February 4, 2023
Paul Couch, City National BankMatt Grimes, Desert Radiology
Dr. Paul Krakovitz, Intermountain Healthcare Medical Group Ryan High, Silver State Health Insurance Exchange
Michelle Joy, Carson Tahoe Health Dr. Ali Nairizi, Reno Tahoe Pain AssociatesMason Van Houweling, UMC
Connie Brennan, Nevada Business Magazine ∙ Dr. John Rhodes, Southwest Medical AssociatesBarry Duplantis, REMSA Health
Todd Sklamberg, Sunrise Medical CenterJon Van Boening, Dignity Health -Photo by Bryan Hainer-

The healthcare industry is no novice to the spotlight. And while it is no longer burdened by a global pandemic, it is still an industry under fire as it grapples with challenges of access, affordability and maintaining a qualified workforce. Recently, healthcare executives met at a roundtable sponsored by City National Bank and held in Las Vegas to discuss these challenges with other experts in the industry.

Connie Brennan, publisher and CEO of Nevada Business Magazine, served as moderator for the event. These monthly roundtables bring together different industries to discuss issues and solutions.

Photo by Bryan Hainer

How severe are Accessibility challenges?

Matt Grimes: The biggest challenge in healthcare right now is access which also relates to reimbursement or the lack thereof. Radiology is looking at a 7 percent cut in Medicaid and Medicare reimbursement next year and that is going to be painful for us.

Todd Sklamberg: One of the drivers to accessibility is the economics of healthcare, in particular on the reimbursement side. Nevada ranks towards the bottom in terms of reimbursement, particularly for Medicaid patients. We have over 700,000 patients on Medicaid here in the state of Nevada and for acute care hospitals [with] reimbursement [being] at 57 percent of our cost, not our charges, but our true cost, it becomes very difficult to maintain the services.

Barry Duplantis: 911 has now become the gateway for most people to access healthcare. People are calling for all kinds of reasons. It could be because someone is having a heart attack or a stroke all the way down to somebody has a toothache and they do not know what to do.

Dr. John Rhodes: If patients cannot be seen for 60 to 90 days, of course they are going to call 911 to get in because they can’t get into a physician [in a timely manner]. Or they are going to drive themselves to an emergency room to be seen. And usually if it takes 90 days to get an appointment, you might not even establish care with somebody because you do not want to wait that long for it.

Is the Healthcare Industry Struggling to Recruit and Retain Talent?

Photo by Bryan Hainer

Duplantis: Healthcare is a calling, it is not just a profession. It is hard as heck, and the work is hard. The hours are tough, and sometimes people do not appreciate exactly what you are doing.

Jon Van Boening: We have a huge shortage of physicians, nurses and other professionals, [from] pharmacists all the way down the line. We need to recruit and retain more people here in Nevada.

Mason Van Houweling: The big thing is the pipeline, especially around nursing. We just do not have enough slots and we do not have enough faculty. We would all probably hire about 200 nurses today if we could get our hands on them. We have great students coming out of high school and college here, but they can’t get into nursing school. I have heard of people having to go to Alaska and to other states [to work], but they want to come back here and people that do their training here are more committed to staying in the community.

Grimes: I work with the radiology students and the demand is there. In fact, they have over 250 applicants for the radiology program, but they can only take 26 students because they do not have enough clinical sites. It is the same with nursing. They have enough nurses that are applying for the school, but they just can’t get into the schools.

Rhodes: [Nevada] is ranked at 48th for primary care physicians per capita of anywhere in the country. And I believe that is probably lower if you just isolated it to southern Nevada. Northern Nevada has a little more. We are actually going outside of the state, even though most residents stay where they trained, we are going outside the state to bring in new doctors into our community. We are trying to do our best to do that instead of just having doctors shift around within the community.

Dr. Paul Krakovitz: Recruiting physicians in the workforce is definitely a challenge. The numbers here in terms of positions per capita are much lower than they are in northern Nevada. In fact, if you isolate it out, we are probably last in the country. We are not 48. If you look at psychiatry and pediatricians, we are last. These are kind of sad statistics to say.

Photo by Bryan Hainer

Duplantis: Employee turnover is really tough in this state. Fewer people are going into healthcare professions, particularly since COVID. We need to start to acclimate and inspire middle school kids and high school kids to pursue careers in healthcare.

Krakovitz: Physicians over the age of 50 are retiring at rates that we have never seen before. The great resignation hit the position workforce as well. [We are] thinking about things creatively. How do we bring in physicians internationally? How do we make an environment that is conducive for physicians wanting to work? More physicians need more flexibility. Over 50 percent of our medical school classes are females, and we must be able to work around the working mother.

Dr. Ali Nairizi: [If you] look at the statistics for Medicare and the payments from 2001 to 2022 and you adjusted for inflation, the physician’s payment has been cut down 22 percent since 2001.

Duplantis: All of our workers deserve to make more. We all want them to earn a living wage. When you really get down and think about it, our workers or the minds and the hands touching our patients, we should want to compensate them more than the guys or gals that are working in fast food, for example. And our wages on the starting entry levels of many of our businesses are very comparable with fast food, where no skills are required, and [yet] we are expecting a high level of skill and an enormous level of compassion for the patient.

Sklamberg: Heading into this legislative session, [we should ask] what can we do to reduce the barriers to attract physicians and nurses? We have a shortage of over 3,000 nurses here in Nevada and we are one of the few states that are not part of the National Nursing Compact. [That] creates additional barriers for healthcare professionals who want to come in the state. First and foremost, we need to ensure that everybody meets the criteria and could provide high quality care. But [we need to] reduce the barriers at the state level to help facilitate recruitment of healthcare resources, nurses, physicians and otherwise.

What Lessons Did the Healthcare Industry Learn From COVID?

Photo by Bryan Hainer

Boening: I think our takeaway was we could do it. We adjusted, we rallied, we focused, we planned and we did it. We took care of all that excess business and all those really sick patients. The masking thing was a nightmare, but we got through it. Thank goodness it is mostly over. The information flow was very difficult to understand for the public. We had to help them sort through that. We all did a great job of handling that influx of those very sick, scared, sometimes misinformed patients.

Van Houweling: It really was a rallying point for us. It strengthened us and brought us closer. It was one of our finest hours to show other industries. It certainly showed that we could all work together and [I am] very proud of our state. Looking back on it, we all responded and I am forever grateful for our state, although not popular, shutting down to give us that pause to get ready for what we saw coming [with the increase in COVID cases].

Grimes: There was some cool technology as well, [including] telemedicine, that accelerated [during the pandemic] to help [provide] preventive healthcare so [that patients could] stay out of the hospital. One of the things that we learned for imaging is how to stay open and stay open safely and also provide care, especially around mammography, to make sure that women were getting the proper breast cancer care so they did not wait and end up in the hospital.

Krakovitz: One of the big lessons we learned from COVID [is that] we must put people in the center of what we do and the collaboration really was our finest hour. It is about not kicking the can down the road. Before COVID there was a huge burnout issue in all of healthcare. We kind of put it under the rug and the same thing is true for the cost of care. That was a big issue long before this. And COVID maybe accelerated [it], but it is a big lesson for us to say when there is a problem, we need to face it and we are best facing it with all the people at the table collaborating as opposed to trying to do it individually.

Photo by Bryan Hainer

Rhodes: If you put the patient in the center of everything we do, the rest tends to work out and the right things will happen. I think through COVID, we did that. We all came together as a community, probably better than we ever had before in healthcare by putting the patient and the community in the center. Instead of us all being in competing businesses within an industry, we came together to make a difference for our community. That is a lesson learned, if we continue to work together. We all have different businesses and different responsibilities, but [if] we can work together and continue to keep putting the patient in the center of it, I think we have the best chance to move everything forward in our state.

Sklamberg: We are seeing that play out now as we are facing what some would call the triple-demic with significant RSV and flu attacks in our community and particularly in pediatrics. We are seeing collaboration. We have weekly calls now with the major pediatric providers here in town looking at resources and at best ways of providing care. We are talking about how we could import additional resources to help out and that was what we did during COVID. We are now seeing it play out in real time today.

Michelle Joy: [The question is] how do we now build off the response that we had during COVID? How do we tell the story of our workforce and of all of those heroes that stepped up and were there to take care of the community? For quality of healthcare, a key component is the quality of care that we were able to provide in such an unprecedented time. Part of that is through ongoing readiness. We were expected to be at the ready all of the time and we were able to do that for our communities. Now how do we continue to build that trust and that confidence within our communities around what we were able to do the last couple of years?

What Issues are Contributing to Healthcare Affordability?

Photo by Bryan Hainer

Krakovitz: There are a million ways you can look at affordability, but the first part is from a patient side and the cost of insurance has gone up dramatically. If you look, in the last decade, at someone’s total income, on average in the state [the cost of insurance] went from 8 percent of their income to 14 percent. That is the first big hit that you see and that hurts. And you see high deductible plans. And that is why we see a lot of rationing of care and rationing of medications. When you look at the cost of medications, they are through the roof. That is all very real, and it all goes back to affordability.

Ryan High: The cost of health insurance may be going down with ARPA (the American Rescue Plan Act) that increased subsidies for everybody across the board. And with the Inflation Reduction Act, the IRA, that passed a few months ago, it extended those increased subsidies another three years. It is making healthcare more affordable.

Boening: The bottom line is that the federal and state government intentionally pays well under the cost to providing healthcare [and so] the cost shifted to the private sector. They intentionally paid well below our cost of providing the service to them and expect private sectors to [use] insurance to cover their shortfall and their underpayments.

Grimes: I also do not think the public understands the total costs. [For example], how much does an MRI cost? It is a million-dollar piece of equipment and it costs $100,000 a year just to maintain it through service contracts. I think we have started seeing a 15 percent increase in our starting wages for technologists and I think it is a little bit higher for nursing as well. So those are big costs that were hitting us right in the face without any increases from Medicare.

Duplantis: The public [also] does not understand the cost of readiness. [For example], in the case of radiology or in the case of a hospital, the public expects you to be there and the doors to be open. [They expect] you to be available to respond any hour of the day or night. There is a cost of readiness for which we have to absorb.

Sklamberg: Healthcare, in particular hospitals, is one of the few industries where we do not have the ability from a revenue side to adjust the revenue model. We have inflation going up 5 or 10 percent per year, but much of our revenue is fixed. Medicaid is a fixed payment mechanism. The state, other than once, has not increased rates in 20 years. So as inflation is going up, the revenue is fixed and we are seeing now a wider gap as it relates to the expense challenges and the inflation challenges.

Duplantis: Medicare takes the point of view that, because they are the highest volume purchaser of services, that they should get the very best discount available on the planet and they basically dictate compensation or reimbursement. What happens is, the typical revenue model for most of us is something like 20 percent commercial pay, 40 percent Medicare, 30 percent Medicaid, and then we do a lot of uncompensated care because we do not turn anybody down when they call 911. When you look at that, and the cost shifting, it is becoming more and more difficult because commercial payers are increasingly pushing back on the fact that the government has taken that posture over the last probably several decades. They are basically saying, “We are not doing that anymore.” It has definitely put a frustration for all of us on the revenue side because costs are rising.

Joy: The math is not working out from the 20 to 30 percent increase in costs, whether it is labor or supplies, and then the continuing decline from a reimbursement perspective. So what is recovery going to look like? How long is that recovery going to be? It is something that we have not faced in healthcare before and [we are] trying to figure out how to focus on value and reducing our spend.

Krakovitz: When you look at payment models, particularly in this state, [Nevada] is one of the lowest paying Medicaid states in the country. And that makes it really difficult to be able to make a margin so that you are able to be sustainable and able to get the great care that we want to be able to provide in this state. The other part is that we have seen so much inflation that it makes it even more difficult for us to really look in the future and ask how to invest to make sure that we’re improving care for the community and for the patient.