The Milwaukee Post

By JOHN TORINUS Some of the best minds in Wisconsin on health care economics met last week at Concordia University, armed with ideas for improving the delivery of care, but less than clear or optimistic about the way forward for disrupting a broken business model. The Mequon location overlooking the expanse of Lake Michigan was a good place for a big think about health care economics, far better than the barren islands inside the beltways of Washington, D.C., or Madison, where concepts advance or die not on their merits, but on the size of the donation check attached. Both parties came up short on a sound national plan. Skepticism, even cynicism, aside about positive change in the medical-industrial complex (MIC), there were some take-homes at Concordia that merit inclusion in the national debate about the stifling impact of out-of-control medical costs. And there was an underlying faith that in the long term, despite enormous inertia, good concepts will work their way into law, regulations, policy and practice. The private sector, which directly pays about half the nation's medical bill and indirectly through taxes pays the other half, is where most of the innovation is surfacing and where most of the take-homes will be put to use. Some take-homes: ■ Consolidation of hospital corpora- tions, for-profit and nonprofit, will continue as they assemble pricing power on the sell side. The touted cost savings from integra- tion did not garner much credibility. ■ Health insurers, the ultimate middle- men, are headed for greener pastures. Aetna is selling out to CVS. Humana may sell to Walmart. United Health Care now employs 30,000 primary care doctors, more than most major hospital systems. They have all moved from the buy side toward the sell side as major players like Amazon, Berkshire Hathaway and JP Morgan Chase prepare to take out MIC middlemen. ■ Bundled prices ($26,000 all-in for a joint replacement, half price compared to mar- ket) are coming down the tracks, but major providers will harvest high, opaque prices as long as possible. ■ Transparency on the quality of hospi- tals, clinics and doctors is moving more slowly than transparency on prices, but there are glimmers of hope for something like Consumer Reports for health care. Jeff Bezos, Jami Dimon and Warren Buffet could inaugurate tough quality audits, as is the norm in most indus- tries. We know who the best baseball hitters and pitchers are. Why not the best bone doc? ■ Total cost of care should be a key metric for the industry, because prices are not the only element of cost. Inappropriate care adds hugely to med- ical bills, such as surgeons who cut when they shouldn't cut. ■ Two doctor leaders called for a single schedule of medical prices for episodes of care. Regional adjustments may be neces- sary. ■ Multimillion treatments are a wreck- ing ball that should be socialized into high- risk pools, much like Wisconsin used to do and Obamacare eliminated. Re-create them at the state or national level. Take those risks, including pre-existing conditions, out of regular insurance pools. That would lower premiums. One to 3 percent of the population generates 50 percent to 70 per- cent of health costs, a bigger disproportion than ever. ■ Specialty drugs are ruining health plan economics. Allow drug purchases from abroad. Though no one likes price controls, government intervention may be necessary. Dr. John Raymond, CEO of the Medial College of Wisconsin, summed up a general theme of the summit: "Cost is prohibitive for everyone." The most recent numbers from Milliman, a top actuarial company, put employer health costs for a family of four at almost $27,000 per year. That is about half of medi- an U.S. household income. The employee share was $11,685 in 2017. There was a ray of sunshine; costs rose 4.3 percent in 2017, the lowest rate since Milliman started tracking medical inflation in 2001. Reformers and payers are slowly forcing a bend the inflation curve, but it's still twice the rate of inflation. There was general agreement with Raymond's statement that "there will be disruption at a rate and scale never seen before." (John Torinus is chairman of the board of Serigraph Inc. in West Bend and blogs regu- larly at www.johntorinus.com. His column runs occasionally in the Post.) April 20, 2018 • Milwaukee County Post • 9 OPINION By OWEN B. ROBINSON The news did not come as a surprise, but it was still a shock. Rep. Paul Ryan has decided against seeking re-election this year. It will be the first time in 20 years he will not be on the ballot. The reverberations of Ryan's remarkable career will be felt in Wisconsin and the nation for generations. And at only 48 years old, he may not be done yet. Ryan entered politics as soon as he gradu- ated with a degree in economics from Miami University as an aide to Sen. Robert Kasten in 1992. He served in various sup- portive roles for powerful Republicans, including as a speechwriter for Jack Kemp, whom Ryan considered an influential men- tor. Ryan got his turn to run for office in 1998 when Rep. Mark Neumann decided to run for the U.S. Senate. Ryan won the 1st Congressional District by a convincing 14- point margin and has firmly held the seat since. Ryan quickly established a reputation as a sincere, intelligent, articulate, consistent advocate for his core conservative beliefs. During his 20 years in Congress, whether in the minority or the majority, he was always pushing to reform the fundamen- tal structures that con- tinue to undermine our nation's potential — rampant entitlement spending and a byzan- tine tax system. It is the nature of American politics that nobody completely gets what they want. Our system of competing interests and bal- anced power ensures that the only way to accomplish anything is through compro- mise. Some of Ryan's detractors criticize him for the fact that he was unable to fully accomplish his oft-stated ideals of reform- ing and restraining the federal government, but it is precisely Ryan's ability to compro- mise without capitulating that led to any accomplishments at all. There are plenty of bomb-throwing ideologues in Congress. We fellow ideologues love them, but they are rarely effective in moving policy. Ryan's style actually moved the ball forward. Ryan's signature and crowning accom- plishment came when he was serving in a role he never wanted and under an unlikely Republican president. Ryan never wanted to be Speaker Ryan because he is, at his heart, a policy wonk. The job of speaker is to cajole the caucus to move legislation written by other people. Ryan wants to write the legislation. Ryan answered the call of the Republican caucus in their time of crisis because sometimes duty and loyalty trump personal ambitions. The landmark 2017 tax reform law marked a transformational shift in the tax code that will be felt for generations. It is a signature achievement that has Ryan's years of effort baked into its very core. Americans will benefit from this achieve- ment long after they have forgotten how it came to be. As speaker, Ryan also wrestled passage of many reforms including the repeal of Obamacare requirements and entitlement reform. Unfortunately, too many of those legislative efforts found their graves in the stodgy, dysfunctional Senate, but Ryan did his job and did it well. Throughout his tenure as representative, committee chairman, vice presidential can- didate and speaker, Ryan also justifiably maintained a reputation as a genuinely nice guy. He had a style in which he was able to aggressively debate and advocate policies without the personal hatred and animosity that infects too many other politicians. In this respect, perhaps he is too much of a throwback to a different era of politics in which his mentors lived. The ability to dis- agree without being disagreeable is becom- ing a rare gift in the modern era. As the first Wisconsinite to serve as the speaker of the House, Ryan stands unique in Wisconsin's pantheon of political giants. He has certainly earned the right to slip into obscurity and indulge in the enjoyments of private life. As for me, I know that there comes a time on the horizon when the peo- ple of Wisconsin will call again for his lead- ership, and I pray that he will answer the call. Until then, thank you, Speaker Ryan, for serving the citizens of Wisconsin's 1st Congressional District and our nation. (Owen B. Robinson is a West Bend resident whose column appears occasionally in The Milwaukee County Post. He can be reached at owen@bootsandsabers.com.) Paul Ryan returns gracefully to private life Robinson Look to private sector for innovation in health care Torinus

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