Published in the Asbury Park Press
The death rate in the U.S. increased for the first time in a decade, according to a preliminary report from the National Center for Health Statistics released last month. Is it just a blip or an indication that the nation’s health may be slipping? We posed that question and several others about the challenges facing health care providers in New Jersey and the U.S. to Linda Schwimmer, president and CEO of the New Jersey Health Care Quality Institute.
Was the the National Center for Health Statistics report a trend or a blip?
Whether it’s a trend or blip is still to be determined, but it does raise some troubling issues, such as the rise in opioid addiction, the greater use of prescription painkillers, and the rise of deaths from liver disease, which is often related to alcoholism. Addiction contributes to the rise we also are seeing in suicide. We need alternate methods to control pain and we need to provide patients with support, counseling and effective treatment for addiction. We also need greater use of the statewide registries of prescribed controlled substances and regulations that require greater warnings and oversight when prescribing these terribly addictive drugs.
The report identified four areas that were significant factors in the increase in the death rate: drug deaths, suicides, increases in Alzheimer’s deaths and a slight uptick in deaths from heart disease. Are these same increases being seen in New Jersey?
We are still waiting for more 2015 state data, but, according to America’s Health Rankings, New Jersey’s ranking has remained stable at 11 from 2014 to 2015. We’ve seen declines in premature death and declines in cancer deaths in the past five years. But in the past two years in New Jersey we’ve seen a troubling 90 percent increase in drug deaths, from 6.9 to 13.1 per 100,000 population.
What are the two most significant health care victories in the U.S. and in New Jersey over the past decade? What are the most encouraging trends?
One clear victory is the New Jersey Smoke-Free Air Act of 2006. This law along with a strong public health campaign has had an enormous impact on reducing the use of tobacco. When you look back today it’s hard to believe people would light up in offices, conference rooms and restaurants without a second thought. The cultural change surrounding smoking has saved lives and improved health in our state. Another advance has been remarkable developments in surgery. Many orthopedic and cardiac surgeries are now far less invasive, meaning that patients can go home sooner and recover faster. They also can often have those surgeries in ambulatory surgery centers. Another positive trend is the advances we’ve seen in cancer treatment with many more cancers becoming chronic illnesses instead of terminal illnesses.
What are the two most significant health care challenges?
Despite some gains, we still are hampered by the lack of electronic health record systems that allow hospitals, physicians, labs and the patients themselves to interact. Without such systems, we are trying to move the health care system to pay for value and to be efficient and avoid waste, but without the necessary and timely health information we need to get there. We’ll need to build a health information network for the state that all providers can tap into and can make accessible to their patients so that they can see their own records and control their own care plan. Another challenge will be to find better ways to meet the needs of an aging population. We are living longer and the large baby-boomer population is aging. People want to stay at home, but they’ll need additional home care, social services and nursing support. Yet the payment system is not set up to provide this care for most people. We’ll need to fix this disconnect in the system.
The Leapfrog Group, an organization of which you are a board member, issues twice-annual hospital report cards. The latest showed considerable backsliding in New Jersey, with about a third of the 42 hospitals graded getting lower marks than they did in the fall 2015 report card. How much of a concern is that?
New Jersey’s national ranking on the Safety Score went down for multiple reasons. There was some change in hospital performance which, in turn, affected the scores. In addition, Leapfrog changed some of the measures used to calculate the score, and increased the cutoff points for what is needed to achieve each letter grade. Under the new methodology, New Jersey did not do as well as in previous years. We know that New Jersey hospitals take the Leapfrog Safety Survey and safety in general very seriously. There is work to be done and like any quality improvement initiative, this is an on-going process. All but six hospitals in New Jersey publicly report their data to Leapfrog. If a hospital that people are seeking information about does not report, we encourage them to reach out to their hospital board and tell them they should provide their community with this information about safety and quality.
Employees covered by their employer health care plans are paying an increasing share of their medical costs, due in large part to increased deductibles. Do you see this trend reversing itself any time soon, and what can be done, or is being done, to provide greater transparency in health care costs to enable consumers to make more informed choices about where they go for their medical care?
I am concerned about the proliferation of high-deductible plans. An earlier Rand study found that when people are in a high-deductible plan they don’t avoid just low-value care, but rather they avoid care in general. This can lead to missing important screenings, follow-ups and a failure to fill prescriptions for important medicine to control chronic conditions. This short-term approach can cause people to miss important life-saving care. Although high-deductible plans are not good for prevention or for the long-term health of the country, I do think individuals should have some skin in the game and be responsible for some costs, but there is a tipping point where it becomes harmful. Do I see the trend reversing? Unfortunately, not in the short term. But, as patient-centered medical homes and other pay-for-performance programs become more popular and incentives are built into plans to engage patients, I think those plans could replace the high-deductible plans.
An appeals court recently upheld Horizon Blue Cross Blue Shield of New Jersey’s Omnia’s tiered hospital plan which offers lower deductibles for consumers who use hospitals in Horizon’s preferred Tier 1. How much money can consumers who use Tier 1 hospitals expect to save, and what impact, financial and otherwise, will a Tier 2 designation have on those hospitals and the patients they serve?
The state appellate court upheld the decision by the New Jersey Department of Banking and Insurance to allow Horizon to sell its Omnia plan. According to Horizon, the premiums of Omnia products were 15 percent lower than premiums for similar non-tiered products. I do think there is potential for tiered plans to disrupt the marketplace, not just for hospitals but for providers as well. Patients are paying attention to what tier their doctors are in before they schedule procedures because the cost difference to them can be significant. These market pressures are changing practice patterns. But keep in mind that other insurers may create different networks with completely different hospitals and doctors in the top tiers. One other benefit of these types of plans is that while choice is narrowed based on price, they do provide comprehensive care at a lower price in a method that is much better for individuals than high-deductible plans.
What can, or is, being done to improve the odds that all consumers will have access to high-quality and affordable health care in New Jersey?
Most important, I believe, has been the expansion of the number of people who are now insured, either because of the expansion of Medicaid or the subsidies that allow people to purchase coverage through the marketplace created by the Affordable Care Act. People who have not been able to afford health care in the past now have insurance. We can’t lose sight of how important that is for many Americans. NJ FamilyCare, as the Medicaid program is known here, now covers 428,000 more people, an increase of one-third, since Gov. Chris Christie approved Medicaid expansion three years ago. In New Jersey, nearly 300,000 additional people obtained coverage through the marketplace set up under the Affordable Care Act. The percentage of people in New Jersey with insurance is now 90 percent. That’s historic.
Even though almost everyone has insurance, we still need to do more to improve quality and make health care more affordable. I think the move to paying for value rather than volume will help in this pursuit.
Do you believe telemedicine, two-way, real time interactive communication between the patient and the physician or practitioner, is being underutilized? What is its future, and what are the barriers standing in the way of broader, more rapid deployment?
There is so much more we can and should be doing with telemedicine. Homebound people and nursing home residents could visit providers and have consultations with specialists using tablets and laptops from the comfort of their beds. Busy people can more easily communicate with health care professionals from the smartphone in their pocket during all hours. What we need now are laws that clarify some issues, such as who can deliver these services, how they will be reimbursed and what consumer protections will be put into place. But we don’t want to put unnecessary roadblocks in the way and hinder innovation with telemedicine. There are possibilities to telemedicine that we have yet to even imagine.
What bills pending in the state Legislation, if passed and signed into law, could make the biggest positive difference in New Jersey residents’ health?
I can speak to some general areas. Telemedicine, as I mentioned earlier, is one area where we need clear laws to support its growth. We also need to finally fix our state’s surprise billing problem where people try to stay in network for everything and still, through no fault of their own, receive bills from providers that are outrageously inflated. Also, as mentioned above, we need a functional statewide electronic health records system and a statewide claims database that can be used for both quality improvement and better health care purchasing by the state — a big budget issue. We also need to give the key state departments that touch health care in New Jersey adequate resources to do the work that our laws already require, such as inspections of ambulatory surgery centers, reporting of patient safety issues, auditing of insurers’ network adequacy, and robust oversight and enforcement actions against licensed healthcare professionals engaged in bad acts. All of these issues are already addressed in law and are needed to protect the public.
What grade would you give Obamacare, and what are the most important fixes that must be made to improve the grade?
A “B,” or perhaps an “incomplete.” For people who never had insurance, and who now have coverage, Obamacare has been life-changing. But we know the program was rushed into law and partisan fighting has stunted amendments to improve the program. If we cannot fix the problems on the national level than we need to address its shortcomings through state action. The program still leaves people out and is still unaffordable for many. Insurance is complex and the marketplace website needs better resources to help people pick a plan that includes their providers and medications and gives some calculators to help project the cost of getting health care under the plan.
The U.S. spends more per capita on health care than any other advanced nation in the world, yet outcomes lag behind many of those countries. What are the two most important reasons why?
Because, simply, the charges for everything in health care in the U.S. are high. Until we decrease those charges and steer care to less expensive locations (e.g., primary care or urgent clinics rather than emergency departments) and less-expensive options (e.g., telemedicine and alternatives to physicians and specialists in particular) we are going to be paying more than the rest of the world. We also spend less than other developed countries on social services, such as maternity leave, day care, safe neighborhoods, good housing and nutrition programs. All of these services lead to healthier residents and hence lower long-term health care costs.
Linda Schwimmer is President and CEO of the New Jersey Health Care Quality Institute. The Quality Institute is a nonprofit organization focused on improving the quality and affordability of health care in New Jersey.