HJAR Nov/Dec 2022

DIALOGUE 16 NOV / DEC 2022 I  HEALTHCARE JOURNAL OF ARKANSAS   Editor That’s exciting. So, why in the world would Medicare cap the number of residents? Shackelford That is a really good question. My guess is there was some budget recon- ciliation act at some point a very long time ago and that was seen as a way to decrease those costs moving forward. That has cre- ated a big part of the problem, particularly for rural states like Arkansas. Editor That seems crippling to a rural state. Shackelford It is absolutely crippling. Editor I hope our legislators are listening across the country. This makes no sense logically. We need more doctors to get in these areas, and they’re forcing the hospital system to take lower payments to do what’s in the best interest to grow a much-needed workforce. Shackelford You’re absolutely correct. Editor Are all states held to this standard? Shackelford Yes, there are some rules in terms of creating new hospitals and start- ing new training programs, but in a state like Arkansas where there aren’t a lot of new hospitals being built and created, the fact that these caps are out there is a real problem. Editor So is this happening in Boston in Massachusetts? If they want to increase their residents, they have to lower the payment a hospital is getting? Shackelford There is probably some variabil- ity frommarket to market. Obviously, Bos- ton is an urban area. Whether their state is classified as underserved or as rural, those were the two things that allowedWashing- ton Regional this opportunity — that because Arkansas is underserved in the number of doctors and because Arkansas has a single area that is classified as rural. I would sus- pect in many areas like Boston, they’re just capped and there’s probably not a way that they can grow those programs and get reim- bursement as they move forward. Editor Thank you. Another topic for another day, I think. Shackelford It’s a very complex one, but it’s one that’s critical for Arkansas. Editor To follow up with that, how is the Medicare area wage index impacting your health system, and do you think it’s fair? Shackelford The fact that Arkansas has only one geographic practice area places us at a very big disadvantage. Lots of states have urban indexes and rural indexes. Part of why I think that presents a competitive disadvantage is, as I mentioned earlier, our cost structure compares a lot more favor- ably with larger metropolitan areas around us like Tulsa and Oklahoma City and Kan- sas City. But, because Arkansas has only one geographic index, we’re paid at an Arkansas rural level, so that means that our reimbursement is much lower, yet our cost structure isn’t. That makes it very, very challenging. Editor So do medical equipment companies charge you less for the same products than they do in other areas? Shackelford They do not. Editor I know you’re not a practitioner but a healthcare administrator. What do you think the solution is to make Arkansas citizens healthier? Shackelford I think it’s probably multifacto- rial. I don’t think it’s unique toArkansas, but one of the problems with having insurance as your payer is nobody feels like they’re spending their own money and you can become disengaged. I think part of what we hope is to really allow our patients to have more control and to have more insight in terms of their own healthcare. As you become engaged, as you have insight, then you will take, hopefully, an active interest in your health. It scares me when I see how chronic conditions in Arkansas — things like diabetes, obesity, hypertension — don’t compare very favorably with other places. If we can change what that healthcare deliv- ery system looks like, if we can get patients engaged around setting goals of their own healthcare, then I think that’s a part of the answer to how we pay less for healthcare over time. If we’re truly focusing on whole person wellness and around those goals, then hopefully we will see improved health and be able to do that at a lower cost. Editor Lifestyle, poverty, and food choices are literally prematurely killing our Arkansans. Obesity is such a huge problem with adults and the children they raise. We all know this will manifest in the chronic conditions that are already crippling the healthcare resources and will only become worse. Healthcare workers can only do so much, often trying to treat conditions that if they were only changed upriver would simply not happen. You happen to sit in Walmart’s backyard. Do you think it would make sense to ask Walmart to conduct an experiment in Arkansas to only serve or offer organic and/or whole foods at nonorganic prices for a few years to see if that would move the health needle of our state’s citizens? It seems like a simple upriver solution that could actually work if it were presented to the right people. Shackelford Well, that is an interesting con- cept. I don’t know that we’re in a different