Presbyterian Healthcare Services, a not-for-profit, integrated health system based in New Mexico, has succeeded in launching care models that keep patients out of the hospital. Dale Maxwell, who officially took over as CEO just over a year ago, says the organization will continue to advance new delivery models. Presbyterian has also been at the forefront in addressing end-of-life care and social determinants of health. Maxwell recently spoke with Modern Healthcare public health reporter Steven Ross Johnson. The following is an edited transcript.
Modern Healthcare: What are some of the characteristics of the types of patients you serve in New Mexico? How do they reflect what we're seeing nationally?
Dale Maxwell: We operate in a challenging business environment. First off, New Mexico has not fully recovered from the economic downturn of 2009. We're not seeing job growth, and we're not seeing any significant population growth like our neighboring states Arizona, Colorado and Texas.
The second piece is that situation drives a pretty high concentration in Medicaid business. So with a lack of job growth, we're not seeing private payer or commercial business grow on a year-over-year basis. What we are seeing are continued increases in Medicaid.
According to the Kaiser Family Foundation, New Mexico now has the second-highest percentage of residents served by Medicaid, and it's estimated that in the near future that 1 in 2 New Mexicans will be served by Medicaid.
Third, we continue to see declines in our government reimbursement from Medicaid as our state struggles with budget concerns, and from a federal standpoint with pressure to reduce overall costs.
MH: We continue to hear talk in Washington about changes to Medicaid. What kind of impact would that have on your business?
Maxwell: My impression of what's going on right now is it's about how we pay for the program, whether it's from a federal standpoint or a state standpoint. New Mexico did participate in Medicaid expansion, and that has had a significant benefit to our state. We now cover about 220,000 more New Mexicans and it's dropped our uninsured population from 22% to just a little over 9%.
If we see reductions in … the match dollars we get from the federal government, it will put significant pressure on the state to fund those additional 220,000 lives. My concern going forward is just understanding the funding mechanism and that those currently insured may fall off the rolls and fall back into an uninsured status.
MH: How does that high proportion of Medicaid beneficiaries affect your care delivery approach?
Maxwell: We're very fortunate that our business model is an integrated system, meaning that we have an insurance company, we have hospitals and we have a provider group that employs a little over 1,000 clinicians. Because of this integrated model and the expertise and knowledge that we've gained over the last 30 years, we have to find innovative ways to take care of the population and to provide high-quality care at a lower overall cost.
Just to give you a couple of examples: first is a program that we call Complete Care, which provides intensive home-based care to our Medicare Advantage members in their last two years of life, who make up about 5% of that total population but about 64% of the total medical costs. Through this program, we take high-risk members and provide access and interventions in their homes. This includes providing care coordination, telemonitoring, palliative-care home health, social workers, etc. This is what we call a "never discharge" model so patients are always in service, and we have a team that is available to assist these patients on a 24/7 basis. The benefits of this program reduce hospitalizations, reduce the overall cost of care, and when we look at hospitalization rates for this population on a predictive basis, we fall about 50% of where that population normally would be.
MH: Speaking of palliative care, your system has been a national leader on that front. Could you discuss your involvement with the Center for Advanced Palliative Care?
Maxwell: It's an important part of how we think care should be delivered. We're proud of the accreditation that we have. And again, it leads back to our integrated model of delivering care and doing the right thing for those patients at their end of life.
MH: How has being an integrated health system helped you address some of the biggest challenges many healthcare providers face when it comes to reimbursement, rising healthcare costs or even physician shortages?
Maxwell: We have the knowledge and expertise that we've gained over the last 30 years. We have answered many of the questions that other health systems are just beginning to ask themselves as they begin to transform from fee-for-service to pay-for-value. It aligns our incentives very differently. We are concentrated more on taking care of a population than just trying to run services through a hospital and a physician group.
Another example is our hospital-at-home program where we provide comprehensive care for patients whose illness is severe enough to warrant hospitalization, but who can be treated safely in the comfort of their own home. Hospital-at-home has been found to be safer for patients, more cost-effective, and the outcomes are equal to or better than a traditional hospitalization. It also allows us to look at access to care in a different way.
You asked about the shortage of physicians. One of the soft launches that we've done in the last quarter of 2017 and in the first two months of this year implemented what we call MD Smart Exams. These are visits where you log into a computer or your phone and conduct an exam in an asynchronous manner. In the first two months of 2018, we provided over 1,400 of these visits, and that's equivalent to about two primary-care physicians as well as their staff. So we can provide quicker access to care, better satisfaction for the patients and our members, and we can do it at a reduced cost.
MH: Your organization has been involved quite heavily in trying to address social determinants of health. What are some of your more recent population health initiatives?
Maxwell: We believe that addressing social determinants of health is part of our responsibility as a health system and it actually falls right in line with our integrated model of taking care of the population. There was a study that was released by the National Survey of Children's Health, and it showed that New Mexico ranks the highest for children who have suffered from adverse childhood experiences, or what is called ACEs. These are events in a child's life that are traumatic in nature that would include abuse and neglect, hunger or extreme economic insecurity. Hunger is a big part of that, and that's an issue where we have played an important role in the community and in the state.
In New Mexico, 1 in 6 residents struggle with hunger and we're actually tied with Arkansas for the second-highest rate of food insecurity among children. We have a food pharmacy pilot in place. This is a program that we're currently testing where you can actually receive a prescription for food. So a patient or member gets a prescription for healthy food and then they visit our food pharmacy to get their prescription filled.
We also have a free meal program. We are partnering with the U.S. Department of Agriculture, and any child under the age of 18 who presents at one of five of our hospitals, we actually give them a free meal.
MH: Have you seen the business case for employing these types of initiatives? Have you been able to generate any type of cost savings as a result of these efforts?
Maxwell: Absolutely. As an integrated system a big portion of our revenue comes in through our health plan. So if I look at our revenue stream, about 65% of that is fixed, it's on a per member, per month basis. We are directly incentivized to provide quality care at an overall lower cost of care. We do have examples of population health management that show benefit and return on the investments that we're putting in place. You know a significant part of that is the data and analytics. We're investing a substantial amount to stand up a robust data and analytics platform that not only looks at clinical information but also looks at the claims information that comes into our health plan. So we can manage that population and have better outcomes for example with diabetic patients or patients with high blood pressure that show pretty significant outcomes.
MH: How have your religious affiliations influenced your care mission?
Maxwell: Presbyterian was started in 1908 as a tuberculosis sanatorium. Rev. Hugh Cooper, who was a pastor at the Presbyterian church here in Albuquerque, saw a need; there was a high prevalence of tuberculosis, and not enough institutions to take care of those patients. So he actually started Presbyterian 109 years ago. Since then, we have obviously transformed into a hospital system, and into an integrated healthcare delivery system.
Although Presbyterian is in our name, we are no longer affiliated with the Presbyterian church. Our legacy of caring continues to move us forward and our purpose of taking care of the citizens of New Mexico remains with us.