Health Care Reform Roundtable

A lot has happened since our 2009 Health Care Roundtable, most notably the passage of a sweeping national health care reform law, the Patient Protection and Affordable Care Act. It has everything from higher taxes for upper income individuals, to subsidies for people who have been unable to afford coverage, to individual coverage mandates, to tax credits for small businesses. After passage, the law remains controversial. Its backers say it provides long overdue access to health care insurance to millions who lacked it, improves health care quality, and bends the cost curve downward. Its detractors say, among other things, that it will remove care decisions from the purview of patients and doctors, while bending the cost curve upward for both consumers and small businesses. IB convened a panel of area health care executives to get their perspectives on the potential impacts of this landmark law on their organizations and on small businesses that want to offer health care insurance to their employees, and do so affordably. (For the full transcript, download the PDF here.)

Our Expert Panel

  • Dr. Frank Byrne, President, St. Mary's Hospital

    "It's been estimated by some folks that what's been passed will actually generate 30,000 to 50,000 pages of additional regulations, so there is a lot of detail yet to be worked out."
     

  • Bill Smith, NFIB-Wisconsin State Director

    "It's really a tax package wrapped up in health care reform rhetoric. There is very little in this legislation that is going to address the number one issue … the cost of health care."
     

  • Dr. Geoff Priest, Chief Medical Officer, Meriter Health Services

    "I would suspect we'll continue to see innovative things, some of which are already in place, such as the Epic project for sharing information. It's working between urgent care centers and ERs."
     

  • Donna Katen-Bahensky, President/CEO, UW Hospital and Clinics

    "By 2030, there will be double the number of people over 65, and you've got 32 million more people insured [under the health care law] … We don't have enough primary-care doctors."
     

  • Dr. Michael Ostrov, Medical Director, Group Health Cooperative

    "Employers realize that when you have health- risk assessments done for an individual employee … then you get them right where they live and you can make those interventions."
     

  • Angela Heim, President, The Employer Group

    "The average small business … they want to know what it [the health care law] is going to do for them. It's very hard to get to the point to be able to say, 'This is going to happen … '"
     

  • Nino Amato, Pres-Exec Dir, Coalition of Wis. Aging Groups

    "A lot of people have been upset at Congress because they have Mercedes-Benz health care. In 2014, they go into the exchanges, which I think is good because it was hypocritical on their part."

The Discussion

Moderator Jody Glynn Patrick [IB]: Frank, could you open the discussion, please, with a general observation about the bill?

FRANK BYRNE: First of all, I think we have to be cognizant of the fact that there's a lot of detail yet to be worked out in the bill that was passed: therein lies the rub. It's estimated by some folks that what's been passed will actually generate 30,000 to 50,000 pages of additional regulations, so there's a lot of detail yet to be worked out.

It's clear that the short-term impact is going to create great challenges for us financially and otherwise. If you look at the way things are currently structured — it's probably less evident here in Madison and in Wisconsin because of things that the integrated systems have done to cover up the flaws in the non-system of health care we have now — [but] we understand the status quo is not sustainable and change must occur.

In the short term, however, a lot of the benefits of reform, in terms of having more people covered, are back-loaded and don't kick in until the later years, while the short-term reimbursement cuts have already started.

NINO AMATO: I think the key that Frank touched on is that the current system is not sustainable and, in fact, some people will say at best it's dysfunctional. The question is: how do you predict the future of health care? And the best way to predict is help create it.

We can all talk about the number of medical mistakes that has resulted in deaths in this country, which was first reported 11 years ago, in 1999. And then the other one is wellness prevention, which our system isn't built on now. It's built on [what happens] after people fall off the cliff, rather than putting a fence up there.

The question is: how do you package it and put it in public policy terms — simple, not 2,200 pages. Whether you feel good or bad or indifferent about what's happening on the national level, there are clearly things we can do here and control our own future health care, and Wisconsin can once again become a model for other states.

DONNA KATEN-BAHENSKY: I think Wisconsin already is a model for other states. We've already come together. We've accepted capitation for a very long time. Group Health Cooperative is really a model nationally that people look at. Our system, the Dean system, the Meriter system — we're linked with doctors, we're linked with insurance products. This is really an opportunity for you to take all of that, package it, and focus on the value.

BILL SMITH: And it's amazing how we can do all of that without guidance from Washington, D.C. Health care is a local issue. The people that serve on your boards are local people, and it's driven by local costs. And yet, the Washington crowd took it upon themselves to create one of the highest tax increases in the history of the country in the name of health care reform.

It's really a tax package wrapped up in the health care reform rhetoric. There's very little in this legislation that we see that is going to address the number one issue in the health care crisis: the cost of health care. The members of the Congress took their eye off the target. All of the things that they dealt with [were] taxes and fees and penalties and mandates — regulations, as Dr. Byrne indicated.

And the only other thing we're having out of this, of course, is a lawsuit that has to work its way through the court system as well. NFIB has joined onto that lawsuit, in fact. So we have Medicare taxes going up; I'm sure that's of concern to some of the panel members here. We have an expansion of the Medicare tax. We have the unprecedented use of the Medicare tax for non health care-related expenses. We have a massive increase in the bureaucracy with regard to the IRS. Just for enforcement and administration of this, it's going to cost billions of dollars over the next 10 years

We're not defending the status quo. We know there are abuses in the insurance industry. We know that we can do better in terms of efficiencies in the delivery of health care. But we must focus on those problem areas and Congress, frankly, failed to do that.

ANGELA HEIM: I completely agree with you. The problem I see right now in dealing with a lot of small businesses is that while everybody in this room is very educated [on the particulars of the bill], I'm dealing with the small business owner who has five employees who really wants to know the impact at this point.

And so I completely agree with everybody's comments so far, [but] the average small businessperson … they want to know what it's going to do for them. It's very hard to get to the point to be able to say, "This is going to happen" or "you don't qualify for this." And there's so much of that.

So I'm throwing this back out to this group — that's what I'm dealing with. They want to know how it's going to impact them. And we're at this point saying, "It's still a bill, there's still interpretation, there's a lot left to come out." And so how can I come back to those small businesses and say, "If we focus on the state, certain things will really help?"

AMATO: There's so much misinformation out there because there are hundreds of millions of dollars that were spent just on lobbying, let alone the national advertising, and a lot of scare tactics are being used. So there is a lot of confusion out there. I think, though, getting to the bill, the cost is fundamental. Take the billing of insurance companies. If you take an institution like Cleveland Clinic, which is well respected, they have 2,200 physicians — and 1,400 clerks to deal with the billing process. Now the feds did step in and have a national billing structure for Medicare. Still a little bit confusing, but it's there. If we're going to control costs, there should be a national standard, and I'm sure we'd reduce costs.

MICHAEL OSTROV: Actually, in the next several years as the transformation occurs as a result of the bill, there's a tremendous opportunity for experimentation along the lines of delivering primary care more effectively. I think our bias is that if you do primary care right, a number of things will follow on the heels of that, which will lead to better, cost-effective care. As mentioned, we have a head start in this community because of our size and because of the business climate, to cooperate to develop these models for accountable-care organizations.

You're right. I think the interpretation of many, many elements of the national reform still to come should not get in the way of us being able to do these very useful experiments. One of the things I'm always excited about is that right here in little Madison, we have some leading-edge experiments going on that compare with the best anyplace else in the nation. When we talk about how health care should be delivered in a better way, I don't see anything in the bill that's really going to get in the way of that.

GEOFF PRIEST: I think it will push change locally in the way we do things, although I think it's been said Madison is unique when maybe it's not unique. When we look at the changes around the country, a lot of places would love to be as far along the curve as we are. I would suspect we'll continue to see innovative things, some of which are already in place, such as the Epic project for sharing information. It's working right now between the urgent care centers and ERs. It's been a great success and I will argue that that's going to be extended to all the organization care sites.

 

IB: Due, in part, to the level of collaboration between the people sitting around the table?

PRIEST: I think that's been a fairly unique attribute in this health care market, plus as Frank said to start, the systems have a lot of integrated features. First of all, they're a large employer, so they have to worry about health care for their own employees. Second, there are physicians involved at the table all the time. Third was a hospital. Fourth was insurance products.

So again, you have a chance to integrate things and make them work start to finish. We still struggle with primary care. I think that's a national problem. I think we're closer to some solutions than the other markets. And as was said, health care ultimately is more local. I was just at a meeting where they were saying that Vanderbilt had this stage for a long time. We were talking about all the great things they've accomplished, and one of the non-clinical people in the audience said, "Well, can you extend this to the whole country?" And their answer was, "We have doing primary care right in our own backyard." There's no way we can extend that to the rest of the country. We have to figure it out locally first, because that's where health care starts and usually finishes.

BYRNE: Right, and I think why we're ahead is [that] the only state that has a higher percentage of the residents covered by insurance than Wisconsin is Massachusetts. But they have coverage but no access because they don't have the primary-care base. Each of the systems around this table has made substantial investments in creating primary care. For example, we've made major investments in providing regional primary care clinics throughout our 18-county service area. We've also been fortunate to be a sponsor and host to the University of Wisconsin's Department of Family Medicine since its founding 40 years ago.

The other systems, they've all made investments in providing access. I think that's perhaps maybe a bit underappreciated in our community, and in some sense is taken for granted. Those investments have increased over the years, and in all candor, I have to say that's a cost curve that has to be bent as well, because those things are unsustainable.

We are very fortunate to have integrated systems here; disintegrated care is more expensive and it's less safe. We work together and we can communicate, not only within our systems but across systems through the implementation of the Epic Care Everywhere. Connections that we've all been pioneers in; major investments to try and make care better and safer.

Lastly, we've also been a national leader in transparency, recognized by the secretary of HHS and others through the Wisconsin Collaborative for Healthcare Quality and other initiatives. So we're positioned to lead and create the future of health care in a way that makes sense for everybody.

That said, my heart still goes out to the small business owner and the independent business owner because they, for the last decade now, have been most challenged. And I don't see, regrettably, that there is a simple solution on the table for them. In fact, as people propose penalties to individuals for not being covered and penalties to businesses for not being covered, my friends who are small business owners said, "Look, I'll take that deal. It's a far better deal for me to pay the penalty that's been proposed than it would cost me to provide health insurance."

IB: Bill and Angela directly answer to businesspeople looking for leadership. Angela asked, "What am I supposed to tell my people? How does this impact them?" Bill, what are you telling your members?

BILL SMITH: First of all, we're letting them know the timeline. It's important to understand when the taxes kick in and when the actual so-called benefits of this legislation become a reality, if they ever do. So that's the first thing that we're doing so that they're aware of when they have to be in compliance with the new law. There's a glimmer of hope. We want to stay at the table in terms of making sure that the so-called exchanges are properly established.

IB: You're referring to the state exchanges?

SMITH: Yes. To make sure they're properly established and are given the best chance of being successful in terms of pooling the small business community to give them more leverage in the marketplace, to give them lower administrative costs, to give them more options — hopefully purchasing options with regard to benefit design or plan design.

We're reporting back the timeline that they have to be aware of [and] when they have to comply. There's a provision in this legislation that says if you do more than $600 in business-to-business transactions, you have to get an employer ID number and issue a 1099 form, increasing costs down the road. Small business owners have to be looking ahead.

Their health insurance plans are going to be taxed. They say it's a fee on insurers. Insurers said in testimony, "we'll just pass that on." And 87% of the plans that small business purchases are subject to those fees. If you're a big business or big labor, you're exempt specifically in the legislation.

So they are trying to hang on to their checkbook, and hopefully we can ride through this recession and get some improvements in terms of where small businesses are economically, but it's going to be a rough ride.

AMATO: Yeah. The Coalition of Wisconsin Aging Groups represents 125,000 people statewide, about 400 organizations, and they're getting all the same type of questions. And we're filtering through that large document, but this is where consumers and costs will begin to conflict in some ways.

The national bill does prevent insurance companies from denying people with pre-existing conditions. Now that's 18 and younger, and then it goes into effect for everybody in 2014. And so that's one of the things that people really want to know, because that has a real impact upon consumers. The thing about the exchanges is, a lot of people politically have been in upset at Congress because they have Mercedes-Benz health care. In 2014, they have to now go in the exchanges, which I think is good because I think it was quite hypocritical on their part.

And I want to pick up on Frank's comments about collaboration, leadership, and vision. Neither Donna nor Frank was here 11 years ago, but Jeff and I were. I was at Meriter with Jeff, and then also later on I served on the UW Hospitals & Clinics board of directors. There wasn't a lot of collaboration. In fact, it was outright competition. And even when I was on the hospital authority board, they went with Siemens rather than Epic. Some of us were fighting for Epic. Now we're there, which is really great. The key is to take HIPAA off and begin to modify that law as an experiment, and get a waiver so all three hospitals begin to have that information.

And then on Jeff's point, primary care docs — somehow we've got to change the fee-for-service because I have a son-in-law who wants to be a family-care doc, but he's specializing because he's going to have a $250,000 medical [education] bill. Now it still does allow incentives for family care docs and primary care docs by deferring other grants, but when you look at rural areas, in this state 25% are rural consumers, 10% primary care docs. You know, this is real disparity. So somehow, we've got to move that forward.

KATEN-BAHENSKY: One thing about how primary care gets stretched: by 2030, there will be double the number of people over 65, so you've got 32 million more people insured, you've got Baby Boomers who are obviously, because of chronic disease, going to require more care. We don't have enough primary care doctors, even though we've made a huge investment, and we don't use them in the right way. Perhaps GHC does, but you've got to supplement a primary care doctor with nurse practitioners, pharmacists, social workers, and other people on the team in order for them to be able to stretch far enough.

I wanted to go back to Bill's comment. I know you don't feel like the costs are going down because of the bill, but I can show you what the impact is to the University Hospital just within the first five years. Not counting the reductions in disproportionate share, it's about $10 million over those five years in the reduction in Medicare reimbursements. So we are going to be forced to have to bring our costs down.

The biggest problem right now in the short term is fee-for-service. And the incentive in fee-for-service is to do more, build more, grow more, [and] buy more technology. It is not to shrink it. So somehow we've got to get through these fee-for-service years until we can get to something different. And until we do that, the cost isn't going to go down.

SMITH: I've heard the medical community struggle and complain and fight for higher reimbursements for Medicare and Medicaid patient population, to the point where some of the hospitals accepted the tax on health care in order to bring in more federal money. We weren't particularly supportive of that because we think it's a bad precedent to tax health care, but I understand how this rather perverse system works with regard to reimbursements.

But it makes no sense to come along here now with this legislation and not only increase the Medicare tax but expand it, and then use those proceeds for non-Medicare reimbursement costs. We're already not getting adequately reimbursed, which hurts that population. So the Congress, in its wisdom, came along and said, "We're going to increase Medicare taxes. We're going to tax that payroll and we're going to increase it. We're going to go beyond the payroll now. We're also going to tax investment income and, by the way, we're going to use that money, those billions of dollars, for non-health care-related expenses."

Also, there's no liability reform in this legislation, which we think is a huge cost factor of health care. Clearly you can't talk seriously about health care reform if you aren't reforming the related liability laws.

So I understand what you're saying, but the small business community doesn't understand how expanding the role of the IRS and expanding the role of government in our health care lives … how that's going to actually five, 10 years down the road reduce the cost of health care.

OSTROV: I think it's fairly simple to understand that incentives will be on a line across the system and, again, we've had some local experiments that help with that. We've had the freedom of movement within our system of primary care to pay doctors on a salary so they're incentivized. They do have several layers of incentive for the quality of care, and particularly for group quality achievements, and for patient satisfaction, and some other small little pieces that are, I think, what is talked about nationally: that if you want primary care to function effectively, you need to incentivize them in a way that they have the tools to take care of their population members in a cost-effective manner.

Likewise, the UW medical group has been willing to take capitation. And we've done it for a long time. We probably started in the late '80s, as I recall, when you first ran and put together all the different specialty groups under a capitation agreement with Group Health. You have to have enough tools for the specialists to understand how they can use those dollars most effectively.

 

AMATO: One of the things that has not been discussed relative to cost is the pharmaceutical industry. Last year, it spent $30 billion on sales, marketing, and advertising, and that doesn't include the so-called seminars that they have doctors fly all over to. That's more money than they spent on research and development.

Right now, pharmaceutical reps basically are salespeople pushing their brand name drugs, and many of the physicians rely upon that for their information. In Pennsylvania and five other states, they actually set up what they call "academic detailing" — a nonbiased, evidence-based informational system provided for doctors using physicians assistants and others. In states like Pennsylvania that have had this in place for 10 years, they've actually seen prescription drug costs come down.

They've also implemented transparency with the UW, where they have to report all their research dollars. UW has a pretty good system now, but the check-off is, "I've received $20,000 or more." Now does that mean $200,000 or more or $2 million or more? The Milwaukee Journal Sentinel did a story just a year ago that talked about a primary chair [at a medical school] who received $19 million from medical device companies who then pushed a lot of the devices on a fee-for-service basis. There's a heavy influence on medical device companies and pharmaceuticals. Good thing here is, in regards to gifts and entertainment, UW has banned it.

And then the other thing is dating mining — market research. In Copps, you get a little card and you have a choice as a consumer to use that card. If so, they will know everything about your buying habits. Then, when you get your receipt, they push coupons of things you don't buy. Pharmaceutical reps and pharmaceutical companies get this [kind of] information [what doctor prescribes which drugs]. And in those states that ban data mining, costs have gone down because no longer can pharmaceutical reps go in to Dr. Angela and say, "Oh, we'd like to give you 100 or a year of free samples, and these are the brand name drugs. And actually, if you buy this, I get a 25% bonus."

KATEN-BAHENSKY: One of the comments I was going to make to Angela: I think the most important thing any employer can do is to get their own employees to understand health care, to ask all the right questions, to really find out the outcomes of a treatment. Where's your evidence that this works? I know it's hard for people to do that. They look at their physician and say, "Okay, doctor, whatever you want to have happen." But the more educated people are when they walk into that doctor's office, the better I believe the outcome is, because they're making better decisions and they understand it.

HEIM: Agreed. Education is really an important piece. And I'm hearing the great things that groups represented here have done, but I don't think the general public knows that.

And I personally don't get it. I would love to, because that is something we can put in newsletters. We can do webinars, and we're more than happy to help the education process along, but we need some help from individuals with more knowledge of what's really going to happen or how the billing really works, or [defining] what is a good wellness program.

AMATO: I think it all gets back down the primary care family care doc who will triage people through the system. That's how it used to be 20 years ago. Now you've got six different specialists my mother was working with. They were getting duplicate exams. They were giving drugs that, in fact, conflicted with each other. It's a mess. And it's a lesson for the intervention of my sister and me, who understood the health care system. [My mother] would have been lost in it.

We talk about consumers … there are 80 million Baby Boomers moving into the consumerism [role]. And there's a great book out by Wayne Glowac [Glowac + Harris + Madison, an area advertising agency] called The Health Care Tsunami, about the wave of consumerism that is going to change health care, and I really believe that the Baby Boomers are going to change the definition of aging. None of us think that we're old until we're in our 80s. Secondly, they're activists and they're educated, and that's going to be a major driver to change the system.

SMITH: Donna touched on something I think we skirted around it a little bit: the current system insulates the consumer from the cost of that service, and that's just not going to work indefinitely. We had a period of time when the HMOs arrived in the marketplace; they had the networks at a lower cost. But it was a closed network that actually pushed competition off the table.

Now most of our members have moved into PPOs because they want more choice. They're willing to pay a little extra for the choice of their providers. So HMOs play a lesser role. But until we connect the consumer with the cost of health care in some way, we're just not going to be good consumers. That's part of the reason why HSAs [health savings accounts] have played somewhat of a role in bringing the cost into closer proximity to the purchaser of the health care.

Having said that, and then picking up on what Nino said, small businesses lose every step of the way right now. We get the assessment for HIRSP, the uninsurable program. Big business, big labor, is exempt. They self-fund their plans. We get all the mandated benefits that the legislature can come up with, and they added three more this last session. We get higher administrative costs. It simply costs more to sell and administer a small group plan than it does for a big business.

We don't have human resource people down the hall. Our HR person is typically an insurance agent — the same agent we probably buy our property and casualty from.

So we want to make sure the insurance agent has a role in these exchanges. We cannot eliminate the important role that agents provide the small business community. We don't want that role diminished, and that's going to be very tricky. But I think health care will remain complicated enough that we'll continue to rely on our insurance agents.

The IRS Code is 71,000 pages, and this is the same agency that is now going to administer or enforce health care. That's the same agency where, in 2006, they had I think it was $10 billion in erroneous payments under the Earned Income Tax Credit program. This is the agency that's going to be responsible for this mandate.

AMATO: Regarding cost transparency, I know people who don't have prescription [coverage] that pay $900 for 30 pills [for an otherwise] $25 deductible [co-pay]. You need transparency so people realize what costs really are.

Also, quality measures for quality outcomes are important, so that if a person wants to choose between hospital systems, they know what the infection rate is, what the death rate might be, or the risk relative to certain operations. Those things must be transparent in the process. If you want a blend between market-driven health care and evidence-based health care, you can't have it both ways. It's got to be transparency all the way around, and we have to educate the consumer.

OSTROV: If I could get back to an earlier comment about how the patient understands all this, given all the direct consumer advertising and the like. We say health care is delivered locally, but actually health care is delivered one patient at a time. Literally, you need a health advisor pathway for people, whether that's a nurse they're in contact with, a nurse practitioner, or the primary care physician.

[Paramount is] setting up systems to help people, even before they encounter any illnesses, to understand what their pathway through their life of health is going to be. One of the things employers have done very aggressively recently is to develop worksite wellness programs; they want the health plan's assistance in setting up and sustaining those programs. In fact, our trend for providing worksite wellness programs has gone from about a dozen a year, 10 years ago, to about 300 a year now. It's kind of an under-the-surface thing: employers realize that when you have health risk assessments done for an individual employee to sit down with a health counselor to say, "these are your specific health risks, and this is what you're going to be facing in the next decade or two if you don't do something," then you get the person right where they live, and you can make those interventions.

HEIM: I want to just make the comment that some of the health and wellness programs you mentioned … most of the companies you work with are quite large.

AMATO: Sure. They can afford to do that.

HEIM: Correct. They can afford it, but I'm working with companies typically with 10 or less employees and those types of investments are not really feasible at this point. So I would again encourage the group of individuals here [to tell us] — is there a way to provide those programs at a shared cost?

If you get 10-person employers together and say, "We're going to do this today at our clinic" instead of at an onsite location? I know there are HIPAA restrictions ÃfÂfÂÂfÃf‚‰ but again, working with small employers, I continually look for items to present that are really affordable to that group.

BYRNE: That's a great point, Angela. We have some very innovative partnerships with large employers like Lands' End to provide worksite primary care and wellness activities, so branching that out, I think there is some hope in that area — again, through integrated delivery systems. We're all using the electronic health record, the Epic MyChart, which allows people to interface with their providers and involve them in their care. The educated patient, frankly, is our greatest ally and asset. I think we've got the basic building blocks in place, but we're just really starting to scratch the surface of how we can use that.

PRIEST: I think Madison has other problems to solve. Mike talked about wellness and prevention and, Nino, you actually started the conversation about getting your mother through a very complicated health care situation. So it affects patients at both the beginning — "What can I do to keep myself healthy?" — and then when there is an illness or a problem — "How do I get myself through this great complexity, seeing six different physicians in 12 different places, with 35 different labs?" There's a need for us to integrate when care is needed. That gets back to primary care. Right now, the plan we offer ends up serving as the primary care physician — negotiating schedules, keeping appointments, juggling medications. We try to deliver on that so that the family isn't burdened with trying to manage all that care, without necessarily all the clinical knowledge of how to.

SMITH: Let me try another side of this wellness issue here. Angela really hit it on the head: we haven't found a wellness model that would really work in terms of efficiencies for small business. We just haven't found it, and we've met with a number of businesses that have attempted it, and we've talked about partnering even with big business. But in a small workplace, you even get into HIPAA violations. You start trying to do a health care assessment with four or five employees, you're in a pretty dangerous area.

But the other thing … our health care system is driving bad health decisions by consumers as well. One of the reasons is that we're so insulated from the cost consequences of bad decisions, so we can go out and eat the wrong things or drink the wrong things or whatever and still get that $10 or $25 drug to take care of the decisions that I've made that really aren't very good for my health.

KATEN-BAHENSKY: And, I think, a willingness for insurance and business to say, "We're not going to pay for poor quality, we're not." Keep telling people from Washington, "If you really enforced that, you would not pay Medicare dollars to non-quality providers or providers that don't provide quality," [and] we would be able to pay for this whole health care system and the revision to it. But there's an unwillingness to do that. I don't know why, but all of these states that have poor quality and high costs are still getting paid.

IB: Thank you. I'd like, now, to close with this question: What's the greatest challenge with the health care revisionist legislation?

AMATO: This is a multi-trillion dollar health care industry. The greatest challenge is dealing with lobbyists who basically are crafting laws that benefit them. When I say "them," I mean the pharmaceutical industry and others. The challenge in Wisconsin will be to make sure we have everybody around the table — not just the elected officials — and have continuity of policymaking. And then, when the new Governor comes in and the new legislature begins to advance these in a very constructive way, at the same time to put political pressure on politicians who are getting pressure from the special interest groups.

KATEN-BAHENSKY: I think the biggest challenge is moving from this focus on "more is better" to "less is better." And in an academic medical center, that's very hard to do because the specialists are accustomed to learning and doing with the highest end. But we also have very complicated patients. So I'm concerned about chronic disease management, about providing care across the continuum and having that coordinated in a way that people don't get lost or fall through the cracks.

BYRNE: The next five years are going to be a rocky road for all of us, and fasten your seatbelts because there are a lot of details yet to be worked out. We're already seeing around the country substantial financial pressure on physician practices, and especially primary care. The hospital — we expect substantial pressure. Our goal for the next five years is to be part of the conversation, to help craft this in a way that makes sense for the people, for the families, for the communities we serve.

PRIEST: I would say for all the systems, it's finding a primary care model that will actually deliver on the promise of health care, meaning that we have patients who we can manage when they're well and we can manage them when they're ill. The hospitals have tended to take a focus as the big financial engines. And obviously what the country's interested in is what we do with the patients when they're healthy — so finding a primary care model that will work, that's sustainable, that will attract the right kind of providers and deliver on the promise of an integrated system.

OSTROV: Our challenge is going to be to make ourselves as attractive as possible while the rest of the country deals with the shortage. Not only partly facetiously, I think there is going to be the challenge of a shortage of primary care — whether it is nurse practitioners, physicians assistant, and primary care physicians. There's just going to be an uphill battle to — as you envision these wonderful, idealized primary care systems — have the people to staff them and make them a reality.

HEIM: Currently, our biggest challenge is going to be resources. We are spending a tremendous amount right now for our clients to try to make sure that we are on top of it and at the table. We have spent a lot of time on our international organization in Washington, D.C., and we have brought in extra hours for an attorney. Frank, you had made that point that you just really need to make sure that you have some type of voice. And so we're making sure that we continue to try to have a voice for these small businesses, but that is a challenge for a 15-person organization. We're a small business ourselves.

SMITH: The new health care reform law will be implemented over the next 10 years, but 2010 to 2013 is when all the taxes and fees and mandates kick in. The health care system reforms really won't come about until about 2014. So there's some time here to get it right, and we've got three pages here of the timeline starting 2010 and finishing, I think, in 2018, when the last tax kicks in. So what we're trying to focus on currently is information on the law, making sure that small business owners and individuals understand the timeline so they can plan ahead, but also so that they can be in compliance with the parts of the law that affect them.

Having said that, we are also participating in the lawsuit to get the whole thing thrown out. I'm not an attorney, thankfully, so I don't know what the odds are of that lawsuit being successful.

IB: Thank you all for your candid comments and leadership.

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