Under their influence

The nation's political forces are bitterly divided over issues ranging from raising the country's debt ceiling to the use of energy-efficient light bulbs, so it's no surprise that the government's role in healthcare is also the source of intense debate.

That division is reflected in Modern Healthcare's ranking of the 100 Most Influential People in Healthcare, with House Budget Committee Chairman Paul Ryan (R-Wis.)—who seeks to remake the nation's Medicare and Medicaid systems—finishing first, and Vermont Gov. Peter Shumlin—who seeks to make his state the first in the union to adopt a single-payer system—coming in second.

Others in this year's Top 10, as might be expected, include President Barack Obama and members of his administration in high-profile positions. After finishing first the past two years, the president finished third on the 2011 list, ahead of CMS Administrator Dr. Donald Berwick (who has made the list every year since it started in 2002) in the No. 4 spot, and HHS Secretary Kathleen Sebelius at No. 5.

Dr. Farzad Mostashari, national coordinator for health information technology, finished at No. 9. Dr. Carolyn Clancy, who President George W. Bush named director of HHS' Agency for Healthcare Research and Quality in 2003 and Obama reappointed in 2009, finished at No. 11.

Rounding out the top tier are presidential candidate and former U.S. Speaker of the House Newt Gingrich, founder of the Center for Health Transformation, at No. 6; Dr. John Wennberg, director of the Dartmouth Institute for Health Policy and Clinical Practice, who led the field from academic medicine and came in at No. 7; Johnson & Johnson CEO William Weldon, the highest private-industry sector finisher, at No. 8; and Therese “Terri” Vaughan, CEO of the National Association of Insurance Commissioners, at No. 10.

Although Gingrich's and Wennberg's offices did not respond to requests for comment and Weldon's and Clancy's declined, both Ryan and Shumlin offered their views on the current state of the nation's healthcare system.

“The primary driver of our national debt is our healthcare program,” Ryan said. “There's no one magic bullet—like pass this and it's fixed—but, save the healthcare system and you're saving the country from its debt crisis.”

Ryan added that healthcare inflation has made healthcare programs unsustainable, so his goal is to make them sustainable long term, “make them meet their mission,” and maintain a world-class system based on “innovation and excellence.”

Shumlin, a Democrat, said Washington has become “paralyzed by partisan bickering,” and explained that a single-payer system would eliminate waste, administrative overhead and insurance company profits, and he wants to have it implemented in Vermont by 2014.

“If you took as an example, all the Tea Party-proposed cuts to our federal budget and you implemented them, and you took all revenue Democrats have proposed raising from the wealthy and you put them together,” Shumlin said, “you would still have the same federal spending challenges, the same growth in budgets and the same trillions of dollars of debt you have right now in three years.”

Both men favor a system that steers away from employer-based insurance so the coverage follows the individual and is not linked to the person's job. For Shumlin, this is a way to “ensure that healthcare is a right and not a privilege.” For Ryan, it means instituting a system where individuals get a refundable tax credit for healthcare costs and “providers compete against each other based on value—price, quality and outcomes—for their business.”

Through transparent pricing and provider-developed, publicly reported quality measures, Ryan said under-performing and over-expensive providers will lose business because the “market can discipline them for not being cost-effective—that's far better than the heavy hand of government.”

For all their differences, both men can sound alike at times.

“We spend more money per person than any other industrialized country,” Ryan said. “We don't spend intelligently either.”

Ryan added that the government should put its money “where it's needed the most,” and that's helping the poor and the most sick. He also said he's always believed in state-based risk pools for patients with pre-existing conditions. “Healthcare should be viewed as an asset and driver of economic growth—rather than a drag on the economy,” he said.

Shumlin, who wants to do away with “this crazy fee-for-service system,” acknowledged the concerns people have about a state-run healthcare program. “I think those who distrust government in healthcare have every reason to do so,” he said. “Government has gotten this wrong every single time.”

Ryan's proposal to cut $730 billion in Medicaid spending over 10 years by turning it into a block grant program was the subject of heated debate at this year's American Medical Association House of Delegates meeting. His plan to cut some $390 billion in Medicare spending (compared with the president's budget), was also criticized by an unlikely source: the free market-promoting Libertarian Party.

“Republican Paul Ryan's plan to ‘privatize' Medicare is just rearranging the deck chairs on the Titanic,” reads a June 3 statement from party Chairman Mark Hinkle. “If Congressman Ryan is so worried about the cost of Medicare, maybe he should not have voted for the huge Republican Medicare expansion in 2003.”

Others on the list from the federal government include Surgeon General Dr. Regina Benjamin, at No. 26; Aneesh Chopra, U.S. chief technology officer, No. 39; Eric Holder, U.S. attorney general, No. 55; Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention, No. 70; Dr. Margaret Hamburg, Food and Drug Administration commissioner, No. 73; Richard Feinstein, director of the Federal Trade Commission's Bureau of Competition, No. 74; Eric Shinseki, Veterans Affairs secretary, No. 84; Richard Foster, the CMS' chief actuary, No. 87; Dr. Howard Koh, HHS assistant secretary for health, No. 92; Daniel Levinson, HHS' inspector general, No. 94; and Dr. Richard Gilfillan, acting director of the new CMS' Center for Medicare & Medicaid Innovation, No. 97.

Other Republican politicians on the list are: Speaker of the House John Boehner of Ohio, No. 21; Sen. Chuck Grassley of Iowa, who's been on the list every year since its inception, No. 47; and Florida Gov. Rick Scott, No. 49.

Rose Ann DeMoro, executive director of the AFL-CIO-affiliated National Nurses United labor union, who has also appeared on the list all 10 years, is not a fan of Ryan—but her disagreement comes from the other end of the political spectrum compared with the Libertarians.

“The market isn't magic and it doesn't trickle down. There's a role for government—I just wish the people in government would play it,” DeMoro said. “The Paul Ryans of the world actually don't want a society. They want individuals and corporations to make ungodly amounts of money. There is no society—only individuals and what individuals can do on their own.”

Her ire, however, is not reserved for conservative Republicans alone. DeMoro is also upset with hospital administrators and Obama for not pushing for a single-payer, “Medicare for All” plan when they had the chance. “He could've embraced and fought for—and had the same amount of opposition—Medicare for all,” she said of the president. “He had the power and didn't use it.”

DeMoro predicted that most political healthcare-related change will be at the local level and said going to Washington is “a waste of time.” She told of a nurse lobbying in the nation's capital who was told that nurses need to “lower their expectations.” According to DeMoro, the nurse replied: “Do you want us to say that to you when we prep you for surgery?”

DeMoro said nurses are losing their jobs as small community hospitals close or they are often supporting spouses, grown children and even parents who have lost their jobs. She predicted the frustrating situation would lead to political change. “Heroes aren't made, they're cornered, and nurses are being cornered—and, believe me, they're hero material,” DeMoro said. “People are angry. We're going to tap that anger and run with that anger.”

Dr. Deborah Peel, an Austin, Texas-based psychiatrist and founder and chairwoman of the Patient Privacy Rights Foundation, after making the list from 2007 to 2009—including the No. 4 spot in 2007—found herself knocked off the 2010 ranking. So she was surprised to learn she made it back this year—especially after spending much of the past year working behind the scenes on the Health Privacy Summit her organization sponsored in June.

“I was the convener,” said Peel, who holds the No. 52 spot. “I just said ‘hello' and ‘goodbye.' ”

Peel joked that her low profile may have helped increase her influence, but she also said there is almost universal support for the privacy protections her organization is pushing to have included in the nation's developing health IT network, saying that both sides of the aisle in Congress agree with her. But she said the Obama administration and the George W. Bush administration have sought to use health IT to create unblocked “windows into the most intimate information about a person's mind, body, finances and family relations.”

To emphasize the importance of patient privacy, Peel cited an HHS study that estimated 586,000 Americans did not seek cancer treatment because of privacy concerns and 2 million did not seek treatment for mental illness.

“The American people are very united on this; the problem is not a political problem,” Peel said. “From the minute we came to Washington, we had some heavy support from both some conservative right-wing groups and the ACLU(American Civil Liberties Union), so we actually had a coalition that was bipartisan—or transpartisan.”

Therese “Terri” Vaughan, who leads the Kansas City, Mo.-based National Association of Insurance Commissioners group, said her group has also managed to avoid the partisan paralysis plaguing Washington.

“It's a group of technical experts on insurance, and we know how insurance works and the primary objective is protecting the consumers,” Vaughan said, adding that “the NAIC is just a conduit or mechanism for putting together the best thinking at the state level.”

The Patient Protection and Affordable Care Act mentions the NAIC 20 times and calls on the HHS secretary to consult with the organization when developing relevant insurance-related uniform standards, rules and definitions. “Members of Congress recognized that we weren't on one side or the other of this issue, though individual members might be,” Vaughan said. “Our job is to make this work effectively for consumers.”

She added that, regardless of their own political bent, individual commissioners become engaged in the NAIC consensus-building culture, which includes draft policies being issued and subject to a comment period before a final direction is set. “I will say that a common perspective of the regulators—regardless of political persuasion—is that the states are the best places for these decisions to be made,” Vaughan said.

Other insurance executives also made this year's ranking: Stephen Hemsley, president and CEO of UnitedHealth Group, comes in at No. 22; Patricia Hemingway Hall, president and CEO of Health Care Service Corp., No. 35; Angela Braly, chairwoman, president and CEO of WellPoint, No. 40; Karen Ignagni, president and CEO of the insurance lobbying group America's Health Insurance Plans, No. 57; George Halvorson, chairman and CEO of Kaiser Permanente, No. 60; Michael McCallister, chairman and CEO of Humana, No. 67; and Scott Serota, president and CEO of the Blue Cross and Blue Shield Association, No. 90.

Ignagni, another honoree who has made the most influential list all 10 years, said payer-provider partnerships in medical homes and accountable care organizations are bringing about reforms that Washington has been unable to accomplish. “We know that fee for service doesn't encourage safety or incentivize cost containment,” she said. “Health plans and providers have come together to move the needle.”

In the healthcare financing debate, payer profits and CEO salaries are coming under scrutiny, but Ignagni deflected any criticism.

“I'm very proud of our industry being the pace car for medical homes, ACOs, transparency and care coordination—all these were developed within our industry,” she said. “Our industry has contributed sustained strategies and programs that are integral to changing the way we pay for healthcare, evaluate quality, and providing assurance to employers and purchasers that they are getting value for their money.”

Maureen Bisognano, who succeeded Berwick as president and CEO of the Institute for Healthcare Improvement and comes in at No. 37, said the healthcare system's woes create “the most pressing time for innovation,” adding that the current models aren't working. “Although the division has the potential to hold us back, I am heartened by local and regional improvements.”

Berwick has taken the IHI's “Triple Aim” strategy of improving population health, improving the healthcare experience and lowering costs per capita with him to the CMS, but Bisognano said the two of them don't discuss that.

“We don't talk about work for a number of different reasons,” she said. “I admire his vision and commitment to improve care. I think the direction he's taking CMS—especially with the Center for Innovation—is helpful because it's creating the forward thinking that we need.”

Dr. Gary Kaplan, chairman and CEO of the Virginia Mason Hospital & Medical Center in Seattle, said healthcare is an extremely complex industry and his concern is that the federal government may wind up tinkering with isolated changes that are not connected to a central vision.

“There is certainly a lot of activity in Washington and still a fair amount of uncertainty,” said Kaplan, who is No. 33 on this year's ranking. “But the train is moving down the track in regards to reform and the hospital and health system executives have an important role to play.”

He said Virginia Mason has had success adopting manufacturing principles to healthcare and working with area employers on employee problems that add up in terms of cost and lost productivity. “I think the reform law dialogue has been a catalyst, but we've known for some time that healthcare needs to be better in terms of quality and safety—and it needs to cost less.”

Chris Van Gorder, president and CEO of Scripps Health and No. 18 on this year's ranking, reiterated that government is the largest payer most providers have. He said the uncertainty over what this payer will do next is leading many organizations to innovate and redesign—and that's a positive development. “When everyone else thinks the sky is falling, I'm running around the country saying, ‘I've never been more bullish on healthcare,'” Van Gorder said.

Kevin Lofton, president and CEO of Catholic Health Initiatives, Englewood, Colo., and No. 45 on the list, said providers, payers and the business community have to realign incentives so everyone benefits by a community's improvement in health. He said it's his sense is that dysfunction in Washington is serving as a catalyst for those outside of government to act.

“Personally, I'd rather not have the government step in and do that. The provider community should take the lead,” Lofton said. “We need to step up.”

Rulon Stacey, president and CEO of Poudre Valley Health System in Fort Collins, Colo., and chairman of the American College of Healthcare Executives, said providers need to identify what they can do to reduce costs and improve quality—and then do it before waiting to be told.

“I think we spend too much time worrying about what the government is going to do,” said Stacey, a first-timer to the list who holds the No. 88 spot. “We're going to wish Congress well while we drive variation out of our organization. It's one thing I can change and will change.”

Stacey explained how, if an organization performs a procedure 10 different ways, “by definition, nine are inferior. When you identify best practices, you drive people to do the things the right way,” he said. “I don't need Congress' permission to do that.”

Teri Fontenot, president and CEO of Woman's Hospital in Baton Rouge, La., and chair-elect of the American Hospital Association, said performance reporting is prompting hospitals to improve faster than any government program she's ever seen.

“I'm a firm believer in transparency and disclosure, and that can have more impact on performance improvement than any payments or penalties,” said Fontenot, No. 79 on the list and also a first-timer.

She added that the AHA looks to the government for funding and stability, and she said it still looks at the passage of the Affordable Care Act as a positive move. “I know that it's still pretty controversial, even among our members,” she said. “The American Hospital Association really views it as the first step in getting people affordable care.”

Dr. Robert Wah, No. 12 on the ranking, is the nation's former deputy national coordinator for health IT and the new chairman of the American Medical Association's board of trustees—another organization that was bashed for supporting the reform law. He said the AMA wants the government to fix the Medicare payment formula, reform medical malpractice liability and change antitrust laws to allow more physician collaboration.

“As a practicing physician, what I see is a time of great opportunity. I always see change as opportunity, and I never like to miss an opportunity,” said Wah, also chief medical officer for IT company Computer Sciences Corp. “It's quite an exciting time.”