WALL: One of the big changes coming out of the 2010 health reform law is a push for health care providers to provide care more based on value, a little less based on volume of services. One concept toward that goal is this accountable care organization concept. It’s similar in many ways to health maintenance organizations that were going in the ‘70s or in the ‘80s and ‘90s and then have waned in popularity since then, and I’d like to ask the panelists what is it about ACOs that are different than HMOs that may give them maybe a better chance of succeeding and lasting longer in the market rather than HMOs? Vicki Perry, I’d like to start with you. You ran an HMO, still run an HMO, you ran Maxicare and Advantage Health also as HMO plans as part of its business. What are the differences and what do you think will help ACOs reach a different outcome than HMOs?
PERRY: I think we always compare the HMOs of the ‘80s and early ‘90s to ACOs of today, but I think probably one of the most significant differences that will bring I think a different kind of value and a different kind of delivery system model is that with clinical integration you have to have data integration and a highly competent technology system that can interface with all of the technology that exists today within the physician practice, so being able to bring information that is patient-centric to the point of care faster, being able to have analytics that have a high degree of accountability to the different leadership and areas that require analytics to analyze performance and outcomes, et cetera, is the biggest difference. I think that the competence factor that providers have now within a clinically-integrated model should be much better than what they had years ago and I think the accountability that you’ll see from an outcomes perspective is going to be much more valuable.
WALL: And can you give one concrete example of how that greater analytical capability might play out in a positive way?
PERRY: Sure. Probably one of the most unique or can be the most unique is being able to identify where there are gaps in care, so if you have a 50-year-old female that’s diabetic that hasn’t had a hemoglobin A1c, with the integration of claims data, pharmacy data, point of care electronic medical record, that provider’s going to know that they haven’t had a hemoglobin A1c or they have had and it’s not below 7, so it gives a higher degree of intelligence and more of a patient focus at the point of care.
WALL: Okay. Bob Brody, what are your thoughts on this? Your Franciscan is involved in two ACOs as we speak, so you like the concept. Why do you think it will work in ways that maybe HMOs maybe struggled to work?
BRODY: Well, we’re involved in two ACOs at the moment with Medicare and the primary difference in this ACO model versus historical HMOs is that these Medicare recipients aren’t restricted in choice, they can go to any provider, so it’s not a closed network, which is fundamental to the old HMO strategy. The ability to move information around, we have capabilities now that were only dreamed about back then, working with our Advantage partners from an information resources capability. The Indiana Health Information Exchange is a great facility here moving data around this marketplace. I think the fact that we are responsible for managing across the continuum, so our role as providers now is more expansive, we’re not just involved in what goes on within the walls of the hospital or within our network of Franciscan providers, we’re responsible for working across the community, whether it be dealing with the home health community, the skilled nursing facility, the long-term acute care, the individual providers who may not be in the employ of our health and hospital system. So quite a few changes and much better. And one other point I’d make in terms of the information capabilities, we can do some predictive modeling now, predictive indexing, actually anticipating when patients may be steering toward a troublesome road and we have the ability to intervene. WALL: Great! Who else has thoughts on this? Dr. Yeleti.
YELETI: One of the issues with data management is that we have come along way, as Bob said, from 10 years ago, but at the same time we’re not nearly as far as we need to be to get the success that we need with any system. I think identifying a strong IT system and data management is key to our future in the next 10, 20 years. We’re nowhere near where we need to be at all, so I think we would be naive in sitting and thinking that we have the data that we need to manage. We have it better now than we did say 10 years ago, but to really manage outcomes we need to define what the outcomes are and have longitudinal shared data to better manage patient populations and we’re not there yet, but that I think is the big focus. The foundation of an ACO of managing patients is I think reasonable, but I think what we need to really care about is what are the outcomes we want from an ACO model, it’s long-term longitudinal outcomes, not short-term outcomes, and we need to really redefine the outcomes and redefine the data that we need to get to those outcomes. So conceptually it makes a lot of sense. HMO models were really to limit care and I think this is to improve care, but the care has to be longitudinal care and we’re not there yet.
WALL: Do you have any forecast on when you think that the system will get better?
YELETI: Well, if I was President…
YELETI: A lot of it is — It’s kind of like, you know, probably 30 years ago we would’ve never thought of not having banks and, you know, now we don’t even need to go to a bank to deposit a check, you take a photo on your iPhone and that’s it, so I still think it’s going to be a long way down the road, probably 10, 15, 20 years at least, to get to where we need to be. But to your point, maybe, I think we need to take advantage of the current data we have now, so we can’t just sit here waiting and say that “We don’t have the data, we can’t do anything.” Let’s start with what we have. Having IHIE in town I think we’re further along than maybe a lot of other cities are, but we still have a long way to go to where we need to get to, and really the biggest issue there, though, is redefining what data we need because right now we’re getting data that we can actually get, we need to redefine what are the outcomes we want and what kind of data do we really need, so a lot of things we need to discuss and understand is what do we want to measure because we’re not always measuring the right things. We measure what we can measure but not necessarily the right things, though.
WALL: Okay. Anyone else have thoughts here?
LARKIN: Yeah. I think, as mentioned, many people don’t realize how far ahead of the curve Indiana is when it comes to informatics and health information technology. Part’s due to IHIE, but there’s other health information exchanges in the state and many states don’t have any. We’re currently working on interconnecting the current state’s HIEs, or health information exchanges, together for the flow of information and, surely, in the HMO days where providers were given some sort of performance review or some sort of patient review, they didn’t believe the data and often it was data development, but with the new informatics and applications, and IHIE has one, others do, too, that when a provider gets information it’s credible and they can reconcile it if it’s not. If they’ve been told about a patient who needed a blood test, they knew they had it, but they can go in now and understand the information they get about how they’re caring for their patients and their certain disease classes is valuable and credible. Add to that, on the public health side we just recently launched something called MyVaxIndiana and Indiana’s now one of the first states to have online 24 hours a day, 7 days a week, access to an immunization database for parents and guardians and soon they’ll have the ability to go on their smartphone, but it’s that type of power when you take access to information so parents will know what immunizations their child has had and which ones they need, which is very helpful because the immunization schedules today are so complex, it’s almost easier to launch a space shuttle than it is to understand who needs what and when, so I think the ability to move data will make the accountable care organizations actually more viable in part.
WALL: Dr. Yeleti.
YELETI: The only other comment I’d make about that is that we think about providers managing the data. I think one thing that we’re all evolving to and I think Bob was talking about is having a system of coordination of care. The provider/physician needs to be the coach for the whole team, but there needs to be a strong system where there’s a team managing the data and then the right data’s presented to the physician. The physician cannot be looking at this data all the time. If you have a team that gives you the right information to manage the team, that’s where we need to get to, so it’s a combination of to have the right system that has the right data. The team-based concept will move us farther ahead with the data.
WALL: Okay. Vicki mentioned clinical integration as something that has happened recently, is happening more and might help in making ACOs successful. A big way that clinical integration has happened is just through corporate integration of physician practices and physicians and hospitals. Mike, you work with all kinds of physician practices. Can you give us a sense of where we’re at in the integration corporately of physician practices? Are we going to see a lot more consolidation or has it largely run its course here in this market?
HEATON: I don’t think we’re even close to the completion of that process. Not only do we have physicians that are already in the middle of the integration processes, some of these systems can attest to, but we still have the ranks of the uncommitteds out there who haven’t decided where they want their affiliation to be, and just starting in this market a little bit, we’re seeing it in other markets around the country, we’re starting to see realignment where maybe the initial three to five year time period affiliation worked and it doesn’t look like it’s going to work going forward, so I don’t think it’s an appropriate assumption the mere fact that an integration has occurred with the physician office practice, whatever physician group, necessarily means that that’s the end of the process. The other part of that, which doesn’t really deal with the integration of a physician practice per se, is we’ve got a tremendous amount of recasting of business relationships with health systems, relationships with different provisions of services, different joint ventures, maybe they have to be reclassed because of regulatory purposes, so the whole relationship between systems and physicians is evolving not just as it relates to the employment and the provision of the clinical service but also as it relates to the entire venture and management of service lines and management of the delivery process.
WALL: So do you think we’ll see more hospitals acquiring more physician practices in the future?
HEATON: I don’t see where that stops, and I think that Bob probably should answer that one.
BRODY: Life is good for consultants. (Laughter.)
WALL: Yeah, Bob, do you want to jump in here?
HEATON: Well, we’re busy. No, in all seriousness, I don’t see where it stops, and the other side of it is the whole model of the way practices see how they’re going to deliver care long term. The cost of the technology that everybody’s talking about, the cost of the information system is obviously not something that a small group medical practice today can even perceive and that whole evolution is the way we see it.
WALL: Bob, do you have thoughts?
BRODY: I think the driver behind all of this change/dynamic is the fact that it’s fairly evident that the payment platform has to change, the old fee- for-service, volume-driven mechanisms just are unsustainable, we all recognize that and have been talking about it for years, and as physicians have aligned with larger health systems, as health systems are choosing partners as we redefine our relationships with the payer organizations, it’s all fundamentally driven by the fact that the incentives are changing and changing I think in a way that’s very positive. As we’ve discussed here in the past, we’re more accountable as health systems for outcomes, both clinical and financial performance, and that’s as it should be. The incentives that we’ve all known and have grown up with in the industry served us well but are incomplete and perhaps, as we’ve discussed, economically unviable.
WALL: Dr. Yeleti, do you have thoughts?
YELETI: Yes. Actually, I have a lot of thoughts. I’m a cardiologist and we integrated with the network about three years ago, so I think to Bob’s point, the reason for physician integration with hospitals is financial, but what we really need to do as an integrated system, though, it has to really take advantage of not only the reasons why the doctors integrated but what do you do with that? Getting back to IT and data, for a physician to really manage patients better you need a large infrastructure so that the system can manage the patients. You know, we were talking about hemoglobin A1c’s. I might see a patient and I might tell them that “Yeah, your weight is 250, you need to lose 50 pounds, your hemoglobin A1c is 13 and you need to get it down to 7 and your blood pressure is 160 and you need to bring it down to 120” and then they leave my office and there’s no infrastructure for me to follow them or for them to follow us, so we need that system to develop the outcomes that we need, so I think we take advantage of — don’t worry about why the doctors decided to join the hospital and, yes, it was all about money, but once you get there, though, take advantage of them to really improve the outcomes and that really increases the physician satisfaction greatly when you know that you have a system supporting you to take care of the patient as you want to, you do what you need to do and the system does the rest, that’s really satisfying as you move in that direction.
WALL: Vicki, go ahead.
PERRY: We’re talking about data integration, but data integration and a system and an electronic medical record that allows view and even data entry into a record for a patient is incredibly powerful and it does allow a broader clinical care team to focus on an individual patient or an event of care and to transition them through the continuum of care that we’ve been talking about as well, so it’s not just report- carding and analytics, it really is helping drive resources at the point of care and the point of time that are best going to treat the patient or the condition.
BRODY: When we say “direct resources,” we are applying a lot of manpower, in fact, to better managing care, hiring care managers. You know, I read an article yesterday that said 20 percent of the health care spent is devoted to 1 percent of the patient population. Expand that to 5 percent and it represents 50 percent of the health care spent across the nation. The sickest folks amongst us are the ones that drive costs up so dramatically, and with our ability to now manage across a continuum and work with a much broader network of providers we’re able to apply resources to really individually touch patients who need the most help and guidance and assistance and support as they navigate the system and we help them navigate the system, so it’s all good.
WALL: Yes, Dr. Yeleti.
YELETI: One last point. To your point about percentages here, the decision a physician makes, medical decision-making, to improve the life of a patient, that’s only 10 percent of their care. 90 percent of their care is system related, so that’s why we do need an integrated health care delivery system to take care, affording all the care, having a unified electronic medical record, sharing the data because 90 percent of a patient improving their care is really dependent on the system, it’s not dependent on the physician itself. The physician might guide the plan but really the true successive outcome is based on the system that they’re in.
WALL: I do want to ask about Medicaid here in Indiana. The Supreme Court rendered its decision on the Affordable Care Act that gave states the option to not expand their Medicaid Programs without losing their existing Medicaid funding and that seems to be an open question here in Indiana, it’s going to be left to whoever wins the Governor’s race and the makeup of the state legislature next year. I’m curious of our panelists what you think if Indiana does not expand Medicaid, what sort of impact does that have on providers and on payers and if it does, what different impact would it have? Who wants to start here? Bob Brody, you look like you’re chomping at the bit, I’ll start with you.
BRODY: Well, first, I think it would be a travesty if we didn’t expand coverage for the 800,000 fellow Hoosiers that are bare right now. As we’ve talked about health care reform over the years, that’s what it’s all about, is bringing more people under the tent and creating access opportunities for those folks to get health care earlier in an appropriate manner and ultimately get a better handle on cost because if, as we know it now, uninsured, when they come into the emergency room it’s oftentimes in dire situations or sometimes it’s for frivolous situations, still the most expensive access point you can have and oftentimes a little late in the game to have a successful intervention, and the fact of the matter is the federal government is providing the bulk of the reimbursement for that expanded coverage, so we should consider moving forward.
WALL: Who else has thoughts on this?
PERRY: I will.
PERRY: Of course I will. I’m not going to side on whether they should or shouldn’t expand. I take the position that I think as a community, little “C,” not big “C,” as a community we need to figure out how to deliver a model of care to the uninsured that is not system dependent, health system dependent, but is community dependent and really figure out how can we bring care into the communities that we serve that will meet the people instead of trying to meet the people into the health system itself. It’s going to be more affordable, it’s going to be more efficient, you’re going to probably get a higher degree of engagement, and I think when we figure that one out we won’t have as many or it won’t be as important to be uninsured because they’ll still have access to care and it needs to be primary and ambulatory care.
WALL: Dr. Larkin, do you have thoughts? And I will remind the audience that Dr. Larkin only works for the State, is not in charge of the Medicaid program.
LARKIN: Thank you very much. I mean, studies well show that an insured population has general better health than an uninsured population for the reasons Bob has mentioned, the uninsured delay care until it’s too late and inappropriately use the system, and whether Medicaid’s expanded or not we’re still going to have a significant percentage of uninsured and the public health department will continue to have as many safety nets that is not covered by any proposal. But another issue, a very interesting article was printed in “Health Care” not too long ago where they took a simulated dynamic model of the US health care system and applied three levers to it to see what would happen in 10 years and one lever was why don’t we just expand insurance coverage to the population, does that improve and save lives and does that save money? Well, that turned out to save the least amount of lives and was the most costly. The second one was what if we improve preventive care and care of chronic disease to this model? And that actually had a gradual return because you’re cutting chronic disease and you had more lives saved, and it was also expensive. The third lever was what if you change community behavior and infrastructure and encourage and actually get some effect in the population of behavior choices? No surprise! And that one would save much more lives, saved six billion dollars more than any of the other two. So, you know, expanding insurance for the state they clearly say that will cost money and the decision will be made where do you not spend, that’s not going to be our decision, it will be the fiscal decision-makers, but also inherent in all of this is if you widen the doors to an auditorium you don’t increase the seats, nor make it more comfortable, and so we can increase access to the insured but I think we still have a real problem with the current health system being incapable to take on a broader insured population because I don’t think necessarily, at least throughout the state, we have the capability that we wish we had. Our primary care physicians and extenders are limited, particularly in rural areas. There isn’t a one lever here that’s provide more insurance and we’ll improve health. I hope it would work, but I think there’s other things that will need to be done.
HEATON: Well, from my perspective or a physician’s perspective the expansion of coverage isn’t going to change anything with regards to access. You’ve got a limited amount of resources in terms of the physician-provider population, obviously especially in the primary care areas they’re trying to use those people differently to take care of those patients, but especially with some of the specialists, there’s only so much capacity within the system and we’ll probably talk a little bit about where we think that’s going long term, but the mere just changing of the label that’s on somebody’s card or putting a card in their wallet doesn’t necessarily automatically create access.
WALL: Dr. Yeleti.
YELETI: The long-term solution is that, is community based reform. Again, health care is a systematic issue, it’s a community issue, it’s not a provider issue in particular. That being said, we have to start incrementally, we have to start somewhere. Getting to being able to modify the system, modifying our community to improve health is a long-term, broad goal. Our government is not in that direction right now, so it’s going to take some time to get there. Medicare itself, I would agree with Bob completely, I think it’s absolutely absurd not to expand it. States like Massachusetts that have expanded Medicaid, they’ve reduced their actual mortality by about 20 percent. 20 percent mortality reduction for a cancer drug can be a blockbuster for a company. So there’s immediate things you can do. Chronically long term that’s not the answer. The long-term solution is to get to the underlying fundamentals of coordination of care, not just access, but coordination of care, and so I think it’s a multi-step process, but if we don’t start somewhere then we’re not going to move the direction we need to go. One last comment is that we’re paying quite a bit as it is without Medicaid. For all the patients that don’t get the care that they need, they end up in the hospital, they end up in the emergency room, then they get complications from their diabetes, from their congestive heart failure, so we’re actually paying quite a bit, and so it’s hard to put a number on how much we’re paying and how much we could potentially save from that, but to say that it’s an extra cost, it is a cost but we’re not realizing the cost of what we don’t do.
PERRY: I would like to see the community at large create an opportunity for individuals that have interest in holistic approach, wellness, health, creating a model or a professional certification that would be health coaching because I think the more that we would have health coaches in the communities working with kids, adolescents, young adults, trying to impact not just the professional clinical side but really the biopsychosocial impact, that the society and where they are within their community itself and greatly diminish any outcome that a physician might be able to provide or try to direct. We cannot get enough nursing graduates in the community, we just can’t, it’s becoming very expensive, but there can be another level of quasi- health professional out there on the coaching to address more of the chronic drivers for health or no health.
WALL: Bob, and then I’ll come back to you, Dr. Yeleti.
BRODY: Well, to Vicki’s point, I think we need to empower our clinicians across the state, whatever level they are, to be able to practice up to the full extent of their license. We need to think about roles differently, creating resources that supplement physicians in delivering some basic services. The assumption about what program and what it would cost Medicaid, we have a Healthy Indiana Plan that was developed here that is very effective, somewhat limited in its enrollment but could be a vehicle. It’s still uncertain as to what vehicle we might be able to use in expanded coverage for that several hundred thousand of our fellow citizens. And the other point about expanded coverage is that in the basic Affordability Care Act equation funds were taken out of hospital reimbursement looking 10 years forward and with the intent that we would create access and coverage for the uninsured. To not follow through and cover the uninsured and still take the cutbacks on the hospitals is kind of a double whammy and I think would end up with the state of Indiana being less served than better served.
WALL: And would you be satisfied, Bob, with an expansion of Medicaid using the HIT plan, would that be acceptable to you?
BRODY: Well, I think it’s something that’s going to be in the dialogue. I think it would answer some of the questions we have about personal accountability, personal stake, put some wellness expectations on patients and financial responsibility, so it’s definitely worthy of discussion.
WALL: Dr. Yeleti, I want to come back to you.
YELETI: Yeah, I think Vicki was bringing up a great point as well as Greg about how we change, how we deliver care and coaches. One of the problems we have with Medicaid and Medicare is the perverse incentives. The way a physician gets paid, for instance, the more patients I see the more I get paid, so I can see the same patient 20 times a year and I’ll get paid more but that’s not the right thing to do and I’m not saying that’s what people do, but what I am saying, though, is that the way we do it the physician is a central player. And I think to Vicki’s point about coaching, at Community Physician Network, for instance, we have a couple campuses where we actually try to manage patients as a group in a patient-centered model where we have a group of diabetic patients, 10 patients that come in monthly, so they sit in a room with the dietician one time, maybe pharmacist the next time, the nurse practitioner the next time. During that two to three hour session then each patient goes and sits with the physician for about 10 or 15 minutes, then they come back to that environment and get discussions flowing and then they go back home. With that, those 10 patients whose A1c has been 13 percent had dropped all the down to below 7 percent. For people not clear about A1c, a 13 percent A1c is having an average blood sugar of about 400 on a daily basis, whereas an A1c of less than 7 percent is having a blood sugar of about 100, 110. Really, the normal range is 90 to 110, and these are patients who have always been motivated, so it’s not that they haven’t been motivated, they just didn’t understand in terms of how to do things. Now, the problem with that, though, is that we’re not going to get paid for that. I mean, the nurses that we’re using, the pharmacists we’re using, that’s an extra cost to us in the system. To change the incentives to improve outcomes rather than to increase volume is what we need to do.
PERRY: There’s a community, literally a community, eastside on Washington Street that is underserved, they don’t have any grocery store close to them, it’s a very high poverty level and Wishard has a clinic there. There is more ambulatory care and services being provided in that clinic, and it’s free, than probably anywhere else, and the model is working and it’s working for kids and it’s working for single moms because the model is where they are because otherwise they would have to get on a bus, they would have to potentially transfer twice to get to a grocery store, to get to a clinic at Wishard, et cetera, so I think getting 10 people in a room and having a group session is great for those that have the means to get there, but I think we’re missing a tremendous amount of opportunity not taking that same delivery model into the community.
WALL: On the topic of clinics, you were talking about community clinics and that concept is sort of bringing the care to people as opposed to or in addition to assuming that if they have an insurance card of some sort that they can find care. Employers have recently been adopting a somewhat similar approach as more and more have done on-site clinics. I’m curious to whether the panelists think that that approach can really move the needle on employee wellness and on health behaviors within employers. Dr. Larkin, can you handle that one?
LARKIN: Well, you know, that’s really not an either/or question. Employers have a great deal invested in a healthy community, this is where they draw their employees from, so the healthier they can be and the more the employers apply their leverage and their presence in communities to raise the bar and do well for all citizens the better and that would be the advocation of public policy, the advocation of community development and so forth. However, on-site clinics, and in my background I had some experience with those at Eli Lilly and elsewhere, all on-site clinics aren’t created the same, but the better clinics that match for employer’s needs depends on the employer’s demographics. The best outcomes of such clinics will increase preventive screening because you need to lower the barrier for employees to take advantage of screening, so if you put it on site during the work hours they’ll have it done. It helps address minor ambulatory care issues where someone may start off with a cold and they don’t see the doctor because they have to leave work and all of this sort of stuff. If they can see someone there and get it addressed early it may not progress into a more severe illness, and as well as chronic disease management, but, again, the clinics perhaps have got to with functionality, but the good ones that can work with the employer and identify these trends can cut back cost. I know years ago at Lilly, and we’ve done that, Lilly has done that for years, and as you mentioned it’s more of a trend now, but looking at our own data when we managed our own health plan we easily could see a reduction in office visits and also a reduction in emergency room visits only because people sought care earlier. The other advantage, and again it depends on the employer, the leverage and so forth, they do it also to, in theory, to increase productivity, if they can keep the people healthier, keep them at work and so forth, but, again, all on-site clinics aren’t created equal, but in the right setting for the right demographics it’s a model that has been shown to work out well for us.
WALL: Does anyone else have thoughts on this topic?
BRODY: We provided extensive access to health care for our employees. We have over 4000 employees in this market area. It seems to me to be an effective way to, to Dr. Larkin’s point, to get a jump on illness. We’re going through a process right now where over the next several weeks we’ll have 99.9 percent of our employees immunized for the flu season. It’s not a bad strategy. I know all of our delivery systems are willing to assist employers in creating that resource if and when and where that’s desired, but overall I think it’s dependent on the circumstances entirely.
WALL: Dr. Yeleti.
YELETI: Talking about what you mentioned, the employee health clinics is only one part of the bigger continuum of coordination of care, I think everyone understands that, is that, again, to really move the needle in terms of health care costs you need easy access, so I think having something on site is critical, but we also need to be able to, again, have the data on managing the patients. Again, being a cardiologist, we have a lot of patients with congestive heart failure. We talk about readmission rates a lot. In a true outcome setting what you should be looking at is the number of patients being admitted for the first time with congestive heart failure. If you’re treating their hypertension, treating other risk factors, you try to avoid the first admission, much less the second admission, so coordinating the care with adequate data in the system to control pharmacy costs and to make sure the patients are taking their medications, there’s a lot of behavioral economics with that, too. Employee health is a critical part but you can’t talk about it in isolation, though.
PERRY: I think clinics can be very expensive and again I think there has to be some scalability within certain employer groups. What we are seeing is interest in almost having what are called virtual clinics where you have primary care sites or urgent care sites that become a preferred point of care site that is very conveniently and logistically located, so kind of creating a clinic model that’s a virtual model that has some unique features to it does increase access and probably will increase the focus on chronic disease management.
WALL: Okay, I’m going to turn to audience questions now, and the first couple both kind of pick up from this wellness topic but focused more on how much patient accountability or responsibility should factor in here, and one question says shouldn’t a person who smokes or is obese, et cetera, be required to pay a much larger premium for their health insurance regardless of the size of the company they work for as a way to encourage wellness?
YELETI: The whole obesity thing, I think we need to remember it’s not a simple behavior issue. Physiologically the way human beings are made, you know, just in the past 30 years we’ve had an obesity epidemic and so the past two million years we haven’t, so to say that the patient’s personality and behavior suddenly changed so they want to be fatter is obviously absurd. Obesity itself is a system, is a cultural issue, it’s not an individual freewill issue by itself. If you think about it, if you think that people go home, including myself, and I run on this little machine, a treadmill, you know, a thousand years ago “What the heck are you doing running on that treadmill?” You know, it just doesn’t make sense. It’s our society that causes obesity to occur, too, and to say it’s simply freewill I think misses the point that a lot of issues we have are system issues requiring collaboration and coordination of care in terms of how we can get things done. I think there’s definitely a personal, individual issue, but even in medicine when we see a patient, as physician colleagues we sometimes in our notes will document “Patient’s noncompliant” and again we need to reassess what that means. “Noncompliant” means that the system has not made it easy for the patient to be compliant, so there’s a lot as a system we need to think about instead of brushing it off as simply that. There’s significant patient accountability but to say it’s all patient accountability misses the bigger picture, I think, and we’ll never get to where we need to be if we don’t address that.
WALL: Vicki, do you have thoughts here?
PERRY: Under health care reform one of the features of it is that pre-existing limitations and exclusions, coverage for individuals with certain conditions and diagnoses is eliminated, that’s a good thing, but one thing they have kept in there is that you can charge a differential for individuals who smoke, and I think if we as employers paid more attention to disincentivizing through credit or something within the premium contribution strategy, I know firsthand that it will work with an employer group and it does dramatically impact the cost of health care of the workforce itself.
WALL: Some of your customers have tried such a design?
PERRY: Absolutely, yeah. We have quite a few employer groups who are aggressively going after that.
WALL: Who else has thoughts here?
LARKIN: The state government itself, they offer lower premiums to nonsmokers, it depends on how you want to define that, but for those that declare they’re a nonsmoker they also randomly test the alleged nonsmokers to make sure they don’t have an indication of tobacco use and if they do it has led to unemployment, so I mean that’s a pretty significant incentive. But with tobacco, in public health we really believe we don’t really need more treatment, we need less disease, and you look at the obesity tidal wave that’s coming, it’s been well publicized, it’s been projected that Indiana will have 50 percent of its population obese in the year 2030 and that brings all the other major complications, be it cardiovascular or diabetes. The American Diabetic Association projects that if we keep on this path it will be within 10 to 15 years that one- third of our children will have what’s now referred to as adult onset diabetes, so as far as employers, whether they want to work with the incentive for the health plan, we really more importantly need to reduce those behaviors be it with community partnerships, start with children as much as we can. A BMI is an indication of weight to heighth that’s used to categorize one’s healthy weight. It is a term that we almost can’t use when we talk about the young population because people feel that somehow you’re being unfair to a child by giving them an unfavorable BMI, but we have to start accepting that these are things that we need to work on, whether it’s genetic or not, what we can do to lowering the incidence of disease will be a whole lot more important than increasing treatment for that disease. And just one other final fact, that for every adult today that dies of a tobacco-related illness there are two teenagers lighting up their first cigarettes. We’ve got a Clean Air Act and we’re doing some things that are positive, but our challenges are far from over.
WALL: Go ahead, Bob.
BRODY: It’s not a health care delivery system problem-solve, it’s society’s problem-solve, and it is multifaceted, as we’ve talked about, and it has to do with diet, it has to do with additives in our food, it has to do with the ability of Mayor Bloomberg in New York trying to ban the sale of quart-size containers of sweet sodas. We have to get serious and recognize — We’ve created bike lanes in Indianapolis, which is commendable, but it’s multifaceted and we all have to get serious about where we want this nation’s health to be in the future.
WALL: Dr. Yeleti.
YELETI: Yeah, I would just echo what Bob is thinking is that it has to be a system. Related to how we get paid, again, I think the incentives are a little perverse right now in health care reform. Suppose what if the employer, a large employer, was going to get kickbacks from the government if they reduced their average BMI from 30 to 28 in their population, or what if the physician or provider health care system got paid if they as a system were going to be able to get extra money for reducing their average BMIs in their system? That’s one way, that’s not the only answer, but the point is that we can’t place it just strictly on the individual, it’s a system issue between providers within the community and the government to try to work together and modify the incentives. Right now the incentives are to put it all on the patient, which is part of the answer but not the full answer.
WALL: The next question from the audience concerns small businesses. It says are you seeing small business employers making choices to no longer offer health insurance benefits to employees due to rising costs and do you feel that the state-based insurance exchanges will positively address this issue if this issue continues to escalate? Vicki, can you weigh in on that one?
PERRY: I would say that we are not seeing a dramatic shift away from coverage. We are still seeing many employers elect to significantly increase the coinsurance or the cost to the individual, which is a meager way of trying to change the outcomes and their health care costs. I do think that we are going to see more employers doing what is called a defined contribution, you know, giving $300 a month to you to elect your insurance and then have you as a consumer have the choice of how much insurance you want to buy and what benefits you might want. I think what we as payers need to do is to make sure that we’re paying for the right thing, that we are changing from a fee-for- service model, but that we’re giving more individuals the accountability for electing and selecting the insurance that best meets their needs. One-size-fits- all isn’t going to work and it’s very expensive.
HEATON: Well, I think a lot of this is going to have to do with what happens next month with the election, too, because we read a lot about employers who are willing to pay the penalty, as it were. If the Affordable Care Act stays intact, then there’s a fairly lengthy list of employers that are already talking about, the small business community, that it’s just going to be cheaper to pay the tax, so at some point in time if all the discussion about the access to care and getting appropriate incentives, because we talked a lot about appropriate incentives and I don’t know anybody who’s really paying for those incentives as we sit here now, but if we’re still paying for episodic care and that care is more expensive than a penalty that’s going to be levied — excuse me, is it a penalty or a tax, I forgot? — then we’re going to be in a position where we’re back to non-covered folks again in the system trying to get episodic care at the wrong point in time.
WALL: Bob Brody.
BRODY: Well, again it gets back to that expansion of both coverage for the uninsured, we’ve got to figure out how to solve that because as long as we don’t attend to that it’ll be a cost shift which the burden falls on the employers with escalating costs which exacerbates the situation, we will have fall-out, we’ve seen fall-out from employers, from really smaller employers just getting out of the system, which only compounds the problems, so we’ve got to consider this in a comprehensive fashion, there are no patches in the system to fix it.
PERRY: Concerning the exchange, which was the —
WALL: Yeah, right, yeah, do you think the exchanges will help this problem?
PERRY: Indiana’s taken a fairly passive position right now and that’s not right or wrong, that’s just reality, so I think until we really understand what Indiana’s position is going to be on the exchanges, is it going to be federal, are they going to opt out, what are they going to do, it’s difficult to say whether or not that’s going to be helpful or just an additional expense.
WALL: Does anyone else have thoughts on the exchanges, whether that will help alleviate some of the pain on small businesses?
BRODY: I don’t know if it will relieve the pain on the small businesses. I think it’s going to impose a lot of pain on the insurance industry and on providers in that, it’s not a bad thing, but we take on more of a retail approach to buying health care and the concepts of insurance are built on large numbers and if you have individuals making decisions about where they’re going to go I think it’s going to create a challenge to understand how to price your services in a way that is sustainable.
WALL: The next question is how do you expect the average consumer to understand all the changes in health care coverage and delivery? Who will be the liaison or communicator to help them understand the complexities of these new models of care we’ve been talking about?
PERRY: Well, for all of the agents out in the audience I would say this is a great opportunity for — We know it’s good for consultants and attorneys, and agents who really want to become helpful will learn to help individuals make decisions and navigate through the complex options.
BRODY: For the longest time I always felt that if people just listened to me… (Laughter.)
WALL: Vicki, for the agents, is there a way for them to get paid for that communications or liaison work?
PERRY: Again, Indiana has not taken a position yet on exchanges. There is a big component, a navigator type component or an agent type component. I don’t think that if it’s through the exchange and the state has those navigators, you know, they’re not going to get commissioned. I do believe, and we see this throughout rural Indiana now, there are agents out there that have very small agencies that are kind of like your pharmacist, you know, they become a part of, you know, your decision process if you live in that community, so there is a way and a room for them I think to be adequately compensated and be very helpful.
WALL: Okay. Well, the next question maybe touched on some of our recent ones as well, but as we’ve talked about better managing care for individual patients across all settings or different places, if you’re a small employer how does that actually save you money? Can someone kind of try to make that connection or maybe say there isn’t a connection, it won’t save them money?
PERRY: Oh, there is. Go ahead.
YELETI: There’s a direct connection. The problem is that there’s the short-term expense and concern versus long-term benefit and so we need to figure out how we can connect it for the long term. What we’re doing today may not affect outcomes — Well, I shouldn’t — There’s two things, maybe. One is you’re actually looking at a population of patients in your business to look at who’s costing the most money in your business and then coordinating their care specifically, that can have immediate short-term results. For instance, having them be on the same pharmacy plan that are taking certain types of medications, those patients who continuously have to use the hospital more often, there’s some probably immediate short-term things you can do with nurse care managers and other things to in the short term reduce the cost for you to better coordinate the care for those patients. The long term is a longitudinal reduction in health care expenses and that’s a little bit more difficult to time. If your employees stay with you for a long time, then you’ll see those on a long-term basis but there’s probably short-term results you can get.
PERRY: I think care coordination is directly responsible for reduction in emergency room visits, i mean we measure this, readmissions for the same diagnoses within 30 days. If you can keep people out of the emergency room, you are going to have a dramatic reduction of hospital admissions, and when we see two and three day hospital stays for an event that is secondary to a chronic condition it’s very costly, very expensive, it’s heavy loaded cost-wise up front because that’s the acuity period, but if you keep them out of the emergency room and you provide a safety net for them through care coordination you are going to limit the acute care events and that has a dramatic reduction in cost to the employer’s premium.
LARKIN: A simple example is that within an employer’s health plan they have hypertensive or people with high blood pressure, they’re paying for medication every day. Medication often isn’t cheap. However, if no one’s really monitoring the blood pressure and making sure that the pills being taken are the ones that are needed then the employer’s expense is being thrown out the window because what the employer is trying to avoid is a significant health event and they’re paying for treatment but it’s not being coordinated or monitored well, same would go for diabetes.
YELETI: One fact about that, as a cardiologist, again, there’s a lot of studies out there showing that if I prescribe a statin, Zocor, Lipitor, to a patient, only about 30 percent of my patients are actually taking it a year after I prescribe it and so talking about monitoring and not just monitoring but having a system in place to do the coordination of care I think is critical. And long-term outcomes, you know, what you could theoretically do for hospitals, hospitals should basically be surgery centers, in other words you should only be in a hospital if you’re getting a procedure done. If you’re in a hospital for a medical condition, that’s a failure of the system. If you’re going there because you have congestive heart failure, if you’re going in there for something else, even pneumonias and so on and flus, if you’re going in for a medical condition, it’s that we have not been able to coordinate the care well, and right now the percentage of our patients that are nonsurgical, i.e. medical, is more than 50 percent, so if you push that down long term is what we really need to get to in terms of outcomes.
PERRY: And it comes back to data, too, because you can as a physician identify when someone is noncompliant with a pharmacy prescription.
WALL: We’ve talked a lot about coordinating care and I think most of the discussion has been on within a hospital system or a hospital system and its affiliated physicians. This question, though, is since patients can move to any hospital system, any doctor, how well now do hospital systems in Indiana and central Indiana collaborate to solve some of these complex issues?
BRODY: Well, I think, as evidenced by the Indiana Health Information Exchange, we are committed as a community of providers to raise the bar. We have the Indianapolis Coalition for Patient Safety, we work together quite closely to where we can, as allowed by the Justice Department, coordinate and collaborate and work to raise the level of health care across the system in this city and across this region. We also have very strong health systems and tremendous resources.
WALL: Who else has thoughts here?
YELETI: I think we’re well ahead of the game than other cities, but just practically speaking, unfortunately, we’re nowhere where we need to be. Even yesterday when I saw a patient, she has cancer, she’s getting her cancer treatment at St. Francis and then she sees me as a cardiologist for her valve condition and then she’s talking about her kidney problems that she’s having but her kidney dialysis numbers are at another institution. It’s better than a lot of other cities but it’s not at all where we need to be and so her care is disconnected and I don’t think she’s getting good care and it’s not the fault of anybody at all, everybody’s doing their best individually to provide her with care, but long term we need to have a uniform platform for EMR and for data, a smooth flow of data. The VA, actually, a government organization, actually is pretty good at that. You can go to any VA in the country and they will have your entire medical record. If you just happen to get sick and you’re driving around in another state like Texas or something, they’ll have your entire record, what medications you’re on, your last lab values, your last x-ray, and for a cardiologist your last EKG, your last EKG is probably the most important thing a cardiologist always wants to see. So getting to a unified EMR, a unified exchange of data, is where we need to get to, but I think Indianapolis is much farther ahead and I think we have the infrastructure to get there but we’re not there yet.
WALL: Vicki, what do you think?
PERRY: I think we have an elephant in the room. Until the health systems decide that we don’t need, this is awful, Bob, you’re going to fire me, but, you know, we don’t need a cardiac hospital on every quadrant of the city. (Applause.)
PERRY: I think if the systems could come together and identify where do you need renal dialysis, do you need four renal dialysis facilities in the city?
BRODY: You know, that’s a great point and as we —
PERRY: So I still have a job?
BRODY: — were engaged in the health care reform debate for years prior to the AC Act being passed, we talked about that, we talked about the limitations imposed on us by antitrust. You know, it would be wonderful to be able to sit down with Community and ration care in a manner that eliminates a lot of redundancy and unnecessary competitiveness, but we are restricted in our ability to do so. There’s a lot of waste, I would call it waste, in advertising —
BRODY: — and developing redundant capabilities, but we haven’t as a society determined that we want to ration those services in a way that most efficiently serves the population.
YELETI: The ration is going to fall on physicians long term, we’re going to have to decide who gets what and what we don’t, whether people agree with that or not that’s what’s going to happen. The problem with having too many hospitals is, again, the perverse incentive system that we have. Medicare, when it came into being in 1965, we had patients dying all the time from acute events, so we know there was a purpose for Medicare when it came out. Now, you know, fast forward to this decade, it’s now longitudinal chronic illnesses. You know, back in the ‘60s a third of patients that came into the hospital with a heart attack died and now that’s been cut ten-fold and so we have ten-fold more people living, so we have to switch from acute care to chronic care, and even the reform we have right now doesn’t address that necessarily. So if we get to that and we change the incentives for outcomes for longitudinal care, that will get rid of the hospital beds and it will really change things.
PERRY: But we as consumers want a hospital on every corner and we do want the convenience of being able to drive 10 minutes away.
YELETI: You’re correct, but we as providers need to figure out what do patients want, not what would they love to have. They don’t actually love to have a hospital on every corner, they want to have good health care, they want to be healthy, so if we could figure out how we can make them healthy, what do they need to be healthy is different. Right now, you’re right, the answer is “I want a hospital right next to me.” Long term that shouldn’t be the answer. The answer should be is I want a system that can take care of me.
HEATON: We’ve got another access issue that we haven’t talked about at all and that’s access to the physician. I mean the last study that I saw, 47 percent of physicians, it’s probably two years old, so it’s probably better than half now, are over the age of 55 and at least my clients that are over the age of 55, they’re not going to be around practicing in 10 years, so if we look 10 years down the road, access isn’t just about facilities, access is about being able to get ahold of a physician, and I’ve got to believe that the practice of medicine is just going to change drastically over the course of the next 10 years because it’s not just a question of being able to go into Bob’s facility and get taken care of, it’s having that cardiologist right there being able to take care of you immediately, I think that’s going to continue to be problematic.
YELETI: To modify that or tweak it a little bit is, again, what a patient may need is not access to a physician but what a patient needs is access to the health care that they need, which is slightly different, because it’s really coordination. The physician, again, would be the coach, from the business standpoint he would develop the strategic plan and have a team that’s going to operationalize it, so you need that operations team there to really be able to get things done, so a patient needs someone they can go to at the right time when they need their care and the physician there is, again, managing the team, so that the role of the physician changes. We need to be practical. You’re right, we only have a term of doctors and that’s not going to change dramatically.
HEATON: Right, but the concern is not just, again, the chronic issue, it’s the episodic care. We were talking about a friend that has a — a colleague that’s practicing in the Netherlands where for a functional nasal surgery it’s a three-year wait and today society does not accept that, it’s “I have this problem and I want to be able to get ahold of somebody now.” My concern is not just the demand of the consumer, if you will, but the availability of the physician labor because you can provide a lot of assistance to the physicians in terms of care management and the nursing and whatever management of patients, but at some point in time there is a skill level that’s required of the physician and that resource is going to be harder to come by.
YELETI: And that’s again we have to change the coordination of care because to me as a cardiologist, when I was in clinic yesterday, I was managing the patient’s blood pressure, I was managing their cholesterol levels, I was even managing some of their diabetes, and as an interventional cardiologist, frankly, I should be in the cath lab opening arteries, I shouldn’t be doing that. In other words, every doctor has to work at the top of their game, so we need to have a system that allows for those chronic conditions to be managed by the right people and so that the surgeon and everyone is at the top of their game and right now we don’t do that effectively and that’s what we need to get to because we’re not going to have more doctors, so how do we make sure that everyone’s at the top of all of their game?
HEATON: I think you have to change expectations because I still expect to call my physician, I want to see my physician, and until we understand that we can’t deliver the care that way —
YELETI: You’re right.
HEATON: — that’s a paradigm I think that we’ve got to change.
WALL: Dr. Larkin.
LARKIN: Well, the other thing I think you have to recognize in Indiana, Indiana does not have the most favorable environment for physician extenders through regulation, being nurse practitioners, physician assistants, and so forth, and we surely don’t have enough primary care doctors and there’s nothing in medical training today that encourages a medical student to want to be a primary care doctor. I am, but there’s too few family doctors or primary care doctors, and why would you in the current environment? Why would you be paid less, work harder and perhaps on a relative scale be less respected in the field when you instead can be high-tech and so forth? The problem with that is that we don’t all need access to a cardiologist but we do need access to a qualified health care provider, be it a physician or not, that can improve your care. My wife is a nurse practitioner, she’s retired now, but when we were in private practice years ago, actually patients liked seeing her more often than me. They would call in and say “Is Lisa there?” and they’d say “Well, no, but Dr. Larkin is.” “Oh, I’ll call back.” (Laughter.)
LARKIN: So I mean that’s the other thing, and I know there’s been at least some interest of looking at how we improve the working environment for physician extenders.
WALL: Bob, do you want to have the last word?
BRODY: Well, I don’t know if it’s the last word, but we have Marian University developing another school here in the state which is going to add additional resources and many of which will fall in the primary care realm, which is great news for Indiana. I think we’re going to have different expectations and I think specialists will not be able to travel the state and deliver services in some of the smaller communities, nor will they need to. I think we will have the ability to move best practice protocols electronically and have the expectation that our providers practice at the state-of-the-art, that’s going to be an expectation going forward that we would be able to deliver on, so I’m more confident perhaps than some about the future. I think we’re heading for a better, more satisfying and more productive health care scene here in Indiana.
WALL: Okay, well, we’re going to wrap it up there.