Ron J. Anderson, MD, is a member of the AHA board. For 28 years, he has been president and CEO of Parkland Health and Hospital System in Dallas, a public system that includes 968-bed Parkland Memorial Hospital. Here Dr. Anderson shares 14 thoughts about the road ahead for hospitals.
1. Health reform never had a mandate. The reform law never had widespread public support. "Thomas Jefferson said you should not impose change through a small minority," Dr. Anderson says, but that is what Democrats did when they enacted the law and what Republicans seem to be doing now, as they try to roll it back. He predicts more tumult. "In two years we'll see another voter backlash," he says.
2. Both parties need to work together. To achieve stability in healthcare policy, President Obama needs to truly reach out to Republicans, as President Clinton did after the Democrats lost the midterm elections in 1994.
3. Some reforms may never be enacted. Hospitals need to face the possibility that some parts of the reform law may be discarded. "Viewing the midterm election results, it is unclear how much of the reform law will be implemented and how much not," Dr. Anderson says. "There are so many ways to hold it up through hearings and not fund parts of it."
4. Piecemeal repeal is bad for hospitals. Partial repeal poses a problem for hospitals. "Different pieces of the law are all tightly woven together," Dr. Anderson says. "If you pull out one thread, you don’t know how much it's going to weaken the whole thing." For example, hospitals have put up with some unpleasant aspects of the reforms, such as lower Medicare reimbursements, with the understanding that there would be more patients to make up for those losses. Should the expansion of coverage be repealed, however, "Hospitals are going to say, 'If you’re not covering these people you're not living up to the deal,' " he says.
5. Hospitals must take the high road. As the debate over repealing the reform law heats up, "we need to stay on their high road, regardless of what happens in the next two years." This means building a healthcare system that benefits the entire country and not just the hospital industry. The AHA has made a commitment to quality, access and safety, as well as social and health justice, Dr. Anderson says.
6. Reform still leaves many uninsured. While an estimated 32 million would be covered under the reform law by 2014, something like 25 million people would not be. Many of them are non-citizen immigrants who are ignored by the reform law, many of whom are in Texas. "The law doesn't address the issues we face in the border states," Dr. Anderson says. "This is a huge issue. There are 5-6 million uninsured in Texas."
7. Health reform has yet to be defined. There are roughly 1,100 instances in the law asking the HHS secretary to make policy. "A lot still needs to be decided about how this law will work," Dr. Anderson says.
8. ACOs are still only 'magical creatures.' Hospitals are awaiting proposed regulations on how the accountable care organization would work. Until it is fully identified by regulations, "the ACO is a magical creature with great healing powers," Dr. Anderson says, tongue in cheek. "The ACO is a unicorn, in the sense that no one has ever seen one." One gaping problem with ACOs is that "patients don’t have any loyalty to the system," he says. "Patients can disenroll monthly if they are dissatisfied." He believes patients should be "locked in" to a particular ACO for one year to give the new organizations a chance to improve their care. "Patients should be accountable for their lifestyle," he says.
9. Medicaid access problems will continue. Even if the Medicaid program is expanded under the reform law, Medicaid recipients would likely still have access problems. In Texas, "something like 38 percent of primary care physicians won’t take a Medicaid patient, and the percentage is higher for specialists," Dr. Anderson says. As a result, a lot of new Medicaid recipients are likely to gravitate back to safety-net hospitals like Parkland. A flood of low-paying Medicaid patients could be damaging. Currently, the hospital makes up for $575 million in charity care with $380 million in tax revenues and by cobbling together dozens of smaller revenue streams, including DSH payments. This delicate balance could be wiped away, he says.
10. Medicaid is very vulnerable to cuts. "Politicians don’t go after Medicare because they know if you touch Medicare, you die," Dr. Anderson says. "There are just too many seniors who would go after you if you did that. But politicians can touch Medicaid because the poor are relatively voiceless." Dr. Anderson has been on the Kaiser Commission for Medicaid and the Uninsured since 1992.
11. EHRs are useful but pricey. Parkland has fully implemented an EHR system, costing more than $100 million. "It allows us to practice much better medicine and we believe there will be a full return on investment over time," Dr. Anderson says. "This system gives us the ability to follow the patient over time." But EHRs may not be affordable for many smaller hospitals. "If I were a small rural hospital, I'd probably think differently, about EHRs," he says.
12. Texas probably won’t opt out of Medicaid. Some politicians in Texas, including Gov. Rick Perry, have been talking about removing the state from Medicaid, which is becoming increasingly costly for states, but Dr. Anderson doubts this will happen. He thinks an upcoming report by the Texas Health and Human Services Commission will dissuade legislators from taking such a drastic step. "Medicaid is an underpayer but it is better than nothing," he says. Without this safety-net program, millions of children and impoverished adults in the state would have nowhere to go and the system would be overwhelmed.
13. Hospitals should be allowed to align with physicians. Texas hospitals have difficulty aligning with physicians because the state has a law against hospitals employing physicians, similar to California's ban on the corporate practice of medicine. Parkland received an exemption to the law from the state legislature but the governor vetoed an exemption for 30 other public hospitals.
14. Midlevel providers are necessary. Parkland uses mid-level providers such as nurse practitioners and physician assistants. Some physician organizations oppose using mid-level providers to take the place of physicians, but with the growing physician shortage, mid-levels need to be able to "practice to their licensed capacity," Dr. Anderson says. "Hospitals should not be constrained by politics. Healthcare should not be restricted to folks who are overqualified."
Find out more about Parkland Health and Hospital System.
1. Health reform never had a mandate. The reform law never had widespread public support. "Thomas Jefferson said you should not impose change through a small minority," Dr. Anderson says, but that is what Democrats did when they enacted the law and what Republicans seem to be doing now, as they try to roll it back. He predicts more tumult. "In two years we'll see another voter backlash," he says.
2. Both parties need to work together. To achieve stability in healthcare policy, President Obama needs to truly reach out to Republicans, as President Clinton did after the Democrats lost the midterm elections in 1994.
3. Some reforms may never be enacted. Hospitals need to face the possibility that some parts of the reform law may be discarded. "Viewing the midterm election results, it is unclear how much of the reform law will be implemented and how much not," Dr. Anderson says. "There are so many ways to hold it up through hearings and not fund parts of it."
4. Piecemeal repeal is bad for hospitals. Partial repeal poses a problem for hospitals. "Different pieces of the law are all tightly woven together," Dr. Anderson says. "If you pull out one thread, you don’t know how much it's going to weaken the whole thing." For example, hospitals have put up with some unpleasant aspects of the reforms, such as lower Medicare reimbursements, with the understanding that there would be more patients to make up for those losses. Should the expansion of coverage be repealed, however, "Hospitals are going to say, 'If you’re not covering these people you're not living up to the deal,' " he says.
5. Hospitals must take the high road. As the debate over repealing the reform law heats up, "we need to stay on their high road, regardless of what happens in the next two years." This means building a healthcare system that benefits the entire country and not just the hospital industry. The AHA has made a commitment to quality, access and safety, as well as social and health justice, Dr. Anderson says.
6. Reform still leaves many uninsured. While an estimated 32 million would be covered under the reform law by 2014, something like 25 million people would not be. Many of them are non-citizen immigrants who are ignored by the reform law, many of whom are in Texas. "The law doesn't address the issues we face in the border states," Dr. Anderson says. "This is a huge issue. There are 5-6 million uninsured in Texas."
7. Health reform has yet to be defined. There are roughly 1,100 instances in the law asking the HHS secretary to make policy. "A lot still needs to be decided about how this law will work," Dr. Anderson says.
8. ACOs are still only 'magical creatures.' Hospitals are awaiting proposed regulations on how the accountable care organization would work. Until it is fully identified by regulations, "the ACO is a magical creature with great healing powers," Dr. Anderson says, tongue in cheek. "The ACO is a unicorn, in the sense that no one has ever seen one." One gaping problem with ACOs is that "patients don’t have any loyalty to the system," he says. "Patients can disenroll monthly if they are dissatisfied." He believes patients should be "locked in" to a particular ACO for one year to give the new organizations a chance to improve their care. "Patients should be accountable for their lifestyle," he says.
9. Medicaid access problems will continue. Even if the Medicaid program is expanded under the reform law, Medicaid recipients would likely still have access problems. In Texas, "something like 38 percent of primary care physicians won’t take a Medicaid patient, and the percentage is higher for specialists," Dr. Anderson says. As a result, a lot of new Medicaid recipients are likely to gravitate back to safety-net hospitals like Parkland. A flood of low-paying Medicaid patients could be damaging. Currently, the hospital makes up for $575 million in charity care with $380 million in tax revenues and by cobbling together dozens of smaller revenue streams, including DSH payments. This delicate balance could be wiped away, he says.
10. Medicaid is very vulnerable to cuts. "Politicians don’t go after Medicare because they know if you touch Medicare, you die," Dr. Anderson says. "There are just too many seniors who would go after you if you did that. But politicians can touch Medicaid because the poor are relatively voiceless." Dr. Anderson has been on the Kaiser Commission for Medicaid and the Uninsured since 1992.
11. EHRs are useful but pricey. Parkland has fully implemented an EHR system, costing more than $100 million. "It allows us to practice much better medicine and we believe there will be a full return on investment over time," Dr. Anderson says. "This system gives us the ability to follow the patient over time." But EHRs may not be affordable for many smaller hospitals. "If I were a small rural hospital, I'd probably think differently, about EHRs," he says.
12. Texas probably won’t opt out of Medicaid. Some politicians in Texas, including Gov. Rick Perry, have been talking about removing the state from Medicaid, which is becoming increasingly costly for states, but Dr. Anderson doubts this will happen. He thinks an upcoming report by the Texas Health and Human Services Commission will dissuade legislators from taking such a drastic step. "Medicaid is an underpayer but it is better than nothing," he says. Without this safety-net program, millions of children and impoverished adults in the state would have nowhere to go and the system would be overwhelmed.
13. Hospitals should be allowed to align with physicians. Texas hospitals have difficulty aligning with physicians because the state has a law against hospitals employing physicians, similar to California's ban on the corporate practice of medicine. Parkland received an exemption to the law from the state legislature but the governor vetoed an exemption for 30 other public hospitals.
14. Midlevel providers are necessary. Parkland uses mid-level providers such as nurse practitioners and physician assistants. Some physician organizations oppose using mid-level providers to take the place of physicians, but with the growing physician shortage, mid-levels need to be able to "practice to their licensed capacity," Dr. Anderson says. "Hospitals should not be constrained by politics. Healthcare should not be restricted to folks who are overqualified."
Find out more about Parkland Health and Hospital System.