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Health Care and Health Insurance on the East End A Times Review TALKS PANEL DISCUSSION

BY MAHREEN KHAN

As advancements in health care surge forward, health insurance premiums continue to rise, leaving many on the North Fork puzzled as to what they need to know to better navigate their medical futures.

At the Oct. 23 Times Review Talks forum: “The State of Health Care & Health Insurance,” a panel of experts discussed its present and future, including Peconic Bay Medical Center president and CEO Andrew Mitchell; Stony Brook Eastern Long Island Hospital chief administrative officer Paul J. Connor III; Anthony Cardona, president of Cardona & Company; Dr. Jarid Pachter, vice chair of ELI Leadership Coordinating Council and SBUH Medical Board & MEC member at large, who is also the director of Quannacut Outpatient; Davin Laurina, associate vice president of commercial sales and broker service for Healthfirst; and Erica Gerrity, director of management services for Peconic Bay Medical Center.

Times Review Media Group content director Grant Parpan moderated the discussion.

Anthony Cardona of Cardona & Co., a panelist and sponsor of the event. (Credit: Kate Nalepinski)

HEALTH CARE VS. HEALTH INSURANCE

Anthony Cardona, president of Cardona & Company, a Watermill-based insurance brokerage, explained key differences between the two often interchanged terms.

“Health insurance is a mechanism to pay for health care,” Mr. Cardona said. “The cost to our country to keep us all healthy is about $3.8 trillion per year — that’s about 18 percent of our [gross domestic product], so every dollar made by every American here — 18 percent of that goes to keeping our country healthy. With that, it comes out to about $10,348 per individual.”

The average cost of plans in New York State today, he said, runs roughly between $7,000 and $7,500, while the average deductible runs at roughly $2,900.

“With our small employers on the East End, predominantly who we work with, what we’re seeing is the cost goes up every single year,” he said. “That cost either has to be paid through premium or out-of-pocket.”

He said the top complaint he hears from clients is that they feel they’re overpaying for health insurance. Mr. Cardona made the case that while doctors and hospitals are now providing patients with additional services, matching patients with the right network and price on the health insurance side has become increasingly difficult.

“It’s an overwhelming concern across the country, but in particular on the East End,” he said.

(Credit: Krysten Massa)

AFFORDABLE CARE ACT

What is affordable health care?

Davin Laurino, assistant vice president of commercial sales and broker service at Healthfirst, a New York City insurance company, said that question is a double-edged sword “because we know health care is not affordable.”

“We started about 25 years ago and we were more on the Medicare/Medicaid side,” he said, “but we have since moved into what we call ‘commercial,’ so, small employers, individuals [who] aren’t subsidized. We are working toward that common goal of trying to keep our members healthy and really, that goal is to try and control the spiraling cost of health care.”

The idea behind “affordable health care,” he said, is to serve as a mechanism for individual insurance subsidies.

“I think the whole premise there is that the government came in and allowed for subsidies for individuals buying insurance on the Exchange, which, depending on their income level can be a few dollars or many dollars,” he said. “We have a long way to go before care is truly affordable.”

Mr. Laurino said Healthfirst is expanding its networks on the East End and that unlike some private insurance companies, Healthfirst reinvests a portion of its profits into hospitals because they own a percentage of the company.

Joe Corso of Cutchogue, an audience member, asked what the consequences could be on the panelists’ businesses if the ACA were to be repealed without a replacement plan.

“I’m not a huge fan of the Affordable Care Act,” Paul Connor III, CEO of Stony Brook Eastern Long Island Hospital said, “but I am a fan of coverage and I have to say, this has covered 20 million more Americans — not so much on the Exchange — but on Medicaid expansion.”

As a hospital administrator, he said, the ACA is successful at getting people on insurance. But, he added, “there’s insurance and then there’s sort of the illusion of insurance.”

That is, until people hit their deductible, their insurance benefits don’t always kick in.

Paul Connor

Mr. Connor said that if the rug is pulled out from under the ACA, “we will have a very, very significant crisis.”

New York has, as of July 2019, enrolled 6.5 million individuals in Medicaid and the Children’s Health Insurance Program — which falls, in part, under Medicaid. This figure represents a 14.51% net increase since the first Marketplace Open Enrollment Period and related Medicaid program changes in October 2013, according to Medicaid’s website. The fiscal year 2019 state executive budget recommends $142 billion for Medicaid, in a two-year appropriation authority, according to the New York State Department of Health.

“We all know New York State is a heavy, heavy Medicaid state,” Mr. Connor said. “Almost half the babies in this country are financed through Medicare; it’s a stunning number. If you take that … if that safety net is gone, we’re going to have a crisis. You can’t take away a service or a feature that we already have without having something equal or better and I’m afraid there will be nothing equal or better.”

PBMC CEO and president Andy Mitchell brought up the concept of “governmental amnesia,” saying that “the Affordable Care Act was enacted with significant reductions to the providers in the payment of Medicare. We gave up, as an industry, billions of dollars in our Medicare reimbursement to ensure that a population that didn’t have coverage would, in fact, have coverage and the grand theory was that if the people who have no coverage now have coverage, it would all come out in a wash.”

It probably has, he said, adding that if the ACA is repealed, Medicare reimbursement will not be restored to all of the hospitals.

“Without that, then we go into a crisis because Medicare reimbursement as it is today is barely adequate to cover the cost of care … 80% of patients in the hospital are covered by government reimbursement, largely Medicare, because of the age of the North Fork and central Suffolk region, and then the remainder is Medicaid,” he said. “We don’t negotiate those rates; we’re told what they are, we live with them, we adopt a certain level of budget to be able to continue to operate under those conditions. Now, take a whole portion of population who is insured out, don’t do anything to make it up and the industry goes into a spiral.”

Mr. Cardona acknowledged the ACA for streamlining benefits in some plans and better aligning other plans to heighten consumer understanding, but said the biggest problem with health care and health insurance is the lack of transparency in costs.

“What would happen is you’d see a lot of people who might be 55 years old, who might be a sole entrepreneur … scrambling to try to find coverage and there’s really no other avenue at this point for them to get individual coverage if the ACA does go away,” he said.

Dr. Jarid Pachter, vice chair of ELI Leadership Coordinating Council and SBUH Medical Board & MEC member at large, who is also the director of Quannacut Outpatient, said he doesn’t see the ACA ever going away.

“Everyday, you turn on the news … and there are hundreds of people dying of heroin overdoses,” he said. “The only reason these people get treatment is because of the Affordable Care Act so, while it may sound sexy at a rally to say ‘We’re going to repeal this, we’re going to repeal that … The people who are cheering this may not even realize that dozens of people they know may lose their treatment without what they’re asking to be repealed. Once I think that’s pointed out to people, they may start backing off because I don’t think any politicians will be elected when they’re letting their constituents continue to die of an opiate epidemic.”

Dr. Jarid Pachter, right, and Erica Gerrity.

CHALLENGES IN MEDICINE TODAY

When asked to discuss the most prominent challenges in medicine today, PBMC Medical Group Director of Management Services Erica Gerrity, who handles billing, said most of PBMC’s patients are satisfied until they get their bill.

“The biggest concern that patients have is that they don’t really understand their policies,” she said. “These patients say, ‘no, I work for a good company and they’re paying for my healthcare; this should be covered’ or, ‘I pay out of pocket, almost $800 a month for my own premium; this should be covered.’ It’s not up to the provider of service, whether it be a hospital or a physician to determine, based on a patient’s insurance, what will be covered and what will not be covered, so there’s always two aspects to that contract.”

She recommended reading contracts thoroughly before making any decisions and shopping around as a savvy consumer would. Most patients, she said, don’t understand how their health care is billed. As an example, she mentioned a doctor’s visit.

“In my head, that’s a visit, but you could have had an injection or blood work, gone to the [emergency room] where you saw multiple providers of service, had some radiology services and a lot of patients don’t know the questions to ask or who to ask them to … Where do you go? Do I ask my doctors these questions when I’m in the ER? The last thing on my mind is who’s paying for this.”

Dr. Pachter, who has been in practice for just under 10 years, said the main complaint he hears from patients is the switch to electronic medical records. He also took personal issue with the consumerism of medicine.

“You want to spend as much time with the patient, looking them in the eyes,” he said, adding that this becomes especially difficult when there is an overabundance of patients, files aren’t uploaded or prescriptions are denied by insurance companies.

“For so many years, people have ordered medications and ordered tests and ordered surgeries that aren’t needed that the costs of these things has gotten so high that it leads to all these battles between CEOs and insurance companies and doctors and insurance companies,” he said. “The biggest frustration throughout a day is medicine is so disjointed. Even within your own system, your electronic medical record doesn’t communicate with your parent hospital or your associate physicians.”

Andy Mitchell

THE FUTURE OF MEDICINE: TECH AND PARTNERSHIPS

How is technology impacting local hospitals and insurance companies?

Panelists discussed electronic medical systems, for which security is a huge concern, telemedicine and medical devices/machines that are oft-costly, but capable of ground-breaking finds and advancements in patient care – to insurance companies developing their own apps.

Mr. Mitchell said PBMC’s new cardiac cath lab cost $65 million to make fully operational and functional. Most of the associated costs were not for the brick and mortar, he said, but for the machinery within.

“One of the issues in the cost of healthcare, is in fact, the cost of technology, and just like computers, the technology that we’ll put in between now and January when we open the building, five years from now, will be paperweights,” he said. “It’s one of the reasons that a community hospital, say, has to be part of something so much larger. One, to be able to leverage the costs of technology and two, to be able to have the capital resources and the ability to get them to the financial markets to raise money to be able to acquire them.”

Mr. Connor agreed with the need for hospital partnerships, but focused his response on telemedicine. Medicare, he said, is, for the first time this year, providing reimbursements for the basic provision of telemedicine. He mentioned teleneurology, which exists at Stony Brook Eastern Long Island’s emergency room, telepsychiatry and primary care-related telemedicine, which Stony Brook is developing an app for.

“We’ll be using telemedicine, likely, in Shelter Island where we are establishing a primary care practice,” he said. “Shelter Island is a big challenge. We have 2,000 people year-round, they’re all Medicare. Medicare is the worst payer, how do make it survive? Well, you subsidize it, but you use technology as well.”

Enabling patient’s to manage their own health by installing medical devices in their homes is a premier way of keeping them out of hospitals, he said.

“That will become more and more important as hospitals get in the risk business, because it’s a liability when they come to your hospital. Right now, we get paid because we’re not in the risk business.”

Mr. Cardona said that from an insurance standpoint, teleapps and telemedicine are becoming increasingly popular.

“We’re seeing younger generations taking advantage of it a little bit more,” he said. “Remember, the insurance company’s goal is basically to take as much premium from you and pay you as little back … You’re seeing a lot of these insurance companies having their own apps, their own groups of doctors.”

Dr. Pachter pointed out the differences between ‘good and bad technology.’

“The last thing that we need,” he said, “which is definitely going to be coming is a little watch, probably made by Apple that will let you know whether there is something going on with your heart rhythm … All these things are going to do are pick up mostly false positives that are going to definitely increase the cost of medicine and further testing down the road.

“I’m all for technology,” he added, “as long as it’s being driven by – not venture capitalists, but not-for-profit hospitals and physicians themselves.”

mkhan@timesreview.com