Efforts underway to improve Arkansas' low overall health ranking

Arkansas is consistently ranked near the bottom in terms of overall public health. Top healthcare executives in Arkansas are determined to "bend the healthcare curve" to help create a population with better health.

"There is likely not one solution, but rather a series of incremental steps that will be necessary to improve overall health in Arkansas," said Washington Regional President and CEO Larry Shackelford. He advocates initiatives to encourage Arkansans to take personal responsibility to be healthier and more active.

"For example, Arkansas has an obesity rate of 36 percent, which is currently the 7th highest rate in the nation," Shackelford said. "However, high school students in Arkansas rank first in obesity in the nation. It is critically important that we educate our youth about the importance of physical activity, that we provide access to healthy foods that meet dietary guidelines and that we encourage less consumption of sugary beverages."

The University of Arkansas for Medical Sciences (UAMS) is in a unique position to help improve healthcare outcomes due to having employees in 73 of the 75 counties in the state according to Chancellor Cam Patterson, MD. That is the focus of the UAMS Vision 2029 plan.

"It is really critical that we ensure that everybody is on the same page," Patterson said. "The strategic plan was created by people who work here. Because of that, it is much easier for us to be sure that everybody is engaged in implementing this plan. We have intense interest and enthusiasm in moving our strategic plan forward."

While it is possible to have exceptional healthcare without great health outcomes, people in rural parts of the state often don't have access to healthcare. That could be due to a lack of providers or lack of transportation.

"We can do great things to improve healthcare in Pulaski County, but to move the state forward in health outcomes we need to focus on working with people in counties with poor healthcare metrics," Patterson said "That is where UAMS is focusing its efforts to make sure Arkansas is not just another Southern state with bad healthcare outcomes."

Conway Regional CEO Matt Troup says poor health does not necessarily mean poor healthcare.

"Health is driven by factors like obesity, lack of exercise, smoking and a poor diet that statewide healthcare has not been able to impact," Troup said. "Faulkner County is the fourth healthiest county in the state largely due to having a population that is younger and exercises more."

But having timely access to healthcare when needed is critical.

Beverly Nix Stone (r) exchanges ideas with Matt Troup.

"Legislators can help with how they fund healthcare," Troup said. "We need to protect the Medicaid expansion. Protecting Arkansas Works is going to be important to improving health."

Patterson said Arkansas has been spared the closure of rural hospitals that have afflicted neighboring states that didn't expand Medicaid. "The legislature has a direct and very beneficial impact on access to care in many of the more rural counties," he said.

Beverly Nix Stone, MA, FACHE, CEO, SHARP, Inc., a physician-hospital organization based in Jonesboro with about 4,300 providers and 173 facilities, agrees the lifestyle issues must be addressed to improve health in the state.

"We are providing care for many people who are obese and who do not engage in a healthy lifestyle," Stone said. "To make improvements, we need to start with our own industry, test some innovative ideas and see what works within our healthcare workforce. Focusing on maximizing cooperative project output and positive work environments for different personality types, and working with exhausted and stressed out people to develop effective stress management skills would be a good place to start."

She also advocates greater taxation for substances that adversely affect health.

"The tobacco tax was a great start, but more needs to be done," Stone said. "We need to make these items as expensive as prescriptions for the treatment of the diseases they are causing. We then need to use those tax funds to reward providers who are doing great work on reducing their patients' smoking percentages."

In addition to poor lifestyle choices, Adam Head, CARTI president & CEO, also points to inadequate health education and limited access to specialists as important factors.

"However, I believe Arkansas is home to the greatest healthcare minds and resources in the nation," Head said. "It's time we figure out how to deploy these resources more effectively."

CARTI's vision is to be the premiere cancer treatment destination for Arkansas.

"This means we not only attack head on the very factors that create our state's poor health rating, but that we also educate Arkansans to understand they are receiving the best oncology care in the nation," Head said. "With the state's largest oncology services footprint, we feel it is not only our responsibility to educate patients on cancer risks, screening and treatments, but to provide them access to first-class oncology services in the communities where they live. CARTI currently serves patients at eleven locations across our state and we are in the process of building two additional locations. We still need to do more."

Head said state legislators and healthcare leaders must work hand-in-hand to bend the healthcare curve.

Patterson said they are beginning conversations with legislators to reimagine how to provide access to great care in sparsely populated counties.

Dr. Cam Patterson

"A great example is our push toward seeking National Cancer Institute designation for the Winthrop P. Rockefeller Cancer Center," Patterson said. "That will have a benefit for people across the entire state improving outcomes and increasing measures to help people prevent cancer."

Conway Regional's Troup said improving health outcomes includes focusing on training and developing primary care physicians.

"You may have heard there are about 250 physicians graduating from medical school who will have to go out-of-state to get residency training completed," Troup said. "We are seriously considering a residency program that will allow us to retain those physicians in state. Studies show physicians tend to stay in the area where they go to school and train. The number one thing we can all do to improve health is to increase access to primary care including preventive care to keep people out of specialist offices and out of hospitals."

Stone advocates teaching children proper nutrition and exercise habits early on.

"When I was a student, school lunches were meals that were healthy and hand-prepared by lunch personnel every day," Stone said. "When I have lunch with my grandchildren at their schools, I see that everything appears to be prepackaged. This is not food that children need to be eating every day, and additional funding for improving those choices is very important. I feel we are raising a generation that might not be knowledgeable about proper eating. I also believe that recess time is absolutely vital. Children are not learning to run and play or realizing how much fun those activities are."

Healthcare organizations can help by leading the way.

"As one of the largest employers in our community, Washington Regional strives to create a healthy work place," Shackelford said. "We recently extended hours of our 5 Loaves Sandwich and Salad counter from 11 a.m. to 1 a.m. to offer healthy and hot food choices to our team members who work on nights and weekends. We offer a wellness plan that includes a reduction in health insurance premiums for those employees who see their PCP annually, participate in health screening and basic annual lab tests, and participate in wellness activities. We also encourage our employees to be physically active and provide discounted rates at our Center for Exercise."

The Affordable Care Act (ACA) was passed in 2010, nearly 10 years ago. Shackleford said Arkansas' ability to expand Medicaid and access to healthcare resources has improved the care for many.

"More timely access has allowed many to receive care earlier in the disease process and allows more cost efficient and effective care," Shackelford said. "Comprehensive primary care initiatives have improved access for more patients to see a PCP and have incentivized primary care providers to be more proactive in risk assessment and management of complex chronic care conditions. The additional resources to allow practice transformation and implementation of care managers have been good for overall care."

However, physician services are inadequately reimbursed compared to many surrounding states.

"The ACA did little to impact the finances of healthcare and little to encourage personal responsibility for patients," Shackelford said. "In addition, we also have uncertainty in funding of Arkansas' Medicaid program following the recent federal court decision that struck down work requirements. These are all issues that must be addressed if we are to have a sustainable health system."

Troup said the ACA helped provide coverage to more than 300,000 formerly uninsured Arkansans. But it also increased demand; waiting times to see a doctor have increased.

"It was good more people were coming to the doctor," Troup said. "But as the ACA continues to get tweaked and whittled down, the moorings it was built upon have begun to erode so the viability of the whole thing becomes threatened. When we don't have the individual mandate, when there are no penalties for not getting insurance, we are left with the only people in ACA being those who are really sick and are more expensive. A basic tenant of ACA was we were all going to contribute and we are all going to benefit. Now with many people opting out, it is driving up costs."

Head said that since the ACA was adopted, the stakes are higher than ever before to provide a high-quality experience for patients since performance is now directly tied to reimbursement.

"While providing a higher quality of accountability and care is of more importance, creating that kind of culture cannot be legislated," Head said.

Stone lists the following improvements as a result of ACA:

1. Mandated coverage for annual exams with many of the immunizations and preventive screenings at little or no cost to subscribers.
2. Coverage assistance based on income for basic plans which increase basic access for some, such as Medicaid non-qualified working poor.
3. Many more people have some coverage.

She said the failures appear to be:

1. Bureaucratized enrollment.
2. The loss of the individual mandate.
3. Elimination of some short-term coverage options.
4. Overly broad standard benefits and reduction in plan design options that led to massive increases in premiums, making it less affordable for most young people.
5. Failure to control drug prices.

What else can we do to give Arkansans better access to care? Patterson said there is no doubt that telemedicine programs have improved healthcare for people in Arkansas.

"A great example is AR Saves, a telestroke program," Patterson said. "Since initiation of that program, outcomes for people with stroke in Arkansas have improved every year. Maternalfetal healthcare throughout the state benefits through the ANGELS (antenatal-neonatal guidelines, education and learning system) program and we have recently doubled down on digital health efforts by creating the Institute for Digital Health and Telemedicine & Innovation under leadership of Curtis Lowery, MD, who is national recognized expert in the area."

Troup said AR Saves has really helped their physicians better manage decisions on acute strokes. He advocates expanding telemedicine.

"Telemedicine is something we have talked about a long time, but hasn't caught on," Troup said. "I think we are on the cusp of that changing as the millennial population starts using healthcare. They may not need to see a doctor, but might access someone on the phone or computer. The future for telemedicine is bright. The payment systems need to keep pace. We need to expand primary care medicine payments for telemedicine. There are models out there whereby you can access your physician over a computer. That is new ground where the state can help support innovation and access."

The state must also improve access to physicians, including specialists.

"The reality is the ratio of physicians and advanced providers compared to the population is significantly lagging," Shackleford said. "Primary care shortages are seen in internal medicine and geriatrics, as well as specialties such as cardiology, neurology, and GI. We are continually recruiting and are especially successful in not only recruitment, but also in retention of physicians. Washington Regional is continuing to develop programs and service lines to allow more patients to receive quality care close to home. Recently we have focused on interventional neuroradiology and stroke neurology, and opened a new 20 bed Neuro ICU. In addition, we have introduced new cardiac programs to include vascular services and valve repair/replacement."

Another effort to improve healthcare delivery includes partnerships with larger healthcare providers. One factor that has benefitted Conway Regional is a management agreement with CHI St. Vincent. Troup said this has been fantastic for Conway Regional.

"CHI St. Vincent has allowed Conway Regional access to services we wouldn't otherwise have," Troup said. "For example, a couple of years ago our physician staffing was in disarray in the ER. St. Vincent was a great partner to come in and help us manage through that transition. They have been able to help us in other areas, too. We can tap into St. Vincent where we need to, but still have a lot of local autonomy."

An issue not affecting the financial health of healthcare providers is timely reimbursement from payers.

"We are not seeing an issue with timely reimbursement from any of the payers," Stone said. "Our denials are low, due to providing the proper documentation requested by the payers. The relationship with the payers could always improve, which could be accomplished by a reduction in administrative burden on the providers and reimbursement transparency through the disclosure of what the insurance companies are receiving in administrative fees. This should be broken down so it is clear for the consumer to see what they are paying the providers and what they are paying the insurance companies."

Another way to bend the healthcare curve in Arkansas would be better cancer treatments. CARTI's Head said cancer comes in many forms and it is a formidable enemy because of the way it adapts.

"In the past 40 years, cancer treatment methods have dramatically improved, now providing positive outcomes for diagnoses that previously felt like a death sentence to patients," Head said. "Though Arkansas has a high rate of new cancer occurrences, what is more concerning and convicting to us is that our death rate from cancer is even worse compared to other states. We believe we can make an impact through access to first-class cancer care in the communities where our patients live. We know that the faster patients can be seen for a cancer diagnosis, the faster our experts and technology can start them on the right course of treatment. For us to change our state's trajectory, we know a cancer care environment has to be non-intimidating, close to home and trusted as the expert. It's a vision we do not take lightly."