Guns, Germs and Hypochondriacs

Opposites attract.

Staff Sergeant Kevin L. Zetina, Platoon 2085's...
Staff Sergeant Kevin L. Zetina, Platoon 2085's senior drill instructor, bellows cadence while practicing for Company G's final drill competition. Deutsch: Ausbilder (Drill Instructor) beim United States Marine Corps. Español: Un instructor abordando a los marines estadounidenses. A drill instructor addressing United States Marines / Not Drill Sergeant (Photo credit: Wikipedia)

They also  marry and discover along the primrose path of marital bliss what the French call, “le difference”.  Love is indeed blind and when a couple is first intoxicated by mutual attraction,  a thick cataract forms over their eyes  – precluding any ability to see things for what they are.  Eventually the X and Y chromosomes recover from their initial pheromone-fueled joy rides and discover the differences in how they approach life.  

Men are loud, visceral creatures who aggressively seek to conquer and accumulate.  Secretly, they are neonates seeking to return to the womb.  Women are more subtle and versatile forms of fauna using their twin skills of nature and nurture to navigate a thankless peanut gallery of expectations. Privately, they just want to be in charge of an all-Italian male model pool cleaning service.

Men are a mass of contradictions. After years of being indulged by their mothers, watching sitcom matriarchs and digesting blatant misinformation from other men, they enter marriages and relationships with a distorted expectation of what their partner must bring to the party.  Apparently, a nice cheese dip is not enough. Men also want their mommy.

Women fall in love with the notion of being in love.  Men appear to them like puppies – cute, friendly and somewhat fragrant.  By the time, they have been taken home, it is too late to give them back and your house smells.    When a woman realizes that her knight in shining armor is really sporting tin foil, wearing dirty underwear and perpetually prone to watch re-runs of the Godfather, a woman can become disillusioned.  This is why you often see mothers and daughters crying at a wedding.  They are not overcome with emotion.  The mother, having drank too much champagne, has just taken their daughter aside and shared with her what life might be like after the honeymoon.  Men misinterpret this matromonial female cry-a-thon as a byproduct of nostalgia when in fact, it is Mom breaking to daughter the news that behind the hunter-gatherer lurks a child who just wants to stay home from work and play with his plastic soldiers.

When it comes to the cold and flu season, roles change with women often morphing into the “drill sergeant “ and men into the “baby”.  A drill sergeant views illness as a temporary setback that must be denied at all costs.  Sickness is a self-fulfilling prophesy and the drill sergeant refuses to acknowlege anything less than blood from three orifices.  Drill sergeants hail from large families and the “suck it up“ school of parenting.  They believe in mud poultices and Mary Baker Eddy.  Babies, however,  are still nostalgic for small country inns, soft blankets and the pulsing heart beat that comes at the beginning of Pink Floyd’s “Breathe” — anything that reminds them of the nine months inside Mom’s pouch. 

Men become huge infants when they are ill.   The slightest cold or fever is usually the beginning of a pandemic. Women are taught to endure.  This plays itself out each season as men complain to other men that their wives show them little sympathy when they are ill.  Wives must keep the house going even when they are sick and as a result, have contempt for “babies” who cannot get up to get a cup of water, let alone, help with the kids.

Men never really notice when their wives are ill.  “My wife never gets sick” a friend shared with me as his wife was coughing up a lung while we were out to dinner.  Yet, when a man is sick, he reverts to fetal rocking, moaning and deep adolescent dependence.  To a drill sergeant, this contemptible behavior is worthy of court-marshal.

I should have registered the subtle harbingers of  intolerance when my wife and I were dating.  I knew she was a first generation Brit.  However, I assumed the “stiff upper lip” and “it’s just a flesh wound” thing was Monty Python hyperbole.  I assumed when the chips were down or coming up, she would transform into a Florence Nightingale that would nurture me by candle light – holding a vigil by my side of the bed until I was well.

 I had grown up in a household where sickness afforded you a temporary celebrity status. In the home of my mother, there was an unwritten  rule that if you were even thinking of getting ill, you went right to bed, eschewed all social obligations and incubated until the illness either hatched or the false alarm had passed.  My mother would organize around the illness.  She would sit like Mother Teresa, a kind silhouette in the flickering shadows of a night-light – cooling our feverish heads, rubbing our backs and humming soft songs.  In a four-boy family where you had to compete for everything – – food, air, space and attention, illness gave you temporary immunity from obscurity.  I often found myself envying my brothers when they became sick.  The mother shepherd focused exclusively on her one wounded lamb, assigning us to our father who resented the fact that he had to talke care of us. It was clearly better to be sick than under the care of a man who still insisted that the Germans had been invited into Poland in 1939.

The arrival of a major epidemic like chicken pox or measles was greeted with 19th century pragmatism – – the infected child and his brothers were quarantined together in a room until everyone came down with the illness.  “Best to get it all over at once “, She would shrug.  In later years, we would feign illness by placing the thermometer on a hot lamp or enduring scalding hot showers to raise our body temperatures.  We would then moan like ghosts wandering into her room to complain of a headache.

When I became a parent, I would disintegrate into worry when my first child became sick.  Yet, I had been trained by the best in triage and bedside manner.  In a strange way, their maladies made me feel more relevant.  Enter the British wife.  To the British female, illnesses are like road works, a temporary impediment that must be driven around.    Years later, as we brought children into the world, the “Stiff Upper Lip“ school and the “It Could Be Plague“ schools would routinely clash over diagnoses and prognoses.

At the first sneeze, she would say, “it’s just a cold.” I would be certain it was Ebola.  At the sound of a muffled midnight cough or sniffles, I was on the phone demanding access to a pediatrician.  A headache ? Meningitis.  That sore throat could be bird flu.  “The last I checked none of us have been to China” my spouse would respond.  ” We ate Chinese food the other night. Those dumplings could have been cooked by a carrier. “

As more children were born, I mellowed, graduating from burning the pacifier when it fell from their mouths, to wiping it on my pants to just popping it back in their mouths. My spouse, born to a midwife in a small English village, seemed pleased with my progress.  We made quantum leaps such as actually agreeing to carry on with a vacation if one of the children came down with the sniffles or developed a cough.  We braved a dinner party if I felt a little under the weather.  And yes, we did send a child to school before they had been symptom free for 48 hours (that one had me sweating)

I suppose this pragmatic return to 19th century medicine is healthy. But, there are times when my entire family is fighting illness — coughing and sneezing, spreading their germs throughout the house – that I hide, paranoid and alone in my den.  I sit wide-eyed reading – a modern day Howard Hughes devouring a book like, Guns, Germs and Steel.  I may have lost the germ wars at home, but I am staying informed on epidemics and holding out for the day when they reconsider my years of hypochondriacal behavior and shake their heads saying, “My God, he was right“.

That’s usually about the only time my wife declares she needs an aspirin.

Taking A Walk on The Wilde Side


“My own business always bores me to death; I prefer other people’s.”  So wrote the acerbic, witty and unrelenting Oscar Wilde in Lady Windermere’s Fan in 1892.  Wilde openly led a movement of aestheticism and public decadence in a time when sins were expected to be committed with discretion out of the public eye of a highly pious Victorian society.  The age-old struggle of good versus evil and the ensuing black comedy that resulted from every human’s double life was his central theme – one as apropos today as it was during the time of this “wicked” Irish iconoclast.

As a recovering collegiate sybarite and literary enthusiast, I have always been fascinated by Wilde.  I am drawn to his sarcasm and often rely on his wit when trying to contend with a world that judges too harshly.  While I cannot condone Wilde’s lifestyle choices, I could never disparage his genius.  Like so many great writers and contrarians, his tortured soul and conflicted contempt for what Victorian society viewed as “decency” compelled him to persistently test its boundaries.  In doing so, he sealed his own fate but left us timeless footprints in the forms of quotes, stories and plays.  Wilde might have been considered a troublesome dissident by today’s standards — constantly prodding and testing our conventions and hidden hypocrisies.  Although I wonder if Wilde was born in 1964 instead of 1854, if society would have been more forgiving — celebrating his brilliance and choosing to not be so offended by his habitual testing of the status quo.  A few gems:

  • Oscar Wilde, three-quarter length portrait, fa...
    Oscar Wilde, three-quarter length portrait, facing front, seated, leaning forward, left elbow resting on knee, hand to chin, holding walking stick in right hand, wearing coat. (Photo credit: Wikipedia)

    “ A little sincerity is a dangerous thing, and a great deal of it is absolutely fatal..” My mother called it “compulsive candor.  Wilde’s strengths taken to excess became his weakness and ultimately led to his decent into a determined frontal assault on society.  However, the truth was too tempting to not flaunt in the face of a pious England that held itself in such high esteem while choosing to conduct its venal pursuits in far off places and under the complicated cloak of class and corruption.

  • “Always forgive your enemies; nothing annoys them more.” There is indeed power, liberation and humor in forgiveness.  Making one’s amends and stepping up to apologize for your part of a conflict defuses a situation and gives you the upper hand.  One spiritual advisor once chided me to pray for my enemies.  “Perhaps if he gets exactly what he wants, he may no longer offend you or better yet, he may actually get what is coming to him. Either way, it’s out of your hands and it takes away people’s power over you to forgive them – especially without their permission.”
  • “A cynic is a man who knows the price of everything and the value of nothing.” It seems in a society that has come to judge material gain as a yardstick for personal advancement, we have come to understand how much everything costs but have lost our ability to understand intrinsic value.  Real moral and spiritual value requires a more complex calculus of living whose numerator is one’s impact on others – the lives we change and the legacies we leave divided by the price others pay as we achieve them. Many build wealth but may not recognize the intangible deficits they accumulate over a lifetime of misguided priorities.
  • “Wisdom comes with winters.” Our emotional intelligence is forged from the difficulties we endure.  The unexpected stone thrown through the bay window of our lives often forms the foundation for stronger character and a more resilient future.  Every winter holds the promise of an ensuing spring of insights, but only if we have the humility to seek these lessons.
  • “When the Gods wish to punish us, they answer our prayers.” We often say be careful what you wish for.  “You want to make God laugh?  Tell him your plans.”  In praying for something, perhaps we would be better served praying for strength to deal with whatever is to come our way.  Our own best thinking and resolve to get our way usually get us into a tangled mess.  Perhaps our lives are best guided by a point of reference other than ourselves.

In the end, Wilde’s determined sybaritic lifestyle – “working is the curse of the drinking classes”  where “only dull people are brilliant at breakfast”) – became his undoing.  In the midst of his physical and intellectual self-indulgence and his war against the English establishment, he penned brilliant works of literature : The Importance of Being Ernest, The Picture of Dorian Gray and The Canterville Ghost among others.

Wilde dared to suggest that human beings are a mass of contradictions.  We must periodically remind ourselves, as mistakes are made, boundaries broken and glass shattered, that it’s all part of the human condition.  As we move back and forth along life’s continuum between self and selfless, we should never forget that no one is without fault.

Wilde paid the ultimate price by flaunting his own self-destructive behavior in the face of an unforgiving society, then publicly challenging its hypocrisy.  He was imprisoned and died penniless three years later.  His “gross indecency” led to his mortal defeat, but also opened society’s aperture to tolerance and change.  He left us as an immortal — a fire that burned too bright, too hot and became too dangerous for the conventions of his day.  

Even now, as I finish this essay and tiptoe into a darkened kitchen in search of Easter candy hidden by my wife, Wilde whispers to me, “I can resist anything but temptation”.

Much Ado About Broccoli: The Constitution, Healthcare Reform and A Generation of Entitled Employees

The United States Supreme Court, the highest c...
The United States Supreme Court, the highest court in the United States, in 2009. Top row (left to right): Associate Justice Samuel A. Alito, Associate Justice Ruth Bader Ginsburg, Associate Justice Stephen G. Breyer, and Associate Justice Sonia Sotomayor. Bottom row (left to right): Associate Justice Anthony M. Kennedy, Associate Justice John Paul Stevens, Chief Justice John G. Roberts, Associate Justice Antonin G. Scalia, and Associate Justice Clarence Thomas. (Photo credit: Wikipedia)

As the Supreme Court debates the boundaries of government’s role in mandating the purchase of insurance, the discussion continues on whether the public or private sector is best positioned to drive market reforms necessary to meet our goals of lower costs and higher quality. As the son of a Phi Beta Kappa neo con who believes government should be the size of a sand gnat and as the husband to a British citizen who loves national healthcare and was born through a midwife, I often find myself lost in a political no man’s land with volleys being exchanged from the right and left.  To complicate Thanksgiving dinner further, thirty years of healthcare consulting, including a three-year stint in Europe, hospitalization for pneumonia in the NHS and a tour of duty as a senior executive for a national insurer has left me with my own conflicted convictions about  how we might fix our broken system.

On the eve of the Supreme Court determining the fate of PPACA, strong opinions are in full bloom like cherry blossoms along the Mall.  In his particularly sharp remarks to government attorneys, Justice Kennedy, considered a swing vote by many, cautioned that Congressional intervention to mandate citizens the “duty ( to buy coverage) to act “ was a slippery slope that sets dangerous precedent and impinges on individual rights. Justice Roberts added, “And here the government is saying that the Federal Government has a duty to tell the individual citizen that it must act … That changes the relationship of the Federal Government to the individual in the very fundamental way.”

Justice Scalia was quick to wade in after Justice Roberts questioning, ” what would be next in the role of the government dictating to its citizens ( if the mandate were to be upheld). “I will tell you the next something else (we will next tell Americans to do) is exercise, because we know that lack exercise contributes to illness.” It seems that this debate is indeed creating odd bedfellows as civil liberties advocates are joining conservatives in warning that the next thing the government will be telling people is that they cannot drink sugary soft drinks or that they have to eat broccoli.  It is hard to find a time when a conservative Justice and the ACLU share a common opinion about anything.

Private Versus Public – Who can Enforce Behavior? 

If legislators and American business want to reduce the cost of healthcare and engage an entire generation of entitled Americans, the practical answer to Justice Scalia’s rhetorical question is “Yes. Justice Scalia. We must mandate personal responsibility for healthier lifestyles.”

Most Constitutional and human rights advocates would agree that the government’s regulation of the “commerce of healthcare” can become a snare that can tangle any government’s legislative foot in a cat’s cradle of complications.  The need to legislate behavior in an effort to help reduce costs is simply a lap too far.  A government dedicated to reducing costs while preserving quality and competition would need to adopt practices currently employed and bearing fruit in the private sector to moderate medical trend and improve affordability.  The reality is many of these efforts – biometric testing, health risk assessments, population based plan designs, value based reimbursements – require a more prescriptive level of engagement by employees.  While the programs are strictly voluntary, it is clear that the cost of declining to engage in health improvement will begin to create a substantial cost sharing gap between those who participate and those who do not.

How Public And Private Payers Seek To Control Costs Fundamentally Varies

Medicaid and Medicare recipients are largely unmanaged.  Patients are free to access any provider who is willing to accept reimbursement and are generally not consistently under the care and coordination of a primary care provider. Fraud, overtreatment and instability among the chronically ill has led to extraordinary spending in public healthcare.  Unengaged and vulnerable patients freely access a system that has found it difficult to close gaps in care, manage compliance or offer visibility on the where to receive the most efficient care.

In the private sector, larger employers have begun to achieve lower per capita health care costs and market reforms by implementing programs designed to impact the unit cost of healthcare and the consumption of services. In the face of the recent recession, the private sector moved rapidly to de-leverage, right-sizing balance sheets and returning to profitability.  Larger firms have concluded that providing healthcare is neither a right nor a privilege but a benefit — an essential tool to attract and retain personnel.  In providing this benefit, there is an assumed  bilateral contract where each party takes responsibility for their role in health and healthcare.

Employers have done a poor job of enumerating expectations around personal health as many feel the idea of employment based health improvement reeks of Orwellian oversight.  Additionally, wellness and health management only works where there is a culture of trust and communications — two commodities often in short supply in a business environment often reducing staff, freezing pay and struggling to achieve year over year earnings growth.  Yet, firms have proven through the harmonic convergence of culture, communications and mutual accountability that medical trends can be reduced through health improvement.

The debate between public and private insurance inevitably breaks down when discussing how to best control costs.  A single payer system relies primarily on global budgets, rationed access and reimbursement based on a complex clinical and financial calculus that balances medical necessity and cost. Inevitably, the specter raised is whether restricted access to quality care suffers when rationed reimbursement is peanut butter spread across all providers who often have highly variable outcomes.  While every physician claims to have graduated first in their class, we know that some providers charge multiples of other providers but cannot clinically prove that their outcomes are significantly more favorable across a similar population.  The private sector has figured out that open access PPOs that promise 90% reimbursement for any in-network provider is contributing to the very problem they are trying to solve – paying for quality outcomes, not for units of care.

There is a case to be made that market based reforms can and would do a better job of preserving quality by reducing not only unit cost prices but also reducing consumption of services and preserving quality. The question remains whether the private sector has the will to convert an entire generation of reluctant and at times, recalcitrant employees who see open access, non managed healthcare as an entitlement.  Employers are now deciding whether they would prefer to take on the thankless task of redirecting employees and their dependents to narrower and more prescriptive primary care based networks or whether to drop coverage and abdicate the role of population health management to the government.

Several Supreme Court justices have already indicated that they do not believe government should play a broader role in regulating the “commerce” of healthcare. The question remains whether employers have the will and the skill to drive this process. Consider five reasons why the private sector needs to work harder to preserve employer based healthcare on the behalf of 180M working Americans.  In doing so, employers could end up preserving a system that rewards higher quality care and achieves lower cost without imposing universal reimbursement rationing.

1.     The Government Can’t Enforce Health Engagement.  Many Employers Won’t. There is a difference. – 50% of all private sector claims are driven by less than 10% of an employer’s population.  We know in many instances, these individuals develop chronic illnesses borne out of poor lifestyle choices.  The issues are difficult to solve for and are complicated by socio-economic issues such as lack of access to primary care, lack of access to healthier diet alternatives and a lack of education about the consequences of poor lifestyle choices.

Medicare and Medicaid do not have the means nor the ability to drive lifestyle based incentive plans or more prescriptively direct care for their recipients.  Less than 15% of Medicare is managed and those recipients are covered under Medicare Advantage plans that are driven by commercial insurers.  For Medicare to make advances, it would need to partner more closely with the very constituency that it vilified in an effort to get reform passed – managed care companies.  Meanwhile states are turning to managed care to help mitigate costs and improve care quality.  Medicaid costs are ballooning and without the ability to improve public health, better dictate access points, close gaps in care and manage the intensity of services being rendered while a patient is in the medical system, the public sector can only ration cost as a means of achieving cost management.

2.     Employers can design plans to reward engagement and health improvement – Employers are now committing resources to population health management – – conducting biometric tests, requiring health risk assessments, implementing rewards based plan designs that offer lower costs and richer benefits for engaged employees.  The result has been behavioral shifts that are fundamentally changing the way employees access care.  The combination of better tools to understand the variability of provider costs for similar procedures, education, rewards and disincentives have all combined to lower trends for many employers committed to driving loss control for healthcare.  The challenge for employers is true engagement requires time and resources.

3.     The Brokerage Community Has Done a Mediocre Job in Managing and Resourcing Health Improvement for Employers.  If you subscribe to the maxim that there are no bad students, only bad teachers, the sluggish move toward population health management, self insurance and aggressive loss management programs has as much to do with the limited intellect and resources of those advising employers as it does the employer themselves.  In the new normal, brokers must become advisors and have access to actionable data analytics, clinical resources, underwriting and actuarial services to more effectively forecast and show a return on investment for health.  The golden age of low transparency, limited access to claims experience, opaque premium and embedded broker remuneration is ending and giving way to an era of accountability where advisors will be paid for value and less for bedside manner and low value administrative support services.

4.     The Key To Quality is Reducing Higher Health Costs that Do Not Correlate to Better Outcomes – Employers have a lot of ground to make up.  After rebelling against HMO plans that had achieved close to zero trend in the mid-1990s but achieved it primarily by focusing on aggressive medical management and redirecting patient’s to lowest unit cost providers, employers demanded a more laissez faire system of access and oversight for employees. Choice and minimal third party intervention was the mantra which resulted in happier employees and annualized trends that swelled like waistlines to over 14%. As premiums soared, insurers and broker remuneration increased.

Over the last two decades, many employers have gravitated to larger, open access PPO networks that offer a wide range of provider choices for employees and also highly variable charges for similar procedures.  To complicate the need for consumer engagement, these variable charges are normally reimbursed at the same co-insurance or co-pay level – as long as they are incurred in network.  Often, the most expensive providers are perceived to be the best.  Employers must commit to narrowing networks and measuring quality based on outcomes over an entire episode of care.

The public sector equally rations reimbursement across all providers irrespective of outcomes or unit cost, shifting the burden to find a quality doctor to the patient.  The ability to reward quality with higher reimbursement while forcing greater transparency in outcomes and costs to better understand who is actually delivering the best care can only be achieved through extensive analytics and an employer’s willingness to begin to reward utility of better providers. While CMS has committed to pilot programs to begin to drive this migration to quality, the private sector has the ability to move more rapidly – but only if employers are willing to tolerate the disruption that this may visit on employees who prefer the status quo.

5. Rationed public reimbursement leads to cost shifting which undermines provider quality and accelerates lack of affordability in private healthcare.  Peanut butter spread reimbursement rewards mediocrity and creates the incentive to drive a higher volume of services to make up for rationed reimbursement.  As doctors and hospitals receive less from state and federal reimbursement, they will naturally attempt to shift these wholesale arrangements to retail commercial customers.  As medical trends spike in commercial health insurance, premiums become increasingly unaffordable with more employers choosing to drop coverage.  Private employers already pay an estimated $1.22 for every dollar of healthcare to compensate providers for public sector underreimbursement. The cycle eventually leads us to more employers dropping coverage and a larger and larger population of uninsured workers.  With 50M uninsured,  a call has rung across the land for public policy intervention to solve for the crisis of affordability and access.  Not unlike Dorothy in the Wizard of Oz, employers have always had the ability to reduce costs but have chosen to pass on cost increases and reduce benefits instead of tackling the more difficult and disruptive process of driving payment reforms and behavioral change.

It’s Now or Never– While CMS is attempting to change reimbursement methodologies to reward higher quality outcomes and to penalize poor management of services such as infection and readmission rates, the private sector still holds the trump card being able to drive more onerous consequences for poor medical delivery.  Determining medical necessity and driving reimbursement reform is tricky business and often disintegrates into political food fights as evidenced by contracting disputes that often arise between payers and providers.

When it comes to refusing to cover certain procedures or penalizing outlier behavior, commercial insurers find it increasingly more politically expedient to wait for CMS to change policy on Medicare reimbursement to provide air cover for their own policy changes. Historically, it has been in vogue for employers to blame insurers for certain reimbursement practices rather than take responsibility that payers are merely administering the employer’s plan document.  Employers need to own their medical spend and they need to reinforce with their employees the bi-lateral agreement that comes with financing care.  In the face of mounting pressure to reward engagement in the workplace, consumer advocates are now complaining that employers are becoming increasingly too prescriptive about population health management. Personally, I support the view of Steve Sperling of Hewitt who recently retorted to criticisms about employer driven health incentives, “House money, house rules.”

The healthcare system is changing as we debate the need for change.  The tectonic plates of hospital and provider delivery are shifting causing great upheaval and alterations in the strategies of large systems, community based hospitals and across a range of stakeholders.  According to a recent Credit Suisse report,  the US still ranks at 150% of the unit cost of services and a full 60% higher than other industrialized nations for overtreatment/consumption of services.  While we can boast higher cancer survival rates and a system of R&D that props up the innovation occurring across the globe, we are not getting enough value for our spend.  It is unsustainable. The Supreme Court now has the dubious honor of killing or upholding PPACA.  Irrespective of the outcome, private employers are our best chance to help fix the problem.

Given the nature of politics and the nature of human behavior in healthcare, it’s my belief that government can fix the cost problem rather quickly but would likely throw the babies of quality and public health improvement out with the notion of private reimbursement.  The private sector has the green light to drive market based reforms that can reduce pricing variability, reward quality and improve public health.  However, it’s a tall order at a time when companies are seeking to reduce administrative costs, are focused on the business of the their business and are lacking the will to burn social capital with workers by playing Big Brother when it comes to health improvement.

In one scenario, the government may want to reduce healthcare spending but really, at the end of the day, the Supreme Court is saying “you can’t. ” In the other case, employers have a golden opportunity to step up and start demanding value for their spend and force greater transparency and conformity around health improvement.  But up until now, they won’t.

Be Careful What You Wish For – Part II – Repealing Reform

The U.S. Supreme Court in 1925. Taft is seated...
The U.S. Supreme Court in 1925. Taft is seated in the bottom row, middle. (Photo credit: Wikipedia)

 

             As the Supreme Court considers the testimony presented at the recent hearings over the constitutionality of certain provisions of the Patient Protection and Accountable Care Act, the debate continues to escalate over the role that individuals, business and the government should play in the “commerce of health care.”

Most industry experts agree that PPACA is first about insurance reform and the expansion of coverage to some 30m Americans; yet,  detractors have criticized the legislation for failing to incorporate any elements that would serve as a catalyst for reducing costs, improving quality and restructuring a misaligned system that has been paid to treat illness rather than prevent it.

In the last two years, hundreds of millions of private and public dollars have been invested as stakeholders adjust to an uncertain but radically changing delivery system.  States are in various stages of constructing purchasing exchanges.  Physicians and specialists are choosing to consolidate, often with hospitals leading the process to create integrated delivery systems and restore the role of coordinated care through Patient Centered Medical Homes and Accountable Care Organizations.  Employers are waiting and watching — seeking greater regulatory clarity while slowly complying with a chronological time-line of new rules and expanded coverage requirements.

Municipal, state and national budget deficits continue to loom large. As Europe battles over mounting sovereign debt and the suffocating burden of  generous public pension and healthcare entitlements,  flash points are erupting across the USA as municipal, government and collectively bargained workers brace to defend retiree benefits in the face of legislative efforts to more aggressively reduce public spending. The Federal government is at a tipping point. Facing a $38T net present deficit in its funding for Medicare and $15T of public debt, PPACA was scored by the CBO as reducing $140B of public debt by 2020.  To achieve this, the government needed to drive $940B of taxes, assessments and spending cuts and fall within estimates of the number of newly insureds likely to qualify for Federal subsidies offered through public exchanges.  The promise of PPACA was to reduce the deficit, not further contribute to it.

With $3T of annual spending and an estimated $2T in tax revenues, Congress continues to renege on promises to reduce public spending.  It has committed to reducing Medicare reimbursements to hospitals and doctors but so far, seems to lack the will to enact the legislation passed as part of prior balanced budget amendments and PPACA.  Almost immediately following the passage of PPACA, an estimated $20B in annual cuts to Medicare was delayed by Congress.  The pressure to follow through with cuts was overridden by the Congressional fear that providers would begin to turn away from Medicare recipients – as they have for years with Medicaid members– citing that reimbursement is too inadequate to cover the true cost of services.  A prescription for remedying reimbursement inequities  known as “the Doc Fix” has been under consideration for some time but so far, the legislation has been continually kicked down the road and is now due to fall firmly in the lap of the next administration.   

Some economists estimate that the delay in implementing Medicare cuts along with other flaws in cost projections all but ensure that PPACA will increase the public debt, not reduce it – placing further pressure on Congress to either raise taxes or moderate spending to balance the budget. Yet, for all its flaws, PPACA is a necessary albeit wobbly baby step toward addressing the complex and broken public and private systems of healthcare in the US.

Advocates for repeal and replace legislation have grudgingly admitted to the need for health and insurance reform but so far have not offered viable solutions that could address the swelling ranks of the uninsured or solve for the inflationary effects of consumer demand and an aging, chronically ill America.   Universally, most pundits and experts feel PPACA was a single stitch attempt to suture a deeper and wider wound.  Most understood  that rising costs, increasing public debt and the potential dumping of insurance by low margin, low wage employers  would force companion legislation  that would pivot the focus of reform from “regulation and expansion of coverage” to “improving health care quality and affordability”.

With the potential for core elements of the bill (individual mandate, community rating and guarantee issue) to be declared unconstitutional, employers are left wondering if this development is a favorable or ill shift in the legislative winds. Ironically, repeal of reform may cause more problems.  Many feel that deconstruction of the law could create greater chaos across a 50 state insurance market where each legislature would be compelled to retreat from, maintain or advance insurance reforms.  This means trouble for America’s insurers who fought to help craft the elements of PPACA which effectively preserved the role of private payers to help drive reforms in the health care system. Minimum Loss Ratio limits and other regulatory controls were imposed with an understanding from payers that lower profit margins might be offset by a larger influx of newly insured Americans.  Without an insurance mandate, insurers would be less enthusiastic about guaranteeing coverage and engaging in less flexible pricing through community rated pools. 

However, insurers and employers are already wary of a state by state cat’s cradle of regulatory and coverage mandates that increase cost and in some cases, reduce competition through artificial price and profit controls.  In the event of a post reform collapse, employers will need to look even harder at the legislative efforts of states as they seek to mandate and managing health care.  Per capita costs to insure workers up to minimal levels of benefits could vary dramatically as states adopt myriad versions of mandated care and cost sharing.  Employers would most likely seek to avoid higher costs associated with mandates by self insuring and in doing so, deflect costly coverage increases as well as reduce revenues paid to the state by avoiding premium taxes.

The US is in between a rock and a hard place.  To repeal PPACA will mean restarting a legislative process at a time when Congress has failed to demonstrate any ability to collaborate to address complex issues that threaten our economic futures.  Most recognize that we must begin to address our public debt but it calls for austerity and measures that could slow our economic recovery and further enrage a public that is already distrusting of business and government. Managing the obligations and expectations of citizens around health care puts private sector management and elected public officials in unenviable positions. 

Both sides prefer to be seen as part of the solution, yet only one side relies on public opinion to keep their jobs.   The private sector has the capacity to move rapidly to drive market based reforms. Up to this point, employers have been slow to assume their role as a payer controlling over $1T in spend on the behalf of 180m Americans.  In many instances, employers abdicate the responsibility of tougher decisions around medical necessity and consumer engagement to insurers who up to this point, have benefited from rising costs.  While they have suffered public relation hits from the Obama administration as the goverment sought to vilify private payers, they have managed to retain their role as the primary service platform to administer and manage care.  The only real risk to insurers is disintermediation as a result of a single payer or repeal of reform resulting in radical regulatory models arising out of more activist states like New York and California.  Employers must understand who works for whom and demand information on claims, population risk profiles and solutions guranteed to drive single digit medical trends.  Until employers demand these solutions, the private sector will fail to punch its weight in the healthcare market.

It comes down to skill and will.  As a society, we seem to be lacking the will to deal with a generation of citizens whose desire for immediate access and rapid resolution are at odds with the fundamental changes required to fix the problem.  It is no longer a question of should employers seize the reins and drive market based reforms, but a question of do they have the will to take the lead.  The government has limited ability to impose all the elements of health care management required to drive affordability and guaranteed access for all.  To generate the necessary savings required to finance an expansion of coverage and guarantee basic essential benefits, we will need to pull every lever — consumer engagement, population health improvement,  the restoration of primary care based models, precertification, transparency to reward quality and marginalize outlier stakeholders and personal responsibility for health.  It will mean disruption.  However, as companies seek to grow earnings in a time of difficult organic growth, one has to consider what is more disruptive: firing employees or restructuring health plans to drive lower cost and a healthier workforce.

If reform is repealed or radically altered in June, it will not be business as usual.  The question will be whether business will revert to the usual behaviors or whether it will assert itself to reduce costs and in doing so, potentially save the best parts of our healthcare system.