Time to Rebuild the Public Trust: A Q&A with Becky Hultberg, CEO of ASHNHA

Becky Hultberg is the CEO of ASHNHA, one of the state’s largest and most important stakeholder voices in health policy.  We conducted this Q&A following a recent MGMA meeting in Anchorage regarding the importance of the health care sector re-building the trust with the public.


DJ: At the Alaska Medical Group Management Association meeting recently, you gave a compelling presentation that included the comment that the health care sector, but particularly providers and the hospitals that you represent, need to go to work to rebuild the public trust. What did you mean by that, that they need to rebuild the public trust?

Becky:  I think that in the context of the presentation, I was really talking about the issue of health care costs and the public attention on health care costs. Specifically in respect to the comment about trust, research over time has shown that people trust their health care providers and trust their community hospital to take care of them, but there is a growing public concern about cost. And we have to address the issue of cost because people also have to trust that when they come to us, they’re going to get good value for the money they and their insurer are spending.

DJ: So, how is that trust related to financial impacts and costs being undermined? Is that being undermined generally or do you think that it’s happening more rapidly or more acutely here in Alaska right now?

Becky: I think there’s general concern in the country about costs. So this is not unique to Alaska, but there are a couple of factors in Alaska that have allowed this issue to bubble up at this point.

The first is the State budget. There’s so much attention on the State budget and the cost of health care is one of the drivers of that State budget. The second factor is the instability of the individual insurance market, the high cost in that market and what we’re going to do about it. And the third thing is the recent media attention on the issue of health care costs. When you take all those issues together, you have an environment today that may not be the same as it was a couple of years ago and is really driving this conversation.


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DJ:  So what does rebuilding the public trust look like in Alaska where the economy is shaky, and yet where healthcare has consumed more and more of the overall economy, even in good years. How does that public trust get rebuilt?

Becky: I think this question gives me an opportunity to clarify a bit. I did use the words ‘rebuilding public trust’ but I really think that implies a one way conversation and we need to be having a two way conversation.  A two way conversation suggests that we as providers need to do a better job of helping the community understand the choices that we have to make together.

Health care is going to be expensive and it is going to be more expensive in Alaska for some very specific reasons. So we have to help people understand what the factors are driving health care costs and what we can impact.

And then I think as a society we have some really important questions that we have to understand.  We can’t have an unlimited supply of an expensive resource and not think that costs are going to continue to go up.

So it’s that two way conversation that has to happen. It’s not as if we alone need to do something without engaging the public in the other side of that conversation. As a community we need to think about what kind of services we want. Do we have an appropriate level of services here? Do we want more? Do we want less? Do we have about enough? We have to have conversations, harder conversations about what we’re willing to pay for.

DJ: You know, I think a legislator would say, “You know this is the kind of thing that probably should’ve been fixed by the health care system years ago and now I as a legislator have to start solving this problem for you in the form of rate cuts, maybe changes in statute and/or administrative policy.” What do you think? Is Alaska as a community late to this conversation or it this the only time it could have happened because of the fiscal impetus?

Becky: I think it’s pretty clear that these conversations happen most often in times of scarcity. I’m not surprised that we’re having this conversation now. Health care, just like anything else, is driven by demand for services. There’s been significant demand for new services, for new technology and the system has met that demand. Now we’re asking the question: In meeting that demand, does it cost too much?

Providers are rational actors and tend to respond to the incentive in front of them. And the incentives to date have been for more services and more care. So it’s easy to look back at the provider community and say “Why did you provide more services and more care?” but in reality that’s what society was demanding. So now we have to ask the question about how we’re going to address that issue going forward. Are we going to focus more on cost, are we going to focus on utilization?

DJ:  We’ve been focusing on providers and hospitals here.  What role does the rest of the system have here, would you argue?

Becky:  What we don’t think about when we talk about healthcare costs are the factors within our payment system that lead to escalating costs. We have a third party payer system that largely insulates individuals from costs. That’s starting to change with the increase in high deductible plans which is one reason we’re paying more attention to cost. But when you have a third party payment system that insulates people from the economic consequences of care and a fee-for-service system it’s a recipe for cost escalation. That is the system we have, it’s not a system created by providers, it’s a system created by government, by insurers, and by the health care industry, so we all have to wrestle with what to do next to address cost escalation together.

DJ:  Thinking about your role as Commissioner at the Dept. of Administration where you were an advocate for smarter system and payment design, and now as CEO of ASHNHA where you represent a diverse range of organizations that are largely unaffiliated with one another, do you think that we need in Alaska to have some sort of managed care entity to help organize the system, to change the incentives and help drive a different kind of conversation?

Becky: No, I don’t think so because I think when you look at the data on managed care in Medicaid specifically what is shows is that you might reset your base, but costs continue to grow at the same rate. So I’m not sure that’s the solution because I think if that were the solution it would be easy just to transplant somebody else’s managed care system into Alaska and solve our problems.  We may have a problem that’s a greater magnitude relatively speaking than in some other state but every state is struggling with health care cost growth.  It’s going to have to be something more systemic than just simply saying we’re going to switch to managed care because I don’t think the data really supports the effectiveness of that.