In the Surgical Intensive Care Unit with Annie Brito, RN

Dr. Bill Atkinson is WakeMed president & CEO.

When doctors made house calls and the infirmed were cared for at home, family members fulfilled the nursing care role. As health care became more sophisticated, nurses quickly became the cornerstone of the health care system.

Today, nurses provide the backbone of hospital care 24 hours a day, 7 days a week and the around-the-clock attention provided by skilled nurses is why inpatient care is so critical to patients’ recovery. As nursing care becomes even more highly specialized and an increased national emphasis is placed on primary care, nursing will continue to become even more critically important to the health of our country.

I would like to take this opportunity to thank all of the dedicated nurses providing quality, compassionate care to patients at WakeMed and in our community. The importance of nursing cannot be understated. To me, nurses are first among equals when it comes to health care.

People who live, work and play in Wake County should be thankful for and take comfort in having such a well-trained, progressive EMS system.  They are consistently on the cutting edge, ensuring that every call they respond to and patient they assist receives the highest level of out-of-hospital care, whether the call is for a cardiac arrest or otherwise. I would especially like to tip my hat to their medical director, Dr. Brent Myers, who also serves as an emergency department physician in the WakeMed system.  

Right now all governmental agencies are under pressure to reduce costs, work harder and smarter. Wake County EMS is an excellent example of a county service that is demonstrating real value as an agency and through its coordination with community health services and organizations. We should all remember that what happens in the field with first responders and EMS is important to everybody who lives in this community, because at any time you could be the one in need.

EMS — especially the field care, transportation, communication and workforce components — is an essential part of the U.S. health care system. However, EMS is often out of mind when the larger scope of the complex system is considered by health care planners.

Even though EMS-related components were only referenced four times in the health care reform legislation, we are well aware anything evoking major change to the overall system will ultimately have a far-reaching impact on EMS and emergency care patients.

The health care landscape is constantly evolving and changes have already been occurring. Relationships between hospitals and physicians have been strengthening. Hospitals have been consolidating. States like Massachusetts have taken greater steps to insure their population.

Major public and private investments in information technology and connectivity have been occurring. Insurance premiums have been rising rapidly, and there is a growing list of federal and advisory standards on quality, safety, education and community health.

And, hospitals have been creating solutions to ease capacity by opening urgent care centers and freestanding emergency departments. This recent legislation accelerates many of these changes and adds many significant new elements to the mix.

Ultimate goal
The legislation’s ultimate goal is to insure more Americans and to make health care more accessible, affordable and higher quality. Thirty-two million more Americans will have affordable access to health care insurance because of this legislation.

In EMS, we are well aware there are “haves and have-nots” when it comes to health care. This legislation should take us far in narrowing the number of “have-nots,” but EMS and emergency departments will continue to serve as a primary entrance to the health care system for the remaining uninsured.

Hopefully, the outcome of this legislation will be a smaller, more homogeneous uninsured population making it easier to provide appropriate and timely health care solutions. But even with a growing number of insured patients, the shortage of primary care providers will likewise continue to contribute to a growing use of EMS and EDs as a “front door” to health care in the United States.

The future of the health care payment system will be based on quality and effectiveness instead of quantity. This model will encourage further integration and coordination among health care providers to ensure the patient is receiving the right care at the right time. This coordination will have to happen at all care and service levels, from EMS to rehabilitation.

The legislation should also help distribute the cost of health care more evenly. In today’s system, cost shifting is a reality. We are paying for health care delivery in one way or another through our own medical bills, insurance premiums and taxes. This legislation should give us a clearer understanding of what we are paying for and what we are getting for our money.

Ideal system
The ideal health care system will include collaboration, coordination, cost effectiveness, efficiency, proven technology, quality and safety, a reduced rate of growth, scalability, sustainability and transparency.

While this legislation is a step in the right direction, there are elements that will not take effect for several years. And, many of the decisions about implementation will occur at the administrative level, so the final impact at the local, state and national levels is still ambiguous.

The history of the health care reform conversation began with President Teddy Roosevelt in 1912 and will extend well beyond the current administration. This, like most things in life, will evolve over time.

There are significant opportunities for EMS to fix the things that haven’t worked in the past, and there are opportunities to make health care better for everyone involved, starting with the patient. Doing the right things — for the right reasons — remains the appropriate focus in EMS and across the health care spectrum as we move forward.

But overseas is not the only place where we experience terrorism.  When people organize with the purpose to cause harm it creates a state of fear – whether the violence happens in your own neighborhood or in the Middle East. 

When a young man is shot after being sought out following a confrontation at the local club Envy (formerly known as Black Tie), or most recently, when a Domino’s assistant manager is fatally assaulted in a robbery attempt* – these incidents are examples of terrorism in our own neighborhood. This is violence we must band together to eradicate. 

Let’s strengthen our communities, work with our neighbors to turn the criminals in and send a clear message that this kind of violence will not be tolerated.

* Note that law enforcement is looking to the community for leads to help catch the Domino’s thief and killer.  A reward fund has also been set up with Eastern Wake Crime Stoppers. Anonymous tips can also be filed by calling the Knightdale Police Department (919) 217-2261.

Representative Brad Miller

Congressman Brad Miller has been a great friend of WakeMed’s since his days in the North Carolina General Assembly in the 1990’s, and has since been elected to the U.S. House of Representatives. He’s on his way back up to Washington this week, and was able to stop by WakeMed on Monday to take a tour of WakeMed’s new Children’s Hospital and discuss several health care reform issues.

Changes must be made to the current health care system, as I’ve said time and again, but the changes must protect – and improve – WakeMed’s ability as a safety net hospital to provide care to our community regardless of their ability to pay.

Currently, Medicaid payments to hospitals and providers fall short in covering the costs of services delivered.  Expanding Medicaid to more individuals, as both the Senate and House bills propose, will exacerbate the already difficult financial situation faced by many hospitals.

Congressman Miller agreed that the proposed health care reform legislation will be an opportunity to start anew, and that a focus on improving cost efficiency is vital. Spending money efficiently and effectively is important because here at WakeMed, we’re already operating on a pretty tight margin. Last year, WakeMed provided more than $135,000,000 in uncompensated care, which accounted for 16.5% of our total operating expenses. Uncompensated care is defined as the total cost of treating charity care patients, bad debt costs and unreimbursed costs of treating Medicare and Medicaid patients. Medicare and Medicaid programs reimburse providers at less than the full cost of providing care.

The Congressman was also interested in finding cost savings in the system. He was supportive of WakeMed’s desire to study cost effective alternatives to the current emergency department triage process – which is complicated by the federal law known as EMTALA.

It was reassuring to hear Congressman Miller’s strong support of the health care reform bills, particularly his support of the issues that are pertinent to our organization – such as the funding for trauma centers that Christine Craig discussed in a previous post, and funding for programs on childhood diseases like asthma and diabetes.

Just after our conversation, State Government Radio caught up with Congressman Miller for an interview. “Health care premiums have doubled in the last 10 years, and we can’t do that again. Something’s gotta give,” he said.

It is true that careers in health care are exceedingly rewarding, stable and come with an infinite number of opportunities.  But contrary to popular belief, no industry is immune to economic changes and pressures.  Health care organizations feel the pain just like most every other industry in this country.  For example, the state budget pressures in 2009 resulted in significant cuts to Medicaid, state employee plans, prisoner health care reimbursement and other state controlled programs.  These changes affect hundreds of thousands of people throughout North Carolina – and not just those on Medicaid or in the prison system. These changes have a trickle-down effect and impact the services health care organizations are able to provide.  

Reimbursement cuts have required WakeMed to make tough decisions in order maintain an acceptable margin so we can continue to live up to our long-standing mission.  Already a lean, efficient organization, we’ve scaled back some services, lost some good workers, delayed construction on certain projects and temporarily reduced some staff benefits.  Partially due to these tough cuts, we ended the fiscal year in a sound financial position and were even able to reward our workers through a payout via our WakeShare (gain-sharing) program. In fact, this represents the sixth year in a row that WakeMed has been in a position to issue WakeShare. Very few hospitals or health care systems in North Carolina have a similar program or record in this regard.

But, we have learned that we cannot be all things to all people and still remain a flexible institution. We need to start looking to our own community — and all health care providers in the county — to help address community issues in a truly meaningful way.  WakeMed has traditionally done much of the heavy lifting by hospitals in Wake County – and we’re happy to continue to do the hard work, but we cannot  continue to do it generally alone.

Let’s hope we see real action taken on health care reform by the end of this year so we are not having this same conversation in 2026.

My hope – and our work –is that our nation will take meaningful steps to assure that everyone in need has true and timely access to care. Likewise, we need to reduce the cost of healthcare and – importantly – make significant advances in the quality and safety of care across the nation. On our watch as healthcare providers, we all have an obligation to be engaged in the discussion and to provide meaningful input. And while it is unlikely that everyone will agree on all the key or even minor points, in America it is important that everyone always has a right to contribute to the final policy outcome. In the care of health care, the decisions made will impact not only everyone here today, but also generations to come. Health care reform is serious stuff and deserves our full and focused attention.

The new payment structure we’re discussing will be designed to focus on the quality of care, instead of the amount of health care services provided.  Currently the nation employs a fee-for-service model where providers are paid for each service they deliver.  The AHA task force is devoting a good amount of time discussing the concept of bundling of payments – where all providers involved in a patient’s care will be paid one flat fee on an “incident of care” basis.  This bundling, as proposed by the government, would encourage teamwork among health care providers, improve cost efficiency and enhance health care quality and safety. Equally important, it will allow for better distribution and use of existing resources and therefore improve the access to care.

As a first step, we have identified several recommended guidance principles to help ensure that all health care providers across the nation are fairly compensated.  This includes figuring out how to handle the differences between various markets, types of institutions and physician practices and payment populations.  It’s important for our nation to create a sustainable model that will work for physicians and, of course, hospitals of all types:  rural hospitals that treat fewer patients, inner city hospitals that primarily care for low-income or uninsured patients and large non-profit hospital systems like WakeMed. 

The AHA task force still has quite a way to go because the national health care system is extremely complex, but when the work is complete, I will share with you a copy of the task force’s final observations and recommendations related to nation-wide reform.

UNC Gillings School of Global Public Health

A few weeks ago I spoke with a group of graduate students at the UNC Gillings School of Global Public Health about health care in America today. We talked about where the American Hospital Association (AHA) stands on reform, what to expect in future health care trends, and when to anticipate seeing real change in the system.

The big news in recent weeks is that both the U.S. House of Representatives and the U.S. Senate voted to approve health care reform bills that include many of the key elements of health care reform addressing access, cost, and quality. The votes were clearly partisan and the proposed bills are far from perfect, but at least there is now a formal legislation-based platform for debate.

But no matter how quickly Congress may approve any form of health care legislation, it’s probably going to be some time before average Americans start to see noticeable changes in the health care system.

Most proposals would begin to introduce elements of health care reform over several years.  But I believe most consumers understand that there is a real world, practical need  to implement at least some basic access, cost and quality changes in the health care system in the U.S.  without years of delay.  In fact, some important fundamental changes are long overdue.  And although we are talking about a very complex system with many very positive and world-class parts, health care providers and systems need to start seriously working without delay on advances in clinical care and information. We all know there are many improvements that can be made, and while I believe that organizations like WakeMed that have the resources and the expertise need to be on the leading edge, I also believe we are in a strong position to help smaller hospitals and community providers with their own move toward access, cost and quality advances.   We all need to commit to working closer together for the benefit of patients.

So while some changes will likely begin to take place in the next few years, many of the reforms being discussed today won’t become reality overnight – though the young Public Health students I spoke with will see meaningful change during their lifetime. And from what I saw in the classroom a few weeks ago in Chapel Hill, I truly believe that some of these students will be the ones to instigate change and improve our health care system. What an impressive group of students! This is no real surprise, I should note, given the strength, commitment to excellence and highly talented faculty at the UNC Gillings Global School of Public Health.  We are fortunate in North Carolina to have many fantastic public and private institutions of high education.

As Carl Sagan said, “In order to make an apple pie from scratch, you must first create the universe.” And that means we’ve still got a lot of work ahead of us to fix our health care system. And, as the AHA notes, and as I told the UNC Public Health students, reforming the health care system in America has to be “an evolution and not a revolution.” But regardless of the timing, patients must remain our primary and central focus. Health care is, after all, still about people helping people.