St. Luke's Dr. Pate opens up on Medicaid expansion, rising health care costs, retirement

Feb. 3--When David Pate arrived in Idaho a decade ago to lead St. Luke's Health System, he was a Texan with a mustache and self-professed conservative politics. St. Luke's was a few hospitals and a lot of medical practices.

Now, the mustache is gone. Pate, 63, is a firmly rooted Boise transplant, his entire family having moved to Idaho. His politics? Well, as he put it in a 2014 interview with the Statesman, "I thought Texas was really conservative -- and I'm a conservative. When I got here, this is re-ee-al conservative." And St. Luke's is now an integrated system with more hospitals, a whole lot more medical practices and thousands upon thousands of employees.

Today, he celebrates his first day of retirement.

Pate steered Idaho's largest health system through a decade that changed American health care more than any other time since the 1960s. That decade changed Idaho and St. Luke's, too.

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This interview has been edited for length and clarity.

Q: You have been a patient here. How has that changed from when you started as CEO to now?

Pate: When I started here, your outcome of care was going to be different depending on which door of St. Luke's Health System you went in. That is no longer true. We've got processes in place where we don't have so much variation in what we're doing. We're all identifying, what are those best practices, and implementing that. That's what's gotten us to be a Top 15 health system (according to IBM Watson Health).

Another thing that's changed is that we've made it easier for people, patients, to get access. I used to always complain that if somebody told me that for one of my upcoming trips, I needed to call Delta or United and schedule my flight, I'd just look at them like they're absolutely insane. But that's what you have to do in health care, you have to call an office. And so, we've already begun changing that. We put a lot of our scheduling online so that patients don't actually have to talk to anybody. And what I've found out about millennials is that, in general, they don't like to talk to people.

The other thing that I'm really, really proud of is, years ago, if you had a child that needed specialty care, a lot of times you had to go out of state to get that care. I had a grandchild who did have a rare disorder -- that we can't and shouldn't be treating here -- and my daughter did have to take my grandchild out of state. I saw what a burden that was. First of all, you're removed from all of your support system. Second, you incur a lot of expenses that you didn't have before, because now you're staying in a hotel, eating out all the time. We have tremendously developed our St. Luke's Children's services and added many sub-specialists so that today, there are far fewer cases where people need to go out of state.

Q: There's only so much you can do to fix health care, though. So much is outside your control.

Pate: Yeah. At times, it can be overwhelming. It can be frustrating. What I do is I consciously sit back and say, "OK, I may not be able to fix everything, but there are things I can improve that will impact people's lives." So, I'm good with that. I go after, what is it that I have the power to influence? And then I constantly ask lawmakers, please, we're trying to fix this, please don't make it more difficult for us.

Q: What do you think of how Idaho lawmakers have approached health care?

Pate: There's been many disappointing things. There's certainly been some good things -- I was very excited when the state decided to take on our own public exchange marketplace. I thought, "Great job." I credit (former) Gov. Otter for his leadership on that.

Q: What about the Legislature's approach to Medicaid expansion?

Pate: I think there is a broad misunderstanding about the Medicaid population. This sense that, you know, they're abusing the system, or they just need to pull themselves up by the bootstraps and shouldn't be dependent on us. I get that. But I've taken care of a lot of Medicaid patients in my practice. I'm not here to argue that there aren't people out there that do abuse the system or take advantage of it. But by and large, the people that I saw were not trying to be on Medicaid. Life is not great when you're on Medicaid. And these were people that either were working, often two or three jobs, and still not making it.

Where this really came home to me is, there was a period of time when one of my daughters was working for a great employer (in Idaho), but they didn't offer benefits to their employees. And my daughter couldn't afford health insurance. And so I saw, OK, my daughter is working hard -- I mean, she was spending about as many hours at work as I do. And that's just really tough. I really gained a lot of sympathy for these folks.

Q: What do you think of Idaho's request to add work requirements to Medicaid?

Pate: I'm not in favor of it. My experience is, most of these folks are very responsible. They want to improve their lot in their lives -- oftentimes not so much for them, but for their kids. And they already are working. And at a time when we're trying to figure out how to balance the state's budget, and we're trying to make cuts in other places, why are we adding millions of dollars of expense to a state agency to monitor these people submitting paperwork?

Several states have already done this. Those have been challenged in court, they have lost in every case. Why do we want to get this implemented in Idaho, get sued, and now spend additional money defending that case and ultimately losing? So, it's ironic that Idaho is generally a fiscally conservative state, but we're willing to spend money on added bureaucracy, and we're willing to spend money on fruitless litigation.

Q: You've said for years that St. Luke's is working to slow health care inflation. But costs are still rising. Why?

Pate: We've accomplished a lot. But we are far from done.

It is just really hard to implement new changes in health care. Let me give you example. My mom called me about a month ago, and she was in a panic because she was going to the dentist, and she discovered that she didn't have the antibiotics that her doctor always puts her on before she goes and gets her teeth cleaned.

So, my mom had a hip replacement when I was a child. And that's why she's taking the antibiotics. The data tells us that those antibiotics don't help somebody like that. She doesn't actually need to take antibiotics before her dental procedure. So I told her, "Mom, relax, you really don't need to be taking that." So there's an example of something that was a no-value service.

Now, you have to know the whole story. My mom has heart disease. My mom, when she takes the particular antibiotics that are prescribed, she always gets (gastrointestinal) symptoms, which cause her to get (dehydrated), which causes her heart problem to act up, which causes her to go to the emergency room, and half the time she gets admitted to the hospital. So, that $10, $30, $50 antibiotic just caused thousands of dollars of care. That's what I'm talking about.

Q: What's next for you?

Pate: I'll continue to write my thoughts in a blog (drpatesblog.com) for those that are interested in my take on health care policy, health care law other things of interest. I am very seriously contemplating writing a book. I love to write, and I've got an idea I'm toying with. I'm going to join some boards. I might do some very limited consulting. (I may work) with boards that are facing some internal crisis related their own CEO that may need the perspective of a CEO. And a lot of it's going to be spending more time with my grandkids. Right now, I can't attend hardly any of their events. And so, I'm looking forward to being able to go to their events and spend time with them.

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