PANEL: Reforms to rapidly reshape health care

October 1, 2011

IBJ: And Kevin Speer or Dr. Park, do you have any thoughts on how just some of the changes going through and then the concept of population health management might alter how providers -- what sort of technologies they’re looking to use or how they’re looking to use them?

SPEER: From our perspective what Jack described and I think you described it as personalized health care --and Jack talks about the right answers at the right time, we talk about coordinating care now and in this continuum of care it’s the right care at the right time in the right place, and so you marry the delivery up with the technology and the pharmaceutical and you have an opportunity I think to find synergies that will increase the quality and decrease the costs and from a prospective position it allows you to start to begin to identify that population that Alex discussed that we all have. I mean, 5 to 10 percent of our employee base use 80 percent of the costs and so can you be proactive with those individuals, can you utilize the technologies and the science that Jack’s bringing to the table and then make them a healthier population as well.

SLABOSKY: Well, one of the ways we’re using diagnostic testing is the increased use of biometric testing of a population, so in our organization we have incentives for our employees to come for an annual biometric testing, get an A1c, get cholesterol tested, and so early on we can identify people who may need assistance in these areas but more importantly we can give information to those people who may not have been aware that they had issues with either blood pressure, cholesterol, diabetes, and get them to modify their behavior, so we’re using this diagnostic testing on a mass basis and we’re seeing more and more employers do that, too.

PHILLIPS: The other thing, again back to this education piece, we’ve all in the room probably have had some kind of blood test done, hopefully, hopefully an annual physical, and you receive that report back and you get that report back and I would venture -- There’s a lot of health care professionals in the room, so there’s probably a lot of people in the room that could actually understand that report, but the general population looks at that report and it makes absolutely no sense, so think of a world where, again, we could literally take these basic glucose results and calcium results and actually put them on a report that’s a visual report that shows you whether you’re in the green zone, the red zone or the yellow zone and what that means and visually show a patient “Look, this is where your glucose is at, okay, this is serious” and actually have them visually see how that is in a continuum of the overall population and how we treat this disease. Those kind of things, they’re simple, okay, they’re things that are in our world today and other parts of our life, but those things we believe will make a huge impact for the physicians to get this report and then the physician to be able to help manage and educate that patient.

IBJ: We’re going to go to audience questions because we’ve got a huge stack up here, but before I do I’m going to ask one other question myself. For Seema Verma, as Jack was making a comment earlier about the challenges of dealing with 30 million new folks having health insurance and likely utilizing health care more, which is the goal of health reform, you’ve looked at, you and some of the actuaries you’ve worked with have looked at what might have to change in the Indiana Medicaid Program to attract physicians to deal with the extra folks in Indiana, I think the estimate is about 500,000 additional Hoosiers having Medicaid coverage, that’s part of the expansion of coverage through health reform, and the actuaries have estimated that the program would have to pay physicians more to attract them into the program to see more of those patients. Can you talk about what your expectations are there and I’m curious as to whether those expectations are tempered or affected in any way by hospitals employing so many physicians and usually requiring them to see Medicaid patients?

VERMA: Yeah, I think we have access problems within the Medicaid program today, so leave aside the Affordable Care Act, in many cases the Medicaid program for hospitals is paying 40 cents on the dollar, for some physicians it may be 10 cents or 20 cents depending on your specialty, whether you’re primary care or not, and that’s been a problem we’ve been struggling with and even though the Legislature has made some attempts to provide some increases that creates access problems and, quite frankly, providers can’t afford to see Medicaid patients and sometimes it even costs them to see these individuals, and so what’s been happening in the marketplace is that providers have had to do cost shifting and essentially what they do is they increase the price for their paying patients to sort of make up for the losses that they’re experiencing in the Medicaid program, and so with the Affordable Care Act what that did was only provide a temporary two-year increase for only primary care doctors and that starts in 2013 and then it ends at the end of 2014, so now you’ve got, as you said, almost a half a million new Hoosiers coming on to the Medicaid program or about one in four, and so I think that really creates challenges for the provider community. Access in general, not just for low income populations, but access in general will be an issue for the state as we bring in all of these newly-insured individuals to the marketplace, and so providers at that point have a choice now of who they’re going to be able to see and if you’ve got Medicaid patients that are actually costing you, I think they’re not going to be inclined to see these Medicaid individuals, and so even though we’re handing out insurance cards, that doesn’t necessarily translate into access. And what the Milliman Projection did was include a modest increase for providers within the Medicaid program. Today they’re paying at about 60 to 65 percent of the Medicare fee schedule and what they put in the projections was to go to about 80 percent and that’s across all programs and so some of our programs actually pay a little closer to Medicare and most of them are below that, so that’s only going to the Medicare fee schedule, and I think that becomes necessary because, as we talked about before, if we don’t do that, then what we’re going to create is more cost shifting and that’s actually going to increase prices for the general population, but that’s going to be a challenge, the cost of providing an increase is 300 to 350 million dollars per year and so Hoosiers or the Legislature will need to figure out how to pay for that and that in and of itself is going to be a challenge with all the other costs we have with the Affordable Care Act.

SPEER: I think access in general, J.K., would be an issue going forward. We have a physician shortage in the state of Indiana. If you look at research done by Debbie Allen at IU around primary care access we’ll probably have inarguably a crisis situation in the future and so clearly Marian University’s decision to establish a doctor of osteopathic program in an environment where a significant number of people in that training program stay in primary care, if we can find ways to expand residency programs and keep those individuals in the state, it’s not a short-term solution, but it’s a 15-year solution and we have to have greater access to both primary care, nurse practitioners, et cetera, to be part of that care team in order to handle the new influx of patients that are going to be out there.

IBJ: Well, the first question from the audience has to do with wellness, that came up in our discussion as well as education, and asks there are work site wellness programs that clearly impact the employees of that employer, but do you see that work site wellness programs actually affect the overall health and well-being of even the families of those workers, does it go beyond, and as we’re talking about these issues of improving health, changing health behavior, hopefully reducing costs, how wide of a reach do work site wellness programs really have? Sheri, do you want to jump in on that one?

ALEXANDER: Sure, I’ll take that one. I think if you have seen one wellness program you’ve seen one wellness program. They come in all shapes and sizes, just like the employees that they are targeted to serve. I think that the question was specific about workplace wellness and reaching the families. I think the majority of them really don’t reach the families. There are a few models out there where the families, especially a spouse, cannot hide anymore and those are gaining some traction, especially in this market, but I think it needs to go beyond a simple change and beyond an employee contribution because folks earn that once and then they’re set for the year and then the next year they go through whatever it is they need to do at the last minute to get that better contribution and then off they go for another year and they don’t think about it, so I think if you can incorporate and design that encourages healthy behavior throughout the year, whether that be in financial incentives or earning your way to better benefits or reward points, there are all kinds of ways to do it, but you can’t just throw it up against the wall and see what sticks, that’s not working.

PARK: The things that we’ve done with our electronic health record as part of our screening when we work with employers directly is we establish goals for every patient and they’re in there and so every visit we talk about those goals, we try to limit it to three things that we’re going to change during the next year and that seems to be pretty darn effective in getting people engaged and then our RN health coaches go through the same electronic health record and reach out to these people and get them in and get them engaged with the primary care physician.

SLABOSKY: Just merely testing people once a year is not adequate. Once you’ve tested your population, whether it’s employees or employees and dependents, you need to provide programs and activities that will help them meet their goals, so within our organization we are providing Weight Watchers free of charge to our employees, making it available on site throughout the year and a number of other programs, health coaching, exercise programs, but you can’t just stop and say “You’ve done your testing and that’s it for the year,” you’ve got to provide programs to help them.

PARK: A shameless plug for an Indiana company, TreadDesk, I don’t know whether you guys know about that, but you walk at your desk, it’s a very slow treadmill, burn about 300 calories an hour while you’re walking at two miles an hour, and I mean this company was truly struggling when they were trying to market in Indiana. They put up a website and they’re shipping these things to California and Colorado like crazy, so a great company, and people should be doing that.

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