 Welcome to Pine Hills, great view. It's almost nice enough to go. There are golfers there. Welcome to our first, first Friday forum of 2012. And I'm Dave Gapp, I'm the chair of the business advocacy committee, which organizes these first Friday forums. So we've got a very good program to start out our year. And I will introduce the panelists real shortly, but I do have some announcements to make. At your table, there should be two sheets. One is titled, Focal Point 2012. And one that's entitled, Shibuya County Chamber January Event Calendar. I'm not going to go over all those items, but I would just draw your attention to those items as to upcoming programs and events sponsored by the chamber. There are a number of very good events on there, and we encourage you to participate in as many of them as you are able to. A couple of other announcements on January 5th through 12th. Congressman Petri is going to be holding a series of town meetings throughout 12 locations in the 6th district. So in Sheboygan, the location is at the Mead Public Library from 2 to 3 on January 9th. The other locations are in Watertown, Waffan, and Berlin. So if you're interested in those locations, see the actual group. And the other announcement I'd like to make is the work that's going to be done in I-43 this summer. I know last year they caught a lot of people by surprise, especially the merchants. And the DOT is trying to do a better job of communicating that. And they are going to have a public meeting for the work that's going to be done on I-43 in Sheboygan County on Wednesday, January 11th at 5 p.m. at the Quarry View Center, which is on business 42-kilometer drive on the north side of town. So if any of you are interested in what the work is going to be and how it's going to affect you, go to that public hearing on January 11th at Quarry View Center. Then for our First Friday forums, as you all know, today's First Friday forum is a spotlight on health care in Sheboygan County with specific reactions as to how local providers, employers are going to be dealing or trying to deal with the federal health care legislation. Coming up in February, we had hoped to have someone from the US Chamber of Commerce speak. We weren't able to get them here in February on our First Friday forum date. It looks like we're going to do that in May. So in February, we're going to have Todd Berry come from the Wisconsin Tax Pairs Alliance. And if you've ever been to his performance or his presentation in the past, that's probably the care crisis. It's always very informative and he really is fairly straightforward in telling you the way he sees it in behalf of the Wisconsin Tax Pairs Alliance. And I'm sure he's going to have a lot of interesting comments on what's happening in Madison from their viewpoint representing taxpayers. So that'll be a good presentation. Then in March, we will have our legislators do their quarterly legislative update. And again, I think there's probably going to have a couple of things to say at that time. We'll be in the thick of all this election business. So that I'm sure will be a very exciting presentation. Then in May, excuse me, April, we're going to have a spotlight on economic development in Sheboyin County. And we haven't put all the cast together yet, but that's the topic. And so we'll give you more details at the February 1st Friday forum. And then in May, our intent is to have, again, the U.S. Chamber of Commerce come here and talk about really what is happening on a national scene from the Chamber of Commerce or Commerce's perspective. And then in June, we have the legislators back for their quarterly. And that takes us through six months of the year, which is far as we've gotten so far. I believe that's it. Anybody have any other announcements that we've missed? John? Okay, again, before I introduce our panelists, all of you have a postcard at your table. If you have a question that you'd like to see whether the panelists might be able to answer dealing with how as an employer you're dealing with health care and Kenzie with health care changes, write your question on that postcard. And then John is going to pick up those postcards and then he's going to bring them back to our table and we'll look through them and see whether we can get any of them up to just do our questioner for the question and answer session. With that, let's get the program rolling. Again, our program today is really on sort of health care locally, how our local providers and employers dealing with the many health care changes that are taking place, most particularly the federal legislation. So I'd like to maybe call up as I announce her name. And we have four panelists. First is Andy Bagnum and Andy is President and Chief Executive Officer at St. Nicholas Hospital. Second, Dave Gravener and Dave is Chief Administrative Officer at Aurora Sheboygan Memorial Medical Center. Next, Julie Hirschlepp and Julie is resources director at Johnsonville Sausage. And last but not least is Dr. Aschuk Rai of Prevea and Dr. Rai is President and Chief Executive Officer of Prevea Health, which is an Ashwabana-based organization with more than 200 health care providers. And Prevea is also a sponsor of our First Friday forums in O-12 as they were in O-11. We're changing things up a little bit this year. We're gonna have a formal question-questioner-answer-e format and performing the Anderson Cooper duties for the questioning side of things is our own committee member, Charles Windsor. Well, welcome everybody. It's a very big topic when we talk about health care in the United States. And rather complicated, we have a handout at your table of the flowchart about the new healthcare regulation system that's gonna be as modified by the Health Care Act. There's an extra copy if you don't have enough for your table, there's more on the table as you exit. And also the Chamber of Commerce has an electronic version which you can call them or email them and ask for. What's nice about that is you can magnify it on your computer and read the citations about what section of the act is calling for the new or altered department. So we're not getting into this. That's more than we wanna handle. What we're mainly concerned about as employers in Sheboygan County is are our people, our employees, gonna still have access, high quality, quick access to health care? What's it gonna cost? And how can our panelists help us make LINE's decision as business leaders? So as you think of your question with them now, please try to keep it to that and not the political side which is way beyond our scope today. Thank you panelists for agreeing to join us. I appreciate that. And for our opening question, I'd like to direct it toward the hospital administrators. And that would be, what are St. Nicholas Hospital and Aurora Memorial Sheboygan hospitals doing respectively to prepare for the health care legislation? It's an open-ended question, but please respond to it relatively short. I know you could go on for a good half hour each. We talked about that earlier. Thank you. This is a very complicated topic. There will be a quiz on the handout afterwards, so. Our TV folks are, you can stand when you talk. There are several things on the proposed reform bill that are still in question. Actually, many of them still in question. For just to tee up the conversation, I thought it would be important to at least give you an idea of why health care reform and what was the intention of even drawing the attention to the health care reform bill. And within the bill, there's over 2,000 pages of legislation, proposal legislation that still is yet to be opened. So with this today, there's still a lot of unknown. So I would throw a caveat into that. But there are several just highlights in terms of what the legislation, what the intent was or at least what was the proposed intent. One was increasing and uninsured population in the United States. So that was one area that needed to be addressed or proposed to be addressed. Insurance market risk select, inefficient financing and delivery systems and uneven burdens and accountability. So the payment system is flawed in terms of how healthcare providers and hospitals are paid today. And it's not really a level of playing field in all cases, depending on quality and cost and the region of the country that you live. So with that background, what is St. Nicholas Hospital doing to prepare for healthcare reform? A lot actually. And I would say more than just preparing for healthcare reform as it is, as much as doing what's really necessary to provide high quality, low cost healthcare for our community, really high value. So with that, what are the specific things? And with this proposed legislation and with that high value is really moving from a system that's been driven on volume-based. So the more volume of patients that you see each and every day to more of a value-based purchasing. So number one, we're in the process of adopting an electronic medical record at St. Nicholas Hospital. That process is gonna be complete on the hospital side January 29th. With that, there's a lot of improved quality, cost, efficiencies that come with that. Reduction of errors, patient safety. With that, we have our physician partners are also going live with Epic at the same time and or even prior. So our entire system of care here in Sheboygan will be on Epic, an electronic platform. Partnerships and alignments, development of partnerships and relationships with employers and providers within our region and our community, but also more importantly, the partnership and relationship we have to our healthcare system in Springfield, Illinois. We are part of Hospital Sisters Health System, which is a network of hospitals across Illinois and Wisconsin for those of you that aren't aware of that. With that is really important to know that with any healthcare system, you have a common purpose, a common vision, common mission, common values, but more importantly, you have a common strategy in how you're going to approach the care of your patients, benchmarking across the system, sharing best practices across the system. How do we spread costs across the system? As many of you may be aware, we're part of the Eastern Wisconsin Division. We have three hospitals across this division within HSHS, St. Mary's Green Bay, St. Vincent Green Bay, and St. Nicholas Hospital here in Sheboygan. And with that, we've been sharing a lot of resources amongst those to increase efficiency and decrease cost across that continuum. More importantly, partnerships through clinical integration with our providers at St. Nicholas Hospital, but more just the partnership and relationship, but partnership in improving quality, efficiency, and a greater coordinated level of care for our patients across the continuum of care. Our relationships with regional providers, there's new relationships developing across this region and within Wisconsin as many of you probably already seen. So a collaborative care model with some of the providers in the area. And then finally, within relationships, partnerships with the community and the employers to help the healthcare costs and try to figure out how do we work together to better reduce costs but also provide high quality care for your employees. Now, what specifically are you doing to pull out the cost at St. Nicholas Hospital? That's I'm sure a lot of you are already asking because that was also part of the healthcare reform bill was it was found that there was a lot of waste in the system and inefficiencies from an operational perspective that could be improved in the healthcare delivery system. We have implemented the lean technology or lean tools at St. Nicholas Hospital in the last couple of years. Many of you are probably aware of lean in many of your businesses, but I will be honest with you, healthcare was a late adopter to those kinds of tools and resources. We've been doing this now for a couple of years. And the goal with that is not only drive out waste but what we're finding is it improving quality, it's improving patient experience and it is reducing our cost of care. And I mentioned before, improvement in spreading cost across our system. Many hospitals across the country may have duplicative systems in their process and or in their departments that they run in their everyday workplace for example at St. Nicholas Hospital we had duplicative efforts being made at St. Nicholas as compared to our other partner hospitals, system hospitals in Green Bay. How can we more effectively lead the three hospitals in our region and spread those costs across again as I mentioned before. And then improving safety, quality and patient experience. We are moving into actually we're already into a more transparent environment in healthcare. There's quality information that's getting posted now on the internet that you can go online and actually see certain quality parameters. There's patient satisfaction information now that's on online. You can go look at and compare different hospitals across the country and where our hospitals are at St. Nicholas and Aurora respectively. And so that this transparency is really driving a rapid improvement and focus in these areas and not to say that that wasn't the right thing to do already but there's an extreme focus on that. I wouldn't even say extreme, appropriate focus. What are our goals at St. Nicholas Hospital? I think it's important with this change what might be different and what are you trying to accomplish? We want to be a highly reliable organization. We want to provide exceptional safety, a great patient experience and quality in our clinical care model that's supported by advanced clinical integration and clinical information systems. We want to provide high value. We want to be in the top desal of performance across our country. That's what we're striving to be. Relationships and collaborations with providers and businesses provide spiritually holistic care that touches on all faith traditions. It's how we were founded on over 120 years ago. And with that, St. Nicholas Hospital has been in this community for over 120 years. We have a very strong commitment to continue that in providing that level of care, high quality care, high patient service, but also partner and have those conversations about what can we do together to reduce cost? What can we do together to improve quality and experience for the patients that we serve? We strive to improve that each and every day for the employers, your employees, and the community that we serve. And we continue to do that, and that is our goal. Thank you, Randy. Well, if I don't read folks, is you writing the questions? I think a most efficient way to get them to us is pass them from person to person down to this corner and then we can have Dave go through them and help organize it. I don't know that I've ever been in this room without a glass of wine. So, I'm gonna take the solitude of the golf course out there. I think, as Andy kind of described, we've seen a lot of change in healthcare. I think that 30%, 35% of our patients are paid by the government with Medicare. So that's certainly a big change, but I think we've certainly been focused on for businesses to be effective, you need to have employees that are healthy, you need to have employees that we're not spending your dollar as you're trying to be competitive elsewhere in the nation. So I think both organizations, that's certainly been a focus, is that we have a certain responsibility around managing healthcare costs going forward, even though maybe not some of our incentives today economically are always based on that. So there's been a lot of change and I think a lot of work over the last several years. And I think as a new member in our community here, we have great healthcare in our community, St. Nicholas and Aurora in how we compare elsewhere. So I think we're starting from a good place where that may not be true other parts of the nation. I think the changes that we've been focused really are around how are we integrating services and some of the pieces that Andy talked about is what kind of work have we made? And so how do we better align our physicians and our clinics with the hospital's core to who we are? We've gone through really an assessment about what are the core services that we believe we're good at and also made some decisions about what things we're not good at and making sure that we're kind of moving to a long-term strategy. So we can't be everything to everybody, but we want to be good in the things that we're focused on. We've done a lot of the operational improvement already, although we have a lot to do. So like Andy talked about, we brought in Lean several years ago. We benchmark nationally to how our operations are, what our costs of care are, and have plans and execution associated with those plans like any business that's going through change. So we're positioned quite well around that moving forward. We also have focused on our programs and what things do we do to support the community and what things do we think our core to our function with the community and then how over time do we make sure we're not duplicating services that aren't sustainable in the community. And so I think that's something we're always asking our question around is how do we do that to make sure we're providing the best care? And then as Andy talked about is the IS system. Banking went through this a number of years ago, but tying our revenue side and our expense side and the clinical component into one system, again, we're making investment as well for that moving forward. So that's going to be a critical part of our infrastructure. The other area that is a challenge and it's a little easier with Andy and I being new, both new to our role is where do we compete and where do we partner? And so I think our organization certainly sees need to meet the needs of the community. We want to provide that service locally and but there may be places that make sense for us that not compete around to do things together. And that's not just St. Nicholas and Aurora. It may be other nonprofits or other services in the community. That's a different approach I think than historically Aurora has taken. So that's a new kind of new direction for us that we think is really critical as we move forward in preparing for healthcare reform. I think, as Andy talked about, our big change from the delivery side in healthcare is Medicare is going to be changing over the next several years in that there's 9% of how they pay us today that's going to be at risk based on our performance. So how we're measured around our mortality in our hospital, how we're measured around how well we're working with nursing homes around avoiding readmissions. All of those things today we're getting paid for without any kind of ownership around those issues. We're in the future, there's about 10 different areas that they're going to be measuring our performance on that will reduce overall cost and improve quality of care. And so we've been very focused on how are we working with our clinic partners and our physicians in development of programs to do that. And then I think the bad debt and charity care and the component of, we're here to serve patients. And so how are we preparing for some of those changes? We've, because of our economics in our community, we've had to make some changes in how we're dealing with bad debt. We've doubled our bad debt at Aurora, Shaborg, and Memorial. I imagine it's similar at St. Nicholas. And so how do we make sure we provide services that allow access for patients, not the emergency room, but care? And so our partnership with around the community clinic, all those kind of things are ways in which we're trying to really support the community given some of the economics that are outside of our control. And then I think lastly is really the focus around how do we move from illness to wellness? And when we're paid as, we're paid on wellness or we're paid on illness and, but, you know, I think for us to manage costs going forward, it's really about how are we involved in education? You know, we've increased our community education budget by a 30% this last year. And that's going to continue because it's going to be important part of what we have to do to support, you know, healthcare in our community. So, and then I think the, you know, the other side to that is we have a, you know, within Aurora, we have 30,000 employees ourselves. And so we see the cost of healthcare and the impact. So we're using our own employee base to help design and develop services that are going to reduce overall costs. And we hope then that learning and experience can be translated in how we work with employers as well. We have a nice question here that follows up on one of your points. And that is, is it rather duplicative to have two hospitals in Sheboygan and it could cause me to reduce if you kind of combine the actually physical facilities as well as just sharing some of the services that are offered. Hi. I think it's a really good question. I'm part of the Early Bird Rotary and they ask really good questions. So I know they had to come from the Early Bird Rotary. I said I'd work that in there, didn't I? Now I forgot the question. So what if I had to not share the service? You know, I think, and Annie and I've talked about this so he can say what he was feeling. You know, it's Yang. You know, I go out and meet a lot of business leaders probably met with you and the community here. And they like that there's competition because it keeps us honest, right? Make sure that we're providing service and our prices, our costs are down. I think the other side to that is that there's capital. We're very capital intensive, you know, technology driven service. And so there may be times that, so that doesn't make sense for us to be in competition. And I think that's part of what you can expect from, you know, at least from me, is that we need to look at those issues and make sure that we're making the right decisions because we see our role is serving the community. The thing I'd like to share is that Dave and I actually play golf together. So we get along. No, and I would agree. I mean, I think competition is a good thing. It does raise the bar of the care that's provided locally in the community. You know, it doesn't have to be seen as raising cost as much as raising quality of the service that we're providing. It forces us both to be honest about that and say, how can we be better? And we have regular dialogue about that. But I can tell you that it sure forces St. Nicholas Hospital to provide a higher quality service when I've got Dave across town trying to do the same thing. So what kind of product are we able to deliver to the community when we do that? So I think, you know, I agree with everything Dave said and just add those comments too, other than the golf. Thank you. Now I'll move on to Julie. She's got an unique perspective because Johnsonville is self-insured. She's really, really in the middle of it all. So I'd like to ask her, excuse me. Julie, you're prepared. Yeah, I'm prepared. Do you know what Johnsonville is doing to be compliant with healthcare reform? Yes, the extra challenges you've been facing. All right. How long do I have? Well, maybe five or 10. Okay, no, I'm just teasing. First of all, we've really focused on what is our strategy going to be around this beast called healthcare reform? Are we going to remain a grandfather plan? Are we going to be non-grandfathered? And we've really come to the decision that we want to be grandfathered. And what that means for us is that until 2014, we're protected from the payment of clinical trials, okay? Can I stand in the soapbox for a while? We don't believe that clinical trials should be paid for by employers or insurance companies. We believe that they're the R&D expenses of those doing the clinical trials. So we want to protect Johnsonville's assets as long as we can because we're at our costs are not fixed. And by doing that, we think one way to do that is to prevent the payment of clinical trials. We have had to change our plan design for 2011. The two major changes that we made were to adjust our eligibility requirements for adult children. So now an adult child, whether they're married or not can be participant in our plan as long as they don't have other health insurance. So that's been a change for us. We've also had to remove our lifetime limit. It was, I believe, $5 million. And that is really a scary proposition for us. You may know, we purchase reinsurance or stop-loss insurance to protect Johnsonville against very large claims. And my fear is that in the future, if we were to ensure someone that has a very high-cost disease like hemophilia, they can incur costs of $2 million every year. And I'm afraid that our stop-loss carriers will laser those individuals and refuse to pay what they would normally pay in other situations. And so it really exposes Johnsonville to increase costs. And so it's really scary. The third thing that we've done to prepare is to communicate with our members. We have been talking with our members and we have been very frank and honest about how healthcare reform will affect Johnsonville, how it will affect them. We're honest with them that it is increasing our costs. It has increased our costs already. And because we share costs with our members, it has increased their costs. And we tell them to vote. We explain how healthcare reform impacts them. And people hear about healthcare reform on the TV, through the news, maybe through their neighbors, but they really don't understand the details of it. But once we tell them, we've had members think, I really had no idea of how this impacts us. And so we encourage them to vote whether they support healthcare reform or not. And we've been communicating this very hard. We started October of 2010. The president traveled with me the month of October and attended all of our plant meetings so that we could explain this to our members. I hit it really hard again this year to explain healthcare reform. And next October, before the election, we'll both be going out to all the locations and talking about it in detail. So people are aware of how it's gonna impact them. How's that? Thank you, Julie. Now we have Dr. Ryan on the panel. He's not only the CEO of Prevea, but he's also a practicing internal medicine physician. So that's the reason he's on the panel is his perspective as a provider. And the first question I'd like to ask him is tort reform is something that physicians have championed for in this legislation, but did not get. Can it bring the impact of liability concerns on our costs to cover care? You know, I think it's a significant aspect of where our charges go and how we practice medicine. I don't think it's exclusive to medicine only. I think tort reform is probably very important to businesses in this room, liability reform would be. What it specifically does without being addressed in healthcare legislation is it's very hard now to truly put a price tag on what healthcare reform is gonna cost. You've now increased your base of who you're gonna cover. There's no limitations on what is covered and there's no protection for the provider in case of medical error. And we're not talking about protections. People should not practice medicine if they're bad physicians or bad providers. We're talking about economic protections, not only for the providers, but for you. You can think of the types of behaviors that are driven to us in training without any type of protection. Every single back pain getting an MRI, Julie being selfish, you can probably see there's certain providers that practice, we're in a mixed company, I won't talk about what we call it, but how we cover parts of our body when we practice medicine. It really is about covering our tail on this and is it appropriate? No, does every headache need a CT scan? No, but it's that one CT scan you didn't do that could result in liability that creates 10 more CT scans and needed. And without any type of tort reform, you already know what the lack of liability insurance or liability protections in the country already cost us in healthcare and it's to the hundreds of millions of dollars and that's been researched. But unfortunately now with the legislation you have now broadened that base of people who have access. So you've exponentially actually increased the expenses and that wasn't really put into the calculation. So that's a fear as a physician, as an employer going forward. I have a follow up question on that. With the increased access, we've heard that there's a physician shortage in the country now. Can you tell us how the number of physicians graduating from medical school is determined? Is that because there's a perceived shortage, does that mean more people are allowed to go to medical school and graduate and it helps to fulfill that point? All right, I'll give you a Med School 101 here. We could open up 200 medical schools tomorrow in the country, have 300 students per and we have not trained one new doctor in the United States. It's not medical schools that determine how many physicians we have on our labor force. It's the postgraduate training after medical school. Those four years prepare us to go out and pick our specialty. So it's the residency training spots. And residency training is actually mainly funded through CMS and Medicare, basically through a government body around graduate medical education. That government body in 1996 capped the number of residency spots that the government could afford and we have not trained really any significant more physicians per year since 96. Residency programs have been allowed to trade spots within their own areas. So you can take two internists here and we'll take those two spots from you, but the total N or the total number of physicians being trained hasn't increased. So what has happened is as medical schools are created or started, you have more American medical grads filling those residency spots. So it does mean that you'll have more American trained physicians practicing in the United States if you open up more medical schools, but you won't have any more physicians. Right now, we have a primary care and specialty care shortage. We're predicted, as you all know, we're now hitting the baby boomer age, where those that are baby boomers are accessing healthcare at a much higher rate than they were, say five years ago. If you look at the shortages, and there's a ton of surveys out there, you can go from 10 to 50 to 100,000 physician shortages going forward. Now, once again, go back to the tort reform question and you've now exponentially increased the number of people who have access to primary care through insurance, which is a good thing. But overall, the legislation did not increase the number of physicians able to provide care. We also have other providers, such as nurse practitioners, physician assistants who are extremely valuable to all of our health systems. But we've not really funded the creation of more of those spots either. So at the end of the day, you have a healthcare bill that provides access to millions more, but still, you already have a strained resource, which is a provider resource, and now it'll become even more strained going forward. I have one more follow up question for you too, Dr. It is, I thought I was batting clean up, I thought I'd fix that there. Well, it has to do with liability, and there's these ethics committees or ethics panels, they're gonna be making decisions, and I understand about the level of care that's provided, is that true? And so, does their decision impact your liability? If they say you cannot perform a procedure, does that absolve you of liability that you did not perform the procedure, which could have increased somebody's life span? That one's gonna get, I'm gonna try not to get political on this one. Try my best not to get political on this one, because there are advantages to review boards. Making sure that the practice of medicine is governed in some way to make sure appropriate care is being delivered downstream. But individual review boards that are mandating or not mandating how care is provided without actually being at the bedside is a frustration for a physician. We have those today, in all honesty. They're called the care managers that work for UnitedHealthcare and Humana and Anthem. We have that today, and we are frustrated by that today. I mean, I very commonly will ask the person on the other end of the phone where they went to med school and when they examined my patient. So it's a very difficult subject going forward if you're gonna do this on a more global perspective without an agreement on the provider side of what shouldn't be put forward there. I would agree that clinical trials shouldn't be paid for by employers, as Julie pointed out. They need, people make a lot of money off of those clinical trials when they actually become a product that shouldn't be funded by all of you as employers. But at the same time when there are therapies that we know that do work, it should be the physician making that decision, not a board, not somebody who's not at the bedside. Thank you. We have another audience submitted question for the hospital administrators. Are you currently forming an ACO? And I don't know what that is, guys. So maybe you can help me spell. And if so, how far along are you and what providers are included? Oh, pardon me. We can take that one together. Well, we can take that. ACO stands for Accountable Care Organizations. And this is a difficult topic because the proposed legislation is complicated right now related to ACOs. The proposed legislation actually, the providers that are currently signed up to participate, how many in the country now? Is it six? No. I think the pilot, there's over 50. I don't remember the exact number. It's a pilot program. There's 50 that are signed up right now across all the providers in the country. Again, it's one of these areas of integration that you heard me talk about earlier with our providers. And it's a detailed integration of how we work together and collaborate to produce high quality. And there's got to be accountability to that quality through really physician-led. And so as a hospital administrator, my role is to facilitate that and put that stuff together. But it's the physicians that are really working on improving quality together for the patients through Accountable Care Organizations. And with that, I know there's a lot of topic or conversations about, well, and I've had a number of you actually approached me about this with skilled nursing facilities. Well, how about we join an Accountable Care Organization together? And I look at them and I say, well, how is that going to work? Not to say that we can't make that work. And I think that there's conversations happening right now across those providers to say how can we all work together across a continuum to improve quality? That's kind of a level of clinical integration, but not necessarily on a formal basis. So for example, I've had several SNFs come up to me and say, well, how about we enter into a contract to do this kind of thing? Hasn't been defined yet. It's a pilot program at this point. We have a relationship with Prevea Health. We also have a relationship with a lot of other physicians at St. Nicholas Hospital to improve quality. Just to give you the physician perspective and actually my own personal perspective, Accountable Care Organization is a concept in all honesty that's being piloted by Medicare. So it's strictly currently when you hear about it out and about, the term gets tossed around between private insurance and government insurance a lot. Right now, ACO as a term is in the legislation. We waited about a year after the legislation was passed to see how that Accountable Care Organization would be regulated. As you all know, and if you haven't spent any time in Washington, I actually don't recommend it. But I have a lot of time on the Hill, unfortunately. And you have 2,200 pages of legislation or something around there with the federal act. You'll likely get tens of thousands of pages of regulation now. And the regulatory body in charge of Accountable Care Organizations is CMS, the Center for Medicare Studies. And obviously you've probably read the political news where their leader has now been replaced. So it's somewhat of a moving target for those of us who are trying to figure out what to do. Do you want to participate or not? But really, if you look at the fundamentals of the pilot, it's about physicians and hospitals and other care practitioners, whether it's home health, hospice or SNFs, which is a nursing facility, short-term nursing facility partnering together, getting maybe paid one time, say for hip surgery, and dividing that among themselves and being accountable. So essentially bundling the payment and being accountable for a population or a person. That concept isn't very new. It's just new to the government. And we participate in Accountable Care Organizations like pilots all the time with our private pay insurers. Humana, Anthem, United, all the payers have some sort of version of a contract that's similar to what the government's trying to accomplish. Unfortunately, the government's not looking at what private pay has done, and extrapolating to that, they want to see what happens at the government level. I think that hopefully answered the ACO question, but, Dave, if you've got something more on what Aurora's working on as well. You know, I think the concepts of an ACO are instead of being paid for an MRI for your hip surgery, for your nursing home care, that in essence you're paid for that whole episode of care to get you healthy. And the organization then is at risk in how we manage that process. And so I think that's, as we talked about what are the things we're doing to get ready, it requires us to measure differently, order differently, work with our providers to have a more consistent approach with that. And so, you know, I think we're focused very hard on the things that we think can improve care that may be the government's measuring that will ready us for ACO. But we're waiting kind of for those things to come out. You know, what's the definition? How will each employer, or how are each insurance cover, or the government, in essence, define that ACO? So, and I think that's, you know, yet to be defined. I think we're, we are going to be participating in several pilots as part of that so we can learn and prepare. But, you know, I think the concepts that we talked about earlier around, how do we guarantee our care that if you leave the hospital you're not going to come back in 30 days. Or that, you know, we don't create infection and additional cost. I think that those are the ways in which we're getting ready for kind of the new payment structure. Another question for Julie. And one factor with the Affordable Care Act is that there's a hypothesis that a lot of employers may drop the coverage that they're offering to their employees and then pay them more to enable them to go and buy their individual policies either in the open market or in one of the exchanges. So the question for Julie is even if you don't provide healthcare, health insurance in the future what role do you feel as an employer at Johnsonville will have on the role and the health of their employees? I think we all know that a healthy member or healthy employee is a more productive member or employee. So I think that employers in Johnsonville will still have a role in trying to improve all of our members' health. And currently we have a very robust wellness program. We have an on-site fitness center. We have Weight Watchers at work. We have a health and wellness center with Aurora Healthcare and Plymouth where members and their families can have access to free healthcare. But in the future what I found is with our wellness program is that a lot of our spouses are incentivized through money. Okay, so for the last two years we're in our third year with a very robust wellness program and our members can save up to $1,200 annual on their health insurance premiums. So we have a very large participation in our wellness programs and without that carrot or stick I'm not sure how much participation we'll have in the future. So even though we may continue to offer wellness programs, offer Weight Watchers at work, I'm not sure how much participation we'll have without that incentive and that health insurance incentive is working for us. So we might have to be more creative in the future about how we can continue that engagement. Thank you, Julie. We have another audience submitted question in this year the top 40 prescription drugs will become generic. Should the drug prices decrease in costs? And is that accurate? I think the top 40 are going to be coming generic and I don't know who to address this one to. I think I'm going to end on the stage you actually write prescriptions. So actually they're all electronic right now. I don't think I've written one in a very long time. Well, that's good. Everybody can read the signature there. Ow. For those of you who haven't seen my signature he's right. Usually the contracts get returned. Could he please sign in the circle because you know that's his signature. I don't know if it's quite 40 but there is a significant amount that might be 40. I think the lay press has been on this. But obviously some of the more popular ones such as Lipitor and others for cholesterol are going generic. It's interesting the cycle of how drugs are created I think that's how a bill becomes a law how a drug becomes a drug. Most of the research is actually funded by federal dollars that they think pharma actually pays for the research. Pharma actually pays for probably the last two phases before a drug actually goes out to market. The majority is done by the National Institute of Health NIH does a lot of research turns over that research to pharma being the pharmaceutical companies they take it the next two steps and essentially what they're trying to do is obviously recoup their cost before it becomes generic. What you have to understand is that there is a lot of healthcare costs around drugs everybody talks about how much cheaper medicines practice in Europe or in Asia, England the Netherlands is cheaper because we're paying for all the drug research for the whole world. Yes, we do trials in Europe but the majority of the pharma companies are actually located here and it's all of our costs so when you start to compare costs there so should costs come down? Do countries bear the responsibility of funding those first few stages most definitely? Are we going to get that? No. But if you look at where all the AIDS research and AIDS medicines for example are happening all the research and development is happening in America but the majority of the usage is actually happening in the African subcontinent. So it's a tough situation for a country that has a responsibility for the world. So yes it should come down yes we should advocate and vote so they do come down but it is a capitalistic market and at the end of the day I don't think regulation should actually create that there should actually be a little less of government involvement and a little bit more on pharma's shoulders and then they'll learn to spread that to other countries but as long as we continue to fund through taxpayer dollars a significant part of that research we'll never actually see the cost trend down because we're not letting the capital markets Thank you. Can I just add? You know and this is from the hospital administrator's standpoint I think four years ago in my past role I budgeted for drugs at 11% increase that was four years ago this last year I think I don't know what you budgeted the change is about 3% so there's a big change and I think it's helpful I think the challenge we're having is getting basic drugs that are really common drugs and a lot has to do with the incentives both the government regulation that's happening with it but also the incentives for drug companies to maintain those generic drugs so I think it's a growing issue not necessarily from an access standpoint but really from an access standpoint and I would echo those comments just last December I'm sure Dave can speak to this as well we're having issues getting common drugs in the hospital for certain things and some of them are pretty common drugs that are required for our patients care every day and we were put in a position where we actually had to put different vials to conserve on drugs because it took on certain ones so that we could provide care to our patients I mean I'm talking very common drugs for patients that are going into surgery for pain etc so it's becoming a big issue not only cost but access news is not enough supply it's important to know that supply is actually regulated by pharma we saw supply decreases in our less expensive medications which obviously could be replaced by much more expensive medications we're probably not the right thing to do but sometimes the only alternative is oncology, we see this in pain we definitely see this in antimicrobials and antibiotics and so you've got an industry that does have maybe a little too much control on that but once again that is business and they're driving the supply to the equation as much as they're determining what choices we have as well if we can get enough enough of a market for a generic producing pharma actually doesn't start getting into that business and we get a section that actually starts getting more into generics and we can see an improvement from an employer perspective we can't wait until the drug goes generic and I'd like to see some reform on the cost of specialty drugs our non-specialty drug costs are very flat and we're just getting killed on our specialty drug costs they're increasing by over 20% going into next year well we're almost to our stopping time of about 1.30 so we have one final question we'll start with Andy again and just work down the panel this line what should our employers take away from this discussion we've all had a lot of good news but please remember what you tell our bosses when we get back to work I think number one it's important that you have two great healthcare institutions providing great care in Sheboyton County and both institutions are very committed to continuing that well into the future and I think you should also be very proud of the fact that you've got two very innovative healthcare systems here thinking ahead in terms of how we prepare for healthcare reform and being open and flexible to changing that to meet our local community needs I think the other piece that really wasn't hit on and I know you mentioned I think it's very important take away is look at your benefit structure take a look and see how can you prevent things from happening to reduce your costs and I think the other piece is to not be afraid to partner with us as a healthcare provider to help you improve the health of your patients I would kind of echo that I think the benefit structure for the large employers is really critical because creating incentive that's aligned with good care but also individual management I think helps us do a better job in caring for patients I think the Andy had mentioned earlier the informed consumer and we see this more and more government and others put some measures around what is good outcomes look like because then it helps us all focus on that so an informed employee providing options for them to improve their health but also make decisions is important and then I think the alignment as we talked a little bit about ACOs we're all going to be looking at ways in which we can support the risk of people going forward and so doing that in partnership between employers and healthcare providers is going to be important first I would say that I think as employers in Sheboyin County we're really lucky to have the purveyas of St. Nick's and the Aurora to help us as employers help our own members and employees become healthy I think they all offer really great programs on the second point is to really focus and concentrate on creating a strategy your business strategy around healthcare reform if I look into my crystal ball I honestly feel that employer sponsored healthcare is going to cease to exist in future years because of the penalties and the incentives not to offer it so I would just encourage everyone to focus on their strategy for the future purely from a physician perspective we were here to talk about a healthcare reform bill let's remember that from Doc's perspective 2200 pages of legislation actually didn't make America healthier it did increase access but it didn't make us healthier but at the same time we shouldn't rely on the government to make us healthier as employers you have a very unique opportunity to engage your employees on creating a healthier workforce Julie's done an incredible job many of you in this room have done an incredible job of providing on-site education on-site facilities to make your employees healthier a healthy workforce is going to be a more productive workforce the legislation itself is going to probably create issues for you going forward on deciding whether to provide employer sponsored health insurance or not but at the same time you should ignore the fact that we still need to be a healthier county I live in Brown County I commute back and forth working I won't retire until we're known to be the healthiest area in the country when I walk into a packer game I used to walk in there as a 28 year old physician and smile because there was job security there is nothing more than job security when you walk through tailgating at Lambeau I've grown up a little since then and now I have to run a company and I have to pay health insurance for 1350 people and I realized if as a health care provider we don't take the pulpit that we've been granted to make our communities healthier and help all of you become healthier we haven't really done our job so don't expect health care reform legislation to do it but hopefully more interaction between employer and health care provider can make us all healthier June and I know if the panel is to be around for a personal question that would be great thank you good job