What he should say

Health­care lead­ers of­fer sug­ges­tions for State of the Union

Modern Healthcare - - COVER STORY -

Mod­ern Health­care re­porters reached out by phone and email to lead­ers from across the in­dus­try to find out what they hoped to hear from Pres­i­dent Barack Obama on Tues­day. Here’s what they said:

Dr. James We­in­stein, pres­i­dent and CEO of the Dart­mouth-Hitch­cock health sys­tem

“The pres­i­dent now needs to call on the peo­ple. Un­til they are en­gaged, we won’t have the dis­rup­tive change that we need and in­no­va­tion to drive that change to achieve what we call a high-value sus­tain­able health sys­tem. To do that, the pres­i­dent should call on groups like the High Value Col­lab­o­ra­tive that’s run out of Dart­mouthHitch­cock.

It’s time to move away from pol­i­cy­mak­ing into prac­tice-mak­ing and im­ple­ment the strate­gies for real change that will cre­ate a sus­tain­able health sys­tem, not a health­care sys­tem, for Amer­ica. The ques­tion is: Will he say any­thing? You would hope that he would, given that that was the ma­jor is­sue he started his pres­i­dency with. I would hope that he would come back and say: We had some his­toric leg­is­la­tion, there’s work to be done to im­ple­ment that leg­is­la­tion and it will re­quire all Amer­i­cans’ at­ten­tion, in­no­va­tion and spirit to change it.

We have to set the chal­lenge. Be­fore the end of this decade, Amer­ica should have a val­ue­based health­care sys­tem that’s trans­par­ently mea­sured and peo­ple can judge health­care as well as they can judge what’s in a ce­real box. To­day, we can’t.”

Dr. Eric Topol, chief aca­demic of­fi­cer at Scripps Health, San Diego, and di­rec­tor of the Scripps Trans­la­tional Sci­ence In­sti­tute

“The most ex­cit­ing, in­no­va­tive di­men­sion of medicine—our abil­ity to dig­i­tize hu­man be­ings (via se­quenc­ing, sen­sors and other tools) and prac­tice pre­ci­sion medicine—will not even be men­tioned. It’s not on the radar screen of U.S. health­care pol­icy to­day.”

Marna Borgstrom, pres­i­dent and CEO of the Yale New Haven (Conn.) Health Sys­tem and CEO of Yale-New Haven Hospi­tal

“Broadly, what I would like to see him ad­dress around health­care is not just how to cut health­care costs to, quote, make it more af­ford­able, but how to really step back and think about what kind of care we want, how we want peo­ple to have it and who we want to in­sure. …

What the de­bate seems to have been about a lot more in the last cou­ple of years is we’ve got to cut a lit­tle bit more, we’ve got to cut a lit­tle bit more, but with­out re­gard to who we’re cov­er­ing and what kind of care and ac­cess we want them to have. …

We shouldn’t just be talk­ing about what we can pay for health­care, we ought to be talk­ing about how we re­late that to help­ing to evolve a more ra­tio­nal health­care de­liv­ery sys­tem. … We have a pro­jected short­age of physi­cians. So at a time when we’ve got the state and fed­eral government in­sur­ing more and more peo­ple, we don’t have a corol­lary plan that says, how are we go­ing to make sure that there are enough physi­cians ... PAs (physi­cian as­sis­tants) ... nurse prac­ti­tion­ers? And ed­u­ca­tion gen­er­ally doesn’t pay for it­self. It doesn’t op­er­ate in a mar­ket where sup­ply and de­mand work. When you leave it to that, you get the wrong distri­bu­tion, wrong mix of providers.”

Joseph An­tos, scholar in health­care and re­tire­ment pol­icy at the con­ser­va­tive Amer­i­can En­ter­prise In­sti­tute

“Pres­i­dent Obama should level with the Amer­i­can peo­ple about the real prob­lems we face in health­care and how we can work to­gether to solve them. It is time to move to a health sys­tem that is re­spon­sive to con­sumers and that lives within its means.

In­stead of ad­vanc­ing an­other round of fee cuts that will never be im­ple­mented, change the in­cen­tives that drive Medi­care spend­ing and give se­niors a choice of plans that com­pete on an even ba­sis. Let states do a bet­ter job of op­er­at­ing their Med­i­caid pro­grams by giv­ing them full flex­i­bil­ity rather than re­quir­ing them to seek waivers for even small changes. Give states that ac­cept that flex­i­bil­ity a pre­dictable fed­eral sub­sidy based on the num­ber of peo­ple served, not the vol­ume of ser­vices pro­vided. In­tro­duce a more real­is­tic un­der­stand­ing of what it takes to im­ple­ment the Af­ford­able Care Act.

At least 20 states will not cre­ate a state in­surance ex­change, and most of the oth­ers

face great dif­fi­cul­ties in mak­ing it work. They need more time, and so does the fed­eral government. A de­lay, al­low­ing states to move at their own pace, is the only re­spon­si­ble ac­tion—but one that will be es­pe­cially dif­fi­cult for this pres­i­dent.”

David Ken­dall, se­nior fel­low for health and fis­cal pol­icy at Third Way, a cen­trist Demo­cratic think tank

“Elim­i­nat­ing waste­ful health­care is crit­i­cal to the na­tion’s eco­nomic se­cu­rity. Pres­i­dent Obama can take some of the credit for the re­cent slow­down in Medi­care spend­ing due to the Af­ford­able Care Act. He should also say, how­ever, that now is the time to lock in that lower growth rate by elim­i­nat­ing waste­ful health­care.

It may take 30 years to elim­i­nate the 30% of health­care spend­ing that does noth­ing to im­prove pa­tients’ health. But the ef­fort will be well worth it be­cause it will avoid two aw­ful al­ter­na­tives: crip­pling tax in­creases on the mid­dle class and ma­jor cuts to so­cial in­surance pro­grams. Ev­ery­one in­volved in the health­care sec­tor will have to change their be­hav­ior to cut the waste. Pa­tients at risk for di­a­betes will have to im­prove their diet and ex­er­cise. Doc­tors who prac­tice in­de­pen­dently will have to work as teams to im­prove care and lower costs. Health plans will have to sup­port all health pro­fes­sion­als with new pay­ment sys­tems that re­ward high-qual­ity care, not the quan­tity of care.

For all that to change, the next step must be bi­par­ti­san. Oth­er­wise, the task of cut­ting the waste will be a vic­tim of the po­lit­i­cal process, not its goal.”

Robert Henkel, pres­i­dent and CEO of As­cen­sion Health, St. Louis

“We hope the pres­i­dent high­lights the enor­mous dif­fer­ence his Af­ford­able Care Act has al­ready made in the lives of mil­lions of Amer­i­cans who no longer worry about pre­ex­ist­ing con­di­tions or los­ing cov­er­age af­ter leav­ing col­lege.

We hope that he re­mains com­mit­ted to ad­dress­ing and re­solv­ing the con­tin­u­ing con­cerns around re­li­gious free­dom as we ex­pand ac­cess to in­surance. We hope he urges states to ac­knowl­edge their spe­cial obli­ga­tion to pro­vide peace of mind to mil­lions of our low-in­come ci­ti­zens by ex­pand­ing the Med­i­caid pro­gram, which cares for those who are poor and vul­ner­a­ble.

We also hope the pres­i­dent ac­knowl­edges that uni­ver­sal ac­cess to af­ford­able health in­surance is pos­si­ble only if we con­tinue the hard work of trans­form­ing our health­care de­liv­ery sys­tem, to re­ward doc­tors, hos­pi­tals, and nurses when they keep peo­ple healthy as well as when they help peo­ple heal.

Fi­nally, we hope the pres­i­dent ref­er­ences the first lady’s ini­tia­tive to en­cour­age healthy foods and healthy life­styles, and re­in­forces the role of per­sonal re­spon­si­bil­ity in a trans­formed health­care sys­tem.”

He­len Dar­ling, pres­i­dent of the Na­tional Busi­ness Group on Health

“What we would like to do is have him say what es­sen­tially would prob­a­bly be no more than two or three sen­tences, but would fo­cus on the really im­por­tant ways that im­prove­ments can be made in qual­ity and safety and af­ford­abil­ity and not through blunt cuts but through build­ing on pro­grams—many of which are al­ready au­tho­rized un­der the Af­ford­able Care Act— and all of the steps that many hos­pi­tals and health­care sys­tems are now tak­ing to, for ex­am­ple, re­duce pre­ventable read­mis­sions and re­duce health­care as­so­ci­ated con­di­tions. …

Those are some of the ways that health­care sys­tems can really make a big dif­fer­ence. And what would be ideal is if he would then cite one or more of them to demon­strate that this isn’t just the­ory; it’s prac­tice. I mean, there are health­care sys­tems, a num­ber of which are award-win­ning, and he could men­tion one in ev­ery re­gion of the coun­try—like Me­mo­rial Her­mann down in Hous­ton, Vir­ginia Ma­son in Seat­tle and the Geisinger sys­tem in Penn­syl­va­nia. I could go on and on. Henry Ford in Detroit.

And by say­ing we’re go­ing to deal with the prob­lem of the na­tional debt and the deficit by re­duc­ing health­care costs, but we’re go­ing to do it in the right way, not in the wrong way, and it’s in ev­ery­body’s in­ter­est. We all contributed to the prob­lem, so we all have to pull to­gether.”

Mark Pauly, pro­fes­sor of health­care man­age­ment, busi­ness eco­nom­ics and pub­lic pol­icy at the Univer­sity of Penn­syl­va­nia’s Whar­ton School

“There are things I’d like him to ad­dress— the odds of it hap­pen­ing are pretty slim. He’s al­ready given the State of the Union lite in his in­au­gu­ral ad­dress, and his com­ment about health­care there was we are go­ing to con­trol costs and main­tain qual­ity in Medi­care. There’s a num­ber of things in the health re­form bill that might work.

There, in my view, al­most none of them have very good re­search sup­port. I just hope the pres­i­dent will be more con­crete, I guess to put it in a pos­i­tive way, about some­thing that we have rea­son to be­lieve that it will work as op­posed to cheer­lead­ing for things that some peo­ple sup­port, but which the ev­i­dence base is really not there. Like pre­ven­tive care is go­ing to save money, and things like that. I hope that he doesn’t talk about that, although I sus­pect he will. … I hope he’ll pro­pose some­thing to con­trol Medi­care spend­ing that really is largescale and ac­tu­ally ad­dress the prob­lem as op­posed to nib­ble around the edges.”

Mike Kasper, CEO of DuPage Med­i­cal Group, Down­ers Grove, Ill.

“We would like to hear Pres­i­dent Obama ref­er­ence and con­firm the key role physi­cians play in the de­liv­ery sys­tem and im­prove­ment of health­care. Most of the ideas and rhetoric thus far have been hospi­tal-cen­tric, fa­vor­ing an em­ploy­ment model as the an­swer for re­vi­tal­iz­ing health­care.”

Richard Pollack, ex­ec­u­tive vice pres­i­dent of the Amer­i­can Hospi­tal As­so­ci­a­tion

“We hope to hear about the pres­i­dent’s com­mit­ment to make mean­ing­ful im­prove­ments to en­ti­tle­ment pro­grams through changes to the de­liv­ery sys­tem, not through in­dis­crim­i­nate cuts to pay­ments for hospi­tal ser­vices. Reg­u­la­tory ac­tion is needed to break down the bar­ri­ers that im­pede the care co­or­di­na­tion be­tween physi­cians and hos­pi­tals.

We hope he can of­fer poli­cies that stream­line and aug­ment the abil­ity of physi­cians and hos­pi­tals to co­ordi-

nate and im­prove pa­tient care. We want to hear him ad­dress the need to care­fully cal­i­brate the re­duc­tions in the ACA to hos­pi­tals that serve higher num­ber of unin­sured pa­tients with the phase-in of the newly in­sured. We would wel­come his ac­knowl­edge­ment that hos­pi­tals need ad­e­quate re­sources to sup­port their mis­sion to serve pa­tients and com­mu­ni­ties.

And fi­nally we hope that he rec­og­nizes that hos­pi­tals have man­aged to hold costs down by keep­ing health­care spend­ing growth at his­tor­i­cally low lev­els for the third straight year. This was done by re­duc­ing in­fec­tions through ini­tia­tives that en­abled hos­pi­tals to make im­prove­ments that are good for pa­tients and help to bend the cost curve.”

Robert Town, as­so­ciate pro­fes­sor of health­care man­age­ment at the Univer­sity of Penn­syl­va­nia’s Whar­ton School

“I think the next chal­lenge, as­sum­ing the chal­lenge of cov­er­age has been mostly solved with health­care re­form, is go­ing to be costs and how do we con­tain costs, yet not lose both the qual­ity of care and, at least at the high end, that do e sn ’ t get di­min­ished and we’re able to main­tain a level of tech­no­log­i­cal im­prove­ment.

Now maybe that’s ‘tastes great and less fill­ing’ at the same time and maybe not pos­si­ble. But I think that’s kind of the real chal­lenge go­ing for­ward. … There are a num­ber of ways to deal with it. You could deal with it as part of tax re­form and do some­thing rad­i­cal, but (some­thing) I think most econ­o­mists would like to see, which would be the re­peal of the pre-tax ben­e­fit health in­surance.

The pre-tax ben­e­fit serves as sub­sidy for health in­surance and prob­a­bly a dis­tor­tionary sub­sidy. It sub­si­dizes peo­ple to pur­chase too much of it and may have too gen­er­ous of plans and that causes prices to be too high, it kind of rip­ples through the whole health­care econ­omy. And by do­ing so, at the same time, you would raise quite a bit of rev­enue. It kind of ad­dresses two is­sues.”

Dr. Kurt New­man, pres­i­dent and CEO of Chil­dren’s Na­tional Med­i­cal Cen­ter, Washington

“We ap­plaud the pres­i­dent’s fo­cus on men­tal health in his re­sponse to the New­town tragedy. At Chil­dren’s Na­tional, we em­pha­size that men­tal health is best un­der­stood as a life­time is­sue that be­gins in child­hood. … To iden­tify men­tal health is­sues ear­lier, we need to train en­tire com­mu­ni­ties of first re­spon­ders.

In ad­di­tion to train­ing emer­gency med­i­cal ser­vices per­son­nel, we also need to train teach­ers, coaches, day­care work­ers, bus drivers and oth­ers in the com­mu­nity who are with chil­dren and teens ev­ery day. Th­ese first re­spon­ders need train­ing to rec­og­nize, iden­tify and in­ter­vene to get th­ese kids ac­cess to care.

We have the tech­nol­ogy, the re­search and the in­fra­struc­ture needed to ad­dress men­tal health is­sues early, be­fore they limit the lives of our chil­dren and teens. We must come to­gether now as a na­tion to com­mit to this work.”

Don­ald Fisher, pres­i­dent and CEO of the Amer­i­can Med­i­cal Group As­so­ci­a­tion

“AMGA hopes that Pres­i­dent Obama will dis­cuss the ur­gent need to re­ward physi­cians for qual­ity of care, rather than for quan­tity of care. AMGA has been ad­vo­cat­ing for the cre­ation of a sep­a­rate cat­e­gory or bucket for high-per­form­ing health sys­tems within the sus­tain­able growth-rate for­mula, more com­monly known as the SGR.

Un­der the pro­posal, high-per­form­ing health sys­tems would be re­warded for suc­cess­fully man­ag­ing the per capita cost of health­care, im­prov­ing the over­all pa­tient ex­pe­ri­ence and im­prov­ing the health of re­spec­tive pop­u­la­tions.

Th­ese sys­tems would be re­quired to demon­strate ac­tiv­i­ties that im­prove pa­tient care: an or­ga­nized sys­tem of care; qual­ity mea­sure­ment and im­prove­ment ac­tiv­i­ties; care-co­or­di­na­tion ac­tiv­i­ties; the use of in­for­ma­tion tech­nol­ogy and ev­i­dence-based medicine; ef­fi­cient pro­vi­sion of ser­vices; accountability; and com­pen­sa­tion prac­tices that pro­mote th­ese ob­jec­tives.”

We­in­stein

An­tos

Borgstrom

Pauly

Pollack

Dar­ling

Henkel

Fisher

New­man

Town

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