How Healthy is Healthcare in Hawaii? - Extended Version
Leading doctors and other experts discuss major trends and problems in Hawaii healthcare
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Giesting: I would also like to bring in the aspect of engaging consumers more in their own healthcare. That really is one of the things we are working very hard on, and it really gets to the heart of prevention. If people are more engaged, if they’re more aware, if we can help them be partners, very competent partners in improving their own health, then that is a real positive direction that we can go. Regardless of the evidence, I think that will have an impact on health and eventually costs.
Andrews: I would like to build off at some of what Beth has said. You’re going to hear more and more with the Federal Health Reform implementation, the role the consumer is expected to play in his or her own health. I would push back on that question and on the way the way we define prevention. There’s a lot of preventive activity going on out there through consumer education. I know just standing in line I was talking with some of the business magazine folks and there was a recent conference that was held for women. So we’ve got to start thinking about what prevention looks like. I would also like to suggest that at least through efforts similar to the Health Insurance Exchange – the idea is to create access to care. By creating access to care, you help shape the behavior of the consumer in how they utilize their services as opposed to what we see in the system now — an over-utilization of the wrong kinds of services. An example would be the emergency rooms. I think that there is prevention going on. Just broadening what prevention means — this really is a lot about educating the consumer around healthcare.
Anderson: There’s one segment of the population that I think is critically important. That’s the elderly and I’ll just give you an example of a prevention effort that I think is important. We’ve been expanding our adult daycare, and just as an anecdote... (Reimbursement is a huge issue in this area) ... but we charge $85 to drop your parent off for the day. If that parent were in the institution (for the day) it would probably cost us 10 times that amount per day. So the longer we can keep people at home and keep them healthy, particularly the elderly, I think the better off we’re going to be in reducing our institutional costs.
I do have a question to Beth, on the issue of continuity of care and continual care issue. I think one of the major issues I see is not having available services where they’re needed. You’re familiar with waitlist problem of not having skilled nursing in the community, which requires that hospitals keep patients longer in acute care beds than they should be because there is no place to put them where they get the appropriate level of care. That’s an area where I think the state can take an active role in trying to support the full spectrum of services that are needed in the community. I’m wondering what your view is on the role of government there?
Giesting: I believe that the direction that we are looking to the extent we can is more in the way of community and home services — like the adult daycare that you talked about. People want to stay in their own homes and we want to help facilitate that, and many of the things that we are trying to do in improving care management will help keep the whole system together.
Pressler: A question for Bruce. Someone asked how much of the state hospital budget goes to OHA?
Anderson: As far as I know, none goes directly to OHA. We have some facilities on ceded lands. We have to take care of all Hawaiians and it was a point in our ancestry so we’ve talked to OHA and others about the issues and we’re working closely with them.
Pressler: We have quite a few questions about the exchange, Coral, so let me start with just the simple one. What percent of consumers are expected to participate in the exchange?
Andrews: It’s early on and we don’t have numbers forecasted. The best benchmark would be looking at the current Medicaid utilization. What I haven’t shared with you is that part of what is going to attach to the connector IT functionality is going to be the Medicaid Eligibility System, which the state is working on transforming to an upgraded IT platform. At this time, we don’t have the demographics laid out yet but I look forward to sharing that with you all at a later date.
Pressler: Who are the eight percent uninsured and what are the projected annual operating costs for the exchange?
Giesting: I could probably say a few things about the eight percent uninsured. I think it is certainly not a monolithic group but there are many reasons why people remain uninsured in our state despite prepaid healthcare. Some of the folks are unemployed and can’t afford COBRA, or their working spouse can’t afford dependent care coverage. There are people who work part-time jobs, people who are self-employed, and then we have those people who can’t work with the system very effectively, such as homeless people and sometimes immigrants who are not working. We have a whole range of who are uninsured and providing affordable insurance products for them is going to be really a big boom.
Andrews: Thank you, Beth. Because the Medicaid component and the uninsured certainly is something the state has definitely dialed into. Let me just back out of the question a little bit because it appears that there is some expectation that we’re further along in the planning and preparation for the exchange then than we are. So, let me give you sort of an idea of where we are, to be able to achieve answers to those questions.
We’ve got to reach back and do a gap analysis as part of our implementation – planning and implementation of the Health Insurance Exchange. Through that gap analysis we hope to identify more specific information about who the users of the exchange are going to be and what the projected costs are going to be in the long term. But as we design the scope on the front end of the exchange, we have to be mindful not to build too big. Does this sound like something you all keep in mind when you create things? Because we have to ensure that the sustainable costs are ones that we are will to be able to cover in the long term. We do look forward to completing that gap analysis, and then we will be going back for a level II implementation grant. But at this point, we are just trying to stand up a nonprofit corporation and get the contracts for the IT functionality and get staff for the connector. So, keep in touch.
Pressler: How do you plan to deal with the issues of adverse selection and administrative overhead costs, which have been big problems for exchanges elsewhere?
Andrews: I believe that the concepts behind HHS setting up the regulatory structure of the Health Insurance Exchanges is an attempt to avoid some of those pitfalls. It has specifics about the kinds of benefits that must be included in their health plans. I anticipate that as the Insurance Commissioner is setting up some of the regulatory oversight of the plans that those kinds of conversations will be ones that we’re going to dive deeper into. The idea is that you want all comers to represent the health insurance plans, to participate on the exchange, and at the same time you recognize that there is going to be a cost structure that they have to consider in order to be able to participate and not lose money.
Pressler: Tom, who will be making the decisions regarding if hospitalization could be avoided or if a test is unnecessary?
Tsang: I guess we can talk about at least coming from CMS (Centers for Medicare & Medicaid Services), which would be applying it to Medicare patients and to Medicaid patients. That policy has already been set in terms of admissions or actually readmissions, so the policy for the readmissions is that within 30 days the second admission through that one patient would not be paid for by CMS and applied to at least three specific conditions: congestive heart failure, pneumonia, and heart attacks. On the commercial side, the evidence shows that 20 percent of all admissions end up being readmitted. That’s partly because of poor discharge planning from the hospitals and it’s partly because of the nature of the processes in place during the transitioning of care: medication lists are not handed over to the receiving doctor, planning and engagement of the patients, etc.; these things are not being done properly and that is why the patient comes back to the hospital within five days for the same exact symptoms. So, the policy is to ding and to kind of push the system forward into putting processes in place to eliminate or reduce the readmissions process.
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