Voices on health care: Health care providers

Joe Ierardi, CEO, Wayne Memorial Hospital, Jesup

The situation: Wayne Memorial Hospital, 70 miles southwest of Savannah, has 84 beds and employs slightly more than 400 people, making it one of the largest employers in the rural community. Ever-greater financial strains on Wayne Memorial and other small, standalone hospitals in Georgia are leading some to merge with or form partnerships with larger health systems. Wayne formed a partnership with Savannah's St. Joseph's/Candler health system in Savannah about 18 months ago.

Impact of ACA: Wayne Memorial could lose much of the $1.1 million in government funding it receives each year to help care for the poor and uninsured. Under the ACA, the federal government will cut in half over five years the $11 billion Disproportionate Share Hospital, or DSH, program that helps hospitals cover defray the cost of caring for uninsured patients. The expansion of Medicaid was supposed to partially offset the loss of the DSH funds. But Georgia chose not to expand Medicaid, leaving hospitals no new source of revenue to replace DSH dollars.

Ierardi's view: As time has moved on, that whole concept of (putting) 'heads in beds' has gravitated to finding alternate sources of revenue and trying to get more out of a dollar. You've seen a lot of hospitals merging with bigger facilities to take advantage of economies of scale, and quite honestly they have a hard time making it. About 18 months ago, we entered into a collaborative agreement with St. Joseph's/Candler. We really think it's a model that people can use throughout the country because most health care is delivered locally.People, especially in smaller communities, they're proud of their hospital and they want to keep that economic engine locally.

That’s been very important to us in preparing for what’s coming down the road. And what we’re already actually experiencing with health care reimbursements. It’s allowed us to get some specialists in here. We’re not big enough to get involved in cardiac care and pulmonology care and neurology types of services. Now our folks don’t have to drive 70 miles to Savannah at $3 plus a gallon. What’s coming down the pike is very concerning. I’m really not sure how I feel about that there are just so many unknowns still with the (health care) law — how it’s going to be with the exchanges, how it’s going to be reimbursed, how it’s going to be done. This law is a very bold, ambitious initiative and it has real aggressive timetables. What I’m concerned about is (whether) the infrastructure is in place to meet these timetables, and I just don’t think it’s there. We count on that DSH money to help us. You take that item off of our budget, we’re going to have to retool some things big time.

That $1.1 million is roughly $100,000 a month coming out of this organization, so things you do in the community you have to take a long hard look at. We’re worried about that day when you just can’t squeeze any more out. It’s a concern because I have a family just like the 399-plus employees do. One of our main goals it to make sure everyone who wants a job here can continue to have that job and for them to get paid every two weeks.

Dr. Scott Bohlke

Position: Family physician

Company: Bohler Family Practice

City: Brooklet

The situation: Bohlke, president of the Medical Association of Georgia, has practiced medicine in the town of Brooklet, about 50 miles northwest of Savannah, for nearly 15 years. He sees about 40 to 50 patients a day, about 5 to 10 percent of whom receive health coverage through the state's Medicaid program for low-income Georgians.

Impact of ACA: Bohlke and other primary care doctors in Georgia will be eligible for increased Medicaid payments created by the law. The goal: expand access to primary care by encouraging more doctors to accept Medicaid. In Georgia, the payment increases begin in November, nearly a year after they were supposed to kick in, and the federal government will only pay for the increases for two years. The ACA also promotes the use of electronic medical records, which can be especially costly for small practices.

Bohlke's view: I've had (an electronic medical record, or EMR) for almost 10 years now. Thankfully so, because if I was to do this now, it's very difficult. It's $30,000, $40,000, $50,000 sometimes even more to implement these things. We're having to add more things on to the EMR because of all of the things they're asking us to do, that requires time and effort. I took over a practice that's been here since 1956, one of the oldest established practices in my county. The physician here used to keep notes on 5x7 index cards, now we're having to give almost a dissertation on each patient visit. I spend less time with each patient at each visit because I'm having to do all of this administrative work.

We don’t feel like (Medicaid) is a financially sound system right now. Medicaid was supposed to increase pay to primary care doctors to the equivalent of Medicare rates Jan. 1 of this year. Well, we haven’t gotten it yet. We certainly want all the care to be given to every Georgian. We’re just not sure if that’s going to be possible in the current Medicaid system as it is now.

John Haupert, CEO, Grady Memorial Hospital, Atlanta

The situation: Grady Memorial Hospital in downtown Atlanta spends more than $200 million a year on free care for the uninsured. It receives about $90 million in federal Disproportionate Share Hospital, or DSH, funds, which help offset the cost of patients who can't pay, and another $60 million from Fulton and DeKalb counties. After years of dealing with huge budget deficits and teetering on the brink of closure, Grady made a modest profit least year and is projected to do so again in 2013.

Impact of ACA: An estimated 43,000 Grady patients would have gained health coverage under the Medicaid expansion and health insurance exchange created by the ACA, but Georgia has chosen not to expand Medicaid. Under the law, Grady stands to lose $45 million from the DSH program, which helps hospitals offset the cost of caring for patients who can't pay. But Grady won't be picking up the new revenue a Medicaid expansion would bring to help make up for the loss.Grady will face significant cuts to clinical services if a solution is not found. Hospitals are also facing financial penalties under the health care law for having too many patients readmitted within 30 days of their discharge.

 Haupert's view: The last thing that the administration wants or people in Congress want is this network of safety net hospitals across the country to fall apart. No one wants that as a legacy, and it's the wrong thing to do. You're going to penalize the most vulnerable populations if that ends up happening. Every health system has services that are important to people but are nice-to-haves. Then there are clinical services that are essential to the community, so we just have to prioritize and decide, "What can we no longer do for the community?" It's a little bit frustrating, but that's what I'm charged with doing. The health care system in this country has to get healthier. We spend way too much money. (At Grady), we are looking internally to determine if we are over ulitizing health care services. Part of what the ACA is about is forcing the accountability back on the hospital and physicians to wring the cost out of it. You're going to get paid 'X' how are you going to make it work? If you have 'X' you have to figure out how you're going to live off of 'X.' The health system in America is way too expensive and doesn't produce the outcomes for the money. One of the reasons I personally chose to spend my career in public hospitals and hospitals that serve vulnerable populations is to stand up for those folks. It just impassions me more to fight the fight.We have this big problem in this country. We've all got to get to the table to figure it out.

Sandy Maclin, CFO, HEALing Community Center, Atlanta

The situation: Sandy Maclin is chief financial and operating officer at The HEALing Community Center, which offers affordable and free care to about 3,200 uninsured, low-income patients each year. The center offers primary care and specialty services, such as ear, nose and throat, OB/GYN, pulmonology, cardiology, mental health, podiatry and health education services. Free and charity clinics in Georgia, such as HEAL, provided $420 million in care last year.

Impact of ACA: Since Georgia is not expanding Medicaid, many of the center's patients will continue to be uninsured and depend on the center for care. Some of HEAL's patients will be able to qualify for federal financial help to buy coverage on Georgia's new health insurance exchange.

 Maclin's view: I'm excited about health reform. (Charity) clinics are going to have to operate a two-business-model approach with the ultimate goal that no person would be denied service based on their inability or ability to pay. We're OK and comfortable entering into the market of competing with the federally qualified health centers, the hospitals, private practices and all because our overall mission is solely to reduce health disparities. We're not concerned about losing patients or funding as we are committed to our mission regardless.

We’re all about preventive care and health education. This year alone, we’ve seen the benefits of us providing education. We’ve seen more people coming for their annual (check-ups). We’re shifting the model from being a sick-care provider to really finding ourselves being a medical home for them. Everything is based upon a relationship. If the provider, if the staff does not establish a relationship with the community, with the patient, they will only come when they have a need. We were never just seeking to address the temporary needs. We were always in it for the long term – for social change. The Affordable Care Act gives us that opportunity. Everyone has the right to have access to care.

If the state allowed the Medicaid expansion, roughly 80 percent of our patients would be eligible. I'm not pleased with state (leaders).You're looking at 650,000 Georgians who could benefit from expansion. It's alarming to suggest that we want to do good and what's right on the behalf of people, but we allow our politics to jeopardize that coming to fruition. You're impacting the lives and the care of many with  one simple decision, and that's putting integrity into question.