CEO Roundtable

By Caroline Hudson and Alex Kacik

An increasing number of health systems are seeking to shift care delivery to home and outpatient care. But regulatory and policy changes are necessary to help enable those changes—and to address ongoing challenges facing the industry, including reimbursement and surprise billing.

In the second part of a two-part series, Modern Healthcare asked the CEOs of Nashville, Tennessee-based Ardent Health Services; Marlton, New Jersey-based Virtua Health; and Rapid City, South Dakota-based Monument Health to share their policy wish lists and plans for spending on projects beyond brick-and-mortar facilities. (Read the first installment about strategies to address staffing needs here.) The interviews have been edited for length and clarity.

What tops your wish list on the regulatory and policy front?

Marty Bonick, president and CEO, Ardent: The Statutory Pay-As-You-Go Act reductions are a looming threat, given the state of the economy for many health systems across the country. We need to solve that once and for all. Sequestration is another cut. And the net impact of inflation is real. It’s baked into our wages, it’s baked into our supply costs, but the payments are not keeping up. If we don’t have legislative relief—and we know there are no additional bailouts coming as a result of the pandemic—we have structural ways the payment systems can be addressed to take some of those threats and pressures away from hospitals.

Surprise billing has been an issue that is continuing to challenge the industry. I don’t think anybody in the industry believes that patients should be put in the middle of these disputes between payers and providers. However, the legislation that was passed and the rules that were enacted are incongruent with each other and greatly favor the payers in these negotiations.

One, we can’t get disputes through the system because of the backlog. Two, we have payers that are actively finding ways to reduce the median rates by putting emergency room codes and anesthesia codes into primary care practices. We’ve got to get some tighter rules and regulations around the intent of this legislation and get away from the inadvertent consequences that it’s caused.

Dennis Pullin, president and CEO, Virtua Health: Because of the demand on hospital beds, many of us have been flirting with the thought of hospital-at-home. And then when CMS made it easier for us to do, we really did accelerate and now have a thriving program. But we also still need those policymakers to make this a sustainable, long-term avenue to take care of patients.

From the graduate medical education perspective, how do we get our policymakers to expand residency slots? How do we make multistate licensure easier to do as we talk about telemedicine? Sometimes it can take four months for a clinician to get their license, so we have to become more assertive with our policymakers to help us do those types of things.

The pandemic also showed us that people are willing, interested and many prefer to have a healthcare experience remotely. We now see our physicians are more inclined to participate in a telemedicine experience.

The models and platforms that we embrace so dearly, we’ve been doing the same way for the last 50 or 60 years. It is time for us to be disrupted. Those of us responsible for taking care of our communities should drive that disruption. And I think if we have the support, from a policy perspective, it will allow that to happen faster.

Paulette Davidson, president and CEO, Monument: The first request based on our payer mix is increased reimbursement for Medicaid and Medicare beneficiaries. Again, I mentioned that we are trying to absorb the inflationary impact for what we’re seeing [with] our medical supplies, pharmacy supplies, labor, but we’re not able to based on the fixed reimbursement that we’re receiving today. It is unsustainable going forward. We need someone to listen to us and recognize that if the reimbursement levels are not adjusted, we will have to address closing some of our clinical programs. Today, we have patients driving an hour to two hours to [get to] a primary care clinic, or three hours to get to specialty care like cancer services or neurosurgery services. If we’re required to pull back or reduce the size of those programs because we can’t afford to operate them, it will create delays in care. Patients will have to wait longer to be seen by a doctor or that specific specialist. They’ll have to drive farther in a rural setting.

Asking our caregivers to do more with less is becoming problematic. They’re tired. The last thing we want them to do is leave healthcare entirely and work in another industry.

How will the continued shift to home and outpatient care change your capital project spending?

Bonick: Telehealth, home health, hospital-at-home—all of those were long needed. I don’t believe the industry by and large needs to add a lot of beds to the system. But we do need to add the technology to be able to care for people in the right place.

The industry has largely been the Field of Dreams: “If we build it, they will come,” and patients came to us because they really didn’t have a choice. COVID has helped provide that choice. And now that people have tasted it, they don’t want to go back to the way things were. We have to embrace that. The good news is that it’s capital-light, comparatively. We all have these big brick-and-mortar facilities that are expensive. They take a lot of upkeep and maintenance, and that’s a real burden. When we’re talking about things like telehealth or hospital-at-home, we’re bringing our services to the patient. Finding the appropriate level of care for patients is important, but we’re certainly going to invest in technology because it is much, much cheaper. While we still have to maintain the core tertiary facilities, this will help us extend our capital resources.

Pullin: The key is, what is safe in the hospital-at-home model? Early results say that it is safer: We’re seeing fewer falls. We’re seeing people who are recovering faster. This is also where technology helps.

You’re seeing the growth and expansion of wearables with the pulse oximeter, blood pressure cuffs, EKGs: all of these things we can monitor remotely decrease the reliance on brick-and-mortar [care]. It’s about moving a patient from a high-cost environment to a lower-cost environment. And if you are getting as good or better results, that is the place to be.

As we look at replacement hospitals, we can build fewer beds as we leverage staff through the use of technology.

We have a mobile pediatric unit, which does health screenings and primary intervention for pediatric patients. We have a mobile cancer screening unit, which offers free mammograms and other cancer screenings in the community. We have to be able to take the care closer to where people live and work.

Davidson: We have a home care service. We provide skilled nursing in the home, hospice in the home. We provide durable medical equipment in the home. We also provide our pharmacy services in the home. We’ve had that program for decades. So, how can you virtually help people and deploy technology to meet those needs? We’ve been doing it for quite some time, but for our rural community, the telephone is one of those technologies that we’ve depended on. We are looking at other technologies to help us in this area, but that’s still in development. We don’t know the complete pathway there.

It’s hard to invest when you don’t know how you’re going to pay for that capital going forward. We’ve looked at a few technologies to help our epileptic patients. We looked at a few technologies to help behavioral health, but again, we need to watch what the reimbursement looks like in order to make sure that we can create a sustainable model going forward.