Reforming US Health Care

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There are some things even God doesnt
understand. Thats why He created politicians.
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NPAG 2007 Hyatt Regency Chicago September 23, 2007
Reform U.S. Health Care Or Else!
Jeanne Scott talking-head-in-chief health-politics
.com
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Jeanne Scotts Not Very Sophisticated Guide to
the Politics of the United States of America
Liberals
Conservatives
The Great Unwashed Middle

• Unions
• Hard working people who believe in bad luck
• Rich People from Hollywood
• Macrobiotics and Vegans
• Pro Choice Advocates
• And assorted left wing wackos, including but not
  limited to hippie scum, tree-huggers,
  philanderers, reprobates, left leaning
  columnists, and outright communists.

• Social Conservatives
• Hard working people who dont believe in bad luck
• Rich People (Non-Hollywood)
• Pro Life Advocates
• And assorted right wing wackos, including but not
  limited to xenophobic talk show hosts and their
  followers and a small number of powerful members
  of the NRA who exercise disproportionate power

• Markets fuel growth
• Americans believe in fairness not equity
• Inspire dont conspire
• Willingness to change and innovate
• A Call for Sacrifice

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Change As Viewed By Each
Liberals
Conservatives
The Great Unwashed Middle

• Access is the priority
• Cost control through wrestling for resources
  top down budgeted and even price controls
• Discounted FFS as payment
• Hamster Care that is cheaper
• Nothing wrong with the delivery system just need
  to get people access to it

• Over-insurance is the problem
• Increase HDHP
• Expand Consumer engagement
• Hamster care
• Nothing wrong with the delivery system as long as
  consumers are willing to pay for it

• Delivery system reform is the priority
• Transparency of BOTH cost and quality
• Value Purchasing to exploit the variation in cost
  and quality
• Capitation/P4P/ Reimbursement Reform
• Delivery system can and should be completely
  re-engineered

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Rising Health Insurance Costs
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Outsourcing of Health Care ???

• Outsourcing is no longer limited to blue collar
  industrial and back-office white collar jobs
• Software development and programming
• Accounting and legal services
• Health care claims processing (Northern Ireland,
  the Philippines)
• And the latest new developments
• Medical transcription
• Radiology and other telemedicine services
• Sending patients to India and other Asian
  locations for surgeries and specialty services,
  (already an option under the British NHP)
• Blue Cross-Blue Shield of South Carolina offering
  overseas option to members and marketing
  nationwide
• Blue Shield of California, HealthNet offering
  Mexican HMOs

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I took the above masthead from a web site --
Companion Global Healthcare a subsidiary of
Blue Cross-Blue Shield of South Carolina.

• Companion Global Healthcare in the News
• Overseas Option for S.C. BlueCross Members
  Featured on NBC Nightly News - May 16, 2007
• Companion Global Healthcare, Doctors Care Reach
  Agreement for Aftercare Services - May 10, 2007
• BlueCross BlueShield of South Carolina and
  BlueChoice HealthPlan Pioneer Global Healthcare
  Alternative - February 8, 2007

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• Rising medical costs are taking a toll
  
• on the auto industrys bottom line and
  ultimately are threatening American
  manufacturers' ability to compete in the global
  marketplace. Congress needs to apply some serious
  medicine to address the nation's severe health
  care problems.
• -- General Motors chairman and CEO G.
  Richard Wagoner Jr.

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Health care insurance, once an employment
benefit taken virtually for granted, has become
a bed-rock issue in todays American industrial
labor-management environment. As the employee
share of the cost has increased, people are
starting to become more aware of the actual cost
of health care and increasingly are seeing
the cost of health care insurance as a critical
political issue one upon which they will make
a voting decision.
A new study from the University of Michigan
indicates that 27 of employers surveyed would
like to eliminate health care coverage for their
employees entirely. 85 said that the employee
share will have to go up by 50 or more.
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• "I fear that we may have already committed more
  physical resources to the baby-boom generation in
  its retirement years than our economy has the
  capacity to deliver."

"Congress in the future will have to weigh the
benefits of continued access, on current terms,
to advances in medical technology against other
fiscal initiatives."
Alan Greenspan November 25, 2005
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Dire Warnings from the Comptroller General
"I would argue that the most serious threat to
the United States is not someone hiding in a cave
in Afghanistan or Pakistan but our own fiscal
irresponsibility."
"I'm going to show you some numberstheyre all
big and theyre all bad."
David Walker, Comptroller General of the United
States
"You know the American people, I tell you, they
are absolutely starved for two things the truth,
and leadership."

• Boomers will be eligible for Medicare in just
  three years and when those boomers start retiring
  en masse, then that will be a tsunami of spending
  that could swamp our ship of state if we don't
  get serious."

"Any politician who tells you that we can solve
our problem without reforming Social Security,
Medicare, and Medicaid is not telling you the
truth."
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• Gosh Darn All Those Pesky Uninsured People
• 44.6 Million officially uninsured in 2006
• (9.5M of which are children)
• 2007 Consumers Report Estimate
• 60 Million Underinsured
• 40 of Americans with no or in adequate health
  insurance

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Never Fear, the Answer is Simple
ALL AMERICANS HAVE ACCESS TO HEALTH CARE. AFTER
ALL, YOU JUST GO TO AN EMERGENCY ROOM! - GEORGE
W. BUSH, Cleveland, Ohio, August, 2007

• 29 Industrialized Nations, 28 With NHI
• EMTALA-Driven Uncompensated Care/Emergency Room
  Crisis
• 37th Ranking in World
• 15.9 GDP
• Movement Away From
  Employment-Based Coverage
• The States Arent Waiting Oregon, Maine, New
  Hampshire, California I, Maryland, Massachusetts,
  California II, Pennsylvania, Illinois, California
  III, Wisconsin,
• Texas

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S-CHIP REAUTHORIZATION DEBATE

• This month, the Senate Finance Committee Approved
  5-Year 60 Billion Increase to be Financed by 61
  Tobacco Tax Increase
• Pay-Go Rules Apply
• Importantly, GOP Senators Hatch and Grassley Took
  the Lead In pushing This Through
  Democratic-Controlled Finance Committee
• Would Fund Care for Children (but no additional
  adults) in Families Up to 400 of the
  Poverty-Level
• (About 81,000)
• House Version Calls for 50 Billion Mostly
  Financed Through a Smaller Tobacco Tax and Cuts
  in Payments to Medicare Advantage Plans
• The White House Announced it Would Veto
  any Such Increase

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Caring for the uninsured is estimated to cost
115 Billion in Transferred Costs to other Payers
and Bad Debt how many would that same 115
Billion cover in a better system?
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This is How Americans Currently Get Their
Healthcare Insurance
Uninsured 46.8M (16)
Employer 153.7M (52)
Medicaid/ SCHIP 37.5M (13)
Dual Eligible 8.0M (3)
Medicare 31.9M (11)
TriCare 3.4M (1)
Private Non-Employer 9.5M (3)
Employer Retiree 3.3M (1)
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Per Capita Health Expenditures, U.S. and
Selected Countries, 2003   
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Health Expenditures as a Share of GDP, U.S. and
Selected Countries, 2003    
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Inflation-Adjusted Physician Income is Decreasing
Across The Board
SOURCE Center For Studying Health System Change
Community Tracking Study 15 June 2006
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Quality Shortfalls Getting it Right 50 of the
Time

• Adults receive about half
• of recommended care
• 54.9 Overall care
• 54.9 Preventive care
• 53.5 Acute care
• 56.1 Chronic care

Source McGlynn EA, et al., The Quality of
Health Care Delivered to Adults in the United
States, New England Journal of Medicine, Vol.
348, No. 26, June 26, 2003, pp. 2635-2645
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Quality of Care Today We are Worse than Shaq
from the Line
Reported October 30 that several hospitals have
hired airline pilots to explain safety
procedures and processes to their staff
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International Obesity 2003 Percent of Population
over 15 with BMI gt30
Source OECD, 2005
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Obesity Drivers

• We are eating more (duh!)
• We are eating out more (In 1970 34 of the food
  budget was consumed outside the home in late
  1990s it was 47)
• Everything is supersized at home and at McDonalds
• We stopped smoking
• We are all working too much especially women
• We dont exercise enough because we are all
  working too much
• The only people who are exercising and eating
  right are people who were thin in the first
  place or bulimic celebrities or rich people who
  dont work or French fashion models

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Obesity is an Illness
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The Future of Health Care

• Fat People Meet Skinny Benefits

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Consumer ResponsibilityArguments For and Against
For
Against

• Consumers insulated from the cost of care
• If they had to pay they would use it less
• If they had to pay they would take more
  responsibility
• Consumers should have the right to choose
• When consumers choose and pay the market is
  working

• The 5/55 Problem
• One day in an American hospital and consumers
  exceed maximum deductible, so
• Catastrophic coverage is a green light for
  esoterica
• Does it save money overall?
• Poor people with chronic illnesses will be
  disproportionately affected

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Across the board, HDHP consumers have more
compliance problems
Treatment compliance problems
Currently insured in employer-sponsored or
self-purchased plan Currently enrolled in high
deductible health plan
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The Good, the Bad and the Ugly of Non-Compliance

• The Good Unnecessary care is foregone
• The Bad You dont take the Lipitor and it hurts
  in the long run
• The Ugly You dont take the asthma medication
  you go to the ER

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Internet Information is ALWAYS Helpful
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ELECTRONIC HEALTH RECORDS HAVE LIMITED EFFECT ON
QUALITY OF CARE, STUDY FINDS

• "In clinic visits in which doctors did use and
  didn't use electronic health records, we didn't
  find clear evidence that EHR use was associated
  with better quality."
• "There's nothing magical about electronic health
  records. You need to have tools in place that
  take advantage of technology to show improvements
  in quality. You need to do additional work
  instead of just turning on the computer."
• -- Dr. Jeffrey Linder, at Bostons Brigham and
  Womens Hospital, study co-author

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Voters View of Health CareWill Health Care Be a
Political Issue in 2008?
Surveys included open-ended and list-style
questions about priorities for government to
address, issues for candidates to discuss, most
important problems facing the nation, and most
important issue to your vote.
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Thinking About the 2008 Presidential and
Congressional Elections, Which Issues Do You
Most Want to Hear About From the Candidates?
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Four Scenarios for US Health Care 2007-2017
Tiering of Healthcare Tiers ? Us Jeannes
Odds 3-2
Minor Delivery System Reform
Disruptive Innovation Wal-Martization of
Health Care Jeannes Odds 5-1
Bigger Government by Request Daughter of
Single-Payer Jeannes Odds 2-1
Major Delivery System Reform
Mostly or Almost Universal Health Care Jeannes
Odds 4-1
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Scenario 1 Tiers ? Us

• SUVing of health care
• CDHC (Consumer-Directed Health Care) and HDHP
  (High-Deductible Health Plans)
• Continued disparities and tiers
• High end providers do well, low end suffers
• Probability over 10 years 40

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The Bush SOTU 2007

• Using Tax Policy to Address the Uninsured
• Families buying individual insurance could deduct
  up to 15,000 of the costs, regardless of the
  cost to them
• (thus encouraging people to buy low-cost,
  high-deductible coverage)
• Families with employment-based insurance would be
  taxed on the value of that insurance in excess of
  15,000
• Amounts would be indexed to inflation but not to
  increases in health costs

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President Bush Puts His Eggs in the Health
Savings Account Basket
Expand Health/Medical Savings Accounts Allow
Individuals and Families to Set Aside as Much as
5,150 a Year, Tax Free Bushs FY2007 Budget
would increase the allowable amount to 10,300
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Scenario 1 Tiers ? Us Impact on Health Care
System

• Health Plans
• Move toward HDHP and CDHC
• Sell whatever anyone will buy
• But always experience rate
• Rising numbers of uninsured and underinsured
• Providers
• Well-heeled, well situated, well run providers
  continue to thrive and distance themselves from
  the pack on quality, safety, and service (one
  third) aided by P4P
• Basket cases that deal with the poor and the
  lower middle class
• A health system for the top third

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Scenario 2 Bigger Government by Request

• Baby-Boomer backlash against cost-shifting
• Democrats run on shoring up and expanding
  Medicare for middle aged and elderly
• Government regulates health care even more
• Slowing innovation, reducing provider payment,
  and limiting profiteering
• Probability over 10 years 30

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Hillary-care Giuliani-care Obama-care
McCain-care etc. etc.

• Would-be, Wanna-be, Could-be, Might-be
• 2008 Presidents are falling over one another in
  proposing health plans for Americans

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Democrats see this as their issue
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What the Democrats are Saying

• Hillary Clinton Im battle-scarred but ready to
  take on the issue.
• Require employers who do not purchase private
  health insurance for their employees to pay into
  a pool for a Medicare-for-all-type plan
• Emphasize computerized medical record-keeping
• Implement purchasing initiatives to reduce drug
  prices
• Emphasize prevention of disease
• Reform the private insurance market by
  prohibiting insurers from declining coverage
  based on pre-existing conditions (guaranteed
  issue)
• Reduce national health care spending by 120
  billion/year
• Universal coverage wouldnt be achievable until
  near the end of her second term

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What the Democrats are Saying

• Barack Obama The public will judge my
  presidency by what I do for healthcare.
• Promises to deliver universal healthcare by the
  end of his first term
• Employer Mandate Play or Pay, provide employee
  health insurance or pay a tax
• No individual mandate (unlike other Democrats and
  Romney as Governor and Schwarzenegger)
• Creates a National Health Insurance Exchange to
  monitor insurance companies in offering the
  coverage. In essence, Obama's plan retains the
  private insurance system but injects additional
  money into the system to pay for the expanded
  coverage
• Expand S-CHIP and require all children to be
  covered
• Allow states to continue to experiment with
  health care reform initiatives
• Reduce costs through computerized records,
  reimportation of drugs and greater use of
  generics, emphasizing prevention
• Raise taxes on those making more than
  250,000/year to pay for the estimated 50-65
  billion cost

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What the Democrats are Saying

• John Edwards Any politicians who say they can
  provide universal health care and other promises
  while ending the federal deficit are not being
  honest.
• Medicare plan for all Americans, but not
  necessarily a single-payer plan that will be
  decided by giving everyone a choice
• Promote competition between private insurers and
  government
• Pay or play system for employers, provide
  employee health insurance or pay a tax
• Establish regional purchasing pools to enable
  consumers to bargain for lower premiums
• Require insurers to pay out at least 85 of
  premium income in benefits, i.e., minimum loss
  ratio
• Cost containment (hmm, does this mean more
  regulation?)
• Will raise taxes on those making more than
  200,000/year to pay for the estimated 90-120
  billion cost of his plan

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What the Democrats are Saying

• Bill Richardson The cornerstone of my plan will
  be to allow all Americans to buy the same
  coverage as Congress.
• Expand Medicare, allowing those 55 and older to
  buy in
• Allow working families to buy coverage through
  FEHBP (the same plan as Congress)
• Impose an individual mandate
• Mandate that private insurers accept all
  (guaranteed issue)
• Refundable health insurance tax credits to all
  based on income
• Streamline existing regulatory system and expand
  health I.T.
• Establish a cooperative relationship" between
  individuals, businesses and states "catalyzed by
  the government"
• Heroes Health Cards for military veterans to
  improve their care
• Cap interest payments on credit card medical debt
• No need to raise taxes, his plan will be financed
  through savings by getting out of Iraq and
  reducing military spending.

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What the Democrats are Saying

• Christopher Dodd (Senator from Connecticut)
• Create a Health Care General Fund (HCGF) with
  employers having a a play or pay mandate,
  exempting employers of 10 or fewer employees
• Individual mandate, for those without employer
  health insurance, buying from HCGF at a price
  based upon their income
• Expand Medicaid and cover all children up to 300
  of poverty level
• Encourage chronic disease management using
  clinical information technology
• Allow nurses to unionize even if they have
  supervisory responsibilities

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What the Democrats are Saying
Joe Biden Senator from Delaware

• Expand health insurance for children and relieve
  families and businesses of catastrophic health
  care expenses
• Support states pursuing alternatives and
  experimenting with universal coverage plans
• Use the experience of these states to develop a
  national universal health system

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What the Democrats are Saying

• Dennis Kucinich (Congressman from Ohio)
• Sponsor of HR 676 that would establish a
  single-payer universal health care plan for all
  Americans called the United States National
  Health Insurance Plan completely funded by taxes
  and run by the government

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But a few Republicans are also talking health
care

• But one cant run

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The GubernatorGov. Arnold Schwarzenegger (R.
Calif.)

• employers with 10 or more employees would have to
  offer health insurance for workers or pay a fee
  of 4 of payroll to a state pool that would help
  workers purchase coverage, with the amount that
  they pay based on income
• employees could pay for health insurance with
  pretax income
• health insurers would be required to sell
  policies to all state residents, regardless of
  whether they have medical conditions
• residents who refuse to obtain health insurance
  could face reductions in their state income tax
  refunds or have their wages garnished
• Medi-Cal, the state Medicaid program, would be
  extended to all adults with annual incomes of as
  much as 100 of the federal poverty level and to
  children -- regardless of their immigration
  status -- in households with annual incomes of as
  much as 300 of the federal poverty level
• additional subsidies would be available to help
  state residents with annual incomes of as much as
  250 of the federal poverty level purchase health
  insurance

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The Gubernator

• the proposal would increase by 4 billion
  reimbursements to health care providers under
  Medi-Cal
• physicians would have to pay 2 of their revenues
  
• hospitals would have to pay 4 of their revenue
  to help cover the cost of the program
• the proposal would be financed in part with about
  5 billion in federal matching funds that the
  state will receive as a result of restructured
  health care programs and with state funds
  currently used for charity care

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The Romney When He Was Governor Plan Individual
MandateHealthcare for Everyone

• employers, most of whom already offer insurance,
  would be encouraged to continue doing so
  voluntarily Romney vetoed a Democratic proposal
  to tax employers not offering health insurance
• individuals who don't have insurance would have
  to sign on to one of two insurance pools
• Commonwealth Care through which people of
  moderate income and small businesses could buy
  insurance from private insurers at a special
  rate. It would not be subsidized by the state.
• Safety Net Care for residents with incomes up to
  300 of the federal poverty level, which is
  28,700 for a single person. Policies would have
  no annual deductible and would be subsidized by
  the state, with policyholders paying 1.3 to 5.8
  of their income, or 2.30 to 32.31 a week, for
  an individual plan.
• individuals who do not get insurance from their
  jobs or buy it through one of the programs would
  lose their personal tax exemption of 3,300
  worth about 175 for an average taxpayer face
  withholding of their income tax refund, or if
  they get medical care, their wages could be
  garnished for payment

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The Romney as Presidential Candidate Plan

• Disavow mandate in his original Massachusetts
  plan
• No mandates, individual or employer
• Phase-out employment-based insurance, all
  insurance should be individual
• Tax-incentives to encourage transition
• Encourage high-deductible, low cost insurance and
  encourage people to use less healthcare, thus
  reducing costs
• Allow the states greater freedom to experiment
  with alternative private sector initiatives,
  eliminating many insurance regulations that
  raise costs, allow cross-state sales of health
  insurance

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Rudy Giuliani
The health care system requires a "paradigm
shift" toward the individual health insurance
market. Currently, about 17 million residents
have individual health insurance, compared with
about 175 million who have employer-sponsored
coverage. Giuliani said that he opposes proposals
to require all residents to obtain health
insurance because government subsidies would be
required for those who could not afford a policy,
which in turn would drive up costs.

• Phase-Out the U.S. Employment-Based Health Care
  System
• Families eligible for 15,000 tax credit to buy
  individual health insurance
• Allow families to keep the difference of they buy
  less expensive plans
• Release Health Care Insurance from State
  Regulations and Mandates and Allow Cross-Border
  Purchases
• All Purchases of Health Insurance Would be
  Tax-Deductible, Regardless of Whether They Were
  Purchased Through and Employer or Individually
• Block grants to states to encourage innovation,
  reduce health costs, enroll eligible uninsured
  and address adverse selection issues
• Increase price and quality transparency
• Reform medical liability system
• Expand Health Savings Accounts
• Invest in Health I.T. to reduce errors and
  improve efficiency

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Mike Huckabee(former Governor of Arkansas)

• Keep health care in the private sector
• Improve private sector delivery system to rein in
  costs
• Tax breaks and paid days off for employees who
  engage in healthy behavior

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Sam Brownback Senator from Kansas

• Establish price transparency throughout health
  system so that consumers, not government can make
  the decision (hmm, what about quality)
• Insure freedom of choice in health coverage so
  consumers can choose health coverage that is
  right for them, even across state lines
• Create a lifetime electronic medical record,
  giving consumers control over its use to insure
  privacy

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Tom Tancredo(Congressman from Colorado)

• Enforce immigration laws and funnel savings into
  health care (exactly what savings are these,
  Congressman?)
• Provide access to lower cost insurance by
  establishing association health plans for
  non-group covered citizens and legal immigrants
• Provide national relief to the states to help
  cover the unemployed citizens and legal aliens
  (are we getting a message here Congressman about
  illegal immigration?)

Photo taken from his official campaign web site
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Not yet heard from

• Former Tennessee Senator, television and movie
  actor Fred Thompson has made no statements (as of
  August 15, 2007) on health care
• Texas Congressman Ron Paul (a physician) has
  nothing on his web site on health care
  (www.ronpaul2008.com)
• California Congressman Duncan Hunter has nothing
  on his web site on health care (www.gohunter2008.c
  om)

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Already Out

• Former Wisconsin Governor and Secretary of Health
  and Human Services Tommy Thompson (the other
  Thompson who based on his DHHS tenure may
  really have had something to say. Tommy, we
  hardly knew ya)

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Scenario 2 Bigger Government by RequestImpact
on the Health Care System

• Health Plans
• Plans become more regulated
• Delegated to becoming back-office processors
• Transaction supporters not market makers
• Providers
• Hospitals are secure but under-funded for major
  capital initiatives
• Top tier institutions make it on philanthropy and
  differentiated care for the affluent elite
• Only cost-reducing technologies are rewarded
• P4P You gotta perform to avoid a pay cut

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Scenario 3 Disruptive Innovation

• Cheapo plans proliferate (high deductibles and
  retail primary care) forcing cheaper delivery
  models to emerge
• New disruptive competitors emerge at a lower
  price point, e.g., Revolution Health, Wal-Mart,
  Kaiser Lite
• Almost as good, and a lot cheaper
• Probability over 10 years 10

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Feature Article BENEFITSGoing the Distance for
Health Savings. Could overseas travel for
lower-cost surgeries become an option in
employer-sponsored health plans?
March 2007 Issue
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Have Surgery. Go Sightseeing. By PAUL B.
BROWN Published March 24, 2007 WOULD you be
willing to have non-urgent medical procedures
done overseas, if you could recover in a fine
hotel and your employer not only picked up all
the costs, but actually paid you for having the
work done outside the United States? You may be
faced with that decision, if HR Magazine is right
in its prediction that medical tourism will
become one of the benefits corporations will be
offering soon. Medical tourism, or medical travel
as it is also called, involves traveling to
respected medical facilities in countries like
India, Thailand or Singapore to have
non-life-threatening medical procedures done,
Betty Liddick writes. It also often involves
recuperation at a resort, or tourist destination,
all for less than what treatment alone would cost
in the United States. The price is obviously the
appeal to employers. According to examples cited
in the article Going the Distance for Health
Savings, the cost of sending a worker overseas
for procedures like removing a gallbladder can be
at least 50 percent less than that of having the
work done in the United States, even if the
employer pays for the worker to spend recovery
time in a fine hotel. To encourage employees to
go overseas, some companies are willing to give
employees a percentage of what is saved in
medical costs. The crucial question about medical
tourism, which Ms. Liddick describes as a small
but growing health care trend, is, of course,
whether the quality of care is equal to what
could be received at home. No one knows the
answer to that, said one expert quoted in the
article. Frankly, were not in a position to
meaningfully evaluate and compare American
hospitals, let alone offshore ones.
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Scenario 3 Disruptive Innovation Impact on the
Health Care System

• Health Plans
• Health Plan HDHP grow enormously
• New competitors in ambulatory space allow cheaper
  alternatives
• Contract with India for the high-tech stuff
• Providers
• Outpatient alternatives grow from Minute Clinics
  to outpatient surgery chains to federally funded
  safety net community clinics
• Hospitals are either struggling as government
  (under)funded geriatric ICUs or thriving as body
  repair shops for affluent baby-boomers
• Primary Care becomes the ultimate P4P its all
  retail

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Scenario 4 Mostly Universal Health Care

• Mandatory universal individual insurance is
  passed
• National policy commitment to restructure health
  care financing and delivery
• True managed health care
• Focus on public health and prevention
• Probability over ten years 20

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Scenario 4 Universal Health Care Impact on the
Health Care System

• Health Plans
• Health plans as active agents for health delivery
  transformation
• Sources of innovation in DSM and new
  reimbursement models
• Get smart or get out
• Providers
• Chronic Care management done right innovation
  in community based chronic care
• New reimbursement systems Daughter of
  Capitation force market leaders into
  fundamental clinical system redesign
• Acute care is evidence-based and standardized
• Innovation concentrated in designated centers of
  excellence
• P4P means better payment and earns the provider
  the right to serve

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Four Scenarios for US Health Care 2007-2017
Tiering of Healthcare Tiers ? Us Jeannes
Odds 3-2
Minor Delivery System Reform
Disruptive Innovation Wal-Martization of
Health Care Jeannes Odds 5-1
Bigger Government by Request Daughter of
Single-Payer Jeannes Odds 2-1
Major Delivery System Reform
Mostly or Almost Universal Health Care Jeannes
Odds 4-1
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Issues and Impacts

• High end patients and providers will always do
  well
• How bad will it be for the rest of us?
• True cost reducing technologies will always have
  appeal
• True clinical breakthroughs that are radically
  better than existing modalities and therapies
  will always be rewarded
• Healthcare is a superior good and will take a
  larger share of national wealth
• But who pays for what and how will be central
  difficult questions for business, government, and
  households around the world forever
• Transforming for good Its all about
  Information and Incentives

82
Issues and Impacts

• No matter what, we will need better value
  measures and more transparency of measures
• Value based purchasing and P4P will become more
  prevalent and have a powerful influence on
  providers and vendors
• Consumers will become more engaged in value
  decisions but we cannot rely on them absolutely
• The systems of health care need to be
  continuously improved to deliver greater value
• Will require clinical skills, process skills, use
  of cutting edge technology and big-time
  capabilities
• Most of all, it will require vision, values and
  leadership

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Theres Not Much We Have to Change.Except

• Our values
• Our Strategic Focus From Pimp My Ride to
  Primary Care and Prevention
• Our Reimbursement System
• Our Delivery System
• Our Individual and Collective Behavior
• Our Expectations

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