The Pulse by Vital Incite
Vital Incite’s podcast series, The Pulse, will help you keep pace with what’s trending in employee benefits. Every other month, nationally recognized subject matter experts from the health and pharmacy industry and top academic and research institutions will provide data-driven insights while giving you actionable, scalable, strategies. If you are looking to reduce medical and pharmacy spend while driving better health outcomes, this podcast series is for you!
The Pulse by Vital Incite
Why are pregnancy complications rising? We look at what’s behind the data.
In 2020, the COVID-19 pandemic led to an increase in pregnancy-related complications. This trend has persisted. In this episode, we’ll explore the factors contributing to this ongoing issue and discuss strategies to help reverse the trend.
Panelists will:
- Take a closer look at the data surrounding pregnancy with complications
- Explore treatment patterns, coding practices and potential revenue-driven care decisions within hospital systems
- Uncover strategies to optimize maternal health programs and proactively reduce complications before pregnancy begins
This episode includes guest speakers:
Cindy Basinski, MD, OBGYN, Founder of Basinski and Juran, MDs, LLC
Morgan F McDonald, MD, FACP, FAAP, National Director for Population Health at Milbank Memorial Fund
HOST
Welcome to The Pulse, produced by Vital Incite, where we keep pace with what's trending in employee benefits. This series was developed to bring together nationally recognized subject matter experts from the health and pharmacy industry, as well as top academic and research institutions. Our goal is to provide unbiased information and offer scalable strategies that give you clarity amid the chaos and provide answers to your most burning questions. I'm your host Mary Delaney, Managing Partner of Vital Incite, an Alera Group company.
In today's podcast we will be exploring why pregnancy complications are on the rise and what commercial health plans or employers can do about it. In 2020, we noticed a significant spike in complications with both pregnancy and deliveries. That unfortunately made sense given the providers and hospitals were dealing with COVID and all the complexities surrounding care at that time. What's concerning is that we have not seen incidences retreat to pre-pandemic levels. In fact, it is just the opposite. Rates have continued to climb every year. Our non-objective opinion was that there was upcoding taking place. That is where facilities have billers find any reason to add codes or complexities in billing to allow the facility to be reimbursed at a higher rate. Believe it or not, these are actual positions in most hospitals. Unfortunately, we don't have a way to research the upcoding hypothesis by just using claims data without clinical notes. Then, within the claims data, we did notice more emergency room visits for pregnancy and delivery, and wondered why – particularly when there are higher rates at certain hospitals. This again raised our antennas that something just didn't seem correct. We became increasingly concerned that certain practices could be inflating the cost of pregnancy and delivery across the country. Some feedback from providers did indicate hospitals were leveraging emergency room versus offices for care, so our concerns were validated by a few providers. But that's just one piece of the puzzle. As we were tracking down foul play, we also wanted to determine if in fact there really is an increase in less healthy births. As well, we cannot deny the incredible expense of preterm or less than fully healthy babies. In a recent publication from the National Alliance of Healthcare Purchaser Coalitions, they noted a premature baby spends on average 25.4 days in a specialty care nursery at an average cost of just under $145,000. The costs associated with preterm births add $26.2 billion to US healthcare costs each year, and the coalition noted that prenatal and neonatal care was one of the top issues that drive high-cost claimants along with cancer, gene therapies and specialty drugs. So although our initial concern was to determine if our clients were paying more for care than they should, we also realized that if the opposite were true, and if there really is an increase in less healthy births, then that is even much more serious.
So to help us understand more about these complex issues are two experts: Dr. Cindy Basinski has been a publicly active figure in obstetrics and gynecology since founding Basinski and Juran MDs, LLC in Newberg, Indiana in 2002. She holds board certifications in obstetrics and gynecology, urogynecology and minimally invasive gynecologic surgery, and has been actively involved in addressing healthcare issues through her leadership roles. As a Trustee to the Medical Practice Consortium of Indiana and an Independent physician coalition representative, Dr. Basinski advocates for increasing independently owned practices, reducing healthcare costs and enhancing care access in Indiana. Her extensive clinical research in gynecologic and urogynecologic care, alongside her educational roles at Indiana University School of Medicine and other institutions, positions her as a knowledgeable advocate for tackling OB deserts. You will learn more about OB deserts during this discussion. Dr. Basinski, I look forward to you sharing your knowledge and experience with us all today.
DR. BASINSKI
Thank you, Mary, for having me. I'm very excited to be here to discuss these very important issues in healthcare, especially surrounding women's healthcare. Thank you.
HOST
Well, so glad to have you with us. And then next we have Dr. Morgan McDonald. Dr. McDonald is a National Director for Population Health and Health Equity Leadership for the Milbank Memorial Fund, a foundation that identifies and shares policy ideas to advocate state health leadership, strong primary care, and sustainable healthcare costs. Dr. McDonald served for eight years in an executive administration at the Tennessee Department of Health, most recently as the Interim Health Commissioner and previously as Deputy Commissioner for Population Health and Assistant Commissioner for Family Health and Wellness. In these roles, she provided senior leadership for the state's pandemic response and recovery efforts, championed the department's rural health and health equity implementation work, and successfully led the state's maternal and child health improvement initiatives. Dr. McDonald began her career as a primary care physician and advocate for people experiencing homelessness. Board certified in Internal Medicine and Pediatrics, Dr. McDonald has continued to see patients in Nashville's immigrant community to maintain the roots of policymaking and patients’ journeys. I realize that many of you are wondering why we're talking to an expert in homelessness and social determinants in a podcast to support commercial health plans, but I am confident you will soon understand why. Dr. McDonald, thank you so much for joining us today.
DR. MCDONALD
Mary, thank you so much for having me. I really appreciate the opportunity to talk with you and your audience around the real levers that employers and plans have in shaping the health of women and children.
HOST
Well, I love that you talk about the real levers because I think many of us feel like we don't know what to do. So this is going to bring hope and hopefully move the needle. So to prepare for our podcast, we always do prep sessions with potential panelists. And before we started to interview our potential panelists, I thought I knew exactly where this conversation would go. I developed that opinion from feedback that I had heard from providers, our data or individual experiences. But as we started to interview panelists, especially the two that have joined us today, I learned so much. I look forward to the opportunity to really explore this topic today to help employers and benefit advisors improve their strategies to help influence both cost and improve health outcomes. So buckle up for this one. I think you're gonna hear some things that will surprise you.
So I am going to start off with something that could be a little easier, or at least I originally thought it would be easier. Our original hypothesis was that there were increased rates of complications in ER utilization being driven by provider upcoding and hospitals promoting ER. Then we had employers wonder if the impact was on women having babies when they were older. So because we have the data, we did our research and actually found that complication rates were significantly less for women 45 to 54 years old than they were for those that were 18 to 44 years old. Yes, opposite of what we expected to find. But we did see higher ER utilization in specific hospitals. Dr. Basinski, can you kick us off with your thoughts?
DR. BASINSKI
Yes, there's been a dramatic change in how women seek healthcare, especially in obstetrical care. Through the years, there's just…in the way that healthcare is paid for in obstetrics, physicians receive a global fee to care for women from the very beginning to the very end and delivery of their patients. With the advent of employment of physicians by hospitals, it's changed how clinicians care for their patient population, specifically in obstetrics. And one of the issues that we've seen in physicians who are employed, or even non-employed, is that…the development of hospitalist OBs. So these are obstetricians who are hired by hospitals to run emergency departments and triage patients. And in the process, hospitals have gotten very smart and have figured out that if we can get physicians to send their patients to our triage centers or our ER centers, that we can obviously increase profits for our hospitals. We have to pay for our hospitalists, but we also want to bring these patients in. So a typical ER visit, and this is across the board, whether it's obstetrics or in a family practice or in pediatrics, a hospital-based care is going to be much more expensive than an office-based care. So if you go to the office, the average reimbursement for an event, even if it wasn't global, would be $150 or so...$100 to $150 if you're looking at commercial payers. If you go to an ER for any reason, you're probably looking at a minimum of $1,000 to $2,000 for that intervention. So what's happened is, is that hospitals have said to the obstetricians in areas, we understand when a patient calls in and they're having a problem, that it might be difficult for you to fit them in the office, you're very busy, just send them over to our triage area and we will be happy to evaluate this patient for you. And especially on call, there's a lot more diversion in which physicians are not even choosing to care for patients in an outpatient setting and sending them directly to the triage for evaluation, even for things that can be taken care of over the phone or in a telemedicine manner. So there are some practices that are driving up hospital costs and some of the issues that we've seen with ER access. Additionally, physician employment is a big issue because they are driving care in different ways than say physicians might behave if they're not employed by a hospital. So for example, if we look at ultrasound reimbursement in a hospital setting, we're looking at an ultrasound cost of around $1,200 to $1,300. That same ultrasound evaluation in an office setting is going to be in the range of $250 to $300. So we're looking at 3 to 4 times the cost. So when you have a physician employed by a hospital sitting in a hospital, hospitals are extremely savvy at developing pathways in which referrals to in-office radiol—, or excuse me, in-hospital radiology services, imaging services and laboratory services are directed which increase cost by 3 to 4 times for a same intervention that can be done in an outpatient setting. So there's some legislation that's being worked on specifically in Indiana to look at site of service neutrality. I do know there's been some movement with that with legislators to try to move hospitals to disincentivize them from directing care to in-hospital settings as opposed to outpatient settings. And also, we're making some movement with insurers to recognize that we need to encourage physicians to want to keep patients out of the hospital. So how can we economically incentivize them and support them to provide this care in their offices, even though it may require more work from their staff and more work from themselves to provide this care? So that's in a nutshell. It's a very complex issue as to why we're seeing these increased utilizations. There's other reasons why I think we're seeing issues with unhealthier pregnancies, which we can go into later. I don't want to monopolize the time right off the bat.
HOST
Yeah. And let me just— it is very complicated, what you just brought up, so thank you. But can I just for clarification…I believe what you said is that, you know, and you gave the pricing, it is much more expensive to get care for outpatient services through a hospital. Hospitals are motivated by leveraging these more expensive services. And what I don't know if I picked up is, the concern of even if a physician…so less physicians are in private practice, but even if a physician is in private practice, they may be paid so low that it's still not worth their effort to go out of their way in the evening and try to get them in their office, bring their staff, and they may not be able to afford to do that. Is that correct?
DR. BASINSKI
That is correct. And also, I mean, it is a lifestyle issue, too, that if you're having to come in at night to care for your patients, it certainly is much easier if a hospital’s there to support you with an inpatient OBGYN who's going to take care of even minor things – a UTI or, you know, maybe a patient's just having round ligament pain and trying to assess that. You can often do that over a phone. They're just being incentivized by the hospital to say, we can save you this distraction or this effort outside of hours and just send them to the OB ER for evaluation.
HOST
Ah, perfect. That makes more sense, unfortunately, to me now. So thank you. Dr. McDonald, do you have any thoughts on all of this?
DR. MCDONALD
Thanks so much, Mary. And thanks, Dr. Basinski. I think it's the, the point that you're making about access for women to have the most appropriate care at the most appropriate place at the most appropriate cost is really driven by how we incentivize the healthcare system. And to…for employers to be able to direct their plans to then put payment emphasis on those most appropriate services at the most appropriate place is what's going to drive that change. Mary, I wanted to also go back a little bit to some of that data that you brought up at the very beginning, and just to state that what you're seeing in claims data we are also seeing in public health data. And so in this case, it's not so much that there is a coding or different coding, but this is a real signal in threats to women's health. And this really began a couple years before the pandemic where we really started to see a significant increase even in maternal mortality, that then peaked in 2020 and 2021 due to infection with COVID 19 at a time when the virus was more deadly and the vaccine was not as available. And then the good news is that CDC actually put out a report in February that thankfully, maternal mortality is starting to drop from that peak in 2021. So there's a drop of about 25% between 2022 and 2023. Tragically, still almost 700 women lost their lives during pregnancy or within 42 days of the end of that pregnancy due to health-related causes, compared to 817 the year before. And I think what probably is most tragic from that report is that the benefit that we saw for women globally in the United States really did not express itself across different race and ethnicity. Black women are still more than 3 times the likelihood of other women of other races to die during and immediately after pregnancy. And there's some key drivers of that maternal health that I think we can get into in our next couple of questions.
HOST
Yeah, those…that data is stunning considering how much we pay for care in the United States, that we are not able to solve for this. When we dug into some more data, the more we were digging into the data, the more fascinating it became. But we do see younger adults having less relationships with primary care providers, which of course can lead to undiagnosis of hypertension, diabetes, other conditions. Our research showed that 36% of women with hypertension had C-sections, 24% of women that were obese had C-sections. And it was much, you know, just surprising the percentages of that, especially unfortunately, as our obesity epidemic continues to, you know, snowball. Complications…rates for women with hypertension were 3 times higher than even individuals that had diabetes but no hypertension. And you know, we've always talked about hypertension being such an easy condition to diagnose, but young women probably never suspect that there's an issue, never get help, and then may not be diagnosed until they finally get care within their pregnancy. Thoughts, Dr. McDonald?
DR. MCDONALD
To revisit some of your points earlier, again, appropriate care for appropriate conditions is one thing that is a very reasonable area of focus. So C-sections, you mentioned that just a minute ago. In the United States, we have about 30% of our babies delivered by C-section, which is a lot higher than the rest of the world. Ideal rates are somewhere between 15 and 20%, and the rest of the world is about 20%. And so we know that about a third of our C-sections are not necessary, and that's at least that percentage of them. Again, women from minority patient populations are more likely to have inappropriate C-sections, which drives up the cost of care and also drives up complication rates. We know that particularly the cost of C-sections is of concern to employers and the physical cost to women for C-sections – pregnancies are more likely to be complicated later if you have a C-section for your first delivery. And then the cost of C-sections is about five times the cost of a vaginal birth. So significant concern there and reason to be incentivizing regular vaginal delivery in cases where that is clinically appropriate. And states have actually formed alliances with hospitals, with benefit plans and insurers to be able to drive down the rate of inappropriate C-section to the benefit of women and to obviously employer cost.
HOST
It's interesting you say that because we have actually reached out to certain hospitals where we noticed that they had excessively high C-section rates, just to kind of ask them if they would take a look at that.
DR. MCDONALD
Yeah. And there's increasing transparency around that. And so women can start to shop around for where they will have less intervention from a surgical perspective.
HOST
So I would have expected the C-section rate to be higher for more affluent women who decide when they want to have their baby. But that's not what you just said. So what drives the other reasoning? Dr. Basinski?
DR BASINSKI
Yeah, so I think C-section rates are really related to, you know, obviously there are some personal physician practices that can drive that rate. But I do think that C-sections occur more often, you said, in obese patients and hypertensive patients. And what you'll see is patients who live in underserved areas or patients who are economically depressed tend to have secondary health issues more frequently than affluent areas. So, for example, obesity, hypertension, some of those issues plague areas of Indiana, for sure, in which there's decreased access to care, also decreased access to good foods and healthy foods. And so therefore, their hypertension is less controlled, and also their dietary intake may be contributing to poor outcomes. So when you look at C-section rates, some of it is driven by the underlying health baseline of patients who get pregnant. So we do need to have better access to primary care to control these issues before women even get pregnant. The other issue, too, with C-section rates is that when you're looking at areas that have lower socioeconomic status or poor access, they're getting delayed care. So additionally, what's happening is they're not able to access that care effectively early on in the process of their disease to get better control. And so by the time they get pregnant, we're dealing sort of at the back end of that issue. And then they end up getting more C-sections because we have complicated deliveries or preeclampsia or unfavorable cervix, so that they're not able to actually progress to a point where they can deliver vaginally. So this is an issue of access of care geographically. The other issue that's happening is that because we have had, at least in Indiana, we have had consolidation of hospital care, a lot of patients live very remotely from the place they're actually going to deliver. And so the question is, how is that impacting healthcare for these patients? It may be obviously less control of chronic diseases, but it also may be that patients go into labor or maybe they're not able to get to the hospital at an earlier stage of complication. By the time they get to the hospital, they're at a point that is not as salvageable as someone who lives close to a hospital and can get that obstetrical care earlier or see an obstetrician earlier. And that's compounded by the fact that when a hospital is consolidated, it's farther away from communities, remote rural areas. OB physicians are not going to reside in those areas because they have to be close to a hospital in which they can actually deliver a baby. They can't leave their office and drive an hour and a half to go deliver a baby and recently come back to their office an hour and a half away in their rural area. So these patients are just really not able to get access when they're having a problem quickly, and then they're often brought into a hospital situation in which it may be harder to control the problem that they were experiencing by that point.
HOST
I'm going to keep going with that point. So let's talk about that a little bit more. It sounds like, you know, we have an issue with…related to lack of OBs in their communities, just like we do primary care providers. How concerning is that, and what do you think is driving that? And Dr. McDonald, I'll ask you to start off, with your public health background.
DR. MCDONALD
For sure. And I'd like to talk both about maternity access as well as about primary care access. And those were…I know you wanted to talk about those as well. Just starting with maternity access – between 2006 and 2020, over 400 maternity programs closed in the United States, creating really significant challenges for people to access that care, like Dr. Basinski just referenced. And then, despite all those closures, 97% of births still occur in hospital settings, and so that means increased distance to care that is associated with poor health before pregnancy, as well as less prenatal care, as well as higher rates of even preterm birth. And so those access challenges are concentrated in rural communities where 72% of hospitals experienced a closure due to low birth volume, which really is related to insufficient reimbursement rates, like Dr. Basinski just referenced, from insurance providers, as well as staffing challenges. And then despite that demonstrated need, there's an increased fertility rate in rural areas. But almost a quarter of rural hospitals who currently have maternity programs are unsure if they'll be able to continue to provide obstetric services. And that really is related to both a staffing workforce issue as well as that reimbursement pattern that we're seeing from plans. And so there's a real lever, as we talked about from the beginning, to be able to adequately reimburse, particularly independent maternity practices, obstetric practices in rural areas, to assure access and improve outcomes and ultimately decrease cost.
HOST
So what you're describing is that OB desert that we talked about in the beginning.
DR. MCDONALD
It is.
HOST
So tell me, what does the future look like? Does that mean that we've got all these med students that are just dying to be primary care and, and go into, or go into OB?
DR. MCDONALD
Well, that's a great question. I think, you know, this is also intrinsically linked to our primary care difficulty. And when primary care is achieving its full potential, it has the capacity to increase life expectancy, improve health, and particularly maternal and birth outcomes, and lower costs. One thing that I think would be a great reference for your audience is our primary care scorecard that Milbank puts out every year. We actually just released that in February, and we've shown that less than 5% of healthcare dollars actually go to primary care. So when you think about the global impact that primary care has on the health of women, we are not putting our money where our value is. And a gastroenterologist, for example, gets paid 4 times as much for an office visit as a primary care physician. And thus 30% of adults lack a usual source of care, despite higher levels of insurance coverage over the last few years. And that provider…you spoke about the future of our workforce, Mary, and we're seeing that fewer physicians are deciding to go into primary care, fewer physicians are deciding to go into obstetric care. There was a drop in between 2022 and 2023 in particularly medical students seeking out residency slots for obstetrics of about 5% nationally, 10% in states that had higher abortion restrictions due to concerns about patient care and being able to get those patients the care that they need.
HOST
Well, it doesn't sound very promising. I hate to say this, it's going to be bleak until we change how we reimburse, probably.
DR. MCDONALD
It's reimbursement practices really are what needs to change. And Dr. Basinski talked about this earlier as well. But when we are able to think about particularly value-based care and being able to pay for the health of a whole population, really across the life course, and make sure that young women, middle aged women, even into senior age are able to access care, and that happens by really, again, putting our money and our funding into preventive services, into primary care, into women's healthcare, as we talked about before. And value-based care is a great way to do that.
HOST
Dr. Basinski, what thoughts do you have?
DR. BASINSKI
Yeah, so I do think that some of the issues with reimbursement, which we are working with some insurers, Anthem specifically has been very open to working on these complex issues about reimbursement. And what we're finding too is that a lot of our resources in healthcare are being diverted to high-cost medications. We've seen that many healthcare dollars are being diverted away from the actual people who care for patients. And you look at hospitals that are also getting a majority of reimbursement, and that's diverting also dollars away from the care that physicians and nurses give and ancillary providers to actual patients. And so a lot of the drivers of dollars in healthcare now are not actually physicians. We're actually taking them away from physicians. And if you look at Medicare, Medicare has cut physician reimbursement over the past five years by about 5 to 10%. If you look between surgeons and primary care, about 5%. But yet they've increased reimbursements to hospitals by 5%. So it's a dichotomy of how they're trying to compensate individuals. I do think value-based care is interesting, but I think as a physician, it deters physicians from wanting to be in areas that are rural. And this has been borne out by the models that have been created within Medicare for reimbursement. When you look at value-based care, it requires extensive software and other tools to prove that you're providing certain outcomes. And what has happened is in some models in Medicare, you're getting bonused or reimbursed based on your ability to meet these qualifications. And if you meet them, you'll get the bonus, but if you don't, you won't. Or even more bothersome is that you get a fee and if you don't meet certain criteria, you have to pay it back to Medicare. And what we are seeing, and this is borne out by some data in Indiana, that physicians who practice in rural areas cannot meet those standards. They don't have the software, the manpower, or other ways to prove that they're providing that care, and they actually are falling short of meeting those requirements. And Medicare is then turning around and asking them for money back from their practices, or not even paying them the bonuses that are built into these systems for incentivization. So we're working with Anthem to try to say, hey, listen, we need to first of all pay primary care physicians more for the work that they do. They're doing these in rural areas especially. They're taking on more responsibility for patients. They're not just their doctor, they're their social…they’re their social safety net. They're the people that are trying to coordinate care in very faraway places for their patients to get them to the care if they need higher access care. Yet these physicians are not paying…getting paid any more than the physician that sits right in the hospital that has access to every specialist at their fingertips. So we really need to look at how we're treating physicians who choose to work in remote areas or underserved areas, and that we need to ease the administrative burden on those practices so that they actually get more payment directly to them. And in Indianapolis, we had a large primary care group who was in private practice working with a large group of patients, and they were having a very hard time getting reimbursement and contemplating selling their practice to the hospital, at which point their hospital would close down. And they're providing a career to a broader patient base or to a pretty broad patient base. And when they looked at their reimbursement, a lot of it was having to do with getting, capturing these extra dollars in these value-based care models or these incentivized programs. And so now they were hiring a third-party company to actually collect the data for their practice. And what happened was when the bonus came in, they met their criteria to get the bonus, 50% went to this third-party company and 50% went to the actual physicians that were doing the work. So this is the question, like, why are we putting a third person in the middle of all of this? If we're going to do value-based care, then it needs to be put upon by the insurer or government to say, okay, we're going to provide the software in the company to prove this data. But again, when you're talking about a rural practice, they're getting by their fingernails, just holding on by their fingernails. They don't have enough resources to meet these value-based criteria or bonus-based criteria.
HOST
So for employers, I'm thinking that there are going to be employers listening to this that are going to say, you know, but I'm not in a rural community, I don't care about that. But I do think what they need to understand is that this software that you speak of includes software that when an employer, a physician is prescribing a medication, they would see which medicine is ridiculously expensive and which medicine can be provided less expensively. Though all of those investments, though, are beyond what they can afford to do. And it's for every private physician across the country. The hospitals, you know, rural hospitals are usually not reimbursed as much as the larger hospital systems. So the rural hospitals also suffer in this. But then the flip side is the hospitals that are getting paid the most have the ability to do that and may or may not be interested because they have a nice little setup where they can get reimbursed at such a high level, they're not really concerned about efficiency of care. So, you know, am I correct in that? I just want to make sure that you two agree with that concept. Dr. Basinski?
DR. BASINSKI
I just think we've stacked the deck against rural physicians in many ways. We've stacked the deck in…they're sitting in areas in which they don't have collegial support, they don't have economic support. And now big systems that can meet pressures to get bonus pay or other things can meet those pressures because they have huge economic pockets to do so in these rural areas, whether they're hospitals or physicians, just do not have the resources to squeeze out an IT department or squeeze out more to get paid to a company to collect the data that's required to get these extra payments.
HOST
Dr. McDonald, what are your thoughts?
DR. MCDONALD
Yeah, I think I agree with that in that the rural providers certainly are getting squeezed out of a lot of this. I want to recircle back around to this concept of really getting value-based care to work in an ideal environment. I think Cindy, you described really well the difficulty with getting particularly onboarded and participating in value-based care arrangement for the smaller entities, smaller healthcare, we're trying to think about rural or urban, but in a smaller system. And that's where I think employers actually can really be asking some questions about what they're paying for, and are they paying for things that we know are lower cost that really work to improve the outcomes for their employees. And those would be things like patient navigators, community health workers, doulas, those kinds of infrastructure as well as the IT infrastructure that we talked about to measure the outcomes but also to improve the employee experience, and to improve their engagement with care, to improve their ability to understand the medications that they're taking, to be able to adhere to treatment regimens prescribed, to be able to get to appointments, be they…you know, are you having…do you have telehealth access or do you have to drive two hours in to a provider? Can you get easy scheduling? There are some interesting examples that have come up around the country, particularly direct-to-employer type arrangements. I know Vanderbilt has got those types of arrangements through its bundles – maternity and otherwise. And those might be the kinds of things that employers may want to take a particularly hard look at to again be able to think about the experience of their employees that then drives the outcomes, that then saves them cost on the back end.
DR. BASINSKI
Well, the other thing too with employers, they have to recognize that even if these patients that are in low access areas are not their employees, they're paying for those patients, because when those patients hit the healthcare system, we are all paying for patients that have complications and have poor outcomes. So it overall increases care costs for everybody in the community when one person is unhealthy. So it is important that we create the concept that even if it's not directly in your company, poor outcomes in your community increase your healthcare costs overall because you're going to pay for that one way or another.
HOST
Yeah, there's a lot of concepts around healthy communities and the influence that has on everything – the viability of companies, of employers, etc. I just want to take a moment and take a step back here and talk about what Dr. McDonald brought up – it’s the…what services employers can provide that could have an impact. Just so I can give some examples, maybe that employers can grasp today is that we have a group that has a high Hispanic population, and what they were able to do is actually find a local pharmacist who spoke Spanish and ends up coming into their industry. It's a manufacturer; I believe they come in once a week, and they give people time off to come and meet with that individual because they can talk about their diagnosis. How are they feeling on their meds? Have they stayed on their medications? When's the last time they've talked to their provider? We also have employers that will put in telehealth rooms. So if you can't afford to have a primary care provider come onsite, which is again added expense within the healthcare system, maybe you can put in a room and have some type of an arrangement with a strong local private practice physician, primary care physician, that could help support that, and then that keeps, you know, the revenue within that private practice that helps them also keep their practices alive in your community. So that's really important. But I do think that when we see employers have the most success, it's when they've taken the time to really think about what their people need in order to be able to meet their needs appropriately. So the social determinants really do come into play. And we typically find that individuals that make less money or perhaps are non-white are less likely to access the resources that have been provided by the employer. So the employer makes all these investments, but perhaps those individuals don't have the time because they're working a second job, don't understand the resources, are still fearful of what does it mean if I use it, etc. So that taking the time to do that is pretty important.
DR. MCDONALD
Yeah. Mary, I'm so glad that you brought that up. You're absolutely right that employers are so reliant on employee engagement, and the things that really improve the health outcomes actually improve the financial outcomes for the…ensure peace as well. And paying attention to team-based care and that team dynamic is going to look different depending on the patient population and their needs. And so you mentioned things like community health workers. That element of a team has been particularly helpful as a significant ROI for the payers. But it has been significantly helpful again to engage patients in what does it look like within a patient's culture to be able to eat healthy foods? That looks very different depending on the type of upbringing that you have, the type of access that you may have to certain kinds of food. Community health workers, nutritionists, patient navigators, can be really helpful in that, and to include that in a value-based type payment for the team that's most relevant to your employees is what's going to drive your outcomes as well as your costs.
HOST
Dr. Basinski, thoughts?
DR. BASINSKI
One thing I will say that I find frustrating with, uh, I think it's fantastic employers hire specific individuals in healthcare to drive up, you know, the overall health of their employees. However, it still is a lot of fragmented care. We have a bunch of little employers all over the place hiring different kinds of people, who I would love to see more cooperation between employers to create centers, especially in areas that are underserved, in which employees of the community could go to to seek this care. So now we're consolidating services and using our healthcare dollars the best that we can. And then we have then built within that we'll provide support systems to bring physicians in who say, okay, I feel comfortable practicing in this community because I have resources available to me to help me care for these patients that I don't have to sit and talk to them and find a translator to, to help me speak to them in Spanish or Russian or whatever that I see in my practice too. And then there's just, for example, even a translator for a physician – that is not reimbursed back by the insurers. The physician has to sustain the cost of a translator. That's really unfortunate. And when you're trying to talk about a small-community person who's trying to run a practice, that can be a huge economic burden if they're in a place where there might be a lot of individuals who don't speak English, whether it's Spanish or Haitian or whatever other, French or whatever other languages there might be. The other issue is with telehealth, surrounding telehealth, which I think could be a huge way to create better access in remote areas. It's not well reimbursed. It's a little bit difficult whether it's a phone or a video. A lot of individuals in low access areas, remote areas don't have access to good video or good telemedicine visits in that way. So there's some structural issues with reimbursement around that. Additionally, if you live close to the border, for example, I live…across the river is Kentucky, and I'm very close to the state line of Illinois. If a patient lives in Kentucky or Illinois, that's a large portion of my patient population. I am not allowed to do telehealth. I will not get paid for telehealth for that. So we have a lot of fragmented care, not only within employers, we have it fragmented between states, between communities. And until we fix some of these infrastructure issues, we're going to continue to have poor access for communities that don't have indwelling physicians in their communities.
HOST
Those are all incredible points. So thank you. What comes to mind is so many employers are looking at near-site or onsite clinics, which may be a positive solution as long as those providers can provide the right type of care and are really there for you and you're not doing a rotation system like a minute clinic. We have to be very careful with that. And a lot of these facilities are 8 to 5, and nobody answers call in the evening. So there is significant fragmentation of care. That could be such a better product if it were set up correctly, as you had mentioned.
DR. BASINSKI
But let me say, and let me tell you a little story. I'm sorry, I don't want to monopolize this, but there was a large OBGYN group up in northeast US who recognized that after our coverage was largely going to the hospital. So they went to the insurers and said, by the way, we would love to offer an after-hours clinic in our practice, but will you reimburse us more because we're having to pay someone to be here overnight? The insurers didn't even want to listen to that. They're like, nope, we don't want to be involved with that. So again, how do we create legislation or how do we create incentives for insurers who pay the bill to say, yes, we are interested in finding lower cost ways? They're just not interested in doing that right now. So how do we motivate them? I don't know the answer to that. Maybe Dr. McDonald has some insight into how we can change that.
HOST
Well, I do think I know how, because in several communities we do have where the employer reaches out to that physician group. Like if it's a primary care office and we need the primary care to be responsive, or the OBGYNs or oncology practice, then they will basically go around the carrier and set them up as a top tier network, more so that they have concierge care, and pay them a PEPM per employee per month or some other stipend to help support that extra service. And what I love about that is, the minute that employers start going around the carriers, suddenly the carriers realize that they may start losing their clout a little bit and maybe they need to move a little faster in this direction. So I really enjoy when I see that happening. And I'll tell you, one of the best things I was ever involved in was, in a small community we brought together once a month and met with the primary care providers and the employers in the same community. And they all talked about learning each other's issues. Employer, what do you need and what's messing up your ability to financially meet your goals and take care of your people appropriately? Providers explaining that they live in two different worlds. And when we start to understand that, as you mentioned, Dr. Basinski, I think that's when we can generate something pretty fantastic. It takes extra work, though. It's not just accepting the infrastructure as it is.
So I'm going to stop us on this topic a little bit because I still want to talk about and just ask the question, I feel like what we have said is there's definitely an issue with quality of care, access to care, but there is a declining health and lack of diagnosis of conditions that are leading to this. So if I'm an employer, I want to think about what can I do? What are the first steps we can do to improving women's health and these health outcomes? And Dr. McDonald, if you don't mind kicking us off on that one, I'd appreciate it.
DR. MCDONALD
Certainly. So I think a lot of that starts with primary care. And if we know that 30% of adults do not have a usual source of care, don't have a source of primary care, then there's a real role for employers to push the envelope there. And you mentioned some of the collaboration directly between employers and providers, and removing some of that middle administration piece, and making sure that they're adequately paying primary care providers to expand their network, to expand their coverage, to expand their team. And expanding their team actually is very cost effective, because a provider, physician or nurse practitioner cannot be their own clinical selves, as well as a social worker, as well as a pharmacist, as well as, you know, a nutritionist. And so that team-based care is critically important, and it's really employers that are going to make sure that the dollars are spent there as opposed to much further downstream cost.
HOST
I know when we spoke to prepare for this, you brought up the terms that come off of your mouth very easily. The women who are, how do you say delivering the care, because I don't mean delivering the weight. Same sense we're talking about today. But you talked about the life course perspective and the pre-conception health being critical. Can you expand on that a little bit?
DR. MCDONALD
Yes. As much as we've been talking about maternity care, the health of…a healthy pregnancy starts long before pregnancy. And what a child grows up with, from a nutritional perspective, from a physical activity perspective, from an education perspective, probably has the greatest impact on their own children later than what we do, even in that maternity care, particularly special place. And so making sure that we're paying attention to access to, yes, healthy nutrition, to physical activity as kids are growing up and as young women are entering the more reproductive phase of their life. Similarly, access to contraception and being able to plan pregnancies leads to healthier pregnancies, leads to lower costs for employers. And so if pregnancies happen within 18 months of each other, for example, we know that there's a much higher risk of preterm delivery, of those long hospitalizations for neonatal complications for babies, as well as for moms. And so access to contraception, be that again through primary care, through women's health access, through engagement with local public health, is significantly important. And just being obviously of a public health background, connections that employers have with public health sometimes goes unstated, but is hugely important. These programs like WIC, for example, which are available from prenatally through the age of 5 for kids, decrease obesity, increase maternal health, decrease complications of pregnancy. And so making those direct local health department connections for employers can also be very cost effective.
HOST
I'm taking notes as things just roll off your mouth like it's just, it's in your brain because you do this all the time.
Dr. Basinski, please.
DR. BASINSKI
Yeah, I agree. I mean, if you…40% of pregnancies are unplanned. It's a shocking statistic, but many of those end either in termination or just poor pregnancy outcome because they were not planned to begin with. So access to good contraceptive care is highly important and we don't do a good job of that. In some ways, I almost think we should be in school systems providing nurses who provide health…contraceptive education, and offering contraceptive options before children even can become pregnant. There are some political and other issues behind that, but that is a huge issue. The other issue that comes up too is the physician workforce. We are going to have a shortage of physician workforce soon. And part of that is physicians retiring who are just tired of dealing with the system. We have more physicians who are disengaged in the healthcare system because they're employed and feel less connected to patient care, which means that physicians are having to see more patients in a day than maybe they're capable of. And if that happens, then they're able, not able to sit and talk to patients more meaningfully to get to the core of health issues. So there's a health physician shortage, and we're trying to use nurse practitioners and PAs to fill that shortage. But the reality is that PAs and NPs do not have the underlying knowledge base that physicians do. It tends to result in more under-recognizing certain disease states may occur, but also utilization of laboratory and imaging services with PA's, NPs compared to, say, physicians, who have a different educational base to assess things clinically. So, you know, I think there's some issues we're going to have to work around to see how do we encourage physicians to keep working, how do we keep physicians excited about being doctors and how do we help increase that workforce so that we can have more meaningful interactions with our patients, and getting paid to spend more time with patients and have meaning…more meaningful interactions. So right now it's a money game. And even if a physician's employed, you know, these RVU values go into how much they get paid. So you have to see a certain amount of patients to meet your RVU values, which then gets you your bonuses. And all of this disincentivizes meaningful interactions and incentivizes just milling patients through. So I think there are some other structural issues that are causing decreased quality of care per interaction with patients on a day-to-day basis.
DR. MCDONALD
And Mary, if I could build on that a little bit, we at Milbank have a tool that I referenced earlier, the primary care Scorecard, that really does break down a lot of this data state by state. And so from a workforce perspective, we're tracking what the primary care workforce looks like in every state; we're tracking what the primary care investment from a funding perspective, what value-based care looks like, but that primary care investment, state by state. And then we've got a toolkit that can be used both for employers in the sense of what are they paying for, as well as an advocacy lens of how do they engage their state legislature, their state agencies in really improving the primary care infrastructure to again decrease their cost on the back end and improve the healthcare infrastructure for everyone, which then improves our…ultimately our health outcomes.
DR. BASINSKI
Are you seeing decrease of physician workforce, decreased primary cares?
DR. MCDONALD
Yeah, and physician workforce, as well as the percentage of NP and PAs going into primary care as well. And that's because of reimbursement. As well as the hassle factor that you mentioned earlier. Yeah.
HOST
And in our data we definitely, you know, see the issue related to even people having a primary care provider. When we were digging through our data, we found that only 36% of women 18 to 26 years old had even seen a primary care provider within the last year. And of course, if you haven't planned a pregnancy, that likely could be a time when you may have a, a baby. And so many times with employers when we talk about incentivizing physicals, their response is one, which is true, “But I can't even find a primary care provider to get in with,” so that becomes that issue. But the other one is, “Ah, these people are healthy and if I let them go see a provider, especially if they're a provider that's owned by a hospital system, they're going to get all these extra tests and procedures. We're going to, they just start in the, the mill of all the procedures and do we really need to do that?” So we've created a, a world where we're spending a lot of money and quality is really declining, is what I'm hearing from both of you, correct?
DR. BASINSKI
Yeah, yeah. It's..it's just all really based in incentivization. And that's just the payments. What we're paying people for, we're incentivizing people to do the wrong things. We've gotta stop that.
DR. MCDONALD
Exactly.
HOST
The system's working exactly the way we've set it up to do. And if employers as the main payer have a lot that they can share and change. So we really want these conversations to help motivate them to create different strategies, use their voice, etc. So as much as I, I hate to end this conversation because it's been incredible and I knew it would be, I just want to thank both of you. This topic is actually much more complicated than I originally thought. I thought we were just going to bust the hospitals for overcoding. There's so much more going on than that. But it's always great to understand all the things that we can do to drive change. I'm just going to try to outline some of the key topics so as our employers leave us today, they can really think about these topics. We need to position primary care. We need to give access to primary care. We need to give access to contraception, which I hadn't thought about that component of it. We need to think about change in how the physicians care for people. They, we, the way our system is set up, we're getting less quality care because if they're in a hospital system, the hospitals are incentivizing providers to do less care. There's less comprehensive care, more fragmentation. The hospitals are motivated to drive to the emergency rooms – that's just a reality. And we do need to get help in figuring out how to decrease inappropriate C-sections, inappropriate ER utilization.
Dr. McDonald, you talked about the most appropriate care at the most appropriate place at the most appropriate time with the correct service, and sounds so easy. We just have to figure out how do we take a step forward in that direction? Because I think that's really critical. Social determinants of health really have an impact. If you're economically depressed, you are not going to risk going to a provider and having extra care. You may avoid that. You may may not have access to healthy foods. So the delayed care, the underlying decrease in health has a huge impact.
DR. BASINSKI
And may I add to that list increasing cost of medications, which then are much more difficult for individuals who are economically depressed to access. So hypertensive medications, diabetic medications.
HOST
That's a great point. And there are certainly strategies to get generic medications at very low cost now that are out there that do kind of buck the system a little bit. Anything else that I forgot that you think we need to make sure people remember? Dr. Basinski?
DR. BASINSKI
I just want to just toss in some overall concepts. One is we have centralized care. We need to decentralize care. That that's got to happen across the board in America. We've got to get away from big hospital systems and move back towards smaller care at smaller centers in multiple areas across our states and our country. And finally, changing incentives about how we incentivize the workforce to take care of our patient population. So physicians, nurses, social workers, other people who really are integral in maintaining health and get away from the idea that big systems are going to do that. It's the people, it's the interaction, people to people that make changes in healthcare.
HOST
Great point. Dr. McDonald, any closing thoughts?
DR. MCDONALD
Yeah, it does come down to what we're incentivizing. And are we incentivizing a trusted relationship, or are we incentivizing the latest and greatest, you know, shiny thing that's been advertised to people? And so those payment structures that employers put into place really do drive the healthcare system and how it is arranged. Employers have huge levers there. The two kind of quick things that I just wanted to emphasize that you touched on, Mary. One is this cost of care also to the employee. And again, that's payment structure. And when we talk about cost sharing, maternity care probably isn't the place to do that because you don't want to disincentivize care when people are pregnant, for sure. And we do know, we actually just published a paper last year that there's some particularly detrimental impacts from that cost sharing and, and of people who make less than 200% of the federal poverty level. So just for context, that's $64,000 for a family of four. There's about a $3,000 out-of-pocket cost for childbirth, which results in those families, about a third of them going into debt collection within a year of a birth, which is a huge impact. That then means that at least half of those then suffer from depression because of financial burdens of that; we know that depression and mental health is a leading driver of maternal mortality and cost. So it's all related. But help employers structure their plans really does matter from an outcomes perspective.
HOST
Wonderful points. You guys have been absolutely better than I even expected and I appreciate everything you're doing because clearly you're passionate and you're trying to drive change, which is what we all want.
DR. BASINSKI
Thank you, Mary. You also are very passionate, so we appreciate you bringing these concepts to a broader audience.
HOST
So to our audience, I hope you feel more equipped to make strategic changes within your plan and maybe even within your community to help drive the change that is needed. In our next episode, we're going to dive deep into mental health, but take a slightly different approach than you may think. At Vital Incite, we are also seeing a significant increase over the years in people seeking care for mental health, mostly for anxiety and major depression. We are going to try to talk to an employer that has really influenced their plan members through a comprehensive approach, and we’ll be joined by other experts who can help develop strategies to again provide better support at a lower cost to the health plan. Isn't that our goal, after all? Better health and less cost. Thanks for listening to this episode of The Pulse. If you enjoyed it as much as we did, be sure to subscribe so you always stay up to date on our most recent conversations. Share this recording and the link with others so they can start to demand something new. Please follow us on LinkedIn. The Pulse is produced by Vital Incite, an Alera Group company. Alera is on a mission to help organizations identify medical spending waste through data-driven strategies, while helping to improve the health of their employees. If you want to make healthcare easier to understand and manage and improve your organization's bottom line, reach out to us at vitalincite.com. I'm Mary Delaney. Thanks for listening.
