Conference Sneak Preview:
JASPR Interviews Healthcare Expert Jonathan Fleece
Laurie Pumper, ASPR Communication Director, St. Paul, and Lori Jackson Norris, Co-editor, JASPR, Senior Physician Recruiter, Dignity Health, Phoenix, AZ
Just days before the US Supreme Court made its landmark ruling upholding much of the Affordable Care Act, two members of our JASPR team talked with Jonathan Fleece, who will serve as one of the keynote presenters at the ASPR annual conference in Los Angeles. Jonathan is a leading healthcare attorney and expert in healthcare reform laws including the Patient Protection and Affordable Care Act. He will be joined by David Houle on Tuesday, August 14, presenting on the topic, “The New Health Age: the Future of Health Care in America.” Jonathan and David co-authored a book, The New Health Age: The Future of Healthcare and Medicine in America, that has been at the top of Amazon’s charts for books about health policy. This article provides excerpts from the interview; if you needed another reason to be convinced to attend the ASPR annual conference, this just might be the one!
The following quote from Jonathan best sums up the interview and what you can look forward to during his presentation: “I’m extremely passionate about this topic… I think your members are going to light up. I predict that your members are going to walk out of that room thinking that they are alive at the best point in history and they are involved in the healthcare space at some of the most exciting times... in American history. It isn’t going to be easy, either. Transformations are very, very hard, and we are going through a massive transformation. For those who are committed and passionate about healthcare, the end game is incredibly rewarding for America. There is a lot of good that can come out of it.”
Q: Jonathan, you’re a healthcare attorney. Describe how you found yourself speaking to groups about why America needs to get healthier.
A: I’ve been practicing in healthcare law for nearly 16 years. I started in the Midwest with a large academic medical center in St. Louis and then moved my practice to Florida in 2001. Even before the Affordable Care Act (ACA) and the Deficit Reduction Act that came about under George W. Bush’s administration, significant changes started to occur within America’s health care delivery system. These two recent major policy changes have brought things to a head.
“I’m extremely passionate about this topic… I think your members are going to light up. I predict that your members are going to walk out of that room thinking that they are alive at the best point in history and they are involved in the healthcare space at some of the most exciting times...
The ACA was the turning point in America that put the issue of our healthcare system on the table for national discussion. My clients were going through many examples of chaos, confusion and fear and misinformation. It was apparent that it was time to study and analyze the issue.
David Houle and I met through an organization that I serve, one of the nation’s largest hospice providers. David helped us put together a strategic plan during a board retreat process. He and I forged a friendship. It was a culmination of seeing many factors coming together at once — and all the challenges that we were facing that the ACA put on the table — that prompted us to write the book.
If I had to report on the recurring themes that crystallized the changes: America spends the most money among industrialized nations in the world on healthcare. We are close to 18% of our GDP spent on healthcare.
Then you have to ask the logical question: Are we getting a return on investment for that spending? When you look at two major classes of ROI (one, the health of Americans, and two, health outcomes within the health care system), we fall very far behind in both categories. Americans right now are not healthy. There’s lots of data that we talk about in our book regarding the number of preventable diseases and preventable deaths that occur on a national basis because we’re not living a healthy lifestyle. It’s estimated that nearly 1.5 million people die every year from some sort of death that was clearly preventable or tied to a lifestyle behavior choice — smoking, clinical obesity, or other behavior that’s a choice. That’s akin to the entire city of Philadelphia dying every year from preventable actions.
“It’s estimated that nearly 1.5 million people die every year from some sort of death that was clearly preventable or tied to a lifestyle behavior choice — smoking, clinical obesity, or other behavior that’s a choice. That’s akin to the entire city of Philadelphia dying every year from preventable actions.”
Looking at outcomes, more Americans die in hospitals a year than on highways. That’s not from disease — that’s from preventable things that occur through bad outcomes in a hospital (infections being the largest percentage of that).
Q: Our members are recruiters in hospital and healthcare settings. What can physician recruitment professionals do to address these key drivers with physicians we are trying to recruit to our organizations?
A: From a recruitment standpoint, I think your role is multi-fold. Educating (physician) recruiters within hospital systems across America about the future directions is important for a variety of reasons. Recruiters need to understand the type of physician and the skill sets and behavior patterns that are going to fit best within this new health age as we’ve defined it. Second, recruiters need to know how to develop compensation systems, incentives and rewards — and disincentives and punitive measures to also foster that change in behavior. If a hospital medical staff is not penalized for its readmission rates (as an example), are they really going to help that hospital change that data? Medicare and private payers are moving quickly toward pay-for-performance modalities that are clearly going to pay hospitals less for certain re-admissions.
I think the best way (ASPR) can help is through educating members about the future and help recruiters develop reward systems and disincentive systems to help change behavior and get the outcomes that health systems are going to want.
I think forward-thinking hospital CEOs who make the following statement are going to win the game: “My job as a hospital CEO is to close down beds over the next 10 to 20 years within my hospital system.” I’ve heard several hospital leaders say that publicly. That tells you that certain hospitals that are proactive, realize that the more we do around disease management, around wellness, and around higher performance while patients are in the hospital to reduce bad outcomes or re-admissions, the more the hospitals are ultimately going to win because that’s where the future of healthcare is going. The more educating about that cultural change and what we define as dynamic flow changes that your members can provide, the more they will be prepared to put in place different systems around that.
Q: We know that America is facing a shortage of healthcare providers, especially physicians. What is your perspective?
A: The data are pretty clear. When you look at the demographics, especially the baby boomers, ten thousand Americans are turning 65 every day for the next several decades. The very nature of aging will tax the healthcare system more and more in the future. When you look at all specialties, there are significant shortages of physicians in the direction we are headed. It is a big issue. I think it needs to be addressed in several ways: Part of healthcare reform needs to involve reform of the medical education system and having more government involvement in funding the education system. Right now, the average loan for a graduating medical student is nearing $200,000 — comparatively, on a global scale that is much, much higher than what all other countries incur for medical education. We have to address that cost issue.
Healthcare providers need to expand the definition of who is the appropriate caregiver for certain tasks. For instance, let’s take disease management. A doctor can run tests and complete his evaluation to reach a conclusion that we have a patient with diabetes. But at some point, I think the physician has to embrace — and this could be part of the educational process that could be helpful for your members — that it is now OK to include other caregivers within the medical home team to help manage and treat diabetes. Let’s say the diabetes is correlated and caused by obesity; the physician can say in the exam room to the patient, “You need to lose weight. You need to exercise. You need to change your diet and nutrition to effectively manage your diabetes.” But the physician has limited time and resources to help that patient achieve the ultimate goal of living a healthier lifestyle and getting the obesity under control. That’s where physicians need to embrace dietitians, nutritionists, physical therapists, trainers, and other caregivers to achieve the desired outcome, which is better health and being proactive to bring down costs. Embracing allied health professionals and extending the definition of caregivers will help us deal with that shortage and give physicians more bandwidth in improving health.
Recruiters need to understand the type of physician and the skill sets and behavior patterns that are going to fit best within this new health age as we’ve defined it. Second, recruiters need to know how to develop compensation systems, incentives and rewards — and disincentives and punitive measures to also foster that change in behavior.
Q: ASPR physician recruitment professionals are at all different stages of their careers, have different levels of education and are in different situations (hospitals, clinics, academic settings). Can you help provide a higher-level perspective — a couple of points?
A: Looking from a higher perspective, an easy way to understand the new health age and the future of healthcare in America is divided into two basic categories.
First, it’s about creating accountable care models — don’t even use the term ACO. Accountable care models are being driven by the private sector (insurance companies and self-funded health plans typically offered by big employers) as well as by Medicare and Medicaid. “Accountable care” is the overarching term to use for new disease management programs, wellness programs, and lifestyle change programs that pay for performance (paying providers bonuses and higher reimbursement to produce better outcomes) on the delivery side. But to truly work, and for the new healthcare age to truly become reality, you have to have an accountable patient. Because if lifestyle factors and other preventable factors are the root causes of these chronic diseases that are driving up costs, at 10:30 at night there is only one force at play that can make the decision when a person opens the refrigerator and asks whether to make that turkey and cheese sandwich: that’s the human mind. Behavioral change has to be part of the overall equation. You have to put a system in place that creates accountable care with an accountable patient. Incentives and disincentives will drive both of those at a high level to ultimately reach the outcome of a healthier society bringing down costs and, frankly, accessing the healthcare system less.
“Accountable care” is the overarching term to use for new disease management programs, wellness programs, and lifestyle change programs that pay for performance (paying providers bonuses and higher reimbursement to produce better outcomes) on the delivery side. But to truly work, and for the new healthcare age to truly become reality, you have to have an accountable patient.
I think the progressive healthcare systems in America (not necessarily just the huge ones like Mayo Clinic or Cleveland Clinic) will embrace that they need to bring not just accountable care solutions to the table for their patients, but also solutions that help patients become accountable. You’re seeing more of that on the private side, where systems will work with big companies and communities to bring employee wellness programs, disease management programs, more screenings, and more preventive care to the table — and disincentives and incentives on the patient side to make them more accountable for what they’re doing. If you step back and think of it that way — that really the future of healthcare is about creating an accountable care delivery system combined with an accountable patient world — everything sort of feeds on that.
Q: We have heard news reports that some large insurers actually welcome some aspects of the Affordable Care Act. How might that play out?
A: The global concepts of what the ACA is trying to achieve is where we are headed. I don’t agree with everything in the Affordable Care Act; let me just put that on the table. But if you just look at the big picture level, that’s where you will start to see agreement.
Where I think the insurance companies embrace parts of ACA:
We have 50 million Americans right now who don’t access the healthcare insurance system and don’t access the healthcare system until the most expensive point, in many cases. In Arizona and Florida, skin cancer is an example of a major disease. If you have a growth on your arm, and you catch it early enough in the process, and you can access the healthcare system, and maybe it’s an early stage I skin cancer and you have it removed, your success rates and survival rates are typically in the 90th percentile. But if you wait until it gets to stage IV or V cancer, your survival rates plummet and the costs that you create in the overall system skyrocket.
Insurers are realizing that their clients are pushing back. The average cost per employee now for health benefits is $12,000 per year, and that continues to go up at 10 to 15% per year. If there is a way to require those 50 million Americans who are shifting a lot of those costs to the private sector to access the system earlier, and pay into the system earlier, the theory is that everyone will ultimately benefit. You’re not waiting until the costs are out of control. You also avoid what the insurance companies call adverse selection; you want some degree of healthy people paying into the insurance system as a preventive measure to help cover the costs of people who are sick. If you only have the sickest people paying into the system, then your overall costs go up. Part of ACA that the insurance industry actually does like is that it forces some of these 50 million Americans who aren’t accessing the system to pay something into it while they are healthy. That helps offset the cost for people who really need it and then also brings preventive, proactive care to that group to hopefully reduce the long-term need to access the system to begin with.
Q: In your book, you cite fear, uncertainty and misinformation as key drivers in healthcare right now. What can physician recruitment professional do to address these fears with physicians?
A: I think education, education, education is the most important part of this whole discussion. Unfortunately, the conversation around healthcare in the United States has become way too political. If you become educated by the political system, you’re not allowing your logic and analytical skills to process what’s really going on; you’re becoming manipulated by politicians and by the messages. Education around the true future and getting outside of the political debate is the most important thing ASPR members can do. When you step back from the political chatter — which David and I have been doing for the last several years — and talk to both sides of the political aisle and the private sector, everyone is really in agreement. It’s amazing to me. We can talk to a Republican congressman and a Democratic congressman — and on the core issues, they absolutely are in agreement: America is a great country. Our health is not where we want it to be on a physical level, nor where we want it to be on an economic level. We have to fix both those problems to remain a great nation.
Unfortunately, the conversation around healthcare in the United States has become way too political. If you become educated by the political system, you’re not allowing your logic and analytical skills to process what’s really going on; you’re becoming manipulated by politicians and by the messages. Education around the true future and getting outside of the political debate is the most important thing ASPR members can do.
That leads to the question of how to get educated. Certainly, reading our book is a starting point! It’s understanding the dynamic flows that we talk about and reaching out to resources that exist all across the country and getting more information — facts and data, not politics — so that people can see the opportunity. Education is step one.
Once people are educated, then in step two, fear actually goes away… A lot of fear is tied to things that have not even happened. The more educated you get that there can be a bright future ahead in healthcare, then your fear will naturally subside. We are working with healthcare systems and providers today that are in early pilot programs of these new health age reimbursement systems that are making more money under the new system for producing healthier patients with better outcomes than they ever made in the old system of a fee-for-service, volume-driven, “the more sick people you take care of the more money you make.” When you educate yourself about where this is going — the new reimbursement models and how payers on the private and public side react around wellness and everything — that’s an exciting story. I have clients who are making way more money in the new system than under the old system. Yet people get so caught up in the political games that they start losing sight of the themes that are not political.
We are working with managed care companies. HMOs and IPAs (the bad words from the ’80s) are reinventing themselves around these new principles and payment systems and bringing new products to the market through Medicare Advantage plans. They’re frankly trying to distance themselves from some of the failures that occurred in the past. We are seeing it from the payer side and then also on the systems side.
We are seeing hospital systems directly, or in joint ventures, or in partnership with physicians, creating new accountable care organizations that are implementing these new payment models of the future. I’m working with several ACOs that are in various phases right now and seeing early signs of real success. Dr. Stuart Levine (who is one of the change decision authors in our book) is with HealthCare Partners. They’ve been so successful with their medical home/ACO model that DaVita just recently acquired HealthCare Partners because DaVita sees the future opportunity of the model. They paid one of the largest multiples I have seen since the dot-com days — like an 8.4 multiple of earnings. I haven’t seen that in healthcare ever. It just shows you that Wall Street and the big players on the delivery side are really starting to get around what the new health age is all about and paying big dollars to make that become reality.
It just shows you that Wall Street and the big players on the delivery side are really starting to get around what the new health age is all about and paying big dollars to make that become reality.
It’s very exciting. And if you become educated about what’s really happening, then the fear naturally falls away. When I sit in a room with physicians, they are usually the ones driving tons of this fear. If you explain that these physicians are going to make more money — creating healthier, happier patients — than they ever made under the 20th Century fee-for-service, the-more-diagnostic-tests-you-perform system, all of a sudden they have hope.
One of the whole purposes of writing the book is to help the country have an intelligent conversation about issues we can all agree on and see where we’re going.
If you explain that these physicians are going to make more money — creating healthier, happier patients — than they ever made under the 20th Century fee-for-service, the-more-diagnostic-tests-you-perform system, all of a sudden they have hope.
We are not going to change the entire healthcare system quickly — it’s like trying to change the direction of a freight train moving 50 miles per hour. It is going to take time. Where you can get tremendous bang for your buck is incorporating and adopting pilot programs so that you have something you can show medical staff that people can rally around and see that it can really work. That’s what’s happening with some of the groups I’m working with. They’re not trying to take their entire patient populations and throw them into these new accountable care systems. They’re taking more chronically ill population groups — where you can achieve some pretty significant savings quickly — and putting those patients in ACO models and showing others how the savings can occur. Then it can grow from that point.
Q: Any closing thoughts, Jonathan?
A: Candidly, the main reason good authors get excited about their work is not the money, but the message. You really are the cheerleaders at the front lines, shaping doctors’ perspectives.
I’m not here to celebrate the future or criticize the future. I’m here to describe the future. We all have two choices: We can either move into the future or not.
We can’t change healthcare spending using the same modalities that we’ve used in the 20th Century. It isn’t going to work.
There’s no doubt that there will be specialty physicians who will lose in the long term. Where I think they will still be OK is because of the demographic issue. Quick example: I’m not sure if I were entering medical school today that I would pursue cardiology as a subspecialty — I would look a lot more at some of the proactive, preventive, disease management specialties if I wanted to be a specialist. We are also going to see a huge resurrection in the importance of primary care/internal medicine physicians. Because overall disease management, being driven by the primary care marketplace, is where many of the new structures are going. Primary care physicians will quarterback many of the changes. It is important for recruiters to know that there are going to be some specialties that are hurt more than others.
It is important for recruiters to know that there are going to be some specialties that are hurt more than others.
In a quote from Jonathan’s website, thenewhealthage.com, the author, attorney and physician advisor urges Americans to continue to educate themselves about this dynamic period in healthcare. “The pursuit and the eventual acquisition of it, whether we obtain it through education, life lessons, or otherwise, is what separates great citizens from all others; because without knowledge, humankind has no basis upon which to see a better tomorrow. Without knowledge, we simply exist versus contribute...”