In the final part of our series, John Dalton looks at how the American health system can narrow the gap from the rest of the developed world and attain the Triple Aim. The Triple Aim is the approach to optimizing health system performance by improving patient experience of care, the health of populations, and reducing the cost of health care. John discusses some features that America could adapt from the health systems in France, Germany and the UK. John also covers some of the obstacles that currently block the path to Triple Aim and looks towards the future and how America can narrow the widening healthcare gap. About the author: John Dalton joined BESLER as Senior Advisor in November 2005 after retiring from NCO Financial Systems where he was Vice-President, Sales and Marketing. He worked closely with Kathy Ruggieri in launching the Transfer DRG and IME products, as well as broadening our geographic footprint, breaking into several states where BESLER had not gone before. John retired at the end of 2010, but has continued to be active, serving on the Board of Trustees of the St. Joseph’s Healthcare System where he chairs the Strategic Planning Committee and as Honorary Trustee at Children’s Specialized Hospital, serving on the Audit & Compliance Committee. He’s also been active at Stevens Tech, where he recently wrote and produced two 20 minute videos, “Stevens & Sons: America’s First Family of Engineers,” and “Tales from Castle Stevens.” He was the 2013 recipient of the Stevens Alumni Award. John is a former New Jersey Chapter President and National Board member. He received HFMA’s 2001 Morgan Award for lifetime achievement, recognizing his work in professionalizing revenue cycle management. John is the only New Jersey Chapter leader to receive that honor. He is a frequent contributor to Garden State FOCUS, and serves as Master of Ceremonies at the Chapter’s Annual Institute. John has a bachelor’s degree in mechanical engineering from Stevens Institute of Technology and an MBA degree with a major in finance from the Stuart School of Management at Illinois Institute of Technology. In his leisure time, John enjoys grandkids, golf, travel, and running.

1. American Healthcare:
Worst Value in the
Developed World?
Part 3: Can America narrow the gap
and attain the Triple Aim?
John J. Dalton, FHFMA
Senior Advisor Emeritus

2. Disclaimer
• The opinions expressed in this presentation and on the following
slides are solely those of the author based on nearly fifty years of
involvement in healthcare as consumer, consultant, regulator,
employer and hospital trustee. They do not necessarily reflect the
views of BESLER Consulting, the St. Joseph’s Healthcare System or the
Healthcare Financial Management Association, and neither
organization guarantees the accuracy or reliability of the information
provided herein.
• Rather, the presenter hopes to stimulate debate and discourse
directed towards broadening America’s goals from “healthcare” to
“health,” and reducing the value gap with the rest of the developed
world.

3. Can America narrow the gap and attain the Triple Aim?
• Love him or hate him, on health care for all,
the Senator from Vermont is right: Single
Payer produces the best results.
• Can it ever happen in America? Highly
unlikely given its reliance on taxation for
funding (although the VA system and Indian
Health Service are single payer systems).
• Are there options available that will produce
better outcomes and begin to close the gap
with the rest of the OECD? I believe so.
• Let’s explore what elements we can apply
from France, Germany and the UK to help the
U.S. achieve the Triple Aim.

4. Can America narrow the gap and attain the Triple Aim?
To begin, let’s identify some elements that already exist in
the U.S. health care system:
• Starting with the HMO movement in the 1980s,
Americans reluctantly have learned to live with limited
freedom of choice and narrow networks.
• Large numbers of Americans receive health care coverage
through their employer.
• The ACA included an insurance mandate, albeit a watered
down one.
• Ten essential health benefits are mandated, including
doctors’ services, inpatient and outpatient hospital care,
prescription drug coverage, pregnancy and childbirth,
mental health and rehabilitation services.

5. Can America narrow the gap and attain the Triple Aim?
What might America adapt from Germany, France and the U.K.? Here
are seven starters worth debating:
• Move aggressively to attain full interoperability to reduce
administrative costs.
• Emulate the French approach of a mandated core benefits package
with the opportunity to purchase supplemental insurance for
expanded coverage.
• Adopt Germany’s employer-based insurance mandate coupled with
competition among not-for-profit insurers for base coverage.
• Copy either France’s patient payment at time of service or Germany’s
patient co-payment approach.

6. Can America narrow the gap and attain the Triple Aim?
What might America adapt from Germany, France and the U.K.?
Here are seven starters worth debating:
• From all three, maintain primary care providers as private
practitioners.
• Provide incentives for medical students to select primary care
(e.g., forgiveness of student loan debt over 15-20 years) to
correct the current imbalance between primary and specialty
care.
• Encourage not-for-profit health care leaders to engage more
closely with social services providers in the communities that
they serve.

7. Can America narrow the gap and attain the Triple Aim?
Competing Interests – Conflicting Priorities
• In July, the Department of Justice filed suit to block the proposed
Anthem-Cigna and Aetna-Humana mergers, contending that they
“would leave the multi-trillion health insurance industry in the
hands of three mammoth insurance companies.” Aetna responded
with the corporate equivalent of a hissy-fit, eliminating its ACA
exchange participation in 11 states, claiming $430M losses since
January 2014.
• Conversely, CEO Bernard Tyson of $61B Kaiser-Permanente is
sticking with the exchanges long term. “I view it through the lens
of my mission. It obligates us to figure it out, not to get out.”
(Modern Healthcare, August 22, 2016, p. 9) He noted that the
market is unstable given adverse selection and underpricing by
some plans to capture market share. “Over time it’s going to work
itself out. This is not rocket science.”

8. Can America narrow the gap and attain the Triple Aim?
Competing Interests – Conflicting Priorities
• The EpiPen’s been around since 1977, but Mylan acquired
the autoinjector in 2007 when they were selling for $57
each. They now cost more than $600 for a two-pack.
People who suffer from anaphylaxis need to keep them
handy at all times.
• Turing bought Daraprim in 2015 and raised the price from
$13.50 to $750 a pill. It is the only cure for toxoplasmosis,
a disease that strikes people whose immune systems are
suppressed (e.g., AIDS and cancer patients).
• Valeant boosted the price of its diabetes drug Glumetza by
about 800% in 2015. The company acquired Carac cream
in 2011, and the price for the treatment of cancerous skin
conditions rose by 1,700% in six years.

9. So Where Do We Go From Here?
Expand and Embrace! Repeal and Replace!
O
B
A
M
A
C
A
R
E

10. Can America narrow the gap and attain the Triple Aim?
Here are the candidate’s platforms.
Hillary Clinton: Universal, quality,
affordable health care for everyone
in America
• Bring down out-of-pocket costs
• Reduce the cost of prescription
drugs
• Protect consumers from unjustified
prescription drug price increases
• Incentivize states to expand
Medicaid
Donald Trump: Congress must act
• Completely repeal Obamacare
• Allow sale of health insurance
across state lines
• Remove barriers to entry into free
markets for drug providers that
offer safe, reliable and cheaper
products
• Block-grant Medicaid to the states

11. Can America narrow the gap and attain the Triple Aim?
Here are the candidate’s platforms.
• Allow families to buy health
insurance on the health exchanges
regardless of their immigration
status
• Expand access to rural Americans,
who often have difficulty finding
quality, affordable health care
• Defend access to reproductive
health care
• Double funding for community
health centers, and support the
healthcare workforce
• Allow individuals to deduct health
insurance premium payments from
their tax returns
• Allow individuals to use Health
Savings Accounts (HSAs) with tax-
free contributions, and allow them
to accumulate as part of the
individual’s estate
• Require price transparency from all
healthcare providers

12. So Where Do We Go From Here?
Expand and Embrace! Repeal and Replace!
O
B
A
M
A
C
A
R
E
Amend, but Extend!

13. Can America narrow the gap and attain the Triple Aim?
Social Services – the Seventh Starter
• May 2016 Health Affairs – “Variation In Health Outcomes:
The Role Of Spending On Social Services, Public Health, And
Health Care, 2000–09”
• “States with a higher ratio of social to health spending
(calculated as the sum of social service spending and public
health spending divided by the sum of Medicare spending
and Medicaid spending) had significantly better subsequent
health outcomes for the following seven measures: adult
obesity; asthma; mentally unhealthy days; days with activity
limitations; and mortality rates for lung cancer, acute
myocardial infarction, and type 2 diabetes.”
• Many of the states with higher ratios of social to health care
spending were in the West, while those with less healthy
spending patterns were in the South.

14. Can America narrow the gap and attain the Triple Aim?
Social Services – the Seventh Starter
In reviewing 74 research studies they found that three
types of services are particularly meaningful:
• supportive housing;
• nutritional support (such as in-home meals for older
adults and WIC supplemental nutritional services);
• some case management and outreach programs.
“Broadening the debate beyond what should be spent on
health care to include what should be invested in
health—not only in health care but also in social
services and public health—is warranted.”

15. Can America narrow the gap and attain the Triple Aim?
Social Services – the Seventh Starter
• “if a patient attributed to us has diabetes and we keep
that person out of the hospital, we are rewarded in a
population health model. But if we invest in preventing
community residents from ever getting diabetes in the
first place, we’re paid nothing extra…Even under the most
advanced population health models, there is no way to get
paid for improving the long-term health status of the
community.”
• “If you visit the home of an asthmatic child and you
remove mold and allergens from that home, it
dramatically reduces that child’s likelihood of coming into
the emergency room.”
Dr. Kenneth Davis, CEO, Mount Sinai
Health System, NYC; MH 6/20/16.
Dr. Steven Corwin, CEO, New York-
Presbyterian, MH 8/15/16

16. Can America narrow the gap and attain the Triple Aim?
Yes – with leadership from not-for-profit healthcare!
• Attaining the Institute for Healthcare Improvement’s
“Triple Aim” will require going beyond our comfort
zones. We already excel at diagnosing, treating and
curing the patients who receive care in our hospitals.
• However, improving the health of the population in
our service areas requires reaching out into the
community’s social services safety net to foster better
health habits among consumers, something over
which providers currently have little or no control.
• Hospitals that succeed in providing better care while
improving healthy behaviors in the communities they
serve will lower the per capita costs of care and
produce better outcomes on the key health indicators.

17. American Healthcare: Worst Value in the Developed World?
Contact Information:
John J. Dalton, FHFMA
Senior Advisor Emeritus
BESLER Consulting
Email: jjdalton1@verizon.net
Tel. No.: 732-310-8782