Sandy BaruahPresident and CEO

Detroit Regional Chamber

Health Care In Transition:

The Big Picture

Paul KeckleyFormer Executive Director

Deloitte Center for Health Solutions

Ed WolkingExecutive Vice President

Detroit Regional Chamber

Handling Change: Challenges and

Opportunities for Employers

David LanskyPresident and CEO

Pacific Business Group on Health

Challenges and Opportunities for Employers (and by extension, individuals and employees)

2014 Health Care Leaders ForumDetroit Regional ChamberMarch 12, 2014

David Lansky, PhDPresident and CEO

©PBGH 2014 9

PBGH Members

AppleFacebookGoogleHewlett PackardMicrosoftOracle….

©PBGH 2014 10

Value of our $3 trillion system

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130%

50%

100%

150%

200%

250%

57%

119%

182%

56%

117%

196%

14%

34%

50%

11%

29%40%

Health Insurance PremiumsWorkers' Contribution to PremiumsWorkers' EarningsOverall Inflation

SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2013. Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), 1999-2013; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 1999-2013 (April to April).

201320122011201020092008200720062005200420032002200120001999

$0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000 $14,000 $16,000 $18,000$16,351*

$15,745*

$15,073*

$13,770*

$13,375*

$12,680*

$12,106*

$11,480*

$10,880*

$9,950*

$9,068*

$8,003*

$7,061*

$6,438*

$5,791*

$5,884*

$5,615*

$5,429*

$5,049*

$4,824*

$4,704*

$4,479*

$4,242*

$4,024*

$3,695*

$3,383*

$3,083*

$2,689*

$2,471*

$2,196*Single Coverage

Family Coverage

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

66% 68% 68% 66% 66%63%

60% 61% 59%63%

59%

69%*

60%* 61%57%

55% 57% 58% 58%55%

52%47% 49%

45%50%

47%

59%*

48%* 50%45%

All FirmsFirms with 3-9 Workers

Percentage of All Firms Offering Health Benefits, 1999-2013

*Estimate is statistically different from estimate for the previous year shown (p<.05). NOTE: Estimates presented in this exhibit are based on the sample of both firms that completed the entire survey and those that answered just one question about whether they offer health benefits. The percentage of firms offering health benefits is largely driven by small firms. The large increase in 2010 was primarily driven by a 12 percentage point increase in offering among firms with 3 to 9 workers. In 2011, 48% of firms with 3 to 9 employees offer health benefits, a level more consistent with levels from recent years other than 2010. The overall 2011 offer rate is consistent with the long term trend, indicating that the high 2010 offer rate may be an aberration.SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2013.

©PBGH 2014 13

Employers considering “exit”

Source:18th Annual Towers Watson/National Business Group on HealthEmployer Survey on Purchasing Value in Health Care (2013)

©PBGH 2014 14

Savings by “Best Performing” Employers

Source:18th Annual Towers Watson/National Business Group on HealthEmployer Survey on Purchasing Value in Health Care (2013)

©PBGH 2014 15

Strategies of “Best Performing” Employers

Source:18th Annual Towers Watson/National Business Group on HealthEmployer Survey on Purchasing Value in Health Care (2013)

©PBGH 2014 16

Strategies to Improve System Performance

©PBGH 2014 17

Large Employer Strategies1. Benefit design with strong incentives to consumers:

1. Tiered networks2. Reference pricing3. Centers of Excellence (travel surgery)

2. Direct contracting: 1. Accountable care organizations2. Primary care networks3. On-site clinics with selected networks4. Intensive outpatient care models (serious chronic illness)

3. Payment reform: 1. Price and quality transparency “value” based payments2. Alignment among private carriers (e.g., bundled payment)3. Alignment with Congress, Medicare, states (e.g., SGR fix)

©PBGH 2014 18

Source: Robinson JC and Brown TT, “Increases in Consumer Cost Sharing Redirect Patient Volumes and Reduce Hospital Prices for Orthopedic Surgery.” Health Affairs 32(8), 2013, pp. 1392-1397.

©PBGH 2014 19

Reference pricing forlower cost servicesColonoscopy Cost Per Procedure – Greater SF Bay Area MSA

2008 2009 2010 2011 2012 2013 $-

$200

$400

$600

$800

$1,000

$1,200

$727 $798 $855 $873 $717 $740

$848 $891

$942 $944

$766 $823

Average Paid for Reference Based Priced Colonoscopies by Year

avg_allw_amt

Average Al-lowed Amount

• 12% increase in use of labs below reference price; 6% increase in low-cost imaging centers

• Driven by steerage to specific, named providers

©PBGH 2014 20

©PBGH 2014 21

Where we are today…• Fading hope that competitive market can

work to manage cost, improve quality• Potential of rapid shift to defined

contribution, private and public exchanges in next 5-10 years

• Consensus interest in value-based payment, alignment of consumer and provider incentives, greater transparency for informed decisionmaking

• The path is clear. Will leadership appear?

Fast-Changing Relationships: The

Road Ahead for Employers

Moderator:• Kathleen S. Neal, Director of Integrated

Health Care & Disability, Chrysler Group, LLCFormer Executive DirectorDeloitte Center for Health Solutions

Panelists:• John Neuberger, Director of Client

Partnerships, Quad/Graphics• Randy Vogenberg, Principal, Institute for

Integrated Healthcare

Impacts of Response: The

Changing Landscape for Providers

Carlos JacksonSenior Associate Director, Federal Relations

American Hospital Association

The Changing Landscape for ProvidersCarlos Jackson

American Hospital AssociationMarch 12, 2014

ACA implementation

Wednesday, February 15Naval Heritage Center

9:30 AM

Implementing reform• Insurance reforms

− High risk pools− Medical loss ratios− Mandates − Insurance exchanges

• Integrated care options− Bundling− Accountable care organizations− Medical homes− Center for Medicare and Medicaid Innovation

• Value-based purchasing• Readmissions

Regulatory Design

Research and analysis by Avalere Health

CMS quality and accountability initiatives provide additional impetus to hospitals’ integration efforts.

Chart 3: Timeline of CMS Value-Driven Payment Initiatives

Incentive Payments Only

Upside/Downside Risk

Penalties Only

Nonpayment

Hospital Inpatient Quality Reporting Program (P4R)

Accountable Care Organizations*

Readmission Penalties for Low Performers

2008 2009 2011 2013 20172015 2018201620142010 2012

Bundled Payments for Care Improvement*

Hospital Outpatient Quality Reporting Program (P4R)

Hospital Value-Based Purchasing Program

Meaningful Use (HITECH Act)

Hospital-Acquired Conditions**

P4R: Pay-for-reportingHITECH: Health Information Technology for Economic and Clinical Health*Program is voluntary**In 2008, Medicare stopped paying for select hospital-acquired conditions (HAC). In FY 2015, Medicare will begin penalizing hospitals in the top quartile of Medicare HACs .Source: Centers for Medicare & Medicaid Services

Research and analysis by Avalere Health

Physicians widely anticipate increased levels of integration with partner hospitals.Chart 5: Percent of Physicians that Believe Physicians and Hospitals are Likely or Very Likely to become More Integrated in the Next 3 Years, by Medical Specialty, 2013

Source: Deloitte Center for Health Solutions (2013). Deloitte 2013 Survey of U.S. Physicians.

All phy

sician

s

Primary

care

phys

ician

s

Surgica

l spe

cialis

ts

Non-su

rgica

l spe

cialis

tsOthe

r

66% 71% 73% 61% 63%

Research and analysis by Avalere Health

Integration helps hospitals gain efficiencies through economies of scale.

Chart 6: Economies of Scale with Increasing Patient Population

Fixed costs, such as medical technologies, are spread across each patient. The more patients that need the technology, the lower the cost per patient.

Variable costs, such as labor costs, scale with the number of patients. As the number of patients increases, variable labor costs can decrease over time due to new efficiencies.

1 patient 2 patients 4 patients

Variable

Costs*

Fixed Costs

Source: Bond, R. (2012). American Healthcare Industrial Revolution: Economies of Scale and the Accountable Care Organization (ACO). ACODatabase.com.

Research and analysis by Avalere Health

Current legal and regulatory barriers are a deterrent to innovative clinical integration efforts.Chart 7: Legal Barriers to Integrated Care Delivery

Law What is Prohibited? The Concern Behind the Law Unintended Consequences How to Address?

Antitrust (Sherman Act) Joint negotiations by providers unless ancillary to financial or clinical integration; agreements that give health care provider market power

Providers may enter into agreements that either are nothing more than price-fixing, or which give them market power so they can raise prices above competitive levels

Deters providers from entering into procompetititve, innovative arrangements because they are uncertain about antitrust consequences

Additional guidance from antitrust enforcers to clarify when arrangements will raise serious issues; guidance is currently available for federally-designated accountable care organizations (ACOs)

Ethics in Patient Referral Act (“Stark Law”)

Referrals of Medicare patients by physicians for certain designated health services to entities with which the physician has a financial relationship (ownership or compensation)

Physicians may have financial incentive to refer patients for unnecessary services or to choose providers based on financial reward and not the patient’s best interest

Arrangements to improve patient care are banned when payments tied to achievements in quality and efficiency vary based on services ordered instead of tied to hours worked

Congress should remove compensation arrangements from the definition of “financial relationships” subject to the law. Arrangement would continue to be regulated by other laws.

Anti-kickback Law Payments to induce Medicare or Medicaid patient referrals or ordering covered goods or services

Physicians may have financial incentive to refer patients for unnecessary services or to choose providers based on financial reward and not the patient’s best interest

Creates uncertainty concerning arrangements where physicians are rewarded for treating patients using evidence-based clinical protocols

Congress should create a safe harbor for clinical integration programs

Civil Monetary Penalty (CMP)

Payments from a hospital that directly or indirectly induce a physician to reduce or limit services to Medicare or Medicaid patients

Physician may have incentive to reduce the provision of necessary medical services

As interpreted by the Office of the Inspector General (OIG), the law prohibits any incentive that may result in a reduction of care, even if the result is an improvement in the quality of care

The CMP law should be changed to make clear it applies only to the reduction or withholding of medically necessary services

IRS Tax-exempt Laws Use of charitable assets for the private benefit of any individual or entity

Assets that are intended for the public benefit are used to benefit any private individual (e.g., a physician)

Uncertainty about how IRS will view payments to physicians in a clinical integration program is a significant deterrent to the teamwork needed for clinical integration

IRS should issue guidance providing explicit examples of how it would apply the rules to physician payments in clinical integration programs

Hospital Squeeze Labor

Life-saving technology/Rx

Older, sicker patients

Redundant regulation

Liability insurance

Info technology

Emergency readiness

Government payment

Private payor pressure

New care delivery models

Rising uninsured

• Prospective coding offsets ($8 billion)• Site neutral payment policies

E&M code/HOPD ($10 billion) 66 additional APCs procedures ($9 billion) 12 procedures performed in ASCs ($6 billion)

• Hospital bad-debt reductions ($20 billion)• GME reductions ($10 billion)• CAH: payment reductions and qualification criteria ($2 billion)• Post acute care ($70 billion)• IPAB expansion ($4.1+ billion)• Medicaid:

State provider assessments ($22 billion) Medicaid DSH “rebasing”

Hospital Vulnerability ListOptions for offsets and deficit reduction

Impact of site neutral payment optionsMedicare Margins for Hospital

Outpatient Department Services 2007-2011 and Projected with MedPAC Proposed Cuts

Source: Medicare Payment Advisory Commission, December 2012 meeting materials and June Report to Congress.

2007 2008 2009 2010 2011 Projected w/Cut

-20%

-18%

-16%

-14%

-12%

-10%

-8%

-6%

-4%

-2%

0%

-12.2%

-13.7%

-11.7%-10.5%

-11.0%

-14.4%

-17.7%

-20.0%

E&M Only

E&M and 66

E&M, 66 and 12

President’s FY 2015 Budget

Key hospital provisions• Replace remaining sequestration with other savings• Reduce GME by $14.6 billion (proposes $5.23 billion for

13,000 new residency slots through a new competitive GME program)

• Strengthen IPAB ($12.9 billion)• $112 billion in post-acute cuts (site-neutral SNF/IRF,

60% rule, reduces updates) • Phase out Medicare bad-debt payments by $30.8 billion• Rebase Medicaid disproportionate share hospitals in FY

2024 for savings of $3.26 billion• Critical Access Hospitals: 101% to 100% and 10 mile

designation ($2.4 billion reduction)

$414 Billion in Medicare and Medicaid Cuts

The Two-Midnight Rule• CMS will generally consider hospital

admissions spanning two midnights as appropriate for payment under the inpatient prospective payment system (PPS).

• In contrast, hospital stays of less than two midnights will generally be considered outpatient cases, regardless of clinical severity.

1

On the Horizon:What’s Around the

Corner for Providers?

Moderator:• Laura Appel, Vice President of Federal Policy and

Advocacy, Michigan Health & Hospital Association

Panelists:• Gina Buccalo, MD, Chief Medical Officer, Partners

in Care• Carlos Jackson, Senior Associate Director, Federal

Relations, American Hospital Association• Michael Madden, President and CEO, The Physician

Alliance

Lunch and Networking

Challenges for the Government – The Federal Response

Tevi TroyPresident

The American Health Policy Institute

Perspectives of a Healthcare Policy Maker

Tevi Troy, President The American Health Policy Institute

Perspectives of an insiderPolicy makers inside government have different

perspectives from those in the private sector. They are often equally competent but they're looking

at things from a different angle have different bosses and different constituencies to satisfy.

In addition they are subject to different rules. The APA governs how regulations are determined and puts the development of regulations in a very tight stricture.

Perspectives of an insiderOne of the challenges in developing the website was that

policymakers had to use federal contractors, a universe with a high bar to entry, using "cost-plus" reimbursement, and requiring certifications of compliance with OFCCP, acquisition requirements, and other federal standards. 

It is true that policymakers come with results that differ from one of those in the private sector would have come up with, but much of this stems from the different perspective and the different rules the government imposes, as well as their lack of private sector experience.

Coping with a Challenging and Uncertain Regulatory EnvironmentHealth care faces significant policy challenges.

Health care environment rife with regulatory uncertainty.

Post-elections/Supreme Court/mandate delay/Shutdown fight, regulatory landscape and employer responses will determine the disposition of the ACA more than Congress in the short term.

51

OBAMA ADMINISTRATION’S TOP ISSUES

Economic Recovery

Foreign Policy & Defense

Energy & Environment

Healthcare Reform

Immigration

Education

Veterans

Taxes

Civil Rights

Disabilities

Rural Family Ethics

Poverty

Social Security

Women

Science

Oceanic PolicyTransportation

Seniors

Faith-Based Initiatives

Arts

Urban Policy

Science

Child Advocacy

HIV/AIDS

Service

Technology

Sportsmen

OBAMA ADMINISTRATION’S TOP ISSUES: Healthcare Reform• Increasing costs

• 1960: healthcare 5% of GDP

• 2011: healthcare 17.9% of GDP - $2.7 trillion

• 2021 (projected), $4.8 trillion - 19.6% of GDP• Government expected to spend $2.4 trillion (50% of

healthcare spending)

52

US Health Care CostsUS Average annual cost of health care was $8,233 per capita

-- 2.7x Japan’s in 2010U.S. households spent 6% of their annual incomes on health

costsU.S. performs more expensive diagnostic tests, such as

MRI’s and CT’sOn the other hand, the U.S. does not have an excessive

number of doctors or hospital beds relative to its population

Similarly, duration of hospital stays is not above average

53http://www.pbs.org/newshour/rundown/2011/11/why-does-healthcare-cost-so-much.html

2030 Baby Boomer Projections In 2030:

The over 65 population will be at 72,091,915 (19% of the overall U.S. population) - 40,228,712

million in 2010 (13% of overall U.S. population)

Over 21 million will be considered obese

Approx. 14 million will be living with diabetes

http://www.census.gov/prod/2010pubs/p25-1138.pdfhttp://www.aoa.gov/aoaroot/aging_statistics/future_growth/future_growth.aspx#agewww.aha.org/content/00-10/070508-boomerreport.pdf

Breakdown of National Health Care Expenditures: 1965-2010

1960 1970 1980 1990 2000 20100%

10%

20%

30%

40%

50%

60%

Private Insurance

Out-of-Pocket

Medicare

Medicaid

CHIP, DOD, VA., 3rd Party Payers, Federal/State/Local Research, Struc-tures & Equipment

Year

Perc

enta

ge o

f Tot

al N

ation

al H

ealth

Car

e Ex

pend

iture

s

Source: Office of the Actuary of the Center for Medicare and Medicaid Services

Before Reform Became Law…5 different committees

3 House 2 in Senate Two Houses of CongressHouse FloorSenate FloorConference

In Senate Reconciliation (51 votes)  or Regular Order (60)

Presidential Signature

56

57

58

Type Pre-enactment

Upon enact-ment

6 months post enact-ment

By Jan 1, 2011

1 year post enact-ment

1 year post enactment to Jan 31, 2011

Jan1, 2012-Dec 31, 2013

2014-2020

Total Percent of total

Medicare 7 29 7 44 7 11 34 24 163 35Medicaid 5 3 3 7 4 2 3 17 44 9CHIP 0 0 1 1 1 0 2 0 5 1Public health

1 44 6 5 5 4 9 5 79 17

HHS 0 0 2 0 1 0 1 0 4 1Taxes 3 3 1 6 0 0 10 12 35 7Insurance 0 3 12 2 3 1 9 21 51 11Long-term care

0 0 0 0 0 0 2 0 2 <1

IHS 1 68 1 0 7 4 5 0 86 18Total 17 150 33 65 28 22 75 79 469 100Percent of total

4 32 7 14 6 5 16 17 100

Analysis of CHT Timeline

60

How did we get here?

Intense effort to micromanage• The Affordable Care Act (ACA) has required almost

20,000 pages of regulations, elaborating on the original 2,700 page law.

• Can be very specific. Consider Section 4102 of the ACA, which states: "The secretary shall develop oral healthcare components that shall include tooth-level surveillance.”

• Not necessarily welcome: 51% of doctors percent felt that the law would have a negative impact on their relationships with their patients

61

Outlook of the next four yearsACA will not be overturned before 2017Implementation challenges greater than expected,

but do not change the central dynamic:Democrats will never admit full extent of the

law’s shortcomings Republicans will never call the law a success

even if it works as promised How should people judge the law?

Judging the LawEvaluate the law based on its 3 main goals

Universal coverage

“Bending the cost curve”

The guarantee of the ability to keep current plan

Promise: Universal CoverageRanging number of uninsured, between 30 – 47

million peopleMoral imperative to cover people Most expansive definitions of the uninsured that

President Obama used included both illegal immigrants, as well as individuals, who were already eligible for public assistance, but not partaking in it

Promise: “Bending the cost curve”President Obama claimed he would reduce premium costs

by $2,500 for a family of fourThere is tension between the goal of universal coverage and

the effort to bend the cost curve

Promise: “If you like your health care you can keep it.”Became standard response to the public’s skepticism

of the ACAPresident Obama mentioned it nearly every time he

spoke of the lawSome sources say he said it hundreds of times

The promise was to ensure Americans that the law would not affect 85% of Americans that already had health insurance

Other metrics to evaluate ACA imposes $1.1 trillion in new taxes over the first 10

yearsEmployers are trying to stay under 50 employees, or

30 hr thresholdHealth care market has been one of the only sectors

continuing to hire during the recessionIn September 2013 there were more layoffs among

health-care providers than in any other industry

Legislation - GOP AlternativeSenate Republican Proposal

Keeps most popular provisions of the ACA o Guaranteed issue, coverage of dependents to age 26, no lifetime

limitsRepeals more than a dozen ACA taxes and the employer mandateProvides continuous coverage protection for pre-existing

conditionsGives tax credits to people who are not employed at large

companiesLimits tax exclusion of employer provided health benefits to 65

percent of plan costs.

68

American Health Policy InstituteAmerican Health Policy Institute

AHPI is a non-partisan 501 (c)(3) think tank focused on health care policy and the employer-based system.

AHPI will be looking at: how the ACA affects employers; what employers are doing about ACA; and policy recommendations.o The first study from AHPI will be on employers costs

under ACA

69

Going forward?Democrats are adamant the law stay in place.Republicans are adamant the law goes. This dynamic means there is no pathway for real improvement

of changes during the remainder of the Obama administrationEmployers need to chart a path forward, recognizing that they

will get little help from Washington. This requires two steps:Creating health care plans that work for employers and

employees within the current structureLaying the groundwork now that will have to come in the future

administration

Transparency: The Root of all Reform

Jay Want, MDPrincipal

Want Healthcare, LLC

The Transparency Remedy

Will seeing what you’re buying increase value?

Searching for the cure to health care costs…

Units X Price = Cost, right?Quick Quiz: What causes American Health

Care to be more expensive than HC in other countries?

• We uses more stuff, i.e., it’s a units problem, mostly.

• The stuff we use is higher priced, i.e., it’s a price problem, mostly.

• Both in roughly equal measure.

How did it get this way?• Fee for service= accountability for activity,

not for outcomes• Industry consolidation for two decades =

oligopoly formation• Third party payer system: those who use

the service and provide the service don’t pay for the service = moral hazard

Where current reform schemes work

• Units– Pay for performance– Nonpayment for

readmissions– Bundles– Capitation

• Prices– Benefit design, e.g.

reference pricing– Price transparency

Providing Answers to:

Consumers…“How much will my knee MRI cost and what are my best options?”

83

Businesses… “Which health plan provides the best value

providers for our premium?”

“How does cost, utilization and

quality compare between public

and private payers?”

Providers and Facilities… “How do I

compare to my peers and

demonstrate value?”

Legislators and Policy Experts…

  State Statewide or partial geographic area

Statutory or voluntary

Provides consumer focused reporting

Currently collecting data?

Currently doing any kind of public reporting?

1.        Maine Statewide Statutory Yes Yes Yes

2.        NH Statewide Statutory Yes Yes Yes

3.        VT Statewide Statutory   Yes Yes

4.        MA Statewide Statutory Yes Yes Yes

5.        MD Statewide Statutory   Yes Yes

6.        KS Statewide Statutory   No No

7.        UT Statewide Statutory   No No

8.        TN Statewide Statutory   No No

9.        MN Statewide Statutory   Yes No (reports are not public)

10.    Colorado Statewide Statutory   Yes Yes

11.    Oregon Statewide Statutory No Yes No

12.    Wisconsin Partial Voluntary   Yes No

13.    Washington State

Partial Voluntary   Yes No

Status of state APCDs• 11 statewide, statutory APCDs, including Colorado, that

have collected data. There are two states that have voluntary data for part of the state (WI, WA).

•  • Oregon has not issued any reports yet, so that is why the

count is often “10 APCDs.”•  • Seven states have issued reports at one time or another.

(ME, NH, VT, MA, MD, KS, UT).•  • Five states allow data release:  ME, NH, VT, MA, CO•  • Three states do consumer focused reporting:  ME, NH,

MA and soon CO

86

Highlights from New Release

88

89

Snapshot Reports Highlighting Variation

Will market forces regulate prices?

• Motivated purchasers/consumers– Benefit design, high deductible– Reference pricing strategies

• Transparent pricing• Transparent and relevant quality• Willing competitors

– Centers of excellence strategies

CMS moving toward greater transparency

CMS NEWS Feb. 21, 2014Quality Data Added to Physician Compare WebsitePatients Get More Information to Help Find a Doctor Today, the Centers for Medicare & Medicaid Services (CMS) announced that for the first time, quality measures have been added to Physician Compare, a website that helps consumers search for information about hundreds of thousands of physicians and other health care professionals. The site helps consumers make informed choices about their care.

What you’d want to make prices real and accurate

• Paid amounts, not charges• Large database so results are statistically

significant• Acuity adjustment methodology that

doesn’t penalize providers who take care of sicker patients

Take Homes• While we have room to improve on how

much HC we use, we’re not that different from others in this regard

• Where we do differ is that our prices are much higher for the same services

• While much of HC cost containment to date has been focused on lowering utilization (units used), we must focus attention on prices as well

Take Homes

• One of the ways we might get better pricing is more transparency

• APCDs offer the chance to get the biggest datasets available

• Oligopolies generally oppose transparency, as they are designed to maintain higher prices and to avoid price competition

Ed WolkingExecutive Vice President

Detroit Regional Chamber

LEAPFROG HOSPITAL RECOGNITION PROGRAM (LHRP)

2013 MICHIGAN HOSPITALSMercy Memorial Hospital SystemMetro Health HospitalOSF St. Francis HospitalPort Huron HospitalSaint Mary's Health CareSinai-Grace HospitalSparrow Hospital & Health SystemSparrow Ionia HospitalSpectrum Health Blodgett HospitalSpectrum Health Butterworth HospitalSpectrum Health Gerber MemorialSpectrum Health Kelsey HospitalSpectrum Health Reed City HospitalSpectrum Health United HospitalSpectrum Health Zeeland Community HospitalSt. Joseph Mercy Hospital, Ann ArborSt. Joseph Mercy Livingston HospitalSt. Joseph Mercy OaklandSt. Joseph Mercy Port HuronSt. Mary Mercy HospitalThree Rivers HealthUniversity of Michigan Hospitals and Health CentersWar Memorial Hospital

Botsford HospitalBronson Battle CreekBronson Methodist HospitalCarson City HospitalChelsea Community HospitalChildren's Hospital of MichiganClinton Memorial/Sparrow ClintonCovenant Medical Center Harrison CampusDetroit Receiving Hospital/University Health CenterDickinson County Healthcare SystemGenesys Regional Medical CenterHarper-Hutzel HospitalHelen DeVos Children's HospitalHillsdale Community Health CenterHuron Medical CenterHuron Valley-Sinai HospitalMcLaren - Northern MichiganMercy Health Hackley CampusMercy Health Mercy Campus

TOP HOSPITALS IN MICHIGAN - 2013 Recognition for top performing hospitals - Leapfrog Hospital

Survey Top Hospital (hospitals coded as Urban)

DMC Detroit Receiving Hospital and University Health Center Mercy Health Saint Mary's

Top Children’s Hospital DMC Children's Hospital Of Michigan

Top Rural Hospital (includes Critical Access Hospitals) OSF St. Francis Hospital & Medical Group Spectrum Health Kelsey Hospital

Regional Initiatives: Detroit and

Michigan-Miles to Go Before We Sleep?

Moderator:• Kirk Roy, Vice President, Office of National Health

Reform, Blue Cross Blue Shield of Michigan

Panelists:• Kate Kohn-Parrott, President and CEO, Greater

Detroit Area Health Council• Christopher Priest, Senior Strategy Advisor, Office

of the Governor

Roundtables and Networking