Akron Children’s President and CEO Grace Wakulchik talks with Keith Coleman, Summa Health CFO, prior to the panel discussion.
Without a crystal ball to predict the future of health care, 6 Northeast Ohio hospital system CEOs have the benefit of the next best thing – decades of experience in the field and the perspective from the top in one of the country’s most respected and competitive markets for health care.
Akron Children’s President and CEO Grace Wakulchik joined the 5 other CEOs for a panel discussion at Crain Cleveland Business’ annual Health Care Summit at Case Western Reserve University on Aug. 29. She was joined by Dr. Akram Boutros, of MetroHealth; Dr. Cliff Deveny, of Summa Health; Dr. Tom Mihaljevic, of Cleveland Clinic; Thomas Strauss, of Sisters of Charity Health System; and Thomas Zenty III, of University Hospitals.
While the discussion covered the opioid epidemic, population changes across Northeast Ohio, and the rising cost of health care, Elizabeth McIntyre, Crain’s publisher, kicked off the discussion by asking the panelists about the most disruptive changes impacting the health care industry.
Crain’s publisher Elizabeth McIntyre (at far right) leads a discussion with 6 Northeast Ohio hospital chief executive officers during a panel discussion on the state of health care in the region.
Disruption comes via clinical innovation, legislation, trends (the shift from inpatient to outpatient to prevention and wellness focus), consumer demands and technology.
Zenty added venture capital and private equity to the list.
“I think we are seeing more of this than ever before,” he said. “If you think about it, if you can get a small slice of the $3.5 trillion dollar industry you don’t need a big piece of it to create a meaningful business opportunity.”
He noted that as the national debt closes in on a trillion dollars, it will place tremendous pressure on the stability of the Medicare and Medicaid systems, which hospitals depend upon significantly for reimbursement.
And with an estimated 34% of all employees now on high-deductible health insurance plans, consumerism will clearly be a driving force in the industry.
“The most exciting disruptive trend is technology,” said Dr. Mihaljevic. “I think the digital transformation that has affected every other industry is going to affect health care in a really good way – from the apps and devices that will allow our patients easy access to their providers and better control over their health, to artificial intelligence, to sophisticated electronic medical records, and to the use of large data to better steer resources in health care.”
Opioid crisis enters a new phase
McIntyre moved the discussion onto the opioid epidemic, and how it has evolved over the last 5 years.
“The crisis is starting to plateau – that’s the good news – we’ve gone from 100 deaths in Cuyahoga County up to 500, 700 – and now this past year, it’s dropped back down to 500,” said Strauss. “But the dangerous thing is to think we’ve won the battle – because we haven’t.”
Strauss said providers at his system are looking at the full continuum of care – offering the right care at the right time for these patients.
Sisters of Charity represents about 16% of all inpatient opioid detox in Ohio and operates the only 24/7 psychiatric emergency department in Northeast Ohio (there are only 2 in the state).
“The trouble is – with that population and that kind of commitment the reimbursement is very challenged [for behavioral health and addiction],” said Strauss. “In the middle of the crisis, some of the major Medicaid managed care players took it upon themselves in December 2018 and to stop reimbursing us for inpatient opioid detox and that was a crisis for us.”
A children’s hospital looks at the crisis from a different lens, noted Wakulchik.
“When you look at children and their substance abuse it’s still mostly alcohol and marijuana, so that’s led us to mostly focus on prevention and screening,” she said. “We have an addiction service program that’s working on inpatient consultation services and in collaboration with the 30 school districts we are involved with.”
Wakulchik went on to say that Akron Children’s orthopedic surgeons have been working on new protocols for prescribing pain medication post-surgery, and, as a result, have reduced the number of narcotics prescribed by 44%.
Grace Wakulchik and the other hospital CEOs discussed the disruptive changes impacting health care at the Crain’s event.
Preparing for population changes
The population in Northeast Ohio is declining, while also growing older and poorer, noted McIntyre.
Dr. Boutros said when he arrived to take the helm of MetroHealth he quickly learned the system was strong in tertiary care but he pushed to have it enter a Medicare accountable care organization to focus on population health.
They have since looked at about 6 years data focused on an overarching question: “What is the reason people do well?”
Recognizing that people spend only 0.2% of their life with in doctor’s offices in and hospitals, the question becomes how to influence the other 99.8%.
Dr. Boutros notes that it soon became obvious that success was less about prescribing medications and lecturing people, and more about listening and asking patients about their priorities. And, it seemed, incremental improvements could be made by offering care coordination and transportation to doctor’s appointments, when needed. MetroHealth is situated near one of Ohio’s largest Latino populations, which has a high rate of diabetes. Rather than addressing the problem with prescriptions, the hospital hired a chef and offered a healthy Latin cooking classes. As a result, several patients were able to get off or significantly reduce their need for medication.
“Literally, we have to change our mindset,” said Dr. Boutros. “We are all extraordinary medical institutions. I don’t think we are good health care institutions. We do really really well with the 0.2% of life and need to focus on the 99.8%.”
Wakulchik followed up.
“When you look at what impacts a child’s health, 80% of it is not what we provide in a hospital setting. It is related to those social determinants of health,” she said.
So, Akron Children’s network of primary care offices are now screening families for issues like food insecurity, concern about housing or having utilities shut off, unreliable transportation to work or school, domestic violence and or how a family member’s alcohol or substance use in the family that could be impacting a child.
The screening revealed patient families who screened positive for food insecurity despite the city’s network of 30 food distribution centers. The hospital is now teaming up with the Akron-Canton Regional Foodbank to offer mobile, or pop-up, food pantries in areas of need.
“We recognize some of the folks who may need food are some of our own employees,” Wakulchik said.
At Summa, discussions have also focused on “Where can we have the biggest impact?” “Should we be involved in housing? After-school programs? Food?”
“While we are blessed with really great medical institutions,” said Dr. Deveny, “we may not be as focused on our neighborhoods. Making sure the care of folks is being addressed, we’ve created a Center for Health Equity, and similar to what Metro is doing, we are listening to people and identifying needs. We have a huge Nepalese, Bhutanese population of almost 10,000 people and there’s a whole different health care perspective with trust issues, language issues, and we have to be more in touch with our communities.”
Since 2006, Sisters of Charity Foundation has reduced chronic homelessness in Cleveland by 86%, said Strauss. Key initiatives include creating “safe” houses, and connecting families who face evictions with legal support.
Significant change impossible without payment model overhaul
“Chronic homelessness becomes a medical issue because people come to our ERs with frostbite and need surgery, and all kinds of issues,” said Boutros.
So, while Dr. Boutros said MetroHealth does not need to become the “housing authority of Cleveland,” he believes his organization should invest in housing in the neighborhood around his campus as a catalyst for further investment.
It seems, he said, that he and other hospital CEOs will have to choose to:
- remain mostly focused on medical care, i.e. finding cures for rare cancers and pushing the frontier on new procedures and treatments, or
- focus on the 99.8% who don’t need those types of “extraordinary” care
“I think everyone up here is doing important and noble work,” said Zenty. “But I think we all need to contemplate how health care can better move from a sickness to a wellness model. We are one of the few developed countries in the world that has a hospital-centric health delivery system.”
The better approach is to give people incentives for wellness and view inpatient care at the opposite end of the spectrum of primary care, prevention and chronic disease management. It would be flipping the entire system as we know it.
“A study that came out last week showed that accountable care organizations have shown empirically to both improve outcomes and reduce costs,” he added.
Dr. Deveny pointed out that strides are already being made with hospital admissions down 4% and people living longer. Until the transition is fully made between the old and the new models, the industry will see more disruption and consolidation.
A frequent point of discussion in the national conversation is this: we don’t have great public health outcomes given the excellence of U.S. hospitals and the 18% GDP spend on health care.
It’s important to note what other Western European nations allocate for their health care institutions and providers is a fraction of what they allocate for their social services, Dr. Mihaljevic said.
“All of the social determinants of health we mentioned require additional allocation of resources at the national level,” he said.
Referring to the idea of hospitals getting deeply involved in transportation, housing and food distribution, he said, “It is inefficient, and we cannot do it effectively.”
However, Drs. Mihaljevic and Boutros agreed that hospitals can be the example for the federal government in their advocacy and commitment to improving people’s lives outside of their hospital facilities, and a change in the reimbursement model will be required for a significant shift to the population health model.
“If you look at work we’ve been doing on the social determinants of health – we’ve been doing this since ’95 – and population health, all the benefit is going to the for-profit insurance companies,” said Strauss. “Look at second quarter’s earnings, the 6 major for-profit insurance companies. Annualize that profit – it is $30 billion. How do we get that investment back?”
However, disruptive change would likely come with a price.
Dr. Deveny pointed out that hospitals are the biggest employers and drivers of economic activity in Northeast Ohio.
“We all talk about this but the machine keeps running and growing, and we’re the ones hiring people. What’s the shift that’s going to have to happen to change that?” he said. “There are 18,000 manufacturing jobs in Summit County and 22,000 health system jobs. Something’s wrong with that.”
Reflecting a mix of optimism and forewarning about the disruption, the CEOs wrapped up the forum with key take-aways about health care in Northeast Ohio. Dr. Boutros predicted that in 10 years, MetroHealth will be a cluster of companies focused on various aspects of population health, and a hospital will just be one of them.
Wakulchik said more can – and must – be done to bring down health care costs and help patient families navigate their decisions, especially those with high deductible plans.
She believes leveraging technology is the way to not only reduce costs but improve access.
The list of priorities grows longer, but Zenty said the region’s health care systems will lead the way.
“We may be part of the problem, but we are the only solution,” he said.
Grace Wakulchik was named one of Crain’s “Notable Women in Healthcare” in 2018.
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