‘We are go­ing to work hard to ed­u­cate sen­a­tors about ex­actly what is at stake here’

Modern Healthcare - - Q & A -

Dr. Bruce Siegel wor­ries that ef­forts to re­peal and re­place the Af­ford­able Care Act will not only leave mil­lions of Amer­i­cans unin­sured, but also se­verely ham­per ef­forts to ad­vance pop­u­la­tion health. The pres­i­dent of Amer­ica’s Es­sen­tial Hos­pi­tals, a trade group rep­re­sent­ing nearly 300 safety-net providers, is also con­cerned about what kind of trades Se­nate lead­ers may have to make to get a bill passed. Siegel vis­ited with Mod­ern Health­care’s editorial team in late June, a week be­fore an ini­tial vote on the Se­nate bill was de­layed. The fol­low­ing is an edited tran­script.

Mod­ern Health­care: You’ve ex­pressed ma­jor con­cerns with the ap­proach House and Se­nate lead­ers are tak­ing with their health­care bills. Are they lis­ten­ing? Do you get the sense that provider groups are be­ing heard?

Dr. Bruce Siegel: There are hints of trac­tion and we are hear­ing some sen­a­tors raise con­cerns. Frankly, we are sur­prised we aren’t hear­ing more. Se­nate Ma­jor­ity Leader Mitch McConnell is a very smart strate­gist. I don’t agree with the pol­icy, but I un­der­stand the pol­i­tics of what he’s try­ing to do.

We are con­cerned that there will be trade­offs to try to get votes, like, “We’ll put money into opi­oid pre­ven­tion, just let us roll back Med­i­caid ex­pan­sion.”

That is a deal that could get of­fered, and we are con­cerned that we’ll lose sight of the big pic­ture.

A ques­tion for me would be: Is Sen. Jeff Flake go­ing to vote to have 400,000 Ari­zo­ni­ans lose health cov­er­age? I hope not. I hope he won’t vote to take $2.5 bil­lion a year out of the Ari­zona econ­omy.

Th­ese are sig­nif­i­cant im­pacts, and we are go­ing to work hard to ed­u­cate sen­a­tors about ex­actly what is at stake here.

MH: What would a trade-off for the opi­oid cri­sis look like?

Siegel: I’m spec­u­lat­ing, but there’s a lot of talk about that now. I am all for putting re­sources into opi­oid pre­ven­tion. Let’s be clear about that, but tak­ing 22 mil­lion peo­ple who are at higher risk of ad­dic­tion, men­tal health, all those things, and re­mov­ing them from the in­sur­ance sys­tem is not a recipe for com­bat­ing opi­oids. That cov­er­age needs to be a ba­sic thresh­old, oth­er­wise those peo­ple can’t be as­sured that they’ll have some ac­cess to the men­tal health or ad­dic­tion ser­vices they need. I’m con­cerned that we’ll be penny-wise and pound­fool­ish to think we’re go­ing to solve the opi­oid cri­sis with some tar­geted fund­ing, but re­ally have kicked the foun­da­tion of cov­er­age out from un­der th­ese peo­ple.

MH: Even some kind of fund­ing pack­age might not go to­ward such things as med­i­ca­tion-as­sisted treat­ment. Do you have a long-term strat­egy to try and com­bat the opi­oid epi­demic?

Siegel: First, the re­sources need to be there, and the cov­er­age needs to be there.

From our point of view, our job is to fig­ure out mod­els out there that re­ally work and spread them in our mem­ber­ship. We’re go­ing to spend time over the next six to nine months both in terms

“First, the re­sources need to be there, and the cov­er­age needs to be there.”

of ed­u­ca­tional ses­sions and meet­ings to get that in­for­ma­tion out there be­cause there are a lot of bright spots around opi­oid treat­ment and pre­ven­tion. That tech­nol­ogy trans­fer isn’t hap­pen­ing as fast as it should hap­pen na­tion­ally, and I think we’re not alone as an as­so­ci­a­tion that is wor­ried about that.

MH: What ef­forts are the as­so­ci­a­tion and its mem­bers mak­ing in terms of pop­u­la­tion health?

Siegel: There’s a lot of con­fu­sion in the area of pop­u­la­tion health and a lot of dif­fer­ent lan­guage be­ing used loosely, and that’s to be ex­pected. We are fo­cus­ing on the so­cial de­ter­mi­nants of health. Many times, talk around pop­u­la­tion health is about bet­ter care man­age­ment, ACO mod­els and the like; we’re all for that, but our fo­cus is go­ing to be very much on so­cial de­ter­mi­nants be­cause that’s a space where we can make a dif­fer­ence.

When we sur­veyed our mem­bers, we have found strong in­ter­est in a cou­ple of ar­eas very specif­i­cally. Hous­ing is one of them, food deserts, and then­this is a lit­tle harder to de­fine- chang­ing be­hav­iors. Hous­ing and food in­se­cu­rity come up again and again. And when I talk about hous­ing, some peo­ple look at it as sup­port­ive hous­ing for those at risk, but a lot of peo­ple are just look­ing at it for hous­ing, pe­riod. We can­not have a healthy com­mu­nity if peo­ple don’t have safe, se­cure hous­ing.

We have places like Bon Se­cours in Bal­ti­more us­ing tax cred­its to build low-in­come hous­ing. They have done things like the Gibbons Com­mons de­vel­op­ment, which brings to­gether hous­ing, re­tail, job train­ing and out­pa­tient care. It’s re­ally quite im­pres­sive.

That is a won­der­ful thing, but a lot of our hos­pi­tals are also ask­ing us, “Where do I just start? That’s a great vi­sion, but I am just be­gin­ning.” Some of the things we’re go­ing to try to do over the com­ing months is help our hos­pi­tals iden­tify where can they be­gin. How do they be­gin to set some pri­or­i­ties out of their com­mu­nity health needs as­sess­ment or some­where else? They need to have some sort of way for­ward.

MH: What’s it like in the board­rooms for your hos­pi­tals? Have they started to come along with that way of think­ing?

Siegel: Some have. Many have not. I see some boards that are quite mo­ti­vated to do this and often be­cause there’s board lead­er­ship, and they are in­vested in this. Some­times it is driven by a con­ver­sa­tion that goes like this from a hos­pi­tal in Mas­sachusetts: “We care for a large, low- in­come com­mu­nity in this pop­u­la­tion who are on Med­i­caid who have many so­cial and eco­nomic chal­lenges. Mas­sachusetts is mov­ing to a Med­i­caid ACO model. We are go­ing to be in­creas­ingly at risk for the care of th­ese pa­tients, and we want to do a good job. If we can’t be­gin to im­pact the so­cial de­ter­mi­nants, we will fail. We will fail clin­i­cally. We will fail fi­nan­cially. If this com­mu­nity con­tin­ues to use the emer­gency room at the rates it uses it, if it has read­mis­sions at the rate it has, then un­der what Mas­sachusetts is now rolling out, we will fail.”

MH: How are pop­u­la­tion ef­forts and com­mu­nity ben­e­fit af­fected by a health­care fi­nanc­ing pol­icy change that re­trenches fund­ing. Does that change your mem­bers’ tra­jec­tory in mov­ing for­ward with those kinds of ini­tia­tives, or do they find a way to do it any­way?

Siegel: I think that they will find a way to do it, but it will be a lot harder. The Con­gres­sional Bud­get Of­fice says 22 mil­lion peo­ple lose cov­er­age, at least from the House bill. We know mil­lions more peo­ple didn’t get cov­er­age who should have be­cause not ev­ery state ex­panded Med­i­caid. So 10% of Amer­i­cans won’t have in­sur­ance who could have had in­sur­ance oth­er­wise. All the work we’re do­ing around ei­ther iden­ti­fy­ing their opi­ate prob­lem in a pri­ma­rycare visit or get­ting them a pre­scrip­tion or food from the food pantry, all those things that de­pend on them be­ing in some sort of or­ga­nized sys­tem of care goes away and they’re back de­pen­dent on an emer­gency de­part­ment or just out of luck.

It’s go­ing to be very hard to move the ball on pop­u­la­tion health if you take tens of mil­lions of peo­ple and just cut them out of the sys­tem. The im­pacts on eq­uity, the im­pacts on value will be sig­nif­i­cant. You start rolling back the ex­pan­sion fund­ing to th­ese states, you’ve be­gun a ter­ri­ble, dis­tract­ing de­bate for years to come over how each state fi­nances health­care. You be­gin a de­bate over whether it even does fi­nance care for th­ese peo­ple or it just pulls back.

When all the band­width of your state Med­i­caid di­rec­tor and your state health com­mis­sioner and your gov­er­nor and your leg­is­la­ture is try­ing to fig­ure out if and how to re­place bil­lions in lost fed­eral fund­ing, there is go­ing to be a lot less en­ergy that goes into re­ally mov­ing on pop­u­la­tion health.

We’ll work on it. It’s es­sen­tial to our mis­sion, and I think hos­pi­tal lead­ers re­al­ize that they can’t change the tra­jec­tory of health in their com­mu­nity with­out work­ing on this, but let’s be real, there’s go­ing to be a bat­tle royal over Med­i­caid—we’re al­ready in one—and that’s go­ing to suck a lot of en­ergy out of the room.

“It’s go­ing to be very hard to move the ball on pop­u­la­tion health if you take tens of mil­lions of peo­ple and just cut them out of the sys­tem.”

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