What is a Safety Net Provider? Interview with NAPH CEO Dr. Bruce Siegel

May 11, 2011
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This is the transcript of my recent podcast interview with Dr. Bruce Siegel, CEO of the National Association of Public Hospital and Health Systems.

This is the transcript of my recent podcast interview with Dr. Bruce Siegel, CEO of the National Association of Public Hospital and Health Systems.

David E. Williams:            This is David Williams, co-founder of MedPharma Partners and author of the Health Business Blog.  I’m speaking today with Dr. Bruce Siegel.  He is CEO of the National Association of Public Hospitals and Health Systems (NAPH).  Bruce, thanks for being with me today.

Dr. Bruce Siegel:            It’s great to be here.

Williams:            Bruce, can you explain what a safety net hospital is and how it’s different from a regular hospital?

Siegel:            Safety net hospitals are hospitals for which part of the mission is taking care of people who don’t have health insurance, taking care of people who are poor, who may be on Medicaid.  It’s really caring for the most vulnerable among us.  Safety net hospitals come in different flavors. Some are public, some are private non-profits. They come in very different sizes, but it’s that mission that brings them together; what also brings them together is that they are very dependent on Medicaid or other government funding.

Williams:            Is there a tie-in between safety net hospitals and the public health system?

Siegel:            There’s a huge tie-in.  In many of our communities, the public hospital is looked to as the first defender for natural disasters or bioterrorism.  Often the public hospital –like in San Francisco– is part of the public health system, literally in the Department of Health.  In Kansas City, Missouri, the public, safety net system, Truman Medical Centers actually provides the staffing for the entire local health department and public health system.  So there’s a very key interaction here.

Williams:            When I hear a term like “safety net” it sounds like something you fall into if things haven’t gone well.  What is the quality level of safety net hospitals?

Siegel:            The quality is as good and sometimes better than we find in other hospitals. Some of our health systems, such as Memorial Healthcare System in South Broward County, Florida have been recognized as top performers on quality measures.  Other examples are the University of Kansas Medical Center and Ohio State University.  The public hospital system in New York has done very well on quality and publishes results on their website.

Our members have really embraced quality. Going beyond that, they’ve also embraced integrated and accountable systems.  They’re running whole systems of care that take care of all aspects of what an individual needs –often in that person’s language.  That’s really high quality care.

Williams:            And what about the NAPH? What kind of a role does the association play?

Siegel:            Our association traditionally has been very involved in advocacy on behalf of safety net hospitals regarding funding, access, and for initiatives to reduce inequities or disparities in care. In the past six months or so, we’ve been moving into a new phase.  We’re going to keep doing those things.  We’re also going to start supporting our members’ efforts to transform their systems to become more integrated systems, to become systems that can realize the promise of improving the health –not just the health care– of the public. To do that, we’re starting something called a transformation center, which you’re going to be hearing more about in the months ahead.

Williams:            It sounds like some of the safety net hospitals are doing quite good things on the quality side. Are there examples where the rest of the health care system might learn from the innovation of your members?

Siegel:            Absolutely.  Some of our members such as Contra Costa Health Services in California have explicitly made the triple aim (better care, affordable care and better health for the population) part of their strategic plan.  They’ve embraced it in its entirety. Being linked to the health department has really helped that.

Denver Health, under the leadership of Patty Gabow has become one of the premier examples of redesign using the LEAN system of approaching their problems. They’ve taken hundreds of millions of dollars out of their system in efficiency improvements and reduction of duplication. As a result they have been able to provide literally billions of dollars in uncompensated care over the last ten years to that community and improve its health.

Those are just a couple of examples of leaders in safety net hospitals around the country who have really made a difference.

Williams:            The Affordable Care Act (ACA) is working partly by a big expansion of Medicaid, so I’m sure that will have an impact on the safety net hospitals and systems.  What are some of the key elements of Medicaid that are addressed under ACA?

Siegel:            There are so many.  The most important one perhaps is that expansion of coverage in the Affordable Care Act really rests upon Medicaid.  A Medicaid expansion of somewhere between 16 and 18 million people is expected. As the largest Medicaid providers in the country, we’re thrilled and we are very supportive of the Affordable Care Act.

We’re thrilled to see so many people who don’t have health insurance now get coverage through Medicaid.  We’re also going to see a lot of things around measuring quality for Medicaid patients that we haven’t seen before.  We’re also thrilled to see that.  I want to make sure that that’s meaningful.

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We do have some concerns.  One of our worries is that in 2014, 32 million Americans will have an insurance card for the first time.  That’s the good news.  The question is where are they going to go?  We saw in Massachusetts under health reform how the safety net was really inundated with people who got health insurance but couldn’t find a doctor’s office, couldn’t get into a doctor’s office, couldn’t get in somewhere else for primary care and wound up in the emergency departments of the safety net.  We don’t want to see that happen nationally and we hope we start to build the sorts of primary care systems to give people a better alternative, a real Medical Home.

Williams:            I guess there will be some time between now and 2014 to get there. But I can imagine that the shock to the system might be even greater if we look nationally, considering that Massachusetts already started out with a very high level of people insured.

Siegel:            It may be.  The year 2014 is going to be here before we know it and the longer we wait the harder it will be to respond to these pressures. Our worries are very acute, especially in places like Texas where we’re going to see huge numbers of people have coverage for the first time.  Today 30 percent of people in some counties don’t have health insurance and there is very little primary care in those communities today.  What’s it going to look like when these folks have that card?  Will that card be meaningful given the situation?

Williams:            We’ve moved about a year beyond the ACA enactment and there’s a lot of spending pressure in Congress and some hostility towards ACA itself.  You hear discussion of issues like moving Medicaid to a block grant program.  What’s your view on what we’re seeing now in terms of pressure on Medicaid?

Siegel:            The pressure is real.  State budgets are not in the place we want them to be.  There have been large deficits although sometimes that’s really also been the result of states making certain decisions in flush times such as cutting taxes or depleting their rainy day funds, but the pressure is still real.

The thing we have to realize is that Medicaid is very efficient.  It often costs less per person than other insurance plans.  It also has grown more slowly than commercial plans.  In many ways Medicaid has done exactly what we wanted it to do.  We wanted it to be a safety net for people in a time of trouble. And we’ve had a time of trouble when this country lost almost ten million jobs.  Medicaid was there, it picked up the slack and yes, that cost money.

Going forward, do we need to address this?  Yes, but we don’t think that just cutting, and that’s what block grants are really about. The proposal on the table is not just block grants but it’s $771 billion in Medicaid cuts over the next ten years.  Cutting is not going to be the answer.

We think the answer is going to be better systems of care that are more efficient.  So let’s talk about ACOs and Medicaid.  Let’s talk about Medical Homes.  Let’s talk about building primary care systems that keep people out of the hospital.  That’s going to be the answer for Medicaid growth, that and an improving economy.  Not block grants.

Williams:            We’ve been talking a lot about Medicaid as it relates to safety net hospitals, but I’m also interested in your view about the interaction between Medicaid and Medicare.  Usually people think about Medicaid as the program for the poor and Medicare as the program for the old and disabled, but there is a big overlap in the form of dual eligibles, who consume a lot of the Medicaid budget. Does it make sense the way that overlap is constructed?

Siegel:            Right.  Dual eligibles are a very high priority for us.  Our health systems treat a very large share of dual eligibles, larger (we think) than most hospitals do. These are often the infirm and low-income elderly, people with disabilities and the like.

We know that dual eligibles cost us a lot more than other patients.  They’re often sicker, they consume a lot of resources, and the lack of coordination and the lack of information between Medicare and Medicaid is really unfortunate. It’s not helping us at all.

We’ve been working with the new office of coordinated care in the federal government, which is looking at this to start to push some new models or take old models like the PACE program and really get them out there.  We know that some of these things work.  We know for instance in Indianapolis that Wishard, one of our members there, has a project called Project GRACE, which is aimed at this population and really brought the number and cost admissions far down.

So duals should be on the radar screen and it’s a prime example where building a better delivery system with the right payment incentives could have a huge impact.

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Williams:            Health care is a contentious topic in Washington. Another one that’s perhaps even more controversial is immigration.  You talked about Texas before, so I wonder how you’re seeing the debate there and elsewhere interact between health care and immigration. What impact does that interaction have on the day-to-day operations of the safety net providers?

Siegel:            It has a huge impact.  I was talking to our friends at the University Medical Center in El Paso, Texas. Not only do they have to deal with undocumented immigrants in their own community, their emergency department and trauma center have now become essentially the first responders to some of the people injured in the violence in Northern Mexico.  Being on the border brings a whole set of issues that aren’t recognized in our payment system.  It’s a huge stress.

We have supported immigration reform as an organization.  We supported care for immigrants.  We think everybody in this country, regardless of status, should get excellent health care and should get the best.  That is a core tenant of our association.

One of the things that worries us in this regard is that there is a belief among many that in 2014 there will be no more uninsured in America and that’s simply not true.  We all know there’s going to be at least 20 to 25 million uninsured, most of them undocumented immigrants. The safety net is going to have to have the resources to take care of them.

Just insuring everybody won’t be enough.  So when people talk about cutting other financing like Disproportionate Share Hospital (DSH) funding, we have to tell them, listen, there is still going to be a need for that because not everyone is going to have health insurance.

Williams:            There’s a term that we’ve heard a lot about in the health care world that I think is making it out into the general discourse, and that’s disparities in health care.  What is the relevance of that term is for you and for these hospitals? How are your members taking on this topic?

Siegel:            First of all we think that disparities is an issue for every American hospital, not just public hospitals and safety net hospitals.  We have so many minority Americans today everywhere in every community. Every organization, every hospital, every doctor needs to make sure to provide the same high level of care to all patients and not, in some way, allow certain patients to not get evidence based medicine.

A lot of our hospitals are focusing on cultural competency, a lot are focusing on collecting race and ethnicity data. This is happening not just in our hospitals, it’s happening in community hospitals across the country.

There’s a key difference for us.  We look at our patient populations across all our organizations and we find that the majority are black and Latino, literally.  So if we want to eliminate disparities as a nation, we have to make sure to support health systems like these in providing the best care to people of color. So a healthy safety net can mean no disparities in health care and that’s what we should be aiming for.

Williams:            Bruce, in the midst of all this activity going on in Washington and around the country, you fairly recently stepped in as the CEO of NAPH. The founder there is retiring after about 30 years on the job, so you have some big shoes to fill.  How is that going?

Siegel:            It’s a challenge, a challenge that I welcome.  Larry Gage really built a lot of the undergirding of the safety net in America.  After 30 years he will be sorely missed. We’re very much hoping and believing we can call upon his expertise and his counsel going forward.

I’m eager and am learning a lot from him and others who have blazed a pathway, but I have to say it’s a lot of fun. It’s the most fun because while we deal with a lot of issues regarding bills, regulations, quality measures, etc., at the end of the day it’s about patients. Our patients really, really need us to do a good job and that is what brings me satisfaction, knowing how important that is.

Williams:            For me it’s easy to get depressed when looking at health care financing, quality, disparities and access.  Would you describe yourself as being optimistic or pessimistic about the future?

Siegel:            I’m always an optimist. We’ve got some tough issues this year.  I think we have to educate people in this context of deficit reduction about what can be wise savings and what might be pennywise but pound-foolish savings.  That’s going to be tough over the next year, but in the long term I am optimistic.

I do think that we’re on a trajectory towards ensuring care for every American.  I don’t think we’re going to necessarily get there very quickly.  We’re not going to be there yet in 2014, but I think we’ve now started to change the conversation, and that’s becoming an expectation. That makes me very optimistic.

Williams:            I’ve been speaking today with Dr. Bruce Siegel.  He is CEO of the National Association of Public Hospitals and Health Systems.  Bruce, thank you so much.

Siegel:            My pleasure.