Q: How will NAPH hospitals change their services or practices to respond to the millions of Americans who are now required to have health insurance?
Dr. Bruce Siegel: Well, first of all, I think expanding health insurance is a good thing. I think we all support that increase in access, but it’s not enough. We have to do more than just give people an insurance card. We’ve seen in Massachusetts that just giving people a card is not enough. Because of the lack of primary care in Massachusetts, thousands of people turn to the ER for care and it has a huge stress on the safety net. This could play out across the country, so this is the time when we really need to think about how we bolster the safety net. The safety net has been called upon to care upon for 32 million Americans who have insurance for the first time, so that’s going to take some work and some resources.
I think NAPH hospitals will be challenged to build medical homes for these patients. They’ll be challenged to find alternatives to emergency care, and they’ll be critical to enrolling people in these new insurance plans.
I think safety net hospitals are already becoming even more oriented toward primary care. And the reason I say that is because public hospitals are already ahead of the curve on primary care — much more than in other hospitals; they have a tradition of serving the needs of people who have nowhere else to go. People who have relationships with doctors often don’t go to hospitals, so in safety net hospitals we have people who don’t have a medical home already. I used to run the New York City Health and Hospitals Corporation, and we had 5 million physician office visits per year.
Q: How is the challenge of improving quality of care different for a safety net hospital?
BS: The safety net has to focus more on the critical resources it provides, like trauma services and neonatal services. Often the safety net hospitals are the unique provider of those things in a community.
I think it’s also different because sometimes patients are even more diverse in safety net hospitals. There are issues of language and cultural competency that have to be addressed. A lot of patients have fewer resources and may not have the social support that other people have in their community.
Q: How will NAPH hospitals assist the millions of Americans who have never had health insurance before now?
BS: It will be an educational challenge, convincing people that paying a little bit more to get insurance is a good idea. Some of the foundation has been laid with health reform, but there’s still a major educational challenge ahead. I think there’s going to be some resistance, so first of all, we need to make it as easy as possible for people to get coverage. We’ve put obstacles in people’s way and made it hard for them to get on Medicaid and stay on Medicaid.
I think we also need to educate people, especially young people, who think they don’t need insurance and that nothing bad will ever happen to them. I think it’ll work in the end, but it’s going to take years. I hope doctors and nurses across America can have a discussion across America, and I think we’re going to see public education campaigns on [taking preventative actions against disease].
Q: What have you learned about improving quality of care through your work at George Washington University?
BS: I’ve been privileged to lead a lot of work around improving quality in hospitals and in doctors’ offices, and we’ve seen often dramatic change. The lesson for me is that we can do a better job. There’s always room for improvement. I’ve seen changes where hospitals have dramatically improved quality of care they give to heart patients; I’ve seen communities improve their care for diabetics. Transformation can happen. It’s real, and I’m going to bring that spirit to my new job.
There can be resistance to improving quality because change is never easy, and I think the key is that people need to believe they have the power and the responsibility to change. Getting both those things together is critical. We have peers learn from peers, because people won’t believe experts saying something, but if they see their peers doing it, they’ll believe in it and follow.
Q: What financial challenges do you foresee for NAPH hospitals over the next few years?
BS: I worry that safety net hospitals won’t have the capital to build the primary care capacity they need, and I worry they won’t have the resources to bring on staff at all levels. Honestly, that’s why safety net funding has got to be a priority.
One of the things I worry about is people saying, “We’ve passed health reform, everyone has insurance, we don’t have to worry about safety net anymore.” Nothing could be further from the truth. Over 32 million people — many who are poor, many who don’t speak English as a first language — need care for first time. We need systems in place to do that, and there are communities where there are no doctor’s offices and no clinics, or existing facilities are at capacity. We’re going to need to set up those medical homes, and it’s important for public hospitals and community health centers to work together to make this happen.
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