HANYS President: This Is a Crucial Moment for the Future of Healthcare
At a time of major change and great uncertainty in U.S. healthcare, the leaders of state hospital associations are doing everything possible not only to ensure the survival of the hospitals and health systems that are their members, but also to work to create and strengthen their bonds with their communities.
One of those associations is HANYS, the Hospital Association of New York State. The Rensselaer-based association states on its website that “HANYS works to ensure every New Yorker has access to affordable, high-quality care. We advance the health of individuals and communities by providing leadership, representation and service to not-for-profit and public hospitals, health systems, nursing homes and other healthcare organizations throughout New York state…. HANYS advocates in Albany and Washington on behalf of our members and the healthcare needs of New Yorkers. We engage with policymakers, agencies, community partners, the media and more, while collaborating frequently with regional, state and national associations. We also provide education, data analysis, quality improvement initiatives, business services and more to our members and partners. HANYS is always there for our members, so they can be there for their communities.”
Earlier this year, HANYS released a report entitled “The Case for Change.” Among the major highlights of the report:
Ø Four drivers are pushing New York state’s healthcare delivery system to an existential cliff. Without significant policy solutions and delivery system changes, health system market disruptions may have a domino effect across the state, impacting all providers and all New Yorkers regardless of their geography, health insurance status and demographics.
Ø The four drivers are thus: Healthcare demand is increasing and changing; the number and mix of healthcare workers cannot meet demand; health disparities persist; the healthcare affordability crisis for all stakeholders is growing.
Ø Without significant policy solutions and delivery system changes, health system market disruptions may have a domino effect across the state, impacting all providers and all New Yorkers regardless of their geography, health insurance status and demographics. The interlaced effects of these four drivers complicate efforts to find solutions. To be effective, policy and delivery system changes must consider the direct impacts of each driver and the amplification effect the drivers have on one another.
Ø New York state’s aged dependency ratio, which relates the number of senior citizens to working- age adults, is expected to grow between 2015 and 2040 from 24 seniors per 100 working-age adults to 37 seniors, reflecting an increase in the 65+ population’s percentage of the total population from 15 percent to 22 percent.
Ø Spending for cardiovascular disease has leveled off, tempered by a combination of new drug therapies, the shift to outpatient care and mechanical interventions. Patients who may have had their lives shortened by cardiovascular disease several decades ago are now living longer, leading to higher rates of many types of cancer. In addition, breakthrough cancer treatments have made many cancers survivable and chronic in nature.
Ø The average number of openings across healthcare occupations in New York state is 168,000 annually.15 In turn, the state produces only about 41,000 new workers to fill healthcare workforce openings each year.16 This major shortfall signifies a structural supply problem that requires creative interventions from government, providers and educators to leverage the skills of currently working professionals and attract new workers to the healthcare field.
Ø In addition to needing more workers, the types of workers also need to change. The demand for home health and personal care aides to serve the aging population and those with chronic conditions is projected to increase by 39.1 percent (199,700 jobs), accounting for 55 percent of the projected need for healthcare workers between 2020 and 2030. The demand for registered nurses and nursing assistants is projected to increase by 17 percent (33,420 jobs and 15,360 jobs, respectively).
Ø Economic disparities across provider types — primary care and specialty care providers, hospitals, long-term care providers, community-based organizations and others — are driven by broader economic factors impacting the communities in which they operate. Using hospitals as an example, those in communities facing the greatest socio-economic disparities often have weaker payer mixes (a higher share of payment for services from Medicaid and Medicare, which pay below the cost of care, and lower share of payment for services from commercial insurers). In New York state, the top 15 financially performing hospitals draw 48.1 percent of their revenue from commercial insurers. High-Medicaid, financially distressed hospitals draw just 19.5 percent of their revenue from commercial insurers. This is comparable to public hospitals in New York state, which typically serve a high share of Medicaid and uninsured patients.
Ø The growing and changing demand for de-centralized healthcare and social services, chronic workforce shortages, health disparities and an unsustainable healthcare financing system present a grave threat to healthcare system stability and patient care. The fusion of these drivers is creating an exponentially dangerous and fast-approaching existential cliff — symptoms of which we are already experiencing. Inaction is not an option.
Per all this, Healthcare Innovation Editor-in-Chief Mark Hagland recently interviewed HANYS president Bea Grause, R.N., J.D., regarding the challenges facing New York state’s hospitals and health systems, and what she and her colleagues at HANYS are doing to address the current headwinds in the U.S. healthcare system and in New York state specifically. Below are excerpts from that interview.
What was the origin of the creation of the report?
It’s a HANYS report, but it is designed to bring other stakeholders to the table. We produced it in a post-pandemic environment where we realized that it became apparent to us that our current healthcare system was unsustainable: we were seeing healthcare deserts, as in OB care; and more and more of our providers, acute and post-acute, who were becoming steadily more financially non-viable. So we wanted to understand why things seemed to be headed over an existential cliff; to understand why but also to be able to understand that in a clear and compelling way.
I actually think the most important driver is demand; everything flows from that. “The Case for Change” was built on our analysis of patients who would use post-acute services into the future. And when you look at those data, the reality is that we have an aging population, and are going to see an increase in needs for post-acute care, in large part due to an aging population. If you had a heart attack 50 years ago, that was considered an acute condition; now, people are living decades with heart disease; similarly, people with cancer are living for decades. And that has led to the need for more intensive resource-intensive services in the post-acute space. More than half of the project workforce shortage in NYS will be in the home care or nursing care space. And that drives unaffordability at every level: consumers, employers, and state and local governments, are all spending more.
And the report noted the looming explosion in demand for healthcare, relative to the inadequate supply of clinicians to meet that demand, particularly with regard to registered nurses.
I think the best way for me to communicate it is that, as we think about the population aging, nurses are aging, too. And I’m a registered nurse myself. And I think the average age of nurses now nationwide is in the 60s. And nurses are becoming senior citizens, too. And the pandemic accelerated the wave of nurses retiring or moving onto other types of employment. And every year, the care gap gets wider, and we’re playing catch-up in the ability to serve those patients.
Nursing schools are seeing faculty members retiring, too, so that’s a rate-limiting factor, correct?
Yes, we’re looking at several different elements there, including an increase in demand, increasing workforce shortages, and health disparities. And, in any industry in which there’s a labor shortage, closing that gap means that wages will go up. So how do you increase faculty salaries in nursing schools, and where, in terms of eliminating that bottleneck? And you have to change the curriculum, too. But that faculty bottleneck is real, too.
And can you speak to concerns around access to care and health equity?
With regard to access to care, there’s a distinction between access to care and access to coverage; and certainly, coverage is a way to access to care. On the access to care side, there are a number of examples in both rural and urban areas that because the financial infrastructure is beginning to fail, it’s creating access problems where patients can’t get access to specific services, such as OB or primary care, in a readily accessible way. In fact, there is a primary care shortage in more than half of the 62 counties in New York.
And healthcare is a local service governed by federal and state law. And Medicare and Medicaid payments do not cover the cost of delivering services. So if you have a majority of residents in a local area being Medicare or Medicaid recipients, providers struggle financially to provide the needed services. That’s the typical way that people think about access. But there’s also a lack of access to OB services, because of high med-mal costs or because of an inability to recruit physicians to specific local area.
What are your recommendations on healing the urban/rural split?
Yes, there are a couple of dozen states with a very distinct urban area, and the vast geographic remainder of the state is deeply rural. And as you saw in the report, there are no specific solutions outlined in it, but we are working on solutions. But we felt first that we needed to stop the blame game and bring people together to figure out how we create a more sustainable healthcare system. And as we develop policy solutions, we have to first look at workforce and make sure we’re doubling down and recruiting critically needed healthcare workers. And NY state is already beginning to do this, to provide capital to help hospitals create more capacity outside the hospital, so that residents can access primary care and post-acute care more fully; and then shoring up the financial infrastructure in different ways: so additional Medicaid payment rates for rurally based providers, to support that critical access to care.
What can senior hospital and health system leaders do right now?
Well, our organization represents them, a nd in my many conversations with them, they are very motivated to make sure we’re reaching out to allies and other influencers to tell this story, to share and communicate our concerns about workforce sustainability, and double down on working on affordability and access over time. There are no easy solutions; but we can’t continue to point fingers. This demand will be sustained over the next twenty years. If we don’t address this, people will lose access to care, and we’ll be further away from access and affordability. I’ll also be working with leaders later this year to develop a vision. We can have a fact-based conversation around how we get from where we are today, to a better future. Our hospital and health system leaders want to help lead that discussion.
Can wise use of technology help us in terms of workforce and access?
One-hundred percent. As the pandemic taught us, we can leverage technology successfully. And in this post-pandemic environment, we’re seeing that in draft legislation, so if you’re dialing in to get your post-op wellness check at home, the person you’re dialing into is licensed and knows what they’re doing, and that video encounter is safe and secure. All those issues are important, but they’re being worked on.
Do you feel optimistic that Congress will work out the extension of the telehealth flexibilities?
I’m pretty optimistic; and the continuing resolution just passed will last until December 20, so that gives members of Congress and their staff time to work things out. So I’m more optimistic that they’ll work out these issues.
What final thoughts would you like to leave our audience with?
I think that it’s really important to think innovatively around the future of healthcare; and I think innovation plays a bigger role if you reframe the healthcare conversation. The way we’ve historically framed the healthcare reform conversation is, how do we make HC less expensive? More constructively, how do we make HC more affordable over time? And one element there is how we can use technology to keep patients out of hospitals, make better decisions, and make it so that patients don’t have to travel great distances to access care. So to me, that reframing really invites innovation and in particular, technology, into the situation, to reduce costs and improve access to care and affordability over time.
Can a combination of technology and value-based care delivery and contracting help to make that happen?
Yes, but I also think that we need to reframe the conversation. And I would say to the Hochul administration that yes, it’s totally appropriate to want to reduce Medicaid spending overall, but they need to do more on the regulatory side to help reduce how much it costs to help reduce healthcare; and that’s the other part of the responsibility in that. So how you address increasing demand and address affordability over time? What are we doing to make the production of healthcare cost less? That promotes affordability and access.
