IBJ: Education came up a few times and while we’re on this theme, another audience question was what can employers do to best and fully educate their employees, is there one or two things that the panel would say is the best thing to do?
ALEXANDER: Well, I’ll take that one, too. Education, I think with the multi-generational workforce that we have now we need to customize our communications to reach the audience, so we’d better be texting and Facebooking and Tweeting, those things, so whatever works, and for your older population, they love to get things in the mail and have people talk to them, so I think that’s a real key issue, know your audience.
PHILLIPS: The other think I’d add to that, J.K., is I think what we see at Roche is it’s all about the culture and it starts at the top, it starts at the leadership level, and, you know, it involves the culture that you want to have, the beliefs you want your employees to have, how you want them to behave at work and with others, but then also the type of company we want to be and then just really every day, it’s got to be an everyday event, it can’t be a onetime event or once a year event or once every six months event, it’s got to be something that’s every day that’s in the culture and I think once you have it embedded, whatever is important to you and what you’re passionate about, which for all of us today I’m sure fitness is one of those or a healthy employee base should absolutely be one of those, then you embed that into what you do and the culture that you live every day and I think that’s where you can make some big strides, and then I think to what you said, Dr. Park, I love that idea of having goals, if you establish goals for individual employees and patients and help them figure out how to see what they need to do, you know, over the next month and not over the next year, I think that can make big progress as well.
SPEER: I agree with Jack’s comments. We take our wellness program out to employers around the state. It is a cultural issue, it starts with the CEO. If the CEO believes in it and makes it part of the culture of that organization, you see it start to trickle down throughout that organization, and as you talk to the leaders of these businesses, probably many of whom are in this room, they talk about the financial investment they’ve made to move someone from graduation from college to a position where they take on more leadership roles and to have that person suffer a heart attack or stroke or diabetes, take them out of that queue, they’ve lost a tremendous financial investment and then taking that culture from the employee to home and you see that in the bariatric programs, the counseling that goes on pre-bariatric surgery is a family counseling because, in all honesty, if mom or dad has bariatric surgery but the spouse at home fixes fried chicken every night and continues to plan on doing that in the future, the surgery is irrelevant, it’ll do no good, and so it has to be a cultural and societal change, and from our perspective from working with employers around these wellness programs, those companies who from the CEO down it’s part of the culture have the greatest success.
PARK: J.K., I think it has to start, too, in the schools. There’s a wonderful organization called PE4life.org and what they’ve shown is that by putting heart monitors in the schools and having kids exercise every day they reduce disciplinary problems by one-third and improve standardized test scores by 20 percent. We don’t have anything that comes close to that and the state should be all over it.
IBJ: Well, the next question from the audience I think refers to some changes made by Medicare over the last couple of years in its reimbursements to physicians and has reduced reimbursements to physicians in specialties, has tried to raise reimbursement to some primary care physicians, so the question is it reasonable to attempt to control health care costs by reducing the pay of specifically specialist physicians?
PARK: That’s a hard one, I mean we have oncologists and nephrologists in our group, as well as a lot of family docs and internists, but the reimbursement probably has gotten a little out of whack in terms of the services and primary care we believe does need to be rewarded a little bit more. We like to see it more on a performance basis. We don’t think the base pay needs to come up that much, but we get money now from what’s called PQRI, we get money from Meaningful Use, we get money for E-Prescribing, we get money from Quality Health First, the Anthem program, and all of those things add up to significant dollars and there’s pretty good coordination between them as to what they’re going after. We think accountable care will be just sort of the next iteration of pay-for-value and we like to see a system that fully endorses that and we think we could work it out inside our organization how the pay-for- value distribution gets distributed.
SPEER: Well, we have a reimbursement problem, whether it’s for specialists or primary care or for hospitals. The changes in Washington, DC, I think we’ve all been watching those, predicting they’re coming. I don’t think they’ve been much of a shock anymore to anyone. As I mentioned in my first comments that uncertainty is what’s driving I think a lot of the consolidation, acquisition, you described it two years ago in the IBJ as a “land grab,” that’s what’s going on and it’s reimbursement driven. I think you have an issue with medical students choosing the primary care specialties and looking at tremendous debt loads to get out of college and undergrad and then choosing a profession which is going to pay them towards the bottom end of that spectrum, so in the specialties of medicine, the primary care specialties are typically towards the lower end. They’re choosing not to be primary care doctors for that reason, you’ve got a debt issue, you have a reimbursement issue. We need to fix the debt issue, the reimbursement issue would be mitigated slightly, and we probably need to have some balancing of the reimbursement system among specialists.
VERMA: I would agree with that. I mean, I think a lot of the things we talked about today in terms of accountable care organizations, managed care, coordination of care, management of chronic disease, all of that centers around primary care and so without a robust primary care network I don’t think we’re going to be able to implement those things as well, and when the reimbursement is sometimes four times as much for specialty care versus primary care you really are not incentivizing medical professionals to go into primary care when they’re graduating from medical school and they’re looking at a $300,000 debt or bill for going through medical school and going into primary care that pays a hundred, $150,000 a year, that’s not going to be as attractive as going into a specialty that pays three times as much, so I think overall we really need to do something about the reimbursement for primary care.
IBJ: The next question from the audience is if you could eliminate one federal restriction or limitation, what would it be?
PHILLIPS: One federal restriction?
SPEER: My lawyer just got up and left the room, that doesn’t make me feel very good. Yeah, I mean, I think one or three would be a good start. I think for health care reform to be effective you’ve got to change the way that the government looks at anti-competitive behavior, you’ve got to look at Stark and you’ve got to look at anti- kickback because all three are really impediments to that continuum of care and the coordination we’re talking about, and I haven’t seen any movement on that. In fact, if you get the leaders in Washington together who are responsible for those three areas, none of them have any intention of revising those three principles, and absent a revision I don’t think we’ll get in a health care system to where we need to be in order to deliver a more effective product.
PARK: I agree, it needs to be more pro-competitive and eliminating the restriction on physician ownership of facilities would go a long way to doing that.
VERMA: I think in terms of the Affordable Care Act, the timelines, I think there’s a lot to get done between now and 2014 and there’s very little preparation and a lot of unanswered questions at this point, and so I think we need some more time. In some cases there are no regulations, I mean I think in terms of the exchanges some of the regs’ major pieces have yet to be released.
SLABOSKY: Well, getting back to accountable care, the feds issued proposed regulations for accountable care I believe early in the year and they were just simply totally unacceptable to organizations who supported accountable care, and they need to be realistic in drafting and proposing the rules and regulations accountable care organizations are supposed to offer. If we’re going to test this concept, they’ve got to be realistic and the first draft simply wasn’t. Well, just the simple complexity of the regulations, there needs to be a greater simplicity in terms of the accountable care organizations because you’re going to be dealing with lots of hospitals, lots of physicians, and the complexity was just overwhelming and they’ve got to be realistic that people cannot devote full-time compliance people to analyzing the rules and regulations, we want to get out and try and experiment with these concepts, but they weren’t presented in a way we could do that.
IBJ: Another question from the audience is also related to accountable care organizations and about palliative care. Since a huge percentages of the cost of medical care do come in the last month or two of life, palliative care is one way that’s been shown is lower cost. In the efforts to respond to accountable care or to form organizations that could function as accountable care organizations is palliative care being rolled in at this point or not?
PARK: Sure, sure it is. The HealthCare Partners folks, I know that nationally 40 percent of Medicare patients die in the hospital and most of us would agree that’s not ideal, and under their model only 20 percent do and many more people get hospice care, and if you look at hospice care, you know, a recent study came out looking at lung cancer and what they found is people who received hospice care lived longer than people who got aggressive therapy, so it’s a quality of life issue and it’s deeply personal, you need to have these conversations with people. People wouldn’t choose the course that they oftentimes get if they had someone to talk it through with them.
SLABOSKY: I would suggest you take a look at what happened in La Crosse, Wisconsin, I believe it’s Gundersen Lutheran Hospital in La Crosse, Wisconsin and they made a community effort several years ago to involve organizations within the community, churches, religious groups, to start explaining to the population about end-of-life care before they needed end-of-life care and they were able to explain the concept of hospice, explain the concept of palliative care and the concept of advance directives and get a huge number of people, a very high percentage of the population of the community to sign advance directives and keep track of these advance directives, but La Crosse is an example of a community-wide project to inform people about this whole issue and they were very successful and this is a model that I think other communities ought to take a look at.
IBJ: How did they avoid getting the label of a “death panel”? Was it controversial?
SLABOSKY: Well, as I understand what they did was they went out and started explaining hospice and exactly what Ben talked about, that people who go through hospice actually may live longer than people who were getting continued care in the hospital, they explained the concept and they really got away from this image of a “death panel,” but you’ve got to do this before people are in need of end-of-life care and you’ve got to do it well in advance and you’ve got to do a good job of explaining it and that’s what they did in La Crosse.
IBJ: Dr. Park, you made the comment that bending the cost curve is really not good enough, that the curve needs to be broken. With that in mind, aren’t all of these things, like better use of IT and on-site clinics, just pecking around the edges, don’t we need a more sweeping approach? You can answer that or anyone else can.
PARK: I think we do and I think where accountable care is heading is it’s essentially giving people a fixed amount of dollars and saying manage the costs within that and that causes you to be very innovative about your approaches, you develop disease registries for taking care of folks, you have nurse call centers that get them in to see when they need to be seen, you start looking at people who have pre-diabetes and you work with behavior modification programs to keep them from becoming diabetic, so it has to be a very broadbased engagement of the patient and the employer on the benefit design side as well.
SLABOSKY: Well, for accountable care to work, again conceptually to work, it’s not going to be successful if you only have a few scattered accountable care projects because you cannot ask physicians and hospitals to change their behavior if they don’t have the vast majority of their patients under a budgetary system. If they only have 10 percent of their people under a fixed budget and everybody else still under a fee-for-service system, you’re not going to be able to change behavior, so we’ve got to see this accountable care at least tested on a large number of people, and I think Medicare was successful when they instituted DRGs a number of years ago, you saw a rapid consistent change across the country in hospital stays, and if Medicare can roll out accountable care successfully for the entire Medicare population, you’re going to see the commercial carriers pick up the concept and you’re going to see a big movement to budgetary health care.