Your life is going to change, thanks to a law passed in 2010.
The Affordable Care Act, better known as Obamacare, has president and chief executive officer of the New Jersey Health Care Quality Institute David Knowlton thinking in historic terms.
“This is a huge sea change. We are tinkering with something that is almost 18 percent of our gross domestic product,” he says.
On the threshold of something so new, which took Congress thousands of pages to delineate legally, nobody understands exactly what is going to happen, Knowlton says, adding that the only similarly large public endeavors of the recent past were the adoption of Medicare and Medicaid.
But at the moment, rather than being so concerned with the big picture, individuals and businesses need answers to some simpler questions.
If you are an individual, what happens when someone you love gets sick? What does Obamacare mean in your life?
If you are an employer, what is your obligation to the people who are working for you? Most employers want to do the right thing, but what does the reform require them to do and what are their options? How much leeway do they have, with healthcare increasingly expensive? Should small employers drop some coverage for spouses, as the United Parcel Service has done?
The upcoming Innovations in Healthcare Conference will cover the overall evolution of healthcare innovations, including the Affordable Care Act, how employers can keep a healthier workforce through wellness programs, and other new innovations in healthcare delivery systems. The conference, organized by the MIDJersey Chamber of Commerce, takes place Tuesday, September 10, from 8 a.m. to 3:30 p.m., at the Hyatt Regency Hotel in New Brunswick.
Douglas Forrester, the keynote speaker (see sidebar, page 34), will talk about “The New Era of Health Care.” Knowlton will chair a panel on “Exploring Alternative Healthcare Options.” Steve Peskin of Horizon Blue Cross Blue Shield of New Jersey, will moderate a panel on “Innovative Trends in Healthcare Delivery.” After lunch Sherise D. Ritter and Eric M. Whelan, both of the Mercadien Group accounting firm, will present the Affordable Care Act Case Study Review. Cost: $139. For more information, call 609-689-9960 or E-mail firstname.lastname@example.org.
Another program on the health care act will be offered by the Princeton Regional Chamber of Commerce on Tuesday, September 24, from 7:30 a.m. to 12:30 p.m. at Mercer County Community College’s Conference Center. Cost: $60 for members, $75 for non-members. For information and registration visit www.princetonchamber.org or call 609-924-1776.
Two keynote speakers, Al Titone of the U.S. Small Business Administration and Dennis Gonzalez of the U.S. Department of Health & Human Services, will address the implementation of the Affordable Care Act. Panel discussions will follow on the payer and carrier marketplace and wellness and community health.
The Princeton Chamber event concludes with a CEO roundtable to discuss their healthcare visions for the future. Participants will include Skip Cimino of Robert Wood Johnson Hospital Hamilton, Darlene Hanley of St. Lawrence Rehabilitation Center, Jerry Jablonowski of St. Francis Medical Center, Al Maghazehe of Capital Health, and Barry Rabner of Princeton HealthCare System.
The ACA is meant to make healthcare cheaper and better for everyone and to give more people access to health insurance. The sweeping legislation forces health insurance providers to cover everyone at the same rate, regardless of pre-existing conditions or sex, among many other new regulations and mandates for insurance companies. (See chart on page 35.)
Knowlton is positive about healthcare reform. “We are the only civilized nation in the world that does not provide healthcare as a right; and even though we don’t do that, our healthcare costs are some of the highest and our quality is nowhere near the top,” he says.
So we have to fix what exists, Knowlton says. Will there be discomfort? Certainl`y. “People will not know what to do,” he says, as patients run around trying to figure out how to get what they need and employers consider whether to drop some coverage and what kinds of penalties might ensue.
An important goal of the Affordable Care Act and other reform efforts is to improve the quality of healthcare, and Knowlton suggests that access is a critical factor. “Nothing predicts quality more than access to healthcare,” he says.
Before the ACA was passed, Knowlton’s institute was working with New Jersey State Senator Joe Vitale to pass a similar type of reform, but one focused specifically on children. They stopped short and decided to wait for the federal reform.
With this momentous reform in place, Knowlton says he wishes the country could get out of the political debate, where Republicans hate it, and Democrats love it.
“The truth is somewhere in between: it deserves to happen but to say it will happen without stress and problems is somewhat naive,” he says.
Knowlton observes that one big problem with the implementation of the Affordable Care Act is the amount of misinformation out there. Knowlton recently spoke with a man from Rhode Island who was concerned that his cost burden could increase to anywhere between $10,000 and $75,000. “He was wrong,” Knowlton says, “because the person who told him was wrong.”
Knowlton says he does not believe there will be a significant increase in costs for employers. “The likelihood that you are going to pay much more is almost minuscule; double and triple is not going to happen,” he says.
But, for argument’s sake, he says, suppose that under the Affordable Care Act costs did go way up. “Everybody would adjust,” he says. “They would do another strategy that would give them an alternative. And there are a lot of alternatives within this reform to bend the cost curve and save money, and businesses have to pay attention.”
Some of these strategies include:
Adjustments to insurance plans that reduce costs, for example, high-deductible plans, self-funding, and multiple employer welfare arrangements.
Local clinics. One option is to give people access to a clinic, either on the premises of a business or nearby; waive copays; and provide healthcare there, as Forrester does at Integrity Health. “Because you control the front end, you can drive costs down, because you are not going from doctor to doctor on the outside,” Knowlton says.
Walmart, CVS, and Rite Aid have latched on to the idea of clinics in their stores because of a new and burgeoning target market — senior citizens. Knowlton notes that 10,000 people a day are turning 65 in America.
Emergency response systems. These systems include ambulances with an x-ray and laboratory on board, with the goal of avoiding emergency rooms; these enable a patient to go directly to the hospital or just go home. Suppose one of these sat outside a high school football game rather than a regular ambulance. Say the quarterback fell and his ankle was swelling. If the ambulance were equipped with an x-ray machine, a fracture could be ruled out, the ankle taped up and iced, and he could watch his teammates finish the game. And the savings might be as much as $2,000, Knowlton says.
More engaged consumers. Knowlton’s institute has been the regional roll-out organization for the Leapfrog Patient Safety Initiative, which among other things has assigned safety scores to hospitals in an effort to prevent the thousands of deaths each year from preventable medical errors.
The idea for Leapfrog grew out of the assignment of sanitation scores to restaurants in Manhattan. “When it started, people said, ‘How awful!’ and now two-thirds of New Yorkers check the sanitation score before they make reservations,” Knowlton says. “Also there are not any C or D restaurants anymore — either they went out of business or improved their scores.”
Grading hospitals is similarly making the care patients are likely to receive more transparent. “We are publicly reporting on the health of hospitals,” Knowlton says. “People will think, ‘Maybe I don’t want to go to that hospital because the hospital is not safe.’” If the lack of safety is because everybody is not washing their hands consistently, for example, the hospital will have to change its practices to improve its score. This reporting, then, is driving hospitals to change their pattern of care, Knowlton says.
Increased videoconferencing. Since cardiac information is largely electronic, Knowlton says, “Do I really need a cardiologist sitting next to me to deliver care or can I have one at the Cleveland Clinic or Mayo Clinic?”
Specialists integrating primary care or offering full care. For people over 65, most of their care comes from cardiologists, endocrinologists, oncologists, and rheumatologists. The result is that much of their primary care is coming from these providers even though primary care is not their specialty. As a result, more specialists are starting to integrate primary care into their model.
Nurse practitioners For younger healthier people, nurse practitioners may take over primary care, while physicians may work with older people who need higher-end primary care.
Knowlton grew up in Lynn, Massachusetts, where his father was a salesman and his mother a housewife. Knowlton earned a bachelor’s degree in psychology at the University of Massachusetts in Amherst and got a master’s degree in educational psychology from Trinity College in Hartford and did his student internship at Massachusetts General Hospital.
When Knowlton was assistant director of housing at Ithaca College, a student committed suicide, and he subsequently got involved in setting up crisis centers in colleges to handle suicide prevention.
As a volunteer firefighter, he got involved in emergency management services and worked on ambulances, where he saw healthcare firsthand. He also worked for the U.S. Fire Administration training policemen and firefighters to deal with crises. “They confront crises on every call, but were not trained in it,” Knowlton says.
Then Knowlton moved to New Jersey to head the Optometric Association. Next he started his own consulting company, and one of his customers was the brand new commissioner of health, Molly Coye, who hired Knowlton as her deputy. “I administered early reform under the diagnostic related groups system in New Jersey,” he says. “We set rates for all of the hospitals in the states; during the Florio years, it was deregulated.”
After he left the state, he set up the Health Care Payers Coalition of New Jersey and became its executive director. The goal was to help unions, labor funds, and businesses purchase quality healthcare for their beneficiaries. In 1992 this group published the first public hospital data in New Jersey, noting which hospitals were good and which were poor.
The New Jersey Health Care Quality Institute (www.njhcqi.org) was initially a committee of the payers coalition, and after the Institute of Medicine did a study reporting that 98,000 people die each year in hospitals because of preventable medical errors, the institute was spun off and the Leapfrog Group founded.
The motivating factor behind healthcare reform is escalating costs. But although change is happening fast and is a little scary, he suggests that we look at what happened when the state of Massachusetts enacted a similar healthcare reform under Governor Mitt Romney. “Everyone screamed, ‘The sky is falling,’ and it was uncomfortable for 18 months,” he says. “But now almost everybody is covered and almost everybody loves it.”
“But it has to happen — the fact that we turn people away who are sick is immoral.”