Health Care Reform Roundtable

Six of the most prominent figures in Dane County's health care landscape came together to discuss ObamaCare, and what employers should do to prepare for full implementation amid congressional and legal challenges.

Our Expert Panel

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

Jim Woodward, President/CEO, Meriter Health Services

Dr. Jeff Huebner, Site Chief-East Clinic, Group Health Co-op

Cheryl DeMars, CEO, The Alliance

Melody Hope, Sr. Benefits Consultant, Hausmann-Johnson

Susan Phillips, President/CEO, HospiceCare, Inc.

The Patient Protection and Affordable Care Act was signed into law almost one year ago, and it remains a controversial piece of legislation. It affects employers, private insurance providers, and every other health care stakeholder, but as regulations continue to be written, and challenges are mounted in Congress and the courts (to the individual mandate), the dispute appears headed to the U.S. Supreme Court.

Following the most recent court ruling, Wisconsin Attorney General J.B. Van Hollen said the ruling means that, for Wisconsin, "the federal health care law is dead," and that our state is relieved of any obligations or duties to carry out the law.

Obviously, we haven't heard the last of this, and employers are left wondering how to prepare for whatever unfolds in this health care drama.

GLYNN PATRICK: Many of the law's requirements are phased in, or have delayed effective dates, intended to give employers time to prepare. Not only do most of our panelists operate in the health care space, but you're also employers, which begs a couple of questions. Number one, how are you – as employers – preparing for full implementation of the new health care law in this uncertain environment? Along with that, what is your best advice for other employers?

WOODWARD: As an employer, one of the key things we're focused on, and this is inevitable even though we're in a unionized environment, is shifting more of the cost for health insurance back to our employees. I would say the same logic holds for other employers.

This marketplace, having come from the East Coast, is one in which employers do not do a lot to provide co-payments or shift some of the burden of health care expenditures back onto the employee so that there's a little bit more sensitivity to how utilization occurs. Without that, it's kind of a carrot and stick; there's going to be a tendency to disregard the cost of care, and where care is provided, it's going to the least costly environment to receive care.

The other thing I would say is that as a health care employer, we're looking very seriously, and have been for several years, in taking cost out of the system. Can we operate more efficiently, more productively, reduce the cost of care, and take variability out of the care process?

At Meriter, we've been taking between $4 million and $6 million in cost out per year from what we had budgeted. This past year, it was $10.8 million. Now at some point, you hit a wall on that, and I know everybody is doing the same thing. I guess the main driver for that is half of our business today is government payers, Medicare and Medicaid, and they don't pay our [full] cost of care.

The slim margin that we have of business that actually pays for our cost has to be spread pretty broadly, and that's not going to get any better. It's up to us to just be as efficient as possible, both as an employer providing health insurance to our employees, and as a provider of care.

HOPE: I agree that the cost of health insurance has been going up for a number of years. I've been in the business for about 25 years now, and rarely do I deliver a reduction in premium. What I have seen the majority of my clients do over the past several years, and what we have done at Hausmann-Johnson, is increase the contribution that the employee has to shoulder and balance that with making plan changes in order to keep the premium down. I don't see that changing much in the time between now and the full rollout of the health care reform.

PHILLIPS: Our staff already shares in their health care costs significantly. Our shift has really been in the last three years to prevention and wellness, and now getting our health providers – insurers and providers – to share in that effort toward wellness and prevention. Thus far, in almost three years, we've been extraordinarily successful, and that has kept our costs down. Our focus now is really on staff and/or their families that have chronic situations, and getting them to take more responsibility for prevention and wellness. But we are really dragging our insurer and our health providers along with us because we've upped the ante in terms of expectations. We want the focus on prevention.

We have received a 14% cut in Medicare reimbursement with the health bill that will be graduated over the next seven years, but it is a huge cut for us because 85% of our revenue is Medicare revenue. That doesn't mean that we're only taking care of people over 65. People who have chronic illnesses like ALS or MS also qualify at younger ages for Medicare support. So we are looking at how to maintain quality at the highest possible levels, and for efficiencies in our system. We really don't have the kind of issues the hospital has in terms of expensive emergency rooms and operating rooms and ICUs. It really is all people-based, so we are looking for quality and efficiency coming out of 600 staff, and how they do their business.

HUEBNER: For Group Health Cooperative, we're in a unique situation where we're obviously insurer and medical delivery under one roof. Most of our employees actually end up staying within Group Health for their insurance, so incentives are aligned where we're focused on the same thing that we want to deliver for the employers that purchase Group Health insurance as we are for our employees – continuing to work on improving quality with reduced cost.

My advice for employers is to touch on some of the same things that have been mentioned. We really believe strongly in wellness programs and prevention, and I think employers should be looking at how to facilitate that for their employees, which isn't necessarily an insurance function. It's also encouraging wellness within the workplace through various means. We do health risk assessments for employers that purchase Group Health insurance, and we think that's a big part of helping people get in the door for their physicals and their prevention and screenings.

I also think employers should start looking more at value-based purchasing. Regardless of what happens with health care reform moving forward, the current system is not sustainable, and I think everybody agrees with that. We really need to be looking at ways to facilitate and incentivize value and quality over volume, and there are various ways to do that. One of the best ways is to facilitate robust primary care in a patient-centered home model.

BYRNE: What Jeff said makes perfect sense, and it's the trajectory our system is on. First, as an administrator, we understand the math. We understand the state budget deficit. We know that in the national reform that's been implemented, the cuts have already started on hospital reimbursement.

The physicians have the physician payment formula flaw hanging over them like the Sword of Damocles. It just gets kicked down the road a few months or a year at a time, so we understand the structural system is wrong. We're focusing on delivering value. I'm pleased to report that we've actually, in our system with Dean and St. Mary's, bent the cost curve over the past couple years.

Sometimes, you're not always managing costs out of the system. For example, in orthopedics we actually increased our staffing ratios in the inpatient units because the patients were staying a shorter period of time, their care was more intense, and so we actually needed to increase our staffing in that area.

The emergency room completely started from a clean sheet of paper in designing care around the patient, and they literally threw out everything they were doing before and they've reduced their door-to-doc time to 14 minutes. That's great for the patient, because they're not waiting. It's also great for us operationally, because we don't have people stacked up like planes over O'Hare waiting for beds and hanging out in the ER.

The good news again about this community is we're capable of being successful under payment reform, which is what we need. We've got to stop paying providers on a per-click, the more you do, the more you get paid basis. We've been an accountable care organization in our system for 16 years. We accept payments from a family, usually through an employer but sometimes individually, for which we agree to help them manage their health care through a year. That's the way we have accountability for not only managing the cost but managing the quality.

As an employer, clearly it's what the others have mentioned: look for value, value-based purchasing, and partner with the health plan you use to encourage wellness. We have dropped as a state in our rankings in health status, and a lot of it is due to behavioral issues. We're number one in binge drinking, we've dropped from 23rd to 34th in terms of obesity, and we're 48th in public health spending.

There are partnerships that should be formed between the providers, not just when you're sick. Everybody at this table is thinking about how to prevent acute things from happening, and keeping you well and keeping you comfortable and providing care in the appropriate place. We're one of the few communities in the country where the structure of the delivery system is such that we can do this.

DEMARS: In light of the magnitude of change and uncertainty in the environment, from the standpoint of The Alliance as a not-for-profit cooperative of self-funded employers, our strategy is to work with our members to help them understand what the potential implications are of health care reform and, quite frankly, to work to shape implementation so that it lives up to its name, the Affordable Care Act.

At The Alliance, a small employer of 35 employees, we're doing what we've always done, which is help our employees maintain or improve their health, as others have mentioned, and also ensure that our benefit design is focused on the right things. For us, that means not just cost sharing and co-insurance, but value-based benefit design where we're removing obstacles to highly effective care and encouraging more cost sharing for things that are known to be less effective.

To your point about advice for employers, I think the key thing is that in times of uncertainty, you focus on the things that make sense, no matter how the future unfolds, and many of them are things we've talked about – to focus on maintaining and improving employee health, to ensure that your plan design is structured appropriately to encourage good preventive care and appropriate utilization, and beyond that, to partner with your employees. Employees have as many questions as employers do, and so it's important to have conversations about how things are unfolding and really engaging employees as partners in navigating health care reform and health care purchasing.

GLYNN PATRICK: Critics of the law say it does little to reduce health care costs, in part because in their view it mandates and extends the kind of insurance that breeds overuse. They claim the medical system is about to be overwhelmed because the law does not have disincentives for overuse. What do you make of that critique?

PHILLIPS: The travesty of the bill is that two pieces that were discussed were dropped. One actually came back up, which was advanced directives – that when someone would come in to the Medicare system, that the primary physician's responsibility, along with that Medicare recipient, would be to make sure that there was an advanced directive. So there was a second kick at the can, and it still didn't go through.

GLYNN PATRICK: When we're talking about an advanced directive, we're talking about end-of-life decisions.

PHILLIPS: Yes, end-of-life decisions, a power of attorney, in discussions that you would have with your physician and your family, it would be well documented and be something that's on file with whatever provider you are using. The second, which was discussed but was also dropped, was that within the Medicare system, there would be care management. That's something very poignant for us because we see so many Medicare recipients who come into hospice, who maybe have five, eight, 10 physicians, and they have made seeing a physician sort of their social network. They are tested, treated, and prescribed medications by those physicians to the point that they have a prognosis of six months or less.

We discharge 13% of the patients who come into hospice every year. The primary reason they're discharged is that once we get them, we start taking all of that apart and we look at the whole person, the whole body, and how they are being treated. As we remove meds and get them stabilized, miraculously they get better, and they get better to the point that they no longer have a six-month or less prognosis. There's probably not a better example of why care management in the Medicare system is absolutely essential. It would not just be a controller of costs and what's happening to the Medicare Trust Fund going broke, and it would be obviously a quality piece in terms of good care for Medicare recipients.

WOODWARD: This issue is very complex, and I would say we have to break it into a couple of big chunks. One is, and I'm willing to bet that everybody around the table is going to agree with this, that at 17% of our nation's GDP, something's got to happen. I think the health care law, as much as we know about it today, and there's still quite a bit that needs to be articulated in terms of detail, that it's a start. It's a move in the right direction.

It is going to be imperfect. It is not going to be exact. Providers and beneficiaries are all going to have to pay in a little bit somehow, some way, but you need to slice it a couple different ways. I do think there are incentives for not over-utilizing care. We're talking about bundled payments. We're talking about payments for management of a specific disease set where everything is incorporated into that. If we can, as a state and as different regions in the country, begin to get a handle on their highest cost illnesses, bundle payment, find out best practices, take out variability, we're going to begin to limit over-utilization.

Where the law is less perfect is that it doesn't take into account some of the regional variation that exists in the country today. Wisconsin and Minnesota, for example, have historically had some of the best outcomes at the lowest cost, and we have had historically higher insurance rates of our population than other states. We're probably going to be more disadvantaged under the way the health care law is constructed today. That being said, we also have a head start on some of the other states, so I think we can get out ahead of some of the issues. It's a gradual, evolutionary process, not revolutionary.

 

GLYNN PATRICK: Jeff, does this medical home concept answer that?

HUEBNER: That's a big part of it, and I think everyone here is familiar with the concept. But for the readership, our medical home concept is one that really builds the foundation of primary care for patients, where patients have a personal physician and a team of coordinated providers that may include extended care providers. I'm thinking about dieticians and the nursing team, home health, different therapists that may get involved with a patient's care to really help with some of these issues that come up that the doctor may not have time to address in our 15- or 20-minute visit.

Along with that, the PCMH (Patient-Centered Medical Home) model is always looking at continuous quality improvement facilitated by a more robust care team via the electronic health record, which we're quite out ahead of here in the Madison area, and Care Everywhere is a great example of that. That's a new program by which the health care providers and the clinics and hospitals' emergency departments can all learn if a patient, if their insurance changes or they show up in a different part of the system and they don't know their medications or some of their past medical history, the doctor and the nurses are easily able to access that with their permission. That helps facilitate more efficient care, less duplication of services, testing, and reduced costs, and hopefully higher quality care.

For people that don't think there are incentives to reduce cost in the Affordable Care Act, they're somewhat misinformed because part of that is the fact our system hasn't done a good job of that. How do you jump over that chasm? People around the table have mentioned some of the ways.

There are some very specific things in the bill. Primary care physicians will be paid more, at least initially, and that should probably continue. There's actually a new center called the Center for Medicare and Medicaid Innovation, which is probably one of the most overlooked parts of the bill, where they have $10 billion initially to facilitate pilot programs around the country to work on these concepts of affordable care organizations, blended payment, and ways to reduce costs and improve quality. Those are definite, tangible ways where costs can be reduced.

DEMARS: I would agree with that, and say that from the perspective of employers managing from the buy side, there are two things that are important to help control the potential for overuse. One is benefit plan design and the second is how we buy health care. Those are both areas where the federal government could learn a lot from looking at examples in Wisconsin. Employers have been doing a remarkable job of fine-tuning their benefit plans so that the right incentives are there for employees to not only improve their health but use health care appropriately.

On the payment side, we're in the midst of an initiative, the Wisconsin Payment Reform Initiative, that many of us are already involved in, that is seeking to redesign how we pay for health care, to get at paying for results and not just paying more. We're hopeful that CMS will be participating with us in that.

BYRNE: To the point of whether what's in the Patient Protection and Affordable Care Act breeds overuse, certainly there are elements and pilots related to the bundle payments and payment reform. As Cheryl has pointed out, we're far ahead of where things are nationally. In my opinion, the reform act is a little light on payment reform.

In terms of your question about overwhelming the system, the system is already overwhelmed, outside of what I would call our Madison bubble, and even Wisconsin. I had dinner with a retired Dean physician friend before he and his wife left for Florida, and they were decrying the difficulty they had finding a physician in Florida. It's because there's not integrated care there, so they were calling around. They got all the predictable health care done here in Wisconsin before they left for Florida, but sometimes you can't predict things.

While we're not perfect, we're certainly far ahead of that. So this physician was just dismayed, calling around, calling around, couldn't find a doctor. He finally found a concierge care physician; no insurance, I don't care. If you collect, great. If you don't, so what? There was an amount, let's say it was a $3,000 retainer for a year, I'll be your personal physician; for $5,000, I'll give you my cell phone number. That's what care has devolved to.

Why don't we have that here? Because as you look around this table and our community, the health delivery systems and the locally sponsored health plans have provided access to care through subsidized means, and we're doing the things that are only nibbled at in the reform act, about supporting primary care as a system.

Wisconsin has the second lowest rate of uninsured people after Massachusetts. The difference between Wisconsin and Massachusetts, however, is you can access primary care here. And again, let's acknowledge the elephant in the room. The status quo is not an option. Whatever you feel about the health care reform act, whatever flavor of reform you advocate for, the status quo is not an option.

HUEBNER: Just to piggyback, one of the elephants in the room is just having an open discussion. As a physician, this is always a challenge when you have a patient in the room, and especially if you have limited time or many issues to address in one visit, but there are times when we need to have an open conversation with our patients about what their costs are and whether something is really going to be a useful service for them. I have patients who would like to have an MRI of their back, and it's really not going to change how I manage their care. 'But doc, I just want to know what's going on.' Well, I have a pretty good idea based on my history and exam, and that used to be the old way of doing things. And MRI is very useful and important to use when you feel like someone has a serious problem that's not getting better or they potentially need surgery, but it's not something that we should just do because we have the ability to do it, or the technology is there.

PHILLIPS: That goes back to the consumer because I think we forget. We often put blame on our health systems, and how we change the mentality of the consumer of health care is just critical. I think this community has done, and this state has done a lot more to get that consumer mentality moving in the right direction.

HOPE: I have seen a big difference in the way physicians are interacting with patients. The best examples, of course, are the prescription drug ads that you see about 12 times every night while you're watching prime time television. It used to be that the patient would come into the physician and say, 'I want that little purple pill.'

HUEBNER: They still do sometimes.

HOPE: But physicians are having more meaningful conversations with their patients as to why you don't need the newest and most expensive treatment. We're asking patients to be more interactive and more responsible for their health care, and primary care physicians are doing a good job leading us down that path.

DEMARS: There is an element of health care reform that's not widely talked about and will help facilitate that – the establishment of the Patient-Centered Outcomes Research Institute. The institute will invest in research that will allow us to compare the relative effectiveness of one thing to another. Right now, the standard is whether it is safe and effective, but there's very little comparison of one treatment to another. Physicians and consumers equipped with that research can make better, value-based decisions about the best treatment for an individual.

BYRNE: Accountability is not just for giving the best care; they've also accepted accountability through the locally sponsored health plans for managing costs, an important element. When I was practicing pulmonary medicine, the patient would say, 'Come on, doc, give me that' – a particularly branded antibiotic that cost $57. He wanted me to give him that so-and-so antibiotic that he got the last time he went to Urgent Care. 'I don't want this $7 generic thing you're prescribing for me. I've got insurance.' Then you have to explain to them Health Economics 101; that just because you have insurance doesn't mean you're not paying for it. That's $50 that your employer is not spending on your salary, benefits, research, marketing, and so you are paying for it. By the way, the $7 antibiotic will work just fine, thank you very much.

WOODWARD: I think that shows the complexity of the whole health care issue. We've been working under the same system for 45 years, and now all of a sudden we're trying to tip it on its head, and physicians are going to have to interact differently with patients. We're going to have to expect something different.

I have a mother who is 93, a wife who is 50, and a daughter who's 17. I would say that my mother is of the generation that whatever the doctor says goes. My wife is probably more of the generation of questioning the physician, but always wanting what's marketed out there, because we've all grown up with that. My 17-year-old, I'm not sure what she's going to have, but I'm probably expecting a blend of two, directed by the physician.

GLYNN PATRICK: She's going to be Googling.

WOODWARD: Exactly. But societal change is one thing that's probably been grossly underestimated. That's why, when you look at the popularity of the new law, the popularity of that on a national level is pretty poor. I think people understand it, but people also think their choice is going to be dramatically limited. To some extent, it will be; not dramatically, but it will be limited.

BYRNE: If you look at surveys that show that less than half of the people are in favor of the law, but then you tease out the elements of that like rescission, where our insurance can be canceled after you get sick, people don't want that to come back. Or the exclusion for pre-existing conditions. People don't want that to come back, and so I'm confused by looking at the data. People seem to like some of the key elements of it. They just don't like the whole plan or the name or something.

PHILLIPS: It's because they really don't understand it. When they are asked those questions that you just mentioned, absolutely, they don't want those to go away. But those aren't the things that have been put out there in the press, and there are some very good things that are included in the health care law.

HUEBNER: Another one that's already gone into effect is first-dollar coverage on preventive services, which is huge. I can't tell you how often I've had conversations with my patients about how much that mammogram is going to cost, or how much is that colonoscopy going to cost? We're going to start doing a lot of screening and care for tobacco cessation and cholesterol screening and cancer screenings that hopefully will save money down the line.

BYRNE: We've been piloting first-dollar coverage for chronic disease. Why would you not cover diabetes supplies, testing equipment, and medications? Would you rather have to pay for eye surgery or kidney dialysis, or an amputation later on?

 

GLYNN PATRICK: Our next question goes directly to Cheryl from The Alliance. Cheryl, your organization represents mostly midsize to large employers. Since the health care package requires automatic enrollment in health insurance plans sponsored by large and midsize employers, and those that fail to offer a minimum level of coverage would be liable for an additional tax, how is the preparation different for these companies than small businesses?

DEMARS: In terms of the auto enrollment feature, we're really not hearing a lot about that yet because the regulations haven't been written, and it's not going to take effect for a while. Employers have just gone through the first cycle, post Affordable Care Act, and their focus has been on the really practical things that they must do to comply with the new law, and to evaluate whether they want to retain their grandfathered status. That's by and large done. They've gone through that cycle, and their focus is turning to the long-term issues. One of the things that we're working to do as a cooperative of employers is to help our members understand the interplay of things like the design of insurance exchanges and the impact that will have on the market, the additional requirements, the potential to be subject to a Cadillac tax down the line, and also the decision about whether to remain in the business of providing health benefits to employees, or to pay the penalty.

Those are big decisions. They're complex decisions because the components of health care reform will interact with one another. In terms of the pay-or-play decision, employers that I talk to recognize that their business success is really inextricably linked to the health of their employees and their well-being. They have a vested interest in making sure that their employees maintain or improve their health, and getting out of the business of providing health benefits would have some risk.

HOPE: There was a massive flurry of activity after Sept. 23, when everything was kind of laid out, in particular the grandfather status. I have a lot of employers who are very concerned about what do we do next – what do I have to do to make sure I'm in compliance? We barely get a chance to take our breath after this first rush before we have to start addressing the next set of circumstances. I'm happy to say that we have a little bit of breathing room here before 2013, when a lot more things have to come into play. Employers were concerned about the auto enrollment, which is going to mean an additional administrative burden on the human resources departments of companies, and I think they're all pretty happy that this has been postponed.

HUEBNER: A lot of the insurance plans in the area, but maybe not so much around the country, are also focused on providing the employers with information about the quality of care their employees are receiving through our health plans. That's something employers and the government can continue to work together on because I think the direction, regardless of where things move in the future, is that individuals are going to have to make decisions increasingly more at that level as opposed to their employer always purchasing the insurance.

BYRNE: In many senses, we're in the national capital of data transparency. As a health care community and employer community, we have worked hard to have transparency, and we've been recognized by the Secretary of HHS and others for being a leader in transparency. That's only going to help people more as they make their choices.

HOPE: We've got a long way to go.

BYRNE: We're doing a lot better on clinical quality transparency than we are on pricing transparency.

DEMARS: We're doing better with clinical quality transparency at certain levels. We've been measuring hospital outcomes and certain outpatient procedures, but the number one question that we get from our members is: can you tell us about the differences in physicians? They choose their doctor. They'd like to know about the relative performance of physicians, and we're a ways away from having that kind of information.

WOODWARD: Wisconsin is very far ahead compared to other states in the country, but it's very relative to what the employers want in being able to have data they can use to educate their employees about how to buy health care effectively, intelligently.

GLYNN PATRICK: We're going to go back to employers with this question. The new law also provides a small employer tax credit to help offset the cost of employer-provided coverage. Generally, a small employer is one with fewer than 25 employees and an average wage of about $40,000.

In 2011-2013, eligible employers may qualify for a tax credit of up to 35% of their contribution toward their employees' health insurance premium. In 2014 and beyond, eligible employers who purchase coverage through a state exchange may qualify for a credit of up to two years to 50% of their contribution. This sounds almost too good to be true. Is it true? At what cost? Who then pays for health care?

WOODWARD: That's one of the areas where there's a lack of detail. When you look at what happened with the midterm elections, Republicans now control the appropriations. So is that going to come to pass? I think that's the gigantic question mark. From my standpoint, I look at national health care reform as though it's on a trajectory. How fast will that be? Over what period of time is this going to unfold?

That is yet to be known, but I think the more looming issue, and it gets to the small employer group, is Medicaid in Wisconsin. That's going to impact how health care is provided. It's going to impact providers, physicians, and hospitals much more dramatically than anything on the national front. It already has started. At Meriter, with the expansion of the eligibility criteria, more people now can qualify for Medicaid.

We have evidence suggesting that those small employers, 10 or fewer employees, are dropping health insurance altogether and going into Medicaid. We've seen our commercial insurance decrease by 3% and our Medicaid increase by 4% in about a six-month period. That's huge, since they pay about 40 cents on $1 of cost.

HOPE: The Medicare reimbursement rate is a big concern. I've heard many stories about physicians who might be on the fence in terms of retirement, and the low Medicare reimbursement rate is just going to continue into the foreseeable future. We're going to end up with a shortage of primary care physicians, and I'm not sure government is doing enough to prevent that crisis in the way of reimbursement for tuition and such for primary care physicians.

HUEBNER: The Affordable Care Act already has implemented a 10% payment bonus for most, we think about 80% of primary care providers who are seeing Medicare patients. Then coming forward in 2013-2014, there is going to be Medicare parity, with Medicare payment reimbursement for primary care. Those things need to continue to make sure the primary care foundation is robust and continues to grow.

I'm glad you brought up the issue of the health care workforce because there clearly is a shortage of primary care providers, professionals, and nurses. Some of what's in the Affordable Care Act actually is starting to implement improved funding for primary care residencies and medical student loan forgiveness programs for students interested in going into primary care, and that is a big part of the puzzle.

DEMARS: The employers I've spoken with, smaller employers, see the subsidies potentially as a double-edged sword because they end. The subsidies might be enough to get an employer into the game of providing health benefits to their employees, but if the cost-reduction strategies fail to materialize or do so too slowly, employers may find themselves having created an expectation among their employees that they can't deliver on in the long term. Whether those subsidies, if funded, will really result in small employers picking up more coverage is a question.

GLYNN PATRICK: The premise is that we need every healthy young person paying in through insurance premiums to make this work. If they opt out, what happens to the pool?

HUEBNER: That's where all the rhetoric is, and I think there needs to be a bipartisan answer to that if the Supreme Court were to rule against the individual mandate. We all agree that the current system is unsustainable. There may be other ways to increase that pool size, but it's not just about the pool size. It's also about responsibility as citizens to say that if we're uninsured and we end up having an accident going down the ski slope, we end up in the ER and have massive hospitalization, that cost is distributed. It doesn't go into uncompensated care. That's why it's important for everybody to be a part of the pool from the beginning.

BYRNE: There's a fundamental flaw in waiting to get insurance until you need it. The first study that RAND did on this was probably 20 or 30 years ago, that people who don't have insurance seek care later and they have worse outcomes. Their high blood pressure is not as well controlled, so they have more strokes and heart attacks. Their diabetes isn't as well controlled, so they have more blindness, more kidney failure, and more amputations. The flaw of saying, 'I'll just stay on the sidelines until I need it,' increases the probability that you're going to need it, and increases the probability that when you need it, it's going to be big-time rather than a generic, anti-hypertensive medication.

HUEBNER: I hear a myth in the media, and in this debate, about how some choose not to have insurance, and there probably are a small number of people that do. Most people would prefer to have the security of having insurance that's affordable. They don't want to become bankrupt, especially the way the economy is right now. I have a lot of 20-somethings that come in to see me once they get a job coming out of college, and they're glad to start thinking about preventive care. That message is getting out.

BYRNE: As Jeff said, it's not a question of them choosing, it's Maslow's hierarchy of needs. They're choosing between food and shoes or health insurance. We've never had a lower percentage, since it's been measured, of employees accepting employer-sponsored health insurance than we have today over those issues.

GLYNN PATRICK: Our last question pertains to perhaps the most controversial aspect of the new law: the creation of the Independent Payment Advisory Board, which some critics view as a death panel because it has been charged with keeping Medicare spending below a certain level starting in 2015. Is this a fair label?

PHILLIPS: I think the first response is how do you respond to something [a death panel] that doesn't really exist and that has really become irresponsible fear-mongering.

BYRNE: Amen.

WOODWARD: We all agree with that.

PHILLIPS: It's not a death panel, and never was intended to be a death panel, and how it has been twisted and turned in the media, and that media has been irresponsible in how they have picked up and spread that message.

HUEBNER: There is a division within the health care professional ranks on the IPAB, and this is something that's challenging to talk about. In general, the American Academy of Family Physicians, of which I'm a member, is actively supporting that because they realize this is going to be a way to constructively work on the cost-containment issue, hopefully in an open, accountable, transparent way.

WOODWARD: In reality, to varying degrees, we've had something like this since I've been in health care. We had gatekeepers. We've had all sorts of different models with HMOs in the past that have attempted to restrict care. Go back to your comment, Jeff, about whether a patient needs that MRI right now? There are other people making those decisions for the physician. We're going to be seeing more of the onus being placed on the professional who knows the patient, knows the history, has made a diagnosis, and is going to be determining how care is going to be provided.

In my view, there has been fear-mongering. There's a lack of clarity around exactly what this board is going to do, but I don't think it's anything new. The Wisconsin Medical Society recently came out with some statements that get to where we need to be, maybe we need to consider rationing. What we're talking about is not life-saving care being rationed, but I think life-sustaining care could potentially be rationed. My father died of liver cancer. He made a decision not to go through chemotherapy and radiation therapy because he knew it was just prolonging a pretty awful situation.

PHILLIPS: We hand out a card with the five questions you should take to your doctor at every single appointment if you've been diagnosed with a life-limiting illness, and they clearly are about quality of life. They clearly ask the physician, 'Is this treatment going to cure me? What's the percent chance it will? If it won't, is it going to buy me extra time? How much?' Not all of those questions can be answered. Without good care management, that piece falls into an abyss.

BYRNE: Of the many low points in the polarized, at times fear-mongered debate that occurred around health reform and the legislation, for me the death panel label was the low point and the most distressing thing. I'm no expert on the mechanism of IPAB and these boards, but I can tell you that as a physician, the quality of the end-of-life experience for families and patients, where they've discussed thoughtfully, out of the glare of the klieg lights in the ICU, what a loved one's wishes are, is dramatically different and better. This is not about money. This is about honoring people's wishes. This is about respect for people. In the course of doing that, you avoid a fair amount of futile care that does nothing and benefits no one.

PHILLIPS: As individuals, it's important to have those discussions with our families and our physicians, and put it in writing, because nothing leaves families more in the lurch than when nobody knows. I would say the saddest situations, the greatest travesties, are when you've got a whole family sitting there and usually they're arguing because there's nothing in writing. It's the patient's experience, but it's also the family's memory, and so we forget that because it lingers. That goes on for years and years if the patient's experience isn't good at the end.

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