INGMAN - State Sen. Kelli Ward and her husband Mike are both physicians. She has a private practice in Lake Havasu City, he works in the Kingman Regional Medical Center emergency room. They sat down with Reporter Suzanne Adams, News Editor Alan Choate and Editor Rich Thurlow on Feb. 22 for a lengthy interview.
Part 1, published in the March 3 Miner, was focused on health care delivery from the perspective of a state senator who is also a physician, with Kelli Ward offering most of the input. This segment deals with health care in the age of the Affordable Care Act - Obamacare.
Miner: Can you give us an overview on the changes in medical care due to the Affordable Care Act?
Mike Ward: I think its important to emphasize that Kelli is very well aware that she ran on an anti-Obamacare message and was elected with over 71 percent of the district. She's sensitive to that. We are, both. We don't believe in it. Philosophically we don't believe in it.
Kelli Ward: I believe in the free market. I think we are going far, far afield of the free market. There really is a great state of Maricopa. So much revolves around that area, which you know, the mega population is right there. But a lot of things they want to do there are not what would work for the whole rest of the state.
But I've had people from the Phoenix area, not legislators but other people, say, "Well, you need to tell your constituents what is good for them and what they want." I think that's one of the things wrong with government, is that people are patting their constituents on the head and saying, "Oh, honey, don't worry. I know best and I'll do what's best for you." I'm really striving to keep in touch with constituents and let them know what's happening and get their input.
I like the lobbyists. I think that they're great. I think they have great information. I equate them to drug reps. In my practice, I always had pharmaceutical reps come in. They have great information, cutting-edge technology and all these things. But I also have to remember the same with drug reps as with lobbyists - take everything with a grain of salt, because they have a product and that's what they're paid to sell you.
Mike: It's knowing your market, too. I think there are some constituencies that would be probably more accepting of, "Oh, well, I trust you to get this done." That's not what's here.
Kelli: Yes. That is not what is here. They want to know what I'm doing and they want to be sure I'm doing what they want. That's what I'm trying to do. I can tell you I get emails from other parts of the state that are not always complimentary. Mostly they're about guns. I've said, "I live in Mohave County. Don't try to tell me from Tucson to bring gun control, because we don't want gun control where I live. We want to enlighten you about the freedom and the rights of law-abiding citizens. We shouldn't be treated like criminals."
It's interesting to see the emails from other places. Our guys really are awesome. Our guys and ladies that send me emails are just amazing. Not one person from our district has sent me a mean or attacking email. Somebody from, I don't know if he's from Needles or Fort Mohave. He's a KTOX guy. He sent me an email to tell me I'm not smart. He asked some of his people to demand that I appear on their station at a time. "We demand that you call in tomorrow at 7:15 a.m." I had a meeting that day at 7 o'clock.
So it's interesting. That's been the only bad guy, hundreds of nice people.
Miner: Can you give us an overview of where we go from here with medical care?
Mike: I think we have a lot of challenges. We know that there are financial challenges in our marketplace in our rural part of Arizona. Kingman Regional is very different from other hospitals in the county, being a not-for-profit entity, being responsive to the community, not to shareholders. It's truly run by a community board by some pretty talented local business people.
The challenges we see are paying for services. Clearly the hospital is doing well right now. I don't know if it's because the volume was up really high through the winter. Really, after Christmas, when flu season hit, we were staggering in volumes. It was crazy what we were doing in the emergency department. There were a couple days we had over 180 patients a day check into that ER. Which is far, far above our average.
Miner: What's average?
Mike: When I started working here in 2004, 80 patients, 90 patients a day was a real difficult day to get through. Certainly the volume has grown, but I think the volume's grown in ways that reflect what's going on out in the community.
They talk about some of the Medicaid and AHCCCS stuff when up to 100 percent of the federal poverty level childless adults started dropping off.
One of the things we heard in one of Kelli's town halls was someone said, "Well, they were kicked off."
Well, no, they weren't kicked off. Had they been responsible and kept their paperwork up and filled out the forms when they were supposed, they would have stayed on. And that's why there are still about 70,000 people, childless adults, throughout the state that are still on. Because they made sure they did the things they needed to do to not fall off, where they have to recertify every so often.
We've seen a change in our payer mix and that's challenging because our volume's gone up. Our average per patient pay has gone down. So we've had to increase staff when our reimbursement is going down.
Kelli: So you do more work for less.
Mike: Our current numbers are changing. Our self-pay rate from July on is up to about 15 percent. In emergency medicine, as an emergency physician group, we collect typically about 6 percent of those dollars and it varies, but our collection rate goes down. Our Medicaid has dropped as a percentage but it was up high. Two years ago, it was 40 percent of patient volumes.
Now it's down to about 30 percent. So about a 10 percent drop.
The problem with Medicaid for me as a business person is that if you come to the emergency department, which is the highest cost care, to seek care for a non-emergency, and because we bill that at a lower level because it's not urgent, sometimes it's not even acute, the reimbursement that we get versus the cost of malpractice, the cost of billing for those services and the cost for paying the provider, whether it's a physician assistant or a PA, we may lose anywhere from $9 to $40 to see that patient.
Kelli: That's what I say to people whenever they ask me about Medicaid expansion. It's basically a slowly failing business model. If you're going to increase the population of people that you lose between $9 and $40 dollars on for every visit, eventually that's going to stop working for you. The people who are able to make up that shortfall are going to be decreased. How will you stay open?
Businesses don't just stay open for the goodness of their heart. They stay open to be able to make a living and to make money. If it's suddenly all negative, how many people will stay in and continue to do it? What will happen to the model that we function under for medical care?
Mike: The other argument is you have lots of people that are self-pay. So you're losing even more money on those so you'll lose less.
Kelli: Except for what I told you before, you're more likely to seek care.
Mike: The problem is they're also not talking about ... if you raise the eligibility percent to 133 or 138 percent, numbers that are being tossed around, there are people who are currently privately insured through their employer or through a family health plan who are trying to make ends meet by keeping their own health insurance who will now qualify.
So those private insurances are what keep us afloat. Commercial insurance may only make up 25 or 28 percent of our payer mix, but it equals more than 50 percent of our reimbursement.
If those people fall out of commercial payers, that's what's going to harm the hospitals. That's what's going to harm groups like me. This isn't a charity organization.
I have people who work for my company who expect to get paid an hourly rate and they, like everyone else in the country, want to get raises. So they pressure you for raises at a time when your reimbursement really is going down, although they're working harder for it. So it's a struggle.
I worry about Obamacare. I think in general there are so many moving pieces. I know (KRMC CEO) Brian Turney talked a lot about the rules and regulations that affect the hospital. It's not that it's so hard to comply with acceptable standards in health care. It's having to hire the people to then create the documentation to prove that you are. That's the other side of the piece. It's not that people in health care don't want to do the things you want to do. It's that you have turn around and prove it.
Kelli: And I think that's in every industry.
Mike: It is. The regulatory burdens as a whole. I always thought that if Arizona positions itself as the place of freedom and opportunity and not of handouts, then we would attract businesses that want an employee base that wants to work. I think the more we give away, the less incentive there is to work.
I don't mind giving my money to whoever needs it. I just don't like giving my money to people that just want it.
There's no accountability in that system. There's no accountability for how our tax money is being spent in the Medicaid system because the federal government says we can't hold them accountable. We can't ask them to pay a co-pay if they go to the emergency department. We can't expect behaviors from them that are healthy, whether it's not using drugs or not smoking or whatever it is. You can't have any expectations.
Even the cigarette tax and fines in Obamacare which go into effect in 2015, which could affect a normal, working, regularly insured person up to $4,000 a year in additional costs.
It's not going to affect those people who are of lower income who will be on the Medicaid system. That accountability isn't there. They're going to be allowed to continue to smoke and to do those other things that the government is trying to modify our behaviors by fining us.
I think in general we're holding up. We're looking forward to the other hospital opening as a free standing ER, which we hope will happen this fall. We need the space, more than anything. We're pretty landlocked. Most emergency departments look at patients per bed per year and we're at the maximum of most reasonably run institutions. Certainly not by design. I think that before Hualapai was going to open, we were looking at plans for not only ER expansion at KRMC but building an entire new wing on the hospital which would have included a brand-new ER that was of the size that would meet the community's needs.
So we're going to have to divide our staff to take care of the same number of patients, which are going to increase because of Obamacare. I think that we're out of space. Flu season is tapering down. We're seeing less and less flu.
Kelli: Spring breakitis.
Mike: We don't see a lot of that here. But what summertime does bring us is increased travelers and a lot more vehicle crashes and that kind of travel.
Miner: As physicians, what's the best thing about the Affordable Care Act?
Mike: I know you asked Brian (Turney) this question. I think that as physicians, certainly we want people to have access to affordable, high quality health care, which shouldn't include an emergency department visit for other than emergencies.
But we're not going to get that. It's a great thing to talk about and yes, its great that your kids can stay on your insurance until you're 26. I think that helps a lot of people out.
Kelli: But the unintended consequence of that is a lot of childbearing goes on between 18 and 26. So, the parents are covered on their parents' insurance but the grandkids aren't. And in Arizona, there is no product that you can buy. Basically, they expect them to be uncovered or on Medicaid in that population. That was not intended, I don't think.
Now, we're seeing the 26-year-olds, some of them have benefited from it, so now they're starting to go off. And they're like "Oh, what do we do? We don't know what to do. I can't [get] insurance. I can't do this. I can't do that."
Are we just going to say, well, you need to stay on your parents' forever? What happens to the next generation? There is no parents' insurance.
I get frustrated because there are public service announcements and things that are paid for with my money to tell me what I like about Obamacare, even though I don't. They're basically doing a propaganda campaign to convince people that they really do like something that all of the polling shows people don't like. They're trying to change public opinion through propaganda, I feel.
Miner: The president says that it's documented that people are saving money, but I haven't witnessed that personally.
Kelli: I haven't had one person tell me that.
Mike: We know that health care costs are rising, health insurance is rising and so to say that the ACA will bring ... it's really a misnomer.
Kelli: It's the UACA, unaffordable care act.
Mike: Because it's really not affordable care. The problem with health care, there's two problems that we agree on.
One, if someone else is paying for your health insurance, you are not a health care consumer. You are a health insurance consumer if you are actually buying it. But in most cases, it's an employer or the government buying it for you, because there's no consumerism, as a general rule. In health care, it doesn't experience the same market forces that other free markets do because there's no responsibility.
If I go to the grocery story and I only have $100 to spend on groceries, I'm not going to spend $200. One, the store won't let me, they'll arrest me. I can't do it.
But in health care, no one knows how much the bread costs. It's not like we're hiding it. Half the time, I don't know what the bread costs. I know what I charge but everyone pays a different rate.
That's one of the major problems with the cost of health care. People are not consumers.
Private health insurance is going up. It's not going down.
Kelli: I can't quote the study, but by 2016 the average cost for a family of four will be $20,000 for their health care.
Mike: It's an IRS study.
Kelli: Yeah, I think it is. Right now people aren't spending $20,000 for a family of four. For me, and maybe I'm just cynical, but I think this is basically set up to put us on a path to single payer health care, which I consider socialized medicine.
As a doctor, would that be easier? Of course it would be easier to have just one person, one rate, but you also lose all of the entrepreneurial ability. The best doesn't rise to the top because everyone gets the same thing. I don't think people will say, "Oh, here's the bar. How can I go over it?" They'll say, "Where's the bar and how can I barely meet it?"
So I think that the quality of care will go down. The amount of care, the services that are offered will definitely go down. But everyone will have a little bit of something.
I don't think that's the best way. I think the best way is to purchase or negotiate for the services you want. Not say, "Well, we need to spread it all out."
I'm not a redistributor. I think you should keep what you earn and help those who can't help themselves. I heard that all the time through the campaign and now in office, that people in our district are very charitable, but they want accountability for people who they perceive, whether it is real or not, are taking from people who work and choosing not to work because it's easier for them.
I'm not a believer in from each of his abilities to those according to their needs, because eventually it works out that nobody is working. Because why would you work really hard to give all of your earnings to someone who's needy and choosing not to work?
The developmental disability community is just so amazing. I wish more people would model after that. They're trying to get more money in the budget. That's one of the people that are lobbying us. And they've been cut and cut and cut.
But the people who live there, we did a legislative forum there, they want to work at New Horizons. They're just crying out, "We want to work more." There are places where they're able to go and able to work.
I was talking to somebody, one of the lobbyists that came in, and they were talking about they were doing some apprenticeships with that community, especially people who have autism. They were having them shadow plumbers. They said if they need something done the same way every single time, this is the guy. They come to work on time. They come to work happy and they come to work ready to do whatever you ask them to do.
That's so rare in the normal population. You want to say, "Hey, let's find some appropriations for this community that wants to help themselves." They need help. You can tell they need help, but they want to be a part of that helping process. I think that's what most people want to do to help people who are in need is have that accountability piece, and that's missing.
Mike: Disclaimer. We have health insurance. We're covered under Tri-Care. I'm still in the National Guard. I'm still active. I'm an active participant in the Guard. So Kelli's not taking the state health insurance.
Kelli: But I know I'm on government insurance through Tri-Care. But we never use our insurance.
Mike: We want it to be there, if we need it. But we're not frequent utilizers of health care.
I guess that's the other dichotomy, and Kelli talks a lot about this as well. When you go out and buy life insurance and homeowners insurance and automobile insurance, it's insurance.
Kelli: Something you buy and hope never to use.
Mike: That's right. When people buy health insurance, they fully intend to use it.
Kelli: A lot, some of them.
Coming Monday: The final questions and answers.