Health Care Roundtable: Will the Affordable Care Act Live Up to Its Name?

The Supreme Court and the American electorate have spoken, and as President Obama has said, the law we passed is here to stay. The Affordable Care Act is moving full steam ahead toward full implementation, but what does that mean for panelists and Greater Madison employers? It means get ready, because Health and Human Services regulations are being issued and several deadlines loom. 

Our Expert Panel

Cheryl DeMars
CEO,
The Alliance 

Dr. Frank Byrne
president, 
St. Mary’s Hospital

Dr. Bob Turngren
president and CEO, 
Meriter Medical Group,
Meriter Health Services

Bill Smith
state director, 
National Federation of
Independent Businesses

Zach Brandon
president,
Greater Madison Chamber
of Commerce

GLYNN PATRICK: Given the pay-for-quality outcome model that the ACA reinforces, providers admit to sharpening pencils, and that it’s going to drive quality over volume. In addition to things like nurse practitioners and more emphasis on home health care and outpatient care, what other kinds of innovations will we see in the provision of care and/or the design of facilities going forward?

BYRNE: The train has left the station on value over volume. Our system has made a commitment to value. We are leaving substantial fee-for-service revenue on the table because you’re not going to be able to flip a switch as things evolve. So from the financial perspective, we’re looking for ways to manage cost. We’ve shown through some actuarial modeling that, for example, through our Dean Health Plan, we have bent the cost curve. Our per-member, per-month costs have actually been significantly lower than predicted over the years by PricewaterhouseCoopers and Milliman. We’ve really focused on quality metrics to make sure that we’re able to not only say we provide exceptional care, but prove it. 

And then, of course, from the patients’ perspective, you have to layer on to that an exceptional experience. Again, we have opportunities for improvement as all organizations do, but we’re really focused on improving the patient experience. Within the past few years, for example, our emergency room has completely redone the model of care it provides, and how a patient comes into the emergency room, and the experience they have. Our patient satisfaction has gone to the 94th percentile from much lower in the past. Our HCAP scores for the hospital experience are at the 90th percentile. So those are some of the things that we’re doing to really focus on the value. 

The other thing that’s really important to us is cross-continuum care management. So making smooth handoffs, which are the places not only errors were occurring but where dissatisfaction can occur, from inpatient to outpatient, not just within the hospital, from the intensive care unit to the floors and so forth. One small example is in joint replacement surgery. We’re able to dramatically reduce the percentage of our patients who go to a skilled nursing facility after joint replacement by starting their pre-discharge care planning before the surgery is even scheduled, to make the proper care arrangements. Again, I think it’s a great satisfier for patients, and it’s a great way to also manage costs.

TURNGREN: At Meriter, we’re very cognizant and committed to the evolution of health care from volume-based reimbursement to value-based reimbursement. To perform well in the future of health care, regardless of a lot of the detail, the general marching orders are there. Yes, the train has left the station, and if you’re not already moving your organization in the right direction, you’re going to be woefully behind. One of the broad aspects that’s very important is to build the infrastructure necessary to support the health care organization in an environment of value-based reimbursement. And that infrastructure comes in many forms – clinical informatics, the arrangement of the care model, the model of care needs to be modified, the alignment of teams of health care providers into a system of care so that the physicians are aligned with the payer and with the hospital. All of these things are very important.

We’re committed to the patient-centered medical home model in our primary care clinics, and you have to dip your toe into some of these things, and you have to commit some resources. So we are, for example, funding our in-case managers, without reimbursement for their activity, and they participate in the care of all of our patients, not just our Physicians Plus members. The doctors work with the nurses to say, ‘this is a patient that could benefit from care coordination and from your help.’ 

The model that I practiced in years ago was myself in a room with a patient where everything happened; I would emerge and order tests and consult. That’s not going to be the model of the future. It will be physicians being the leader of a health care delivery team, with more activity from behavioral health practitioners, pharmacists, nurse practitioners, nurses, all practicing within the scope of their license and their training to deliver patient-centered care. 

GLYNN PATRICK: We heard the shortage of nurses is being addressed and the expected shortage of general practice, family doctors, is still being addressed, but moving reimbursement monies will help that. Are we also seeing the triage function changing within this new model?  

TURNGREN: Triage traditionally would be before the visit occurs, figuring out whether this patient needs to go for whatever their problem or question is. I think, yes, there will be more support for non-physicians to help direct that patient to the right place to get the right care at the right time. But then after that assessment, whoever does it, other members of the health care delivery team will follow up with that patient, provide the educational resources and the follow-up that’s necessary. And it won’t all be in that traditional exam room. I learned earlier this week that Kaiser is requiring their primary care doctors to spend one hour a day on email with patients – a very different model, answering their questions, addressing their concerns. Sure, in some of their emails they’re going to say, ‘You really need to come in and be seen by me, my nurse, or the nurse practitioner,’ but it’s very different. I was an early adopter of emailing patients before we even had secure email. I was kind of out of bounds, as it turned out, but we’ll look at a lot of different ways, and there will be a lot of different members involved in the care. 

BYRNE: You definitely see more movement to team-based care. The primary care medical home really involves the multidisciplinary team that might include a primary care physician, nurse practitioner, a physician assistant, dieticians, psychological counseling, and things of that nature. There’s some encouraging evidence to show greater levels of satisfaction with that approach. 

Handing off patients

GLYNN PATRICK: Given a new model, let’s discuss handoffs from provider to provider. How are you going to handle more access to your system and still move these patients through as quickly? 

BYRNE: When we had these conversations a decade ago, we didn’t have the deployment of the electronic health record as we do now. With every patient I ever saw in my pulmonary critical care practice, the first thing I did was look at the available old records, whether in the ICU, emergency room, or my office. With the electronic health record, major systems here are on Epic; we exchange records, we work with colleagues at the state of Wisconsin to overcome some regulatory barriers, and we can provide your record. If you’ve traditionally gotten your care in one organization, you end up in another’s emergency room, and we can get your record there. That’s a huge patient safety and quality asset. There’s no more trundling around. A patient would come to my office with two armfuls of X-rays, but the one particular CT scan that I needed wouldn’t be in the packet. That doesn’t happen anymore.

Lastly, we are focusing a lot of attention on communicating better ourselves, face-to-face. So we’ve adopted a technique that we stole from the aviation industry for non-hierarchical communication. And the shift-to-shift handoffs and the physician-to-nurse conversations are formatted in a thing called SBAR, the Situation Briefing Assessment Recommendation, to make sure that we’re communicating more effectively, because handoffs are really where the errors can occur.

TURNGREN: The electronic medical record is huge and will help so much in the Madison area, with all of the hospitals and all of the significant medical groups on Epic. It’s not perfect yet, but it’s quite functional and light-years ahead of many other markets. The Integrated Delivery Systems, the large medical groups that function in Madison, give us the ability to deliver a very high level of care. Because of alignment, you get everyone on the team wearing the same jersey, working on the same clinical initiatives that drive quality high and can help drive the cost low. Drive a couple of hours toward Chicago, and health care is tremendously disintegrated. It’s light-years different, and we’re very fortunate in this town. This is why, nationally, Wisconsin’s health care costs for Medicare, for example, are much lower than in most other states. 

DEMARS: I think from the standpoint of employers and consumers, that care coordination is something we are looking for, and another area we’d like to see in this shift from volume to value is the whole area of the appropriate use of services. We think this is a big opportunity to make sure that we’re spending our health care resources wisely by delivering the care that people actually need. There are a number of studies that document unnecessary care. We can do a lot more to ensure that the care that’s being delivered, the procedures that are being delivered, are really necessary. We’re investing in shared decision-making with patients so that they can have an informed role to play in the care they’re receiving. If we have appropriate guidelines and clinicians are following them, that provides some [legal] safeguards.

TURNGREN: It’s helpful for the physicians to have best practice guidelines behind them. Our society has a great desire for the best care, and often we misinterpret the best with the most. Patients often will walk right in and within the first couple of minutes tell you that they would like to have a CAT scan of their back, and they don’t wait long enough to listen to what the doctor thinks. Doctors are under tremendous pressure from various directions to keep that patient happy.

Some of the most advanced electronic medical record systems and clinical systems will give, at the bedside, prompts for best practice. Earlier this month, I talked to an ear, nose, and throat surgeon out of the Mayo system; the computer tells him for a certain situation to look at the sinuses or look in the ear, whether CT or MRI is better for that. He was joking that he and the computer don’t always agree, but he was having fun and learning.

BYRNE: There’s so much we can do. In the Epic electronic health record, we’ve embedded the BPA, Best Practice Alert, that will guide you in the right direction. You don’t have to do it, but you have to explain why, and that’s also a part of our documentation for quality purposes. There may be a reason why you don’t give aspirin after a heart attack – a patient might be allergic to it – but document that. In terms of the shared decision-making, I’m delighted to see trends in this direction. I always enjoy dialogue with my patients, very interesting medical and pharmacoeconomic discussions. 

Cost curvature

GLYNN PATRICK: When it comes to bending the cost curve downward, a recent New York Times report notes that health insurers across the nation are both seeking and winning double-digit increases in premiums, perhaps due to the lack of a provision for denying rate increases. Is this a temporary situation that’s going to fix itself as the stakeholders adjust to the law, and is it common in the Madison market? Bill?

SMITH: Part of what’s driving premiums is just getting ready for the ACA. There’s a good deal of uncertainty about how it’s going to impact health care costs, which ultimately drives our insurance premiums. How many people will be in our clinics, at our hospitals, that aren’t there now because they don’t have coverage? That will drive them to the health care providers. The free preventive care is an example in the expansion of the Medicaid population, the coverage for Medicaid, so there will be additional demand pressures put on the health care providers, if everything stays as is, under the ACA. That, of course, will drive some insurance costs, and they’re being driven now because of the uncertainty about where this population will end up in 2014. 

There are also going to be new costs in 2014 – the health insurance tax, for example, which will hit all insurers in the small group market, as well as individuals. Some insurers are looking ahead to how those costs will impact the demand for care, and these new populations that will be showing up throughout the provider system. 

And there is the uncertainty. How will the ACA impact the people we insure, and the decisions that will be left for them to decide? In Wisconsin, the exchange is very important, and we’ve kind of punted that over to the federal government, and we have no idea what that’s going to look like. There are a lot of unanswered questions with regard to the formation and the operation of exchanges. And then (as of this discussion), the governor has not decided whether to expand the Medicaid population. Those are two important state decisions that I think the insurers are looking at.

GLYNN PATRICK: Do you think we missed the boat with the governor saying our exchange is going to be set up by the federal government?

SMITH: We supported a state-based exchange. Whatever decisions are left for the state to make, we thought important to be controlled at the state level. I think that’s where the governor was at, and then as the year progressed and the [Supreme] Court decision came down, the governor moved away from that and decided that the federal government should be the entity to create the exchange. 

I think the governor is correct. There are a lot of unknown issues relative to the cost of the exchange and who would pay for those costs, and they are significant. He put the taxpayers first and said, ‘I’m not going to commit to creating and operating an insurance exchange with all these unknown entities.’ The cost, and even a lot of the decisions with regard to that exchange, are all going to be made by the federal government. Why do we want to put our taxpayers through that? So I respect that decision. Having said that, there is also the argument that some governors have made, that we want to keep that seat at the table.

The other thing is that every insurance market is different. Michigan essentially has one insurer for small businesses. We have 30. So having the federal government design insurance plans, which will impact our individual market and our small group market, is risky and could destroy those markets. 

Then the final consideration, really, is whether or not the states that are choosing to have the federal government create them slow down the whole system, and whether tax credits and subsidies are, in fact, going to be available in the federal exchange. There is a very strong argument that those were put in the law to give states an incentive to create their exchanges. So what the state is saying now is, ‘we don’t want to have anything to do with that.’ The federal government is kind of surprised by that. 

So while the IRS has said all of the subsidies and credits will apply to federal exchanges, there are some states that may file lawsuits on the basis of they did not have the authority to do that, and the statute is quite clear on that. It was never the intent of the Congress to give the federal exchanges the same menu of tax subsidies and tax credits. It remains to be seen how that’s going to play out. 

BRANDON: On the question of the cost curve, [of the panelists here], I might be the only person who has had to actually procure health insurance for a small business. I can tell you that a double-digit trajectory of cost is not new. If you look back over the last decade, the cost of health insurance has gone up 94%, and more than 100% of that has been passed on to employees. We’re told by members that the cost of insurance is the number one barrier to growth. 

I remember sitting in plenty of meetings with small business owners saying, ‘I can no longer afford to provide health insurance to my employees. It’s a needed benefit, it’s something I need to be able to recruit and retain employees, but I can’t do it.’ I had a very young demographic, but yet I was still seeing 18%, 20% increases in health insurance. 

The second part of the question was the question of the state exchange, and I was surprised that the governor went the direction he did. When you see organizations like the NFIB and WMC and the organizations involved that represent the medical industry in the state all having one sense of direction where we’re headed, to have that go a different direction was surprising. Was it the right decision? Time will tell. But I do agree that if it is a cost question, you can’t negotiate cost if you’re not at the table. 

I have an economic concern beyond just the cost to taxpayers. I share that same concern, and want to make sure that we’re making those right decisions, but for me the questions are: we have really good providers in this region when it comes to insurance, and if the federal government decides to put a one-size-fits-all solution in place, how will that exchange work? 

How is that pay structure going to work? What kind of services are they going to provide? We could, unwittingly, be squeezing out the best of what we have in this region when it comes to health insurance by letting somebody at the national level come in and operate in the region. We have great providers and great facilities and great insurance, but I want to be careful that we don’t lose that opportunity and those options for our businesses and for their employees. 

SMITH: Our position was based on a survey of our membership list, and I applied that survey to establish our policy. The small business community felt, let’s keep it within our state authority. We feel better about the state doing it than having the federal government come in from afar and create, really, a marketplace here in Wisconsin. We’re close to our state, we’re close to our local government, and so they had a much higher comfort level. Even with all the unknowns, all the uncertainties, they just had a higher comfort level.

TURNGREN: We’re prepared for either direction. We would have embraced an opportunity through Physicians Plus to be at the table, but we were also prepared so that if it went to the federal side, we would raise our hand from the provider angle. There are a lot of unknowns.However, in the end, the focus is going to have to be on the quality up, the cost down, in an environment of service. 

BYRNE: I would hope that a national exchange would not undermine the good that exists in health care in Wisconsin. If it’s a one-size-fits-all federal exchange, if it advantages the large national health plans over our local provider-sponsored plans, it would be a real negative for the business community, obviously for the health care community, and most importantly for the people who get health care in this community. 

While we all have opportunities to get better in every aspect of the work we do, we have managed to mitigate cost increases. As a former small business owner myself, I understand. I talk to a lot of small business owners, and I understand the pressure they’re under. The statistics I saw a while back indicated that in the state of Wisconsin, they spend about 20% more per employee for health care in eastern Wisconsin than they do in south central Wisconsin. A lot of that has to do with the integrated systems … it all comes together in a three-legged stool of hospitals, physicians, and health plans working together, and I just hope that a national exchange doesn’t undermine that model.

DEMARS: When we talk to our members about their preference for either a state-based or a federally based exchange, the response we got was that we want an efficient, effective exchange that really supports free market health care. For us, that means good access to objective information with which to compare cost and quality. So we didn’t really take a position on whether it should be federal or state, what we care about is how it works. We also recognize that whatever decision was made, it’s not a now-or-never proposition. Wherever we’re starting, if it’s not working, we’re hopeful we’ll change course. 

Payer or player?

GLYNN PATRICK: In past roundtables, we’ve addressed the nuts and bolts of the law’s play-or-pay provision. But when it was first cited in the law, a lot of employers’ positions were, ‘I’m just going to pay the penalty and dump my employees into the exchange’ because in the end, their concern is business viability. They’re finding out that it’s not as simple as that. We know 86% of the businesses in Dane County employ 10 people or less. What would you advise them to do?

SMITH: In January 2014, the exchanges are supposed to be fully operational, and a lot of the taxes and mandates will kick in. So in 2013, it’s time to get ready. Determine your number of employees and full-time versus part-time status. You have to at least start thinking about that 50-employee threshold, because once you hit that, a lot of things change. 

It’s no longer an option. The penalties are severe if you don’t offer health insurance, if you don’t meet all the criteria and the benefits that the federal government says you have to have in your plan. So a number of things are going to occur. Even if you’re a small business, you need to be thinking ahead a little bit and try to determine how you’re going to continue in 2014. 

One study said smaller businesses are three times more likely to drop their current plan. If you’re under the 50-employee threshold, you’re not subject to all of the same penalties and there is a credit that has been available already for smaller employers under 10 to help subsidize the purchase of their health insurance. Unfortunately, not many small business owners are qualifying for that credit. It’s very complicated. There are salary requirements, thresholds to meet and employee numbers to meet, and that credit will go away. There is that part that they could be doing right now and having their health insurance subsidized. 

Beyond that, try to keep coverage with these increases that we’re seeing, but make sure, looking forward to 2014, to stay in compliance. Smaller businesses don’t have the human resource departments to help them get through this. So attend a webinar or participate in a workshop or seminar.

Many small business owners are actually in denial that it’s ever going to actually happen. The lawsuit, the Supreme Court decision should have kind of pushed them in the other direction. But there still are 35 lawsuits filed in the country just on the mandate for contraception coverage. The state of Oklahoma will or has filed a lawsuit based on the mandates. Utah has an exchange, but they want to do it their way and not comply with the requirements of Health and Human Services. There’s still a lot of turmoil out there, in both the courts as well as in some of the regulatory authorities in Washington.

GLYNN PATRICK: Wouldn’t that promote a feeling that this is really going to take five years, and so small business is not recognizing the big wave coming?

SMITH: Absolutely. If you’re under 50 employees, the impact will be much less. But if you’re right around 35, 40, 45, you better be looking at this law and making sure you’re prepared for its impact on your workforce as well as on your business, because it will have a direct hit.

BRANDON: There’s some complexity to making a decision about do you procure? Do you change providers? Do you push your employees onto the exchange? A lot of it can be dictated by the industry, the size of the company, the type of benefits that your competitors provide. You have to be able to provide the right set of benefits to employees to either attract or retain them. There are calculators that are helping people, there are simple flowcharts that people are able to watch. If you have less than 50 employees, which you noted that a large percentage of Dane County employers have, the law doesn’t require you to provide health insurance, but there might be a tax benefit to providing it. You should not only look at it from the standpoint of your risk as an employer, the associated cost or potential cost, but also is there a benefit to maybe start providing it as well? 

GLYNN PATRICK: Is there a potential tax credit for businesses that will decide to provide health insurance on the horizon? You’ve talked about the one that will sunset, but will there be a clear incentive to continue to provide health insurance and not put your employees in the exchange?

SMITH: I wouldn’t call it a carrot; it’s a penalty. Individuals in 2014 will be subject to a tax if they don’t have health insurance. It begins at $95 or 1% of the hospital bill, whichever is greater. Everyone will be subject to this tax, even if you aren’t in a small group. So other than that, this law has got 19 or 20 tax increases in it, and 13,000 regulations at the last count. It’s incredibly complex, and it is going to affect our lives, everybody around this table, in our professional lives as well as our personal lives. Whether there is a tax incentive, we’ll have to wait and see what the exchanges look like. There will be some employers who are going to say, ‘we’re out of the insurance business, so we’re going to let you loose and let you go out into the individual market, if there still is one, or go to the exchange and buy your insurance there.’

BRANDON: A majority of our members, at least for the upcoming year, expect no changes other than cost for health insurance. But they aren’t going to make any kind of wholesale decisions about moving all their employees off, or changing major parts of the benefit package. They expect that they’ll have increased costs associated with that trend line, that cost curve that has been that same trend line for over a decade, maybe multiple decades.

DEMARS: Our employers are not just looking for something different, they’re looking for something better. And if putting employees into an exchange isn’t better, they’re not likely to do that. They are, for the cultural reasons that you described before, needing to attract and retain employees, but also, employers understand that their business success is really inextricably linked to the health of their workforce. It will be a complicated decision about whether employers continue to play their role as sponsors of employer health benefits, or whether they have employees access health insurance through the exchange. There is a lot of misinformation and false assumptions about the tradeoffs, so it’s going to be important for people to have thoughtfully analyzed the pros and cons.

BRANDON: It won’t be a one-size-fits-all solution. Every business is going to have to examine this and how it affects not only their operation, but also their bottom line and their employees’ health. 

GLYNN PATRICK: This is called the Affordable Care Act versus the Accessible Care Act, and employers are thinking, ‘you’re doing all of this to get my costs under control, so my costs are going to drop.’ What is the reality likely to be?

BRANDON: If you think about the five reasons why employers make decisions, one of those is a decision that revolves around having a well-trained, healthy workforce. In my small business, there was a time where I was offering a great package, a $10 co-pay. I paid a large percentage of it, and they had a very small cost, maybe 10%. I was surprised that a large portion of my employees were not interested. When I went back to them, I was procuring the wrong insurance. That’s not what they needed. They didn’t need a $10 co-pay, everything is covered. They wanted to pay less money and have something for catastrophic; or if they broke their arm, they wanted to be covered. They were young and healthy and didn’t want to spend limited resources. 

TURNGREN: Over the next few years, we’re going to see the emergence of creative health plan offerings. Plan design is going to include the emergence of narrow networks to keep costs down because that network is more aligned. There will be wellness initiatives built into the plan design and the plan benefit, and that will be attractive to the employer. The individual workers will be more interested in health and wellness activities, and benefits and education, than the interventional side of health care. These market forces will drive some creative change. The business owner is going to have to address the balance between health care cost and the freedom of movement of the employee for their health care options. 

BRANDON: If we go out a little bit further, there is real opportunity for this region, from an economic development standpoint, for those types of health care IT to grow. It will be one of the places where innovation will continue to occur. Somebody will figure out a way to make money from these changes, and we stand to potentially benefit from that.

On the flipside, there is some harm in this law for what I call biomanufacturing, and it’s the medical device tax, the increase that’s being put on those companies. We have a significant amount of those coming out of the UW-Madison, but also as a state. That tax increase is a drain or a drag on high-growth, high-potential companies that could become major community wealth creators in the future, with opportunities to look at foreign markets.

There will be changes. Every major piece of federal legislation of this size and caliber requires modifications over time, and we will learn from it as long as the law stays nimble and flexible and reacts to what the market needs, how businesses operate, and not how the government thinks businesses operate. Large parts of this will become very workable, and I would say repealing the tax on medical devices, which Congressman [Ron] Kind said he’s going to introduce, will be an important component at a larger level, as far as economic development is concerned. 

BYRNE: It’s important to point out there is a potential sweet spot in here for employers and providers in a market [like Madison] with some very creative employer-provider partnerships. I’ve talked to some employers who are potentially very excited, who think they’ll be more competitive in a time where there is competition for employees – especially with certain skills – with provider-employer partnerships around wellness, prevention, and promotion of healthy lifestyles. We’ve done employer-based clinics that people seem to like and employees seem to like, so there is a potential for a competitive advantage here and a way to manage costs more effectively.

Cost or investment?

GLYNN PATRICK: Perhaps the most disruptive event that occurred in our business was not so much the recession as it was our buyer’s decision to switch plans based on cost. If there was an option where our insurance company said you can stay with the provider you want, I would be looking at that not as a cost but an investment. 

BYRNE: Thankfully, in the course of a year, most of us will not have to be admitted to a hospital. All of us should see our physician, our primary care provider for preventive care as well as for any ongoing acute conditions. That is the relationship that people value the most. What do people look at when that new health plan book comes out? Is my doctor in this network? Okay, so that’s important. You talked, Jody, about choice. The issue about choice and being flexible, being able to go from one system to another, is all about managing populations. We have good health care systems in this state that are capable of managing the health of the population that entrusts their care to them. But there’s got to be bidirectional loyalty.

One of the flaws in the way the Accountable Care organizations are set up, and we are an Accountable Care organization, is that patients have no obligation to seek care within the system they’re assigned to. It’s a difficult thing to manage. But if we’re going to do these creative arrangements with employers, there’s going to have to be bidirectional loyalty. If you can’t manage the health of a population, then you’re not really managing. Actually, with our care management, we’re working toward seamless care, where you can’t tell whether it’s the health plan, the clinic, or the hospital. But if you’re opting out of the system, and opting out of the use of those tools and systems we’ve put in place, how can we possibly help you manage the cost of your care and your health most effectively?

GLYNN PATRICK: Most employers are looking for the ‘medical home’ that you are talking about, and the workforce is healthiest when they have stability. The problem is when someone else is the buyer for your insurance. So literally from year to year to year, we don’t know where we’re going to be. Would the exchange level that out, or are we still going to be ping-ponged based on cost?

DEMARS: It depends on how the exchange is set up. If it is set up so that individuals make a choice, it could be a real benefit, because then individuals can choose where they wish to go. The other component of this that’s part of the Affordable Care Act, but isn’t widely talked about, is the emphasis on increased transparency of information. By that, I mean information to help consumers and employers compare the cost and quality of care. If you have choice, plus good information to make comparisons about value, you have more of a marketplace and you have individuals that are exercising informed choice for care.

TURNGREN: One of the basic tenets of the patient-centered medical home is patient commitment to self-care, self-determination, and involvement in the process. Along with the team approach, the use of disease registries to help drive team activity, and a few other basic tenets, that commitment on the part of the patient to be an active participant is core and key. 

As a physician who’s practiced over 20 years in the primary care realm, I was aghast in the ’80s when my first patient said to me, ‘I have to leave because our insurance is changing.’ That was just the most bizarre thing I’d ever heard, but over the next ensuing decades, it’s not been my experience that most people leave their employment to get back with their doctor. There can be some tearful farewells, difficult for patients and for the physicians. The physician-patient relationship is a very special one. 

At the same time, if I were the VP of HR for a large company and you’re seeing these double-digit increases, if I see a truly viable opportunity to really partner bidirectionally with a system that can deliver the goods we’re looking for – the quality, the service, the cost, at a lower price – and I believe they have the infrastructure and the commitment to maintaining that, it’s tough to turn down. The pressure is just going to be higher on the businesses because, as a nation where the percentage of the gross domestic product spent on health care approaches 20%, that’s not healthy for our economy.

DEMARS: There are a lot of decisions yet to be made. There is really an opportunity to influence how this unfolds, particularly if employers educate themselves about those things that are being decided, and can weigh in about ways that the law could work for them. This is going to be a regulatory sprint year, where regulations will be coming out fast and furious about how to implement the Affordable Care Act. What’s key is for employers to tune in. There are really a number of good resources available that can help employers understand, what’s going to impact me? What do I care about? What’s being decided? And then to weigh in, to contact their legislators, to work through associations they belong to, to make their point of view heard. The voice of non-health care business sometimes gets drowned out, but it is impactful when we make ourselves clear.

Advisory board

GLYNN PATRICK: Any final advice? 

BRANDON: My message is, be prepared, don’t ignore the law. It will go into effect. Understand how it affects your business, your employees. Treat it like you would treat any other benefit package. The 401(k) system is not an easy thing to navigate and to understand, for the employer or the employees. Treat it like that type of benefit, where you’re making very strategic decisions for the future of your business and for your employees and their health. Rely on resources. Certainly this magazine is a great resource, the chamber is a great resource, NFIB, the Alliance. There are great resources in our community and the nation, and there are calculators.

I think people will get very nervous about change, but here are real opportunities for companies both in being able to procure insurance, but also for those who are thinking creatively to change their cost curve. There is technology and innovation potential that could come out of how we react to this law, and this can change the cost curve. 

TURNGREN: To address the challenges that our health care is too expensive and not available to enough people will require more than any one thing. Health care reform will, in its broad form, force providers to re-examine how they deliver care, be innovative and creative, and start to partner and create teams that can change the way care is delivered. We believe the hospital will not be the center of the universe. It will be a place that you go, on very rare occasions, hopefully, to get highly specialized care that needs to be of the utmost quality and efficiency. 

Wellness, prevention, and access to primary care will be the key, and we are blessed in Dane County with tremendous providers. The integration and alignment
of those providers within those groups is absolutely critical to their high level of function. We need to take a new look and take action.

DEMARS: The Affordable Care Act has created a changing marketplace. The status quo is no longer viable, and that creates opportunity to really drive some different things. We’re seeing employers with a new boldness to be innovators and catalysts for change, particularly in the areas of transparency of information that employers and employees can use in wellness and health promotion. [Employers are] developing meaningful strategies to drive that level of change in their organization and in the area of payment reform. That’s come up a number of times – the need to stop paying for volume and shift to value. So in spite of the Affordable Care Act maybe not being all that we would have hoped, there really are good opportunities in the change that’s occurring in the marketplace, if we take charge and make some things happen.

SMITH: It’s been an interesting couple of years since this passed. As you know, NFIB went to the Supreme Court to try to get it repealed, and failed. We’re trying to prepare our membership for the inevitable, whatever that may look like, in 2014. I agree that this law is far from perfect – 2,700 pages, plus 13,000 regulations, and billions of dollars in new taxes, that strikes me as a strange way to make our health insurance and our health care more affordable. It’s almost perverse because of its negative impact on our economy and job growth, and it’s costing every American. Every person in Wisconsin is going to feel some impact from the Affordable Care Act, from taxes, from access, from choice. At the end of the day, we have no real assurances that we’re going to have better quality or anything more affordable. 

2013 is important to get ready for 2014, but the states now become the players with the Medicaid decision that hasn’t been made in this state yet (as of this discussion), and how that population impacts the overall cost of health care and this whole affordable care system that we’re creating. So it suddenly has become more of a state issue in many ways. 

As we look to the presidential election in 2016, it will be a huge issue then, because health care is so important to everyone. When they go out, wherever those candidates are, they’re either going to run on or against the success or failure of ACA. History will write the verdict on that. As I said earlier, it’s going to cost everyone higher premiums, fewer choices, and we think that it will actually decrease the quality of care. 

The ambiguity of what’s ahead of us is certainly a drag on the economy but, hopefully, as we get closer to 2014, these questions will be answered and you can make the necessary changes to truly make health insurance more affordable.

BYRNE: My closing remarks are a message for people considering health care careers. Whether clinical or non-clinical, do it. Please join us. There’s never been a better time to pursue a career in a health care field. We have tools, technology like the electronic health record that we really couldn’t have imagined would help us so much. We have analytics to help analyze the quality of care and what we do, and improve what we do, that we couldn’t have dreamed about 15 or 20 years ago. 

In all the years since I’ve graduated from medical school, I’ve never been more excited about the opportunity that we have ahead of us to get it right this time, to focus on populations, to focus on preventions and wellness. We have systems of care developing now that are actually equipped to do these things, and as opposed to the older models of fragmented care with disparate care and uncoordinated handoffs and things of that nature. 

So we really have an opportunity to get it right, and we need bright minds to join us and bring new ideas and help us get it right this time, because the status quo, wherever you are on the bus at this time, is not working.

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