 Welcome to a first Friday forum. My name is Lynn Podian and I am the facilitator for our group, the Business Advocacy, and I am the chairperson. I'd like to give you a few announcements so that you can finish eating. There will be no first Friday forum in July. That is our regular scheduled month off. We'll be back again in August with creative hiring practices. We'll be focusing with Dana Czekolinski from the CDC. In September, we'll have the DOT secretary, Mike Gottlieb here. In October, we'll do energy focus. And we're going to be actually not at the bull in October. So please don't come here. There's going to be a beautiful wedding getting set up. And we do not want to be a part of that. That would be very sad for the bride. She would not like to have another 50 people that she didn't expect. So we're going to actually be over at the Inn on Woodlake. We're very happy to get to try out that new facility. So keep that in mind at October. And then in June, we'd like to talk to you about our focal point that's coming up, June 18th. That's, oh gosh, that's in two weeks, isn't it? Two weeks? Yeah. It's going to be the secret habits of successful entrepreneurs. Jeff Leesmer? Lesmer? Good. I'm glad everybody else knows who I'm talking about. Mary Pitch, Jim Kregel, and Caitlin Brotz are going to be with us that day. So today, though, we're here to talk or to listen to Dr. Rye. And he is here with Prevea. In 2000, Dr. Rye started at St. Mary's Hospital Medical Center. And he developed the organization's first hospitalists services. So you're going to have to, my question to you today is going to be what is hospitalist in comparison to hospital? Okay, so I had to write it numerous times. I need to know this. And then St. Mary's Medical Director for Hospitalist Services and Physician Quality Director. Then he's been Prevea Health Senior Vice President and Chief Medical Officer. Today, he is the President and Chief Executive Officer of Prevea Health, where he's the leader of 1,200 staff members and 300 plus primary and specialist providers. He's also the happy father of four beautiful children, three boys, and a little girl. Welcome, Dr. Rye. Thank you. She just said to me that wasn't too painful, was it? All right, so I'll define a hospitalist for you. It's those board certified in internal medicine that spend their entire life taking care of sick individuals within the hospital and the intensive care unit. So it's kind of humorous that I now run a clinic but never worked in one. I've always worked inside the hospital walls, but many of my partners and I have done that. And we actually have a program here at St. Nicholas as well. Thank you all for having me today. When Betsy asked me to speak about trends in healthcare in 2014, I promised myself I wouldn't just make it about the ACA or the government, but I would give a brief update, but I really want to talk to everybody about what's going on in healthcare. Not only this year, but what we see as an organization and more importantly, what we see as a community coming in the next five years to the next decade regarding healthcare. And I tried to make this relate to us since you're all within business directly to those in business. Sorry, they got a mic in one hand, a remote in the other and notes in front of me, so I hope not to fumble this too much. So, you know, the three categories I wanted to talk about today and would love to have questions either during my talk or after. I'm fine with both. But one is to update everybody on payment reform. What's going on right now? Post-implementation of most of the Affordable Care Act. What I mean most is there are certain other things that are going to happen throughout the year, but most of it. And then a focus on health and wellness. What is going on in that category within the country and what do we see coming forward? And then a term that's more popular every day in healthcare, big data, and talk a little bit about what are we doing with all of that data. So, starting off with healthcare reform. I like this little graphic here, but it's unfortunately not a game to us anymore. It's real. And so now we can talk a little bit about healthcare reform and its specific effects on the state. You know, prior to this year, there were some conceptual things that were being rolled out, but obviously it wasn't real until people started going on the exchange. If we looked at our ACA enrollment within the state of Wisconsin this year, about 140,000 individuals purchased a plan on the exchange. And actually I got to correct my language on that. 140,000 people enrolled on that paid. We're still trying to figure that out. And a novel concept for those that have, and you got to understand most of these individuals, haven't had to purchase health insurance in the past. So they paid their first bill, not knowing that the amount they agreed to was monthly. So we're starting to run into, what do you mean I have a second bill? So we're running into how many people are actually enrolled versus paying their premiums. Looking at the breakdown, about 55% female, 45% male. Those needing a subsidy, about 91%. And those that could pay for it fully on their own, about 9%. For those of you that have not been on the exchange, the health plans are graded by a metal tier and then a catastrophic plan. Platinum being a very expensive one, even with a subsidy, hard to afford. It's only about 1% of what we saw in Wisconsin was platinum, about 6% gold. This is where you're going to see those individuals who didn't need a subsidy once again, kind of their price point wanting a larger plan. The majority of those receiving a subsidy were in the silver range. And then once again in the bronze range, those that either received a subsidy and couldn't afford the small amount of premium, or those that just wanted something out there from a coverage standpoint. So what's our age demographic in the state of Wisconsin? Those that have actually purchased health insurance this year off the exchange. You'll see the sweet spot for the state of Wisconsin actually was in the 55 to 64 range and 45 to 54. That's slightly above the national average. So we had an older population going to the exchange. Why does that matter? Really what makes the exchange work and what makes all of this purchasing work is you need a balance between those who are going to need health care and those who are not going to need health care. And logically as we get older we need more and more health care so you need a strong young base purchasing to make the overall finances work. And we didn't see that in the state of Wisconsin. And that is probably nationwide everybody's biggest concern right now is the affordability of the payment reform really depends on a bunch of young healthy people who don't ride motorcycles, drive the speed limit, never drink, have never looked at a cigarette in their life enrolling, which would be what, maybe about two people and spoiling in Brown County. Having grown up around here we all know. You know this year we also had a couple curve balls throwing at us and what I mean by we, I'm not only talking to you as a health care provider and somebody who runs a health care organization and an insurance company but I'm also talking as an employer. Actually we're up to 1600 employees now and 1700 by the end of this summer so this matters to us in a variety of ways. So when Washington decided at the last minute to you can keep your coverage we were caught in a trap. All the insurance companies were ready to implement something and then had to figure out how to rewind. It allowed people not to impact some of the ACA provisions onto those that are purchasing. Some were. It got very confusing for individuals. More importantly very confusing for those in small group and large groups. Do we change health plans now? What is going to be the effect on us? I know we have a couple insurance brokers in the room too but I could tell you everybody's heads were spinning right at the end there trying to figure out so what do we do with everybody? And it has been a confusing year from that perspective. So what are the things that are going to happen really as a result of ACA? This isn't meant to be an anti-affordable care act talk in any way. To be honest with you as a health care provider I can see positives and negatives coming from Washington through this. One of the biggest positives as a health care provider and somebody who cares about the health of the community is we've seen about a two to five time increase in the emphasis on wellness initiatives and incentives within companies. Something that as a health care provider we've been trying to drive for a long time with companies and many of you know that here in town but it's been very difficult to get traction. A little easier to get traction now as people are starting to understand the true cost of health care. We're starting to see increasing or considering increasing emphasis on high deductible health plans. It's interesting and Andy Bagnals in the room here from St. Nicholas, both Andy and I if we were to call up our controllers right now and ask them what's going on with bad debt, people not paying. A larger portion every year of our bad debt are people who actually have health insurance. In the past most of our bad debt were people who did not have health insurance could not afford it and we wrote it off. The majority of the biggest class of increasing bad debt almost 50% for us are those who have health insurance because they can't afford the high deductibles. And we're talking about deductibles not a 500 or a thousand. 2,500 and 5,000 is very common in Green Bay. 2,500 pretty common around here for a family and we're seeing more and more of that. And companies what are they thinking right now? In a recent survey about 69% thought they had an okay understanding of the ACA but not excellent and they need more education. I must tell you for somebody who practices medicine and once again in my role I need education every day. More importantly I'll spend next week in D.C. on the Hill and it's fun to ask them if they know what some of the rules are. They get to play a little game on the Hill. They don't score very well, I'd be very honest with you. If I asked any one of our elected officials to quote me some of the stats I was about to quote you or some of the information they wouldn't know it. So what else are we seeing? Statistically some of the research is showing us not many people. There was a big fear that people would start to lay off their employees because of the cost of health care. We have not seen that effect of ACA this year thankfully. What we have seen though about 16% of employers mainly what you look in the categories of the food industry and the service industry cut the hours of employees. This is that 28 hour rule or 32 hour rule basically trying to get them under full time and make them part time status so they don't have to get purchase them health insurance in the future. Some of the employers have done this for effect to make a political point and for some it's real but whatever the reason behind it we are seeing it happen at about 16% per the stats that we get. About two thirds of employers have actually analyzed the impact on them and the majority of employers see about three to four percent cost hit right now at least this year from the ACA. What are people doing out there when surveyed about this about 43% are increasing the premium costs or increasing in network deductibles or out of pocket limits. These are what we're seeing in plan design changes across the country right now both on the employer side and on the insurer side. You had fumble at some point. This is really important especially in Sheboygan County and Brown County the two major counties that per base located in that 94% of employers are saying that they will continue to provide health insurance and probably the biggest reason is and I know we have many of us work with manufacturing in this room is the shortage of skilled labor and it's still one of the biggest ways to attract and retain a labor force just by providing the benefit. So we're still seeing that for now and that may change. For those that are going to discontinue there's still two thirds are saying that I'll still give you some sort of subsidy but it'll have a cap. So this year it's 12,000 and it will never increase and that's all you'll get. The issues with subsidies is the taxation around them. There are some ways to not quote get around that but to have plan design so the subsidy is not taxed but in other cases employers are just saying here's an increase in your salary and it will be taxed. So today none of us are taxed. If those of us who have provider sponsored healthcare we don't pay taxes on that. You can imagine getting that subsidy you're only getting about a third to a half of your value right there. And really right now when we talk to employers and research this they think that the requirement is what's going to increase their cost. So the requirement that they have to offer to full time is an increased cost and that's their biggest fear right now. So what about some of the costs that are going to now be coming in 2014 and 2015? There is what's called the risk adjustment program. So beginning this year, so unfortunate trend in healthcare there will be a dollar per member per year that you sponsor for individuals and small group plans. So this is an increase in the premium of what people are paying and it's really, I don't want to call it a hidden tax but it's a fee meant to somewhat equalize that healthy to unhealthy amount that people are paying. So to put more in to take care of the sicker that are now joining. And then a traditional reinsurance program that's always been used to offset the cost of high cost individuals on the exchange. There'll be some benefits that'll go away. So for those who have health plans on the exchange this is our for lack of better words backup insurance to participate on the exchange. And as that subsidy goes away from the government that cost increase will go down to the consumer. So right now if you have a health insurance plan you may be getting a subsidy of $5. Next year if it's $3 that $2 will then be passed on to the consumer. So you will see a guaranteed increase in cost over the next few years driven by the legislation. And then there's this interesting, I've yet to see the research out of and we'll be curious to see what it shows. The patient centered outcomes research institute fee. I think there's one person in Washington that just comes up with names and abbreviations. So the PCORI, the PCORI is basically a dollar per month tax out there or fee. That money is going into research to see if what we're doing is actually the right thing to do or not. For lack of better words. To see what programs designs are actually going to work or not. So that's what PCORI is working on is researching some of the health and wellness initiatives and seeing if actually paying for health insurance gets us a healthier America, those types of things. So a little bit more on cost. So starting in 2014, a lot of interesting trends in 14. If you asked me to give this talk in 13, this would have been a much more boring talk Betsy. Actually it's probably boring right now because I don't know who's talking the numbers. But starting in 14 another fee is coming our way and this is actually a fee on health insurance carriers. Depending on the size of your book of business, this is how much the government needs to collect from you. What they're going to collect in fees is not tax deductible. So the unfortunate part is that whatever fee or whatever amount of premium they sell, they are going to have to increase that cost to make up to pay for this fee. So as you can see, the government expects about $14.3 billion from the health insurers throughout the country. Well, Wall Street expects the exact same margin out of those health insurers. So the only way to make them whole is to pass that cost on to the consumers and to the employers that are purchasing the health care. So you see an increasing guaranteed cost here that's essentially legislated over the next five years. All right, that's enough about the Affordable Care Act, at least the negative part of it. Now, like I mentioned, probably the best thing that came out of the Affordable Care Act, from my perspective, is an awareness in this country that we need to get healthier. The only way you make all those numbers really disappear is to have a healthier America. And how do you do that? You don't do that by providing health insurance. All you're doing by providing health insurance is a payment, but you haven't really taken care of the underlying fact of how we actually seek health care and what we're seeking health care for. Many Americans still, if we were to go around our companies today, wouldn't be able to identify a primary care physician or what they've done for their health and wellness. But they'll tell you who their doctor is when they get sick. And that's not the mentality we need. And the cool part about what happens out of ACA is we're starting to see employers engage us in the health care industry to make populations healthier. So first of all, what we're seeing now is participation in wellness programming that informs and educates. As an organization, we truly believe everything starts with education and really educating the workforce, those that are getting the insurance. So we've got lunch and learns, and more and more people are asking us to do on-site fitness and on-site nutrition counseling. Who here has vending machines in their organization or where they work? A few of you. How healthy are those vending machines? No. What was that? Believe it or not, companies now bring us in to give them healthy vending machines. And we actually have that in our own buildings now. And in the past, where companies refused to do that because they were worried about the HR office receiving complaints, now we're starting to see companies make bolder and bolder moves and allowing us to actually put healthy food and take the soda out of the vending machines. I hope nobody hears from Coke or Pepsi. I almost get myself in trouble. I have a good habit of doing that. The other thing is that we're starting to see companies now do something with their data, too. Many companies for many years offered health risk assessments to their employees. It's kind of humorous when I started going around and meeting with employers about six years ago. Every HR director would pull out a file and put on the table a stack of their health risk assessment results. But they couldn't actually tell me what actual activities they did to address the specific things they found outside of some did smoking cessation. Now we see more and more employers really engaging on doing something with that data. On-site fitness classes, medical programming, we call it a healthier U-program, but many other companies have different names for it where we find out 30 or 40 individuals in a company may have a risk factor for developing diabetes called the metabolic syndrome and specifically programming around that. So we're seeing companies really engaging around that these days. Obviously, smoking cessation, we're also seeing people actually bringing us in to help with sleep, a big component of staying healthy. And well-being, you know, managing chronic diseases in the workplace. It's such a nice captive audience there and you can educate them. You're paying for their health insurance as an employer and we're starting to see more and more engagement throughout the country on that. Definitely in our local areas. We're also seeing people doing more because the whole concept of addressing a pre-existing condition is gone. So one of the fears or barriers to actually even looking for what's wrong in a company is identifying some sort of pre-existing condition. There was a fear factor in America of even seeking healthcare. That's gone now. So we're seeing a lot more engagement in the long term because insurances can't hold that against you. So definitely seeing that and we're also seeing a lot more incentives with employers. They want to put skin in the game and we've been begging employers for a long time to help us with this, to put skin in the game. You're paying for their health insurance. Why don't you motivate people to get healthy but also reward them? We do it with lower premiums, monetary rewards, free offerings and I'll talk a little bit about the pebble in a little bit. You know, attend a class, pay less and it's really creating traction. Also fun things we're seeing, we're also seeing and I guess I'm on a podcast right now so I can say this. We're starting to see video podcasts being distributed in organizations so it's easier to get health and wellness education across. That's a much bigger trend for us in 2014 and we're starting to see those that are much more active about health coaching on site. That's a big deal. For the longest time people did their health risk assessments and then who here would get a phone call from somebody trying to coach them over the phone to get them healthier. We saw that that wasn't the best way to do things but live coaching, we've seen positive results and the research is showing us across the board that if you get a health coach in there you can make about 70% of the time we can make a change versus when there's not a health coach there. So that's what we're seeing in health and wellness around the country and obviously can answer a lot of questions about that. This is actually probably one of my most favorite topics and it's data because I'm a geek. I am. And we've been aggregating data now for over a decade. Our medical record is EPIC based in Verona, Wisconsin used across the country. More than half the country has their medical record on EPIC as far as citizens and now in Sherwood County both hospitals are on EPIC as well. So we're starting to see a coordination of care but the cool thing having made this decision back in 2002 is that we have ten years of ones and zeros and now we can actually do something with it. So we've partnered with a couple IT companies one is named up there really looking at all the data we have what are patients missing in their healthcare and I've worked with the company a lot to start making our data actionable because in the past it's ones and zeros locked away on a server to be honest with you if we did nothing with it we spent 50 million dollars on a really expensive version of Microsoft Word. We really needed to do something with the data that we were collecting. You can see here I've given John Doe screenshots for you today so this is all protected information but on any typical patient within our organization we can bring up a page like this up that has a chronic disease see what their current rates are so those are lab tests, LDLs for anybody who's ever had their cholesterol checked we can see where our goal is we can see where a patient's trends are obviously look at alerts and recommendations so in the past what reminded us what the patient was missing it really was our own head and going through a checklist now everything is automated so a physician doesn't always need to do this a staff member can pull up this page see what the patient is missing make sure all that is done before the patient even sees the physician so we're much more efficient using data we can look at the medications and we can also see last time we communicated with that patient and how we did it phone, email, in person because guess what? Healthcare is no longer going to be regulated to just the physician's office once again a couple other screenshots here of what we do every day with the patient management this is one person's work list within the organization for their physician pulling up all their patients what conditions they have who their insurance is why do we have the insurance settled out because we can pull up insurance and now by the end of the summer by employer so if company X asked us what are you doing for our diabetics today or what can we do for our diabetics today we can literally narrow that down this takes us about 90 seconds on a computer to do we also can benchmark our physicians against each other and this isn't to say you're bad and you're good but you've all heard the medical school jokes of how many pre-med students it takes one to play ball two, one to screw it in one to pull the ladder out from underneath them we're inherently a competitive breed and you start unblinding data within an organization and showing physicians where they're at they get really good about learning who's doing it great and then taking that into their own office and we've seen that across our organization so we give them these benchmarks and then they help us learn what are the best practices and then we spread them this is kind of a unique thing I can once again go on my laptop and do this where every doctor can see their patient population in a discreet way like this about where they're leading towards healthy or sick and if they hovered above any one of those dots the patient name shows up so who's my worst patient and literally can hover over that and usually they'll have their medical assistant call that patient right away and say you need to get in and once again care opportunities this is how we can literally send an automated campaign so this is new for 2014 we were one of the first companies in the United States to pilot this a lot of what you're seeing on the screen here was actually designed in Green Bay the company's based in Dallas but they embedded their employees up by us so we told them what we needed and they designed a product for us this is basically saying what if I wanted to take everybody on Humana and what are they missing and I really want to focus on blood pressure today and send out an automated campaign so in about two minutes they can get that and they can hit a button where they'd either each get a phone call or an email or some sort of reminder that we need to see them for this reason and the automated campaigns are going very well and engaging a patient population that maybe was, you know, not wanting to come see us so that's the data we have on the sick or that who need us to develop the health and wellness data this is a whole new area for us this summer to focus on is the health and wellness data so we've been telling employers please incentivize your employees to get involved please do this, please do that HR departments probably want to kill me because they have to manually try to figure out what their employees are doing record that and then send that to the insurance company about the premium or the HR department we're now partnering to automate all of that so you can see screenshots here this will be introduced it's actually coming to this market here this next month and it's actually being introduced at Prevea we actually have a full FTE and all she does is record 1600s employees wellness activities that FTE now she'll find a job, don't worry but we've automated everything for that person now so as different employees participate in different areas of their health and wellness they self report the company will then adjudicate that or make sure that actually happened and in some cases say it's an activity thing where they're wearing a pebble which is a tiny little pedometer all they have to do is walk by a computer they don't have to enter anything and it's automatically recording their activity and they're automatically getting the points for their benefits recorded this has made it much easier for HR departments to track how an employee would enter in but say an employer had 2000 employees and they would give a $50 discount to everybody that had an HRA we just take that HRA data feed it directly into here and the employer already knows who did it and who actually acted upon it and once again, examples of the scorecard and more importantly for the employer the sheets they get on everything their employees have done so no longer is it somebody in HR having to manually track this or have an Excel spreadsheet so what are the biggest trends we're seeing right now across the board really the healthcare company in the past as I've talked here we've really in the past focused on what can we do to you today how many of you here have seen a commercial about a robot or what we can do to your eyes or what we can do to your heart that really is what we were paid to do we were profits were driven by volume and illness, I mentioned I'm a hospitalist I actually went into administration not because I got sick of being a hospitalist I love it and I still practice is because I got to see every day the failures in medicine and to me a patient in the hospital is the failure of of what we could have done to prevent that so it gave me an opportunity in this role to do something about all the failures I saw so many of the patients I saw or so many of the patients I pronounced dead to be honest with you could have been prevented and done 10, 15, 20 years ahead of time and we had perverse incentives think about it we get paid the most the sicker you get you know, open heart surgery is great but guess what after open heart surgery if you're not breathing well and we have to put a tracheotomy in you we make an extra $10,000 that's how perverse medical incentives are and they need to change that's the reality of it and I'm here to say that's the reality so the healthcare system of the future so you had companies of the past and now it takes an entire system to care for a patient we got to focus on keeping the population healthy profits are driven in a risk or gain sharing model in other words if the physicians and the hospitals don't have risk or skin in the game they'll never change their incentives we did ours by having our own insurance company nothing riskier in the world than doing that let me tell you and then technology focus on keeping people healthy so the biggest advancements in technology when I was in training we're really around stents and what we can put in you and robots and what we can do to you and now the biggest technology trends we're seeing across the country are ways we can keep you healthy and we need to focus on that as well and maximizing access to information expertise without needing to come to the office and this is not something that doesn't exist this year this is actually something that does exist this year and that's the virtual visits and you'll see this coming out more and more we'll be rolling this out to all of our employer customers here this year where if we have an employer clinic within you and it's 10 o'clock at night and we're not open you can pick up your iPhone you can FaceTime, you can Skype it's all legal it'll actually be embedded in an electronic medical record and you can create and get care so Betsy said you wanted to see your doctor from your office you can now see your doctor from your office what does this do? we have a physician shortage throughout the United States in certain specialties psychiatric care is a great example of a shortage across the country well psychiatrists generally probably shouldn't be touching the patient and so they can do so much more on video so we'll have telepsych starting for us in September and then virtual urgent care visits hopefully before the end of 2014 so you'll see more and more of this happening with the physician shortage and a patient population that wants to interact with us this way I think it's more important that we're responding to the patients and the consumers needs now this is how they want to stay healthy we need to adapt so no more building big hospitals smaller clinics more efficient clinics we'll see starting in 2014 going on there's a time where I never thought I would buy into this now I think this is the way we need to go one of the biggest fears people have is we'll over prescribe and actually the data shows that the antibiotic prescription rate in a virtual visit is about a third than if you have to see the patient because you're not getting guilted by mom right in the room and we're seeing that across the country so this may actually be a better way to provide acute care as well and a great way to provide education we have about what's going on in 2014 for us in healthcare we'd be happy to answer questions or take comments so there'll be certain things such as narcotic prescription schedule 3, schedule 2 that'll be restricted from this the state of Wisconsin is a little bit more forward thinking in this category where we have the control substance agreement between pharmacies so we can actually find out who's doctor hopping I know if you've read some of the records that as well on the increasing use in heroin the starter drug for all that is narcotics and then when they can't get access to narcotics they go to a cheaper version which is heroin we actually are trying to lead the way in the prevention in this but Wisconsin actually has more fail safes in this and we won't be doing pain medication from this or scheduled substances actually would be the first clinic in the state of Wisconsin that we've been told they'll require mandatory drug testing for anybody on a chronic narcotic so if you want to refill you've got to get drug tested to prove that you're actually taking the drug well you would hope that integrated records were that good if you stay in a coordinated system yes but there are other medical records in the state of Wisconsin so you can hop and you know I worked ER to pay my way through to get my first down payment on my house in Green Bay so and I worked in a very small town ER and I've seen every excuse and every trick in the book and there's ways you know those who are seeking illicit drugs have a way to get way to get them yes for North East Wisconsin probably our biggest concern is an organization and what we're addressing is the area of pediatric obesity we actually have a medical home dedicated an entire project and a strategic plan initiative to combat pediatric obesity and we want to have a focus on this it makes sense like I said so much of what I saw in the hospital could have been prevented 20 and 30 years before so by the time I'm getting a 35 year old sometimes it's too late sometimes the damage has been done it was very very shocking when we pulled our data it was depressing you know we were scrolling through on the screen and I couldn't believe I was seeing 400 pound 12 year olds on the screen and so we definitely are focused on that the other trend we're seeing is there's an interesting form of non-compliance and non-compliance to me is not just not seeing or not taking your medication or listening to your doctor but many people with chronic disease aren't having scheduled visits they're not interacting with the health care team whether it be a physician or somebody else in a regular manner and that's why we redesigned our care around chronic disease we have this thing, our statement is that the visit never ends so depending on the severity of your disease depends on how often we're going to touch you whether it be a physician or a nurse call or an automated call all of that is actually tiered depending on the severity of your illness now it would seem to me that we're going to have to have a really cataclysmic need shift with what gets advertised if you watch weekend sports it's beer sort of things like that if you watch the evening news it's one medication after another and I think that's the way most people pick up their news pick up their information so to me it seems like there's going to have to be a really big change in how people get information how even pushing it down to the younger ages to understand the long-term benefits for deficiencies of how we live the hard part there is that there's so much money and you have to have guts for those of you who saw our game changer program we took six individuals, three from Sheboyne County three from Brown County and focused on making them healthier so think about spending seven figures as an organization to make sure you don't make any money you think about that entire marketing campaign focused on us not making any money because remember our perverse incentives how we get paid you have to go out there and put your neck on the line to change it now we make enough money that we can do that but if we don't start focusing on the health and wellness of the community I'm not going to have anybody left to work for us I mean it's that bad but the only way you can combat that you can't sit here and regulate and legislate against somebody's voice we're proud that you can't do that in this country but then you have to have bold enough voices to market over that yes Is it the goal to try and get everybody to this? No, into the green quadrant there there's different quadrants depending on the disease process I mean you can actually change your X and Y axis on that in that slide we want to get to a better quadrant there Yes, in the back Well this tax credit for businesses had been taken in 2015 and it helps to cover the cost of starting wellness programs here in the state of Wisconsin and it's for smaller employers and 50 and fewer and we are extremely grateful to Madison for that we fought a lot for that we're kind of hoping it would be more than 50 employees but we understand that but it's fantastic we have for example I can give you a company that we work with every week on on-site fitness that has less than 50 FTEs at that site and they've had us on-site now for five years and that's Suji's chocolate I guess they had a thing about eating their product but think about a chocolate company taking the leadership and investing money on on-site fitness they did it on their own pockets but now thanks to Madison and a really very important piece of legislation probably one of the most important from a healthcare provider standpoint it was the first healthcare piece of legislation it wasn't sick care it was a healthcare piece of legislation that was put forward we wish it would go national and hopefully we can send an example by showing some data trends those of us that are involved in that we want to track the health now that the employers are going to take advantage of that tax credit track the health of those employees and that's a prominent piece of legislation so thanks for mentioning that your program I'll share that as we look at tax credits because we oftentimes create tax credits and then there's very little use of them and it costs us a lot of money actually as a city to have these programs out there so if your business is interested please participate and that will help to grow the support of the program our two health and wellness sales people are sitting there and they'll be reminding every single employer 15 under the reason is a three-year pilot because I would agree with Madison make sure it works before you pay for it forever so our point is that we're going to track that data to prove that it works Andy you want to plug yours for me Andy and I are good friends and we are colleagues we're partners as most of you know Preveza 5050 company and really if you look at all of the trends acute care hospitals aren't going to become the center of healthcare anymore they just aren't but they are extreme on society and they're major employers so there's always this balancing act you don't want the hospitals to go away because they're usually the largest employer in town but at the same time it's where we're spending all our money that we don't need to we're trying to find unique ways of redesigning hospitals so they're really there to be large intensive care units for the really really sick and those that are giving birth and those for emerging care and more ambulatory solutions more clinic based solutions for the rest you're now seeing who here's known somebody who's had a hip replacement you know hip replacements you should spend 3.4 days, 3.2 days in a hospital by statistics and then go off to a rehab facility you're starting to see many surgeons now and there's two in northeast wisconsin one is ours that are piloting same day to rehab right out of surgery so there yeah it's two days now for most of ours at St. Nick's and at St. Mary's and St. Vincent's where we do the most of our hips but one of our guys is piloting right to rehab now it takes the right patient for that the right elective patient but we're starting to see us getting bolder and bolder about what needs to be out of the hospital you know what and the early results are showing those people are doing better because guess what's at a hospital usually you're getting hip replacement you just got pain, you're not sick you don't want to be around sick people actually we're starting to see more and more thinking around that and actually St. Nicholas has done those investments in an ambulatory surgical center moving things into more of an ambulatory environment I'd say between Andy and I there's a lot more growth going on the outpatient side than there is an inpatient side almost 2-1 right now our business now and that's a big shift now the hard thing is with all of us moving to an ambulatory environment how are you going to continue to pay for those really big buildings in the infrastructure that's going to be a challenge for some systems that have built a lot and that's cross country and we're seeing that that's why we're seeing a lot of consolidation in healthcare some of that's needed some of that I think we've got to wait 5 years for what's going to happen with the electronic medical data is that information now accessible to the patient? yes that's a great question I love that question actually if I can pull my iPhone out for you right now I can pull out my own medical record for you we have our app the MyPervaya app and you can make an appointment you can do your refills you can check your blood pressure and more importantly if you're in a car accident in some place and the person that's with you says they're from Green Bay we can now look at epic records across the country and pull what we need to to take care of you that day and we're already doing that we do it every day if a patient from St. Nick's gets transferred to us it's actually the same record so say somebody comes in with chest pain needs open heart surgery emergently gets transferred there before the patient even arrives we have it within probably less than 10 clicks have access for example we are the actually I can officially announce this we're the healthcare provider for the 2015 PGA so we'll have tens of thousands of people from around the country but we'll have Epic on site in case they happen to have a medical record there we can pull it up so it's providing better care well thank you everybody for having me thank you for these lunches and happy to stick around for any other questions we'd like to thank you because this has been a very inspirational conversation and we appreciate you coming so thank you so much ladies and gentlemen once again don't forget next week is the focal point on June 18th we have flyers at the door that John will be making sure you take home with you give them to your friends, your neighbors, your family just kidding also we still would like to have some of you for the business advocacy team so our meeting is next Friday morning at the chamber we started 7.30 and you're all invited to come and see what that is like to be a part of the group that actually develops these meetings and puts this out for you so thank you all for coming and I hope you have a lovely afternoon and a beautiful weekend