Who’s No. 1?

With his influence over the in­dus­try not in ques­tion, there’s lit­tle dis­sent with our choice

Modern Healthcare - - FRONT PAGE - An­dis Robeznieks

Dur­ing con­fir­ma­tion hear­ings in 2005 af­ter he was nom­i­nated by then-Pres­i­dent Ge­orge W. Bush to be­come the next chief jus­tice of the United States, John Roberts de­scribed a judge’s role as that of an “um­pire.” Well, the ed­i­tors of Mod­ern Health­care called it as they saw it and named Roberts the most in­flu­en­tial per­son in health­care for 2012. Al­though his name did not ap­pear on Mod­ern Health­care’s bal­lot for this year’s 100 Most In­flu­en­tial Peo­ple in Health­care an­nual rank­ing, there should be lit­tle ques­tion about Roberts’ influence (See ed­i­to­rial, p. 17).

Roberts cast the de­cid­ing vote and wrote the ma­jor­ity opin­ion in the U.S. Supreme Court’s rul­ing to up­hold the con­sti­tu­tion­al­ity of the Pa­tient Pro­tec­tion and Af­ford­able Care Act’s in­di­vid­ual man­date. It’s a move that will un­doubt­edly have long-last­ing im­pact even af­ter the Novem­ber elec­tion.

It is Roberts’ first ap­pear­ance on the list. This is also true of the sec­ond- and third-place fin­ish­ers: Mark Ber­tolini, chair­man, pres­i­dent and CEO of Hart­ford, Conn.-based in­sur­ance gi­ant Aetna, and Dr. John Kitzhaber, gover­nor of Ore­gon. The other first-timer in the top 10 is Mar­i­lyn Taven­ner, act­ing CMS ad­min­is­tra­tor, No. 8.

Be­sides Roberts and Taven­ner, the other Wash­ing­ton of­fice­hold­ers in the top 10 are Pres­i­dent Barack Obama, No. 4, and HHS Sec­re­tary Kath­leen Se­be­lius, No. 5.

The oth­ers in the top 10 are Ber­tolini’s in­sur­ance in­dus­try peers: Ge­orge Halvor­son, chair- man and CEO, Kaiser Per­ma­nente, Oak­land, Calif. (No. 6); Stephen Hem­s­ley, pres­i­dent and CEO, Unit­ed­Health Group, Min­netonka, Minn. (No. 7); An­gela Braly, chair, pres­i­dent and CEO, Wel­lPoint, In­di­anapo­lis (No. 9); and Michael McCal­lis­ter, chair­man and CEO, Hu­mana, Louisville, Ky. (No. 10).

Health in­sur­ance, and whether Congress could com­pel peo­ple to buy it, was the main is­sue be­fore Roberts and the other jus­tices. While courts have rec­og­nized the power of Congress to reg­u­late com­merce, the in­di­vid­ual man­date was un­charted ter­ri­tory.

“Leg­isla­tive nov­elty is not nec­es­sar­ily fatal; there is a first time for ev­ery­thing,” Roberts wrote in the rul­ing handed down in late June, but he then cited a 2010 court de­ci­sion that stated some­times “the most telling in­di­ca­tion of (a) se­vere con­sti­tu­tional prob­lem … is the lack of his­tor­i­cal prece­dent.” He later added that, if the man­date were within its power, then Congress could “use its com­merce power to com­pel cit­i­zens to act as the gov­ern­ment would have them act” in other mat­ters as well.

Congress al­ready “en­joys vast power to reg­u­late much of what we do,” but it should not be al­lowed to take this fur­ther and reg­u­late what cit­i­zens do not do, Roberts wrote, con­clud­ing, “that is not the coun­try the Framers of our Con­sti­tu­tion en­vi­sioned.”

What Congress can do, Roberts ar­gued, “is make go­ing with­out in­sur­ance just an­other thing the gov­ern­ment taxes,” such as pur­chases and in­come.

“The ques­tion is not whether that is the most nat­u­ral in­ter­pre­ta­tion of the man­date, but only whether it is a ‘fairly pos­si­ble’ one,” Roberts wrote, adding that the Af­ford­able Care Act should not be struck down be­cause Congress did not specif­i­cally re­fer to the penalty for not buy­ing in­sur­ance as a tax as dis­sent­ing jus­tices ar­gued.

“In ef­fect, they con­tend that even if the Con­sti­tu­tion per­mits Congress to do ex­actly what we in­ter­pret this statute to do, the law must be

struck down be­cause Congress used the wrong la­bels,” Roberts wrote. “The Af­ford­able Care Act’s re­quire­ment that cer­tain in­di­vid­u­als pay a fi­nan­cial penalty for not ob­tain­ing health in­sur­ance may rea­son­ably be char­ac­ter­ized as a tax. Be­cause the Con­sti­tu­tion per­mits such a tax, it is not our role to for­bid it, or to pass upon its wis­dom or fair­ness.”

In his de­ci­sion, Roberts would later re­peat that he was rul­ing on the law’s con­sti­tu­tion­al­ity, not its mer­its.

While some hailed the de­ci­sion as well as Roberts’ rea­son­ing, oth­ers such as Rep. Jack Kingston (R-Ga.) felt be­trayed. Af­ter the rul­ing, Kingston tweeted “With #Oba­macare rul­ing, I feel like I just lost two great friends: Amer­ica and Jus­tice Roberts.”

Still oth­ers saw more pos­i­tive ef­fects of the rul­ing. “The Supreme Court de­ci­sion was very im­por­tant in terms of pre­serv­ing the link­age be­tween par­tic­i­pa­tion and mar­ket re­forms,” says Karen Ig­nagni, pres­i­dent and CEO of Amer­ica’s Health In­sur­ance Plans, the top in­sur­ance in­dus­try trade group, who fin­ished at No. 72 on this year’s rank­ing.

Mean­while, Dr. Pe­dro Jose “Joe” Greer Jr., as­sis­tant dean for aca­demic af­fairs at the Her­bert Wertheim Col­lege of Medicine at Florida In­ter­na­tional Univer­sity in Miami, says of Roberts’ de­ci­sion: “Among my peers, it’s been a very pos­i­tive re­ac­tion.” (Greer is not on this year’s rank­ing of the 100 Most In­flu­en­tial.)

Al­though the high court’s de­ci­sion also lim­ited the fed­eral gov­ern­ment’s abil­ity to force states to ex­pand their Med­i­caid cov­er­age, Greer says the Med­i­caid pro­vi­sions of the Af­ford­able Care Act are needed. “It expands Med­i­caid— but it also al­lows physi­cians to be re­im­bursed prop­erly,” says Greer, who re­ceived the Pres­i­den­tial Medal of Free­dom from Obama in 2009. “I’m try­ing to find the fault with that.”

Along with tout­ing the rul­ing, Greer cred­its the influence of the pres­i­dent for get­ting the law passed in the first place. “This is a land­mark pol­icy and it’s his ad­min­is­tra­tion that did it,” Greer says, adding that it’s up to lo­cal com­mu­ni­ties to make health­care re­form work.

“It’s not a blue and red is­sue, it’s about mak­ing this a health­ier coun­try,” Greer says. “It would be nice if we just talked about mak­ing peo­ple health­ier.”

As con­tro­ver­sial as Roberts’ de­ci­sion might have been, Ber­tolini says that, while Aetna “will continue to fully com­ply” with Af­ford­able Care Act re­quire­ments, the rul­ing it­self is not hav­ing a great im­pact.

“The Supreme Court’s de­ci­sion did not change our busi­ness strat­egy or com­mit­ment to sys­tem re­forms that make qual­ity care more af­ford­able and ac­ces­si­ble, and im­prove sim­plic­ity and con­ve­nience for con­sumers,” Ber­tolini said in an e-mail.

Aetna re­cently an­nounced its plans to buy Coven­try Health Care—which of­fers Medi­care and Med­i­caid man­aged-care plans—for $5.7 bil­lion, in part to in­crease its “pres­ence in the fast-grow­ing gov­ern­ment sec­tor” (See story, p. 10). It also made news this sum­mer by an­nounc­ing plans to cre­ate a new com­pany—In­no­va­tion Health Plans—jointly owned with Falls Church, Va.-based Inova Health Sys­tem, and to col­lab­o­rate with Aurora Health Care on the Mil­wau­kee-based in­te­grated health­care sys­tem’s ac­count­able care or­ga­ni­za­tion.

“The agree­ment be­tween Aetna and Inova to jointly form In­no­va­tion Health Plans rep­re­sents com­plete align­ment be­tween a health plan and a health sys­tem,” Ber­tolini said in his e-mail. “The joint own­er­ship drives a new level of shared ac­count­abil­ity across all as­pects of health­care— from un­der­writ­ing to pa­tient care.”

Ber­tolini also said that col­lab­o­ra­tion with Aurora had been dis­cussed “long be­fore the Supreme Court rul­ing. … We ex­pect that to­gether with Aurora, we will im­prove the co­or­di­na­tion and qual­ity of care in this mar­ket and cre­ate more com­pe­ti­tion through our lower-cost plans.”

Ber­tolini also de­scribed how he leads “an or­ga­ni­za­tion that im­pacts the health and well­ness of nearly 37 mil­lion peo­ple,” and said he uses that role as a plat­form “to cre­ate and influence pos­i­tive changes” to a health­care sys­tem that “is not work­ing for too many peo­ple.”

“We are com­mit­ted to mak­ing the sys­tem sim­pler, more fo­cused on well­ness and en­sur­ing that chronic pa­tients get the co­or­di­nated care that will help them achieve bet­ter health,” he said. “I am hop­ing I am on the list be­cause Aetna sees this ef­fort as a col­lab­o­ra­tive en­ter­prise, where all health­care play­ers have the same eco­nomic in­cen­tives to do what is best for the con­sumer. We are not wait­ing for re­form to hap­pen, we are lead­ing the change.”

AHIP’s Ig­nagni made the list for the 11th con­sec­u­tive year. She is one of only eight peo­ple who have made the rank­ing in ev­ery year of its ex­is­tence (See box, p. 57).

“I think it is a re­flec­tion of the im­por­tance of our mem­ber­ship to the de­liv­ery sys­tem and to pol­i­cy­mak­ing,” she says. “I think it’s a re­flec-

tion of the work our mem­bers are do­ing.”

Ig­nagni de­scribes that work as a col­lab­o­ra­tive ef­fort “to turn the boat in a new di­rec­tion that will al­low the sys­tem to be sus­tained” and to­ward “set­ting up a sys­tem to re­ward high per­form­ers.”

“I’m very ex­cited about the changes that are com­ing to the re­im­burse­ment sys­tem that will drive higher qual­ity and lower costs,” she says. “I see a real com­mit­ment to col­lab­o­ra­tion, which is cru­cial to tak­ing the leap we have to take.”

An­other peren­nial win­ner is Chip Kahn, pres­i­dent and CEO of the Fed­er­a­tion of Amer­i­can Hos­pi­tals, an ad­vo­cacy or­ga­ni­za­tion for in­vestor-owned hos­pi­tals. Kahn, who placed No. 33 this year, says health­care re­form has moved into the sec­ond in­ning of a three-in­ning game, with the first be­ing the Supreme Court rul­ing, the sec­ond be­ing the Novem­ber elec­tions and the third be­ing con­tin­ued im­ple­men­ta­tion if Obama is re-elected or un­known ac­tion if the Republicans win the White House.

Kahn says his influence stems from his job and, while he rep­re­sents only 20% of the na­tion’s hos­pi­tals, they are part of the largest sys­tems and tend to have the largest mar­ket share in the com­mu­ni­ties where they’re lo­cated.

Kahn de­nies a story that’s been widely cir­cu­lated on the In­ter­net that he used his influence to strip a gov­ern­ment-spon­sored “pub­lic op­tion” health plan from the Af­ford­able Care Act.

“In our dis­cus­sions with pol­i­cy­mak­ers—in terms of the big-pic­ture is­sues—there was hardly a men­tion of the pub­lic op­tion,” Kahn says. “It was our feel­ing that the pub­lic op­tion was some­thing that wouldn’t make it off the cut­ting-room floor.”

The high­est-plac­ing elected of­fi­cial on the list was Ore­gon’s Gov. Kitzhaber, a Demo­crat who ear­lier this year was able to push through a Med­i­caid re­form plan in his state with bi­par­ti­san po­lit­i­cal sup­port as well as with fed­eral fi­nan­cial sup­port.

Kitzhaber, a for­mer emer­gency medicine physi­cian, on March 2 signed the law cre­at­ing Med­i­caid co­or­di­nated-care or­ga­ni­za­tions. On May 3, the CMS an­nounced that it would be pro­vid­ing a $1.9 bil­lion grant to be paid over five years to help fund the new pro­gram for Ore­gon’s 600,000 Med­i­caid ben­e­fi­cia­ries. If the pro­gram works as planned, it’s pro­jected to save $11 bil­lion over the next 10 years (May 7, p. 6).

Crit­ics, how­ever, have re­ferred to the plan as a “gam­ble.”

“I would say the cur­rent sys­tem is a gam­ble,” Kitzhaber replies. “We know it is cost­ing huge amounts of money and pro­duc­ing very poor pop­u­la­tion health sta­tis­tics. We also know there is ex­cel­lent ev­i­dence that shows that, if you de­velop an in­te­grated sys­tem that seeks to man­age chronic con­di­tions in the home and in the community and ac­tu­ally seeks to link up with pro­grams that fo­cus on well­ness and pre- ven­tion, you can save vast amounts of dol­lars.”

Kitzhaber says the plan could eas­ily serve as a model for other states to use and that, while Ore­gon’s House of Rep­re­sen­ta­tives is split evenly be­tween Democrats and Republicans, the Med­i­caid re­form plan passed on a 53-7 vote.

“If there’s the po­lit­i­cal will, cer­tainly any state could move in this di­rec­tion,” Kitzhaber says. “In a year when health­care has be­come a po­lit­i­cal football, been di­vi­sive and par­ti­san, I think we’ve demon­strated here in the state of Ore­gon that it doesn’t have to be.”

For­mer Mas­sachusetts Gover­nor and pre­sump­tive Repub­li­can pres­i­den­tial nom­i­nee Mitt Rom­ney, whose state’s pro­gram for univer­sal cov­er­age is con­sid­ered to be the model for the Af­ford­able Care Act, re­turned to the list in the No. 13 spot. He also fin­ished at that same spot in 2006 and was No. 2 in 2007—be­tween Sis­ter Carol Kee­han, pres­i­dent and CEO of the Catholic Health As­so­ci­a­tion who was No. 1 that year and then-Cal­i­for­nia Gov. Arnold Sch­warzeneg­ger in the No. 3 spot.

Rom­ney’s run­ning mate, House Bud­get Com­mit­tee Chair­man Rep. Paul Ryan (R-Wis), fin­ished first last year and No. 24 this year, though the votes were tal­lied long be­fore he was cho­sen as the GOP vice pres­i­den­tial can­di­date.

Ryan has pro­posed to trans­form Medi­care into a “pre­mium sup­port” sys­tem where se­nior

cit­i­zens will re­ceive a cer­tain amount to buy health in­sur­ance and could pick the plan of their choice—with those who pick less-ex­pen­sive plans get­ting a re­bate and those who choose more ex­pen­sive plans pay­ing the dif­fer­ence out of their own pock­ets.

“We be­lieve con­sumer-driven, mar­ket­based re­forms do more to al­ter the cost curve of health­care in­fla­tion,” Ryan says in an in­ter­view (Aug. 20, p. 8). Ryan’s Demo­cratic co-spon­sor, Sen. Ron Wy­den of Ore­gon, makes his first ap­pear­ance on the 100 Most In­flu­en­tial rank­ing, hold­ing the No. 44 spot.

The other elected of­fi­cials on this year’s list: Obama, who placed No. 4 (he topped the rank­ings in 2009 and 2010); House Speaker John Boehner (R-Ohio), who fin­ished at No. 19 in his sec­ond time on the list (he was No. 21 last year); Se­nate Fi­nance Com­mit­tee Chair­man Max Bau­cus (D-Mont.), com­ing in at No. 35 for his seventh time on the rank­ings (he fin­ished fourth in 2009 and 2010); House Ma­jor­ity Leader Eric Can­tor (R-Va.), mak­ing his first ap­pear­ance at No. 42; Florida Gov. Rick Scott, mak­ing his sec­ond ap­pear­ance, climb­ing to No. 43 af­ter plac­ing at No. 49 last year; Rep. Pete Stark (D-Calif.) mak­ing his 10th ap­pear­ance on the list at No. 49; Sen. Chuck Grass­ley (R-Iowa), the only elected of­fi­cial to be on the list all 11 years, holds the No. 56 spot (See re­lated story, p. 22); House Ways and Means Com­mit­tee Chair­man Dave Camp (R-Mich.), mak­ing his first ap­pear­ance on the list, at No. 65; and Ver­mont Gov. Peter Shum­lin, No. 86, who fin­ished sec­ond on last year’s ros­ter.

One per­son push­ing back against the Medi­care pre­mium-sup­port plan is Rose Ann DeMoro, ex­ec­u­tive di­rec­tor of Na­tional Nurses United/AFL-CIO, who also has made the mostin­flu­en­tial list ev­ery year, hold­ing the No. 36 spot this year. DeMoro ad­vo­cates a “Medi­care for all” plan, and her or­ga­ni­za­tion is col­lect­ing anec­dotes of the hard­ships faced by peo­ple with­out in­sur­ance.

“The sto­ries are heart­break­ing,” DeMoro says, telling of an in­stance where a woman hav­ing a heart at­tack was pre­pared to die rather than call an am­bu­lance be­cause she was afraid that, if she went to the hospi­tal, she would lose her home and her son would have no place to live. DeMoro says the woman’s son called an am­bu­lance.

DeMoro con­tends that the big­gest influence in health­care to­day is in­for­ma­tion tech­nol­ogy. She says health­care CEOs have be­come “cap­ti­vated” by IT and wor­ries that tech­nol­ogy is re­plac­ing hu­man judg­ment and the hu­man touch. “All the hos­pi­tals wor­ship it, and they’re try­ing to pro­vide health­care with­out hu­man be­ings,” she says. “Nurses are now mon­i­tor­ing the mon­i­tor in­stead of mon­i­tor­ing the pa­tient.”

Mak­ing her third and high­est ap­pear­ance on the list is Ju­dith Faulkner, founder and CEO of Verona, Wis.-based Epic Sys­tems, the na­tion’s lead­ing ven­dor of elec­tronic healthrecord sys­tems. At No. 22, Faulkner was the high­est IT pro­fes­sional on the list, and she says the big­gest influence on her is the feed­back her cus­tomers pro­vide.

As Faulkner rises in influence, she’s find­ing her­self—rather than her com­pany—in the spot­light, which she says is not al­ways pleas­ant.

“I’m fre­quently re­ferred to as ‘me­dia shy,’ so to me, pub­lic­ity is some­thing I pre­fer to avoid—not be­cause it’s good or bad—but be­cause I pre­fer to be some­one who’s not in the pub­lic eye,” Faulkner says, adding that in­ac­cu­rate ar­ti­cles—such as a re­cent Lon­don Daily Mail story—do lit­tle to change her mind. “Peo­ple read it and be­lieve it.”

The Daily Mail story de­scribed her as a “Harley-David­son-rid­ing friend of Pres­i­dent Barack Obama.”

“I don’t know (Obama),” she says. “And, by that, I don’t mean I’m an en­emy, but I met him once and that was for a few sec­onds—and I don’t own a Harley.”

Dr. Carolyn Clancy, di­rec­tor of HHS’ Agency for Health­care Re­search and Qual­ity, holds the No. 32 spot in her 10th ap­pear­ance on the list. And she says she’s ex­cited about the work AHRQ is do­ing in us­ing tech­nol­ogy to ad­vance health­care qual­ity and pa­tient safety— even if the fis­cal 2013 Repub­li­can bud­get calls for elim­i­nat­ing fund­ing for her agency.

“We’re very op­ti­mistic,” Clancy says, adding that it’s be­cause she’s hear­ing a com­mon mes­sage across health­care in­dus­try sec­tors. “They want to dra­mat­i­cally ac­cel­er­ate high-qual­ity care, but they need good in­for­ma­tion, and that’s what AHRQ does.”

Of par­tic­u­lar in­ter­est is the $475 mil­lion AHRQ re­ceived from the Amer­i­can Re­cov­ery and Rein­vest­ment Act, which was used to de­velop a health “data in­fra­struc­ture” that Clancy says cre­ated a plat­form for fu­ture stud­ies.

“We rec­og­nize that that the Re­cov­ery Act was a one-time in­vest­ment and we would never have the op­por­tu­nity again,” she says, adding that the in­vest­ment helped cre­ate a sci­en­tific foun­da­tion for “tran­si­tion­ing from peo­ple run­ning around look­ing for pa­per charts to get­ting feed­back in real time for do­ing the right thing.”

One tech­no­log­i­cal in­no­va­tion that Clancy high­lighted was at a Cal­i­for­nia hospi­tal where the pa­tient pop­u­la­tion speaks 21 lan­guages. In ad­dress­ing read­mis­sion chal­lenges, Clancy says the hospi­tal de­vel­oped a sys­tem where pa­tients are pro­vided a pass­word-pro­tected record­ing in their own lan­guage and can lis­ten to their dis­charge in­struc­tions over and over. “It’s hard not to feel op­ti­mism,” Clancy says. Dr. Eric Topol, chief aca­demic of­fi­cer for Scripps Health, San Diego, and di­rec­tor of the Scripps Trans­la­tional Sci­ence In­sti­tute, feels the same op­ti­mism. Topol, mak­ing his sec­ond ap­pear­ance on the list, hold­ing the No. 64 spot af­ter land­ing at No. 69 last year, says ge­nomic medicine is mak­ing “re­mark­able” progress in fight­ing can­cer and Alzheimer’s dis­ease. He also notes ad­vances in tele­phone tech­nol­ogy that can di­ag­nose a child’s ear in­fec­tion, help to reg­u­late a pa­tient’s high blood pres­sure med­i­ca­tion or cal­i­brate a new pre­scrip­tion for their eye­glasses.

Topol, who this year was named to the No. 1 spot in the Mod­ern Physi­cian and Mod­ern Health­care 50 Most In­flu­en­tial Physi­cian Ex­ec­u­tives in Health­care com­pe­ti­tion this year, says he con­tacted some Aus­tralian col­lege students who de­vel­oped Steth­noCloud, a tele­phone at­tach­ment that can help re­motely di­ag­nose pneu­mo­nia. He says that, in their re­ply, the students told him they were in­spired by his book The Cre­ative De­struc­tion of Medicine.

De­spite all the at­ten­tion fo­cused on the Af­ford­able Care Act, Topol says the pol­i­tics are “in a sep­a­rate or­bit from what we’re talk­ing about.”

“The hope is that, through con­tin­ued, re­lent­less ef­fort, we will be able to get that pub­lic de­mand and get that con­sumer-driven rev­o­lu­tion,” Topol says. “This is highly threat­en­ing to the med­i­cal community, but highly em­pow­er­ing to the pub­lic.”

1 Chief Jus­tice of the United States John Roberts

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