Whatcom health care providers seek solutions
Overwhelming complexity of issues precludes easy answers

 

When you start to explore the condition of the health care industry in Whatcom County, you soon find out that it’s a vast labyrinth with dozens of entrances and no exits. Addressing the state of that industry in a magazine article is like trying to write War and Peace on a matchbook cover.

Everyone, it seems, acknowledges that there is a plethora of problems, none of which have any easy or obvious answers. Indeed, the situation as a whole may be beyond the grasp of any individual.

The one thing everyone seems to agree on is that health care costs are out of control and not likely to level off anytime soon. Attributing causes to that escalation is like taking a multiple-choice test with dozens of possible answers. The correct one is: (Z) all of the above.

One of the great ironies of the situation is that Whatcom County residents are essentially being punished for being healthy. A major factor in the county’s crisis is low Medicare reimbursements from the federal government. Those reimbursements are based on a number of historical factors, one of which is utilization of the health care system.

Residents of Whatcom County are traditionally a rather healthy segment of society. Add that to the rugged individualism characteristic of northwesterners and you have a group that doesn’t call the doctor for every case of the sniffles. If you can believe the statistics, locals only seek medical aid when the Grim Reaper is telling a knock-knock joke.

That is called “underutilization” of the system. Somewhere in the baffling bureaucracy of the federal government, a number-cruncher looks at that statistic and arrives at the conclusion that Whatcom County doesn’t need as much of the limited Medicare budget as, say, Peoria. Peoria, where hypochondria is rampant, overutilizes the system and is rewarded by getting higher Medicare reimbursements.

It’s somewhat more complicated than that, of course, but the end result is the same. Whatcom County health care professionals get lower Medicare reimbursements than their colleagues almost anywhere else in the country. There are a number of ways physicians can deal with this.

They can stop accepting new Medicare patients. Many have already done so.

They can boost fees to non-Medicare patients to help compensate. Many have already done so.

They can move to Peoria where Medicare reimbursements are higher. Many have already done so.

They can work themselves into a coma trying to make ends meet. Many have already done so.

They can try to reconcile their Hippocratic Oath with the health care system and go broke, if not crazy. Many…well, you know the chorus by now.

The system has not only led to physicians moving away, but also makes it much harder to recruit new ones. Thus we have a severe shortage of health care professionals in Whatcom County.

One of the ways health care professionals have chosen to address the problem is by creating large clinics where many physicians can share the costs of doing business. Administration can be centralized. Duplication of facilities can be avoided. In-house laboratories and pharmacies help keep the profits from going elsewhere and improve patient service. Nursing staffs can be utilized more effectively.

Bellingham’s Madrona Medical Group, PS, is such a facility. Madrona CEO Dr. Erick Laine is confident about his facility, but uses the word “tenuous” to describe the state of the industry in Whatcom County.

‘There are three mandates everybody agrees on,” says Laine. “Quality, cost, and accessibility. Not everyone, however, agrees on the definitions of those terms. Reconciling those three elements is a huge challenge.”

While critics of the American system hold up other nations as an example, the reality is that health care is dysfunctional almost everywhere. For proof, one need look no further than just across the Canadian border. The once-vaunted Canadian health care system is in a shambles.

Yes, there is near-universal coverage at minimal cost to the consumer. But patients needing what is sometimes arbitrarily defined as “elective surgery” may have to wait months. Health care professionals throughout the country are staging strikes, slowdowns, sick-ins and any other action that will draw attention to their cause. Advanced medical equipment is in short supply. Public hospitals are closing at an alarming rate and even some emergency rooms are going unstaffed. There is a huge shortage of nurses, more of whom are leaving for the Promised Land south of the border every day. Those who remain face mandatory overtime and almost certain burnout.

Canadians are, in fact, coming to the US in droves in order to get treated in a timely manner and have access to the latest technology. Proponents of a two-tier (public/private) system in Canada point to that outflow of patients to underscore their argument that people who are willing to pay should have access to whatever they can afford.

On the Whatcom side of the line, access to medical care is the big issue.

“It’s usually defined by the press and the legislature as access to health insurance,” Laine explains. “But having insurance does not automatically grant access to health care. You must have access to a provider and that is where the problem lies in Whatcom County.”

Those skimpy Medicare reimbursements have played a major role in the burgeoning shortage of physicians. Laine claims that there was a turning point about five years ago when the attractions of the Whatcom County lifestyle ceased to offset the lowered income expectations.

“Medicare reimbursements are a huge factor at Madrona,” said Laine. “Older patients make up the largest segment of our business. The population as a whole is aging and older patients have more complex needs. It was an agonizing decision for us not to accept any more Medicare patients, but we did not choose the economic reality.”

Federal, state, and managed care mandates have all contributed to the physicians’ loss of control over the revenue stream. Patients themselves, who are far more sophisticated than they used to be, are also forcing changes.

On the whole, Laine thinks that’s a good thing.

“There has been a sea change in the physician/patient relationship,” said Laine. “Patients are now consumers, as well. The profession of medicine thereby transmutes to the business of medicine. The implications are dramatic.”

The change from physician-controlled care to patient-controlled care is a profound one.

“Responsibility and authority need to go hand-in-hand,” said Laine. “If the patient controls the treatment, the physician needs to be relieved of some medical liability.”

A lot of patients, however, feel that they have lost some of their new found control to insurance companies. Health Management Organizations (HMO’s) were formed by the insurers and touted as one solution to the health care crisis. But patients and physicians both rebelled at having medical decisions made by actuaries. One medical administrator described it as “…managing access, not care.” As a result, HMO’s are going down almost as fast as they went up.

Physicians insist that the insurers are merely purchasing services. Insurers take the position that physicians are merely providers of those services. Both sides insist on providing professional judgment. The patients weigh in with their case for having a say and the legislature tries to reconcile the warring factions. A lose-lose-lose-lose situation.

Market and regulatory forces are insufficient to make lemonade out of the mess. Laine thinks there is an economic solution that is yet to be discovered and that it is about 10-20 years off. Hence, his use of the word “tenuous.”

St. Joseph Hospital vice-president Barbara Dember, on the other hand, uses the word “bullish” to describe her assessment of the same situation. The divergent descriptions, perhaps, point up the dichotomy between the for-profit and the non-profit sectors. St. Joe, as it is affectionately known by locals, is not burdened by the necessity to turn a profit nor is it too concerned about simple survival. The hospital has been here 110 years and dominates the health care environment the way Mt. Baker dominates the scenery.

Dember describes it as a “mission-focused” organization. That mission is dictated, in large part, by the values of the Sisters of St. Joseph of Peace, described as “an order of progressive religious women.” The name of the non-profit corporation that owns St. Joseph, PeaceHealth, pretty well sums it up.

The fact that the mission does not involve turning a profit helps take some of the pressure off. So does access to sources of income not available to for-profit entities. St. Joseph, along with several other providers, recently received a $1.9 million grant from the Robert Wood Johnson Foundation for the purpose of “pursuing perfection in health care.”

The prevailing philosophy at St. Joe is that the hospital does not stand alone, but is a vital part of the community. As such, the concern of the hospital goes beyond the state of the health care industry and embraces the health of the community as a whole.

“We responded to the grant proposal as a community, not just as a hospital,” Dember says.

She sees working in collaboration with other providers as part of the future that fuels her determined optimism. Joining St. Joseph in the Pursuing Perfection grant are FamilyCare Network, Sea Mar Community Health Center, and North Cascade Cardiology. Payers involved in the pilot program are Group Health Cooperative and Regence Blue Shield.

They will be working with adults suffering from diabetes and/or congestive heart failure “…to improve access to care, improve communication across health care organizations and support patients in being full members of the care team.”

Addressing those out-of-control health care costs is very much at the heart of the program.

“The intent of the project is to reduce the need for admissions and re-admissions to the hospital through innovative chronic care services focused on strengthening patients’ ability to manage their own care. Improving the safety of the medication management process between providers and patients will also be an area of emphasis,” according to the PeaceHealth website.

Dember may be bullish, but she’s not blind to the problems facing health care professionals.

“Our health care system is oriented toward regulation,” Dember claimed. “That creates administrative bottlenecks which drive costs up and take time away from patient care. Regulations are necessary to a certain extent, but too often they are knee-jerk reactions to perceived abuses. The pendulum has swung too far.”

She admits she does not have all the answers, but insists that something must be done before the system is irretrievably damaged.

“Most health care dollars are spent on chronic illness,” Dember says. “People suffering from those diseases require multiple visits to physicians or the hospital and extensive medication. We must find a way to control chronic illness outside the hospital.”

If ways can be found for the chronically ill to manage their own diseases, it will do a lot to reduce health care costs. This, according to Dember, is where the HMO’s failed.

Another major issue that affecting care, if not costs, is patient privacy. Patients rightly believe that their medical records should be confidential. Recent regulations, however, have made it difficult for providers to share that information among themselves. In other words, if you have a coronary that puts you in St. Joseph and then need the services of a cardiology clinic or a long term care facility, should the hospital be able to forward your records to them without obtaining your permission? Does the necessity for facile communication between agencies outweigh privacy concerns? If communication is restricted, how will it affect the quality of care? The debate rages on.

One widely-touted solution to health care costs is preventive medicine, or “wellness.”

This can be as simple as having your children vaccinated or as difficult (for some of us) as eating right and exercising regularly. Historically, the US health care system has been weighted toward treatment rather than prevention. From an economic standpoint, however, it is much less expensive to prevent illness than to treat it.

“Preventive medicine offers a big bang for the buck,” says Madrona CEO Laine. “But the number of patients actually applying those principles is relatively small. The time and energy necessary to educate people about wellness doesn’t come cheap and it’s not paid for by insurers.”

Intimately connected with the wellness concept is the idea that when treatment becomes necessary, it is more effective to treat the whole patient. This mind/body connection is a guiding principle at St. Joseph, made easier by the fact that they see their mission as spiritual as well as physical.

Social justice plays a part in the St. Joseph philosophy.

“We don’t turn away anyone,” Dember says. “Part of our mission is to reach out to the vulnerable and underserved. Our first question to someone entering the hospital is not, “Who is your insurer?’”

Treating the uninsured and indigent is no less expensive than care for the insured, however, and contributes to the upward pressures on health care costs. The local shortage of physicians often means that people are forced to wait for treatment until the next level of care becomes necessary and up go the costs again. Because the health care system is so complex and interconnected, a breakdown in one part of the system affects all the others and the sound of falling dominoes is deafening.

Dember believes that some of the eventual solutions are being pioneered at St. Joseph.

“We work together as much as possible; the hospital, long-term care, nursing providers, pharmacies, medical equipment suppliers. If others could see how we collaborate across the whole system of care, it might help solve some of the problems.”

The insurance industry claims it is equally burdened by bureaucracy. Few would disagree that too much of the health care dollar is going to administration and not enough to patient care. Again, government regulation is fingered as the culprit.

“Insurance companies are not allowed to ask questions of individuals covered by group plans,” according to Bethany Den Hartog of Snapper Shuler Kenner in Lynden. “Some insurers would like to create a separate pool for healthier people and give consumers a choice between standard or preferred coverage.”

So far, that idea hasn’t impressed anyone at the insurance commissioner’s office. Nonetheless, consumers do have a few more choices than they did even a year ago. At that time, Northwest Washington Medical Bureau (NWMB) and Group Health were the only insurers in the market. Regence Blue Shield bought out NWMB and a lot of trade organizations offered plans to their members.

For example, contractors can now save money by signing on to a group plan offered by the Building Industry Association of Washington. Many other small businesses are joining plans offered by chambers of commerce. The competition that kept rates low in the Seattle area is gradually working its way north.

Primary Care Provider (PCP) plans are shoving the HMO’s aside because they offer the consumer more freedom of choice at a lower cost. That freedom has become more of an issue with consumers since some of it was lost with HMO’s. Freedom, of course, is not free.

State and federal mandates requiring insurers to provide for contraceptives, maternity care, and mental health complicate the situation because not all consumers want or need those coverages. Meanwhile, people who don’t use those coverages pay for those who do.

“It’s an endless, ugly cycle no one can figure out,” says Den Hartog. “I’m not going to solve it. All I can do is try to help clients determine what’s best for them. My role is to understand all the forces at work and work with what’s available.”

Given the proliferation of health plans, it’s a daunting task and Den Hartog admits she can’t always keep up with all the information that’s available. She also expresses sympathy for employers who have to deal with the complexities.

“There are some new federal regulations on the way,” Den Hartog says, “that govern how an employer discloses benefits. Employers are expected to know how to use the new system and are responsible for obeying the law, but most of them don’t even know it exists.”

Steep increases in group coverage, however, have caused a lot of employers to pay much closer attention to their insurance plans.

Jessica Waggoner handles health insurance for Pulse Publications.

“We are into our fourth year of providing health benefits,” she says, “and we have switched companies each year because of rate increases. We still faced increases of 10-20 percent, but would have faced 30 percent or more if we hadn’t switched.”

The company strives for stability despite costs going from $150 to $220 per person. If things continue the way they are, Waggoner believes that employees will soon have to pay for part of their coverage. Indeed, whereas most plans used to include spouses and children, they now require employees to pay extra for that coverage.

Bethany Den Hartog believes that employers will increasingly lay out the cash value of their benefit packages when recruiting employees. Employees, for their part, are already considering lower salaries in exchange for more comprehensive benefit packages.

The Whatcom Coalition for Healthy Communities (WCHC) is trying to come to grips with the magnitude of the problem preparatory to seeking solutions. The Coalition and its four sponsoring agencies (Whatcom Community Foundation, United Way, Whatcom County Health Department, and St. Joseph Hospital) will go public this fall with a program called Community Counts. It will seek to measure where we are and how we are improving.

WCHC coordinator Susan Gribben agrees with the idea that our past is coming back to haunt us.

“The roots of the problem lie 20-40 years in the past,” Gribben says. “Once a system gets locked into place, it’s very hard to change.”

At this point, that system has left 13-14 percent of Whatcom County residents with no health coverage at all. Because they cannot afford it, they rarely seek health care until the situation becomes critical. By that time, what might have been prevented inexpensively must now be treated at a much higher cost.

“Health means different things to different people,” says Gribben. “We need to start thinking about how we as individuals can improve our behavior and take more responsibility for our own health.”

Adult smoking is on the rise. Obesity is expanding. Substance abuse is widespread. All of these are behaviors that contribute greatly to the overburdened system. All are, ultimately, preventable.

In the end, it appears that we are all responsible in some way for the dilemma on whose horns we are presently impaled. It also appears that we will all have to take part in whatever solution is found.

So what is the prognosis for health care in Whatcom County? In a word: guarded.