-nets, Grady is facing questions about patients' behavior once they gain coverage under healthcare reform. Largely, will patients opt to continue visiting the largest safety-net hospital in the state or choose to go elsewhere? A 2011 study published in Health Affairs showed outcomes varied for acute myocardial infarction, heart failure and pneumonia across safety-net and non-safety-net hospitals in select urban areas, but mortality and readmission rates were broadly similar. Non-safety-net hospitals outperformed safety-net hospitals on average by less than one percentage point across most conditions — better clinical performance from the safety-net hospitals than many people would expect. Despite this demonstrated clinical proficiency, patients remain generally less pleased with their experience at safety-nets. A 2012 study from the Archives of Internal Medicine found safety-nets scored worse in patient satisfaction compared with hospitals that didn't provide a disproportionate amount of care to uninsured and Medicaid patients. "There is a belief — and I would affirm it — that safety-nets have not always done everything they can to endear themselves to patients," says Mr. Haupert. "We've been forthright about letting the community know we need to do better." A realistic definition of "patient choice" President Barack Obama's administration has emphasized the need for health systems to act as the mouthpieces for the reform law, particularly when it comes to educating the public about health insurance exchanges. Georgia declined a state-run exchange, meaning the federal government will operate the HIE. The goal is not to abandon the mission but fund the mission. Grady CEO John Haupert says safety-nets will take on a different role in the reformed healthcare landscape, but it will take "heavy lifting" to position these institutions as providers of choice in some markets. There are five other general acute-care hospitals within Atlanta's city limits that neighbor Grady Memorial Hospital, and Mr. Haupert is cognizant of the niche people have traditionally expected GMH to fill in that market. "There's a perception out there, especially with the commercially insured, that Grady is only the place you go to after a bad car accident or for burns," says Mr. Haupert. "We need to change that perception, but it's hard to do that overnight." The stubborn dichotomy facing safety-net hospitals Massachusetts has been the crystal ball of American healthcare reform since it enacted its own statewide reform in 2006. Despite the significant reduction of uninsured patients since then, a 2011 study published in the Archives of Internal Medicine found demand for care at safety-net hospitals and community health centers continued to rise. Most safety-net patients surveyed did not view these facilities, such as Boston Medical Center or Cambridge Health Alliance, as providers of last resort. Instead, nearly 80 percent said they visited safety-nets because of their convenience, and more than 70 percent cited their visit to safety-nets' affordability. The availability of services other than medical care and difficulty getting appointments at non-safety-net providers were also common reasons patients visited safety-nets, even though they could have gone to one of Boston's many prominent academic medical centers. Despite this promising finding, other studies have shown a gaping dichotomy in how consumers perceive safety-nets. Specifically: Patient experience ratings do not correlate with safety-net hospitals' clinical outcomes, suggesting public hospitals for the poor have their work cut out for them when it comes to improving their public perception. In response, Grady has stepped up to the challenge and is concerting communication efforts to ensure patients know about their new insurance options. "We're taking a leadership role on the patient side, making sure patients are aware of the exchange, qualified and get into the HIE," says Mr. Haupert. Even in states that do not implement the Medicaid expansion, such as Georgia, the presence of either a state-based or federally facilitated health insurance marketplace paired with the individual mandate to obtain insurance coverage is likely to affect participation in Medicaid by people who are eligible under the current rules but have not enrolled. Still, it would be overly simplistic to link health insurance coverage to increased provider choice, as the two are hardly synonymous. Realistically, "provider choice" could remain very narrow for the newly insured, depending on the market. Physician groups, hospitals and health systems may not accept the new insurance product, particularly if it reimburses at a level similar to Medicaid, which typically pays hospitals 93 cents for every dollar spent. Fewer physicians are accepting Medicaid patients, too, which paints a stark picture about what "provider choice" really means under healthcare reform. A 2012 study from Health Affairs found about 69 percent of doctors nationally accept new Medicaid patients, but that figure ranges from 99 percent in Wyoming to 40 percent in New Jersey. Payers participating in the exchanges must offer three levels of coverage, organized by "metal tiers," and it appears the silver plan will be the most widely purchased by consumers. A silver plan is required to have an actuarial value of 70 percent, meaning covered individuals would be expected to pay 30 percent through deductibles, co-pays and other cost-sharing features. Mr. Haupert says he has significant concerns about health systems and physicians not accepting newly insured patients. Grady may very well continue meeting that safety-net need, if so. "Even in Atlanta, there are some social issues I think may pop up with some health systems that have historically not provided care to the poor," he says. "That's not an excuse to change what we do at Grady." There's also the vice-versa scenario, which has been coming to a head as insurers in California, New Hampshire and Illinois limit the choices of pro-