Monday, July 27, 2009

Re-making up is hard to do

This article by Kevin Sack in the New York Times provides an excellent description of person-on-the-street reactions that explain why change in health care is hard to do. Note, this is not ideological stuff. It is just normal people's reactions.

The President tried hard from the outset to sell the proposition of providing access, controlling costs, and enabling consumer choice. He decided he had to stay away from terms like rationing and general tax increases. But people understand that you can't give everything to everybody without taking something away from somebody or asking for general sacrifices. As the debate over health care reform continues after the summer, it will be interesting to see how the various plans are modified and explained.

Some people have asked what I would do if I had the magic wand. Here's the simplified list of my major recommendations. My goals would be: Providing access and security to people; covering the costs of that access in a broad-based manner consistent with a national priority; limiting the expansion of uneconomic new technologies; and shifting the payment regime to the part of the health care system best able to control costs in the long run. I have tried to pick ideas that are properly jurisdictional at the national level, only preempting state jurisdiction where necessary for the sake of uniformity.

1) Eliminate the nasty practices of insurance companies by requiring them to take all applicants, eliminating pre-existing condition restrictions, and the like. In essence, provide a preemptive overlay of national regulation of health care insurers above state regulation. This would provide assurance to people that, when they changed insurance providers, they could maintain coverage. Do not create a public insurance plan.

2) Provide subsidies to people, based on income, to enable them to purchase insurance. Under the national regulatory scheme mentioned above, require a spectrum of insurance packages so people could have choice of several levels of coverage, from basic to advanced. Require people to enroll in one. (These provisions are the core of the Massachusetts access model.)

3) Pay for the subsidies by eliminating the current pretax treatment of insurance benefits and applying new taxes in areas that would, themselves, contribute to a healthier population (cigarettes, sugar content, and the like).

4) Create a national standards board that would review new medical diagnostics and therapies and equipment for cost-effectiveness, to supplement the efficacy determinations made by the FDA. Do not prohibit non-cost effective remedies, but make them ineligible for insurance coverage.

5) Revamp the payment system to shift emphasis to primary care providers so that they no longer serve in a mere triage function, but in fact have the time to properly manage a patient's care. Whether this is done by shifting payments within the fee-for-service environment, or moving to capitation, or a combination, would be subject to regulation by each state for the private insurers. For Medicare, the determination would have to be for the country as a whole.

I am not wise enough to judge the political acceptability of this package in Congress, but friends I have talked with so far have indicated that they like the themes. I'm happy to get your comments.


eglovsky said...

Good ideas, but what happens to people with pre-existing conditions? If we only provide insurance for the healthy, it leaves a huge chunk of people without insurance, or only with access to insurance with huge premiums.

Paul Levy said...

Please see item #1. I think I covered that.

Anonymous said...

Well, good for you for having the gazongas to put your specific ideas out there, better than Obama OR most of Congress.
Your #'s:

1. I reiterate, I saw nothing in the existing bill about regulating premiums. If Insurance is forced to cover everyone without some sort of premium control, those of us outside employer-sponsored insurance will continue subsidizing others, making our (and maybe everyone's) premiums unaffordable.

4. The National Standards Board used to exist, called something like Agency for Health care technology assessment. It disappeared. Also recall that the AHRQ suffered a death and resurrection when it said that back surgery is largely unnecessary (since backed up by solid evidence). It was killed by the orthopedists with the assistance of Congress. Also witness the gyrations of the FDA under pressure.
This new board would have to be COMPLETELY immune to political meddling; I don't know how.
In addition, some technologies are at first ineffective and then improve with modification. The Board would have to be quite flexible in reviewing these things.

5. Shifting to primary care prominence will require modification of family practice/internal medicine residencies to emphasize areas in which training is now deficient; e.g. presentation with a surgical-type problem. Example: an acquaintance with whom I garden had pain and swelling (no redness) of her dominant hand index finger metacarpal (where it joins the palm). Her primary did a million dollar workup with innumerable lab tests, imaging, etc. to r/o everything,(all normal) and is NOW sending her to an orthopod. Half of those tests would have been unnecessary if one lab test (ESR, a nonspecific indicator of inflammation) were normal. My bet is the orthopod will take one look at it, do some simple physical exam tests, and make a diagnosis. So which is cheaper?? My money is on the orthopod.

Not to criticize, as we must get something done this year. Just illustrating the complexity of the problem. My idea is, like you have done with quality improvement - just jump in with SOMETHING and then learn and modify as you go along.

nonlocal MD

fairhavenhorn said...

I would add two items and adjust two of yours. The adjustments are:
1. Add to the insurance availability changes steps to ensure that employment and insurance are separated. Most employers try hard to pick insurance that is suitable, but it is unreasonable to expect one employer selection to be appropriate for all of their employees. Also, allowing employers to restructure employee medical relationships at will and synchronizing job loss with insurance loss is counter-productive.
2. Change the cost effectiveness measure into an effectiveness measure. Costs change independently of effectiveness. Effectiveness is often highly dependent upon the situation. With an effectiveness measure, the patient and physician can make better cost effectiveness decisions.

This leads to the two new ones:
1. Eliminate secret prices. This is not only secret deals between hospitals and insurers. It includes prices for procedures and drugs. I've heard far too many physicians complain that they don't know what different drugs will cost their patient and they feel guilty about possibly prescribing drugs that are too expensive.
2. Add patient education and responsibility. This change will take time, but it is already demanded by younger patients. They want to be part of the decision process. We also need to place some
limits on the "frequent fliers" that continually demand service. (I'll admit to having little sympathy for patients who won't pay
$10 for 3 month supply of blood pressure medicine and demand that insurance cover it. These patients are not so poor that they cannot find that money.)

The patient education may eventually lead to the cultural shifts needed for some of the other cost savings. I would wait on these.

One expensive American cultural trait is the "Doctor, do everything possible to save beloved grandma." In the 1950's this was a reasonable request. Technology and medicine had not reached the point that futile care was a serious problem. But now, it's fairly easy to add a week or two of futile care to the end of life medical costs. This is very expensive care with no realistic expectation of meaningful recovery. You can see changes in these cultural attitudes already. I would let education and experience with making other healthcare care decisions drive the cultural changes.

Paul Levy said...

While I might agree with some of those ideas, I don't necessarily agree that they are all ripe or right for national legislation. For example, if employers want to offer an insurance plan that is "better than average" to attract staff, why shouldn't they be allowed to. Ditto for patient responsibility issues. I don't see those as topics for federal legislation.

But I admit, this is all new territory. Let's see what others say.

Anonymous said...

I wonder If removing the current pretax treatment of insurance benefits and increasing taxes on things that aren't good for you will create enough money to provide subsidy for all the people who aren't currently insured. In addition, how will you determine if someone's insurance coverage is adequate? Will this be done by the national health board you are advocating?

fairhavenhorn said...

A suitable federal phrasing for breaking the employee-employer relationship would just be separation of the benefit amount (X dollars toward insurance) from the chosen insurance vendor. If employees like the employer selected insurance, let them use it. If the employees want to continue with an existing insurance relationship, let the X dollars go toward that one. That's sufficient for me. It places the decision with the employee, while allowing employers to compete on insurance offerings if they want to.

As for patient responsibility, there are many immensely intrusive federal efforts proposed already. I don't mind killing all of them. But steps to enable patient access to information, decisions, etc. are reasonable.

Jerry said...

Well, Tip O'Neil famously said, "All politics is local," and while you may have said "this is not ideological stuff" to emphasize the rational nature of your reccs, the matter of reforming health care financing is most certainly an ideological issue.

I think this early quote from the linked story says as much, "What we do know is there is going to be more government control, and with more control you’re going to have fewer choices. It’s an innate part of being American to have those choices.”

I also think that the linked story is, by its own nature and emphasis, ideological. The overriding narrative is based on conflict, not information.

Commercial media loves conflict, but not the policy-wonk details that would inform a productive discussion.

I think the public has been left dangling here, in the same way that most people enter the hospital uninformed and entirely at the mercy of others.

The subject of our individual health is big, scary, and not something we even want to think about unless we absolutely have to - when it's often too late.

I also think that delay is the enemy of change, and that the well-heeled opponents of meaningful reform know that their only game is to run out the clock.

I think that this is a pretty good assessment of the state of things as they currently stand.

I also point to this in support of an earlier comment of mine, which you took exception to, where I called folks like Kent Conrad 'nominal Democrats.'

It's a prime example of simply delaying the game, but no foul's been called.

There's way too much money at stake for everybody involved, and for too many, health care is a goose laying big fat golden eggs.

I very much like your magic wand approach - not the details of your particular wave so much as the plain idea of waving the wand in the first place.

I'm gonna chew on those pieces of yours for a bit, and toss out a few of my own.

Peace out.

Ray Brown Scholar said...

I agree with your thoughts that some type of national regulation of health care insurers is needed rather than the creation of a public health plan that I'm assuming is meant to force the insurers to change their behavior based upon a competitive threat.

Barry Carol said...

Paul – I agree with your list.

The two that I would add are (1) malpractice reform which would move medical dispute resolution to special health courts instead of juries and give doctors a robust safe harbor from failure to diagnose cases if they followed evidence based protocols, and (2) change the default protocol around end of life care from “do everything” to allow doctors to apply common sense depending on circumstances without having to worry about being sued. We should also find ways to proactively increase the number of people who execute living wills or advance medical directives and ensure that the information is readily available to doctors and hospitals when needed.

Your #3, taxing health benefits, would increase revenue by more than $200 billion annually according to the CBO. Unfortunately, the impact on middle class wage earners with family coverage could easily exceed several thousand dollars per year even if the taxation of benefits did not also include FICA payroll taxes. This is why the unions so vehemently oppose the concept. In theory, we could reduce income tax rates and/or raise the standard deduction to mitigate or even offset the impact of health benefits taxation on the middle class which would be my preferred approach to this issue.

Finally, user friendly, robust price and quality transparency tools that made provider contract rates available to both patients and referring doctors would be helpful. If we expect referring doctors to steer patients toward the most cost-effective providers and the most cost-effective drugs, we need easy to use tools that would provide them with that information.

Jim Roosevelt said...

Paul, to a great degree, #1 on your wish list already exists in Massachusetts. No health insurers in this state are allowed to base coverage on health status, so the good news for all of us is that there is no denial of care for pre-existing conditions or waiting period for coverage. Also, the board of directors of America's Health Insurance Plans, the organization that represents health plans from around the country, has publicly stated support for "guaranteed issue," which is what we have here in Massachusetts. That's good news for all of us who believe that we can achieve universal coverage without a government-run insurance plan.

Paul Levy said...


Thanks for pointing that out. I had forgotten to mention those attributes of the MA insurance laws, but that is what made me comfortable about applying them nationwide. Good to see agreement from AHIP.


I agree that the taxes needed could be collected in a more progressive fashion if the suggestions you make are added.

I think the likelihood of tort reform is so small that I did not include it. On end-of-life care, I agree, but wonder why it is necessary for federal legislation, as opposed to leaving it to state jurisdiction.

76 Degrees in San Diego said...

Point #1 - eliminate "preexisting". OK, if you eliminate this, then the other two variables come into play: premium price, and benefit level. Interestingly, this only applies to the PPO/indemnity plans. For "fun", try "problem #2" -

Point #5: Promoting primary care This is best done with a medical group. There are clearly regional variations in disease. Here in SD, we don't smoke and we eat salads(somewhat). But, we are out in the sun (sorry about your rain this year-but we could use some). So, maybe we have less COPD patients and less vasculopaths, but more skin cancer expenses. So, our medical group distribution of expense could be different than in Boston, I assume.

For individual physicians to enter into negotiations with any insurance monolith (private or governmental) is an exercise in total frustration. If physicians join together for the expressed purpose of negotiation, it is considered a violation of the antitrust act.

So, in the end, it seems that physicians need to find themselves in large legal entities that encourage optimal care(outcomes) and enable negotiation.

Anonymous said...

Paul, I agree with not creating a public insurance plan. Wholeheartedly. And yet, I know that there has to be a way to get the uninsured covered. Eliminating the nasty insurance practices would be a great start-the only question is how? Since they are primarily for- profit, I don't see how they will ever give up predictive modeling. It seems politically impossible, given their lobbying power and the American stronghold- protecting Capitalism. Do you have any suggestions for how the government can legislate to remove or restrict these common business practices of insurance companies? Thank you, Megan

Paul Levy said...

Hi Megan,

See Jim's comment above. There has been state legislation in MA regulating insurance companies. There is no theoretical reason Congress can't do the same. It takes political will, though.

Jerry said...

1) Eliminate the for-profit health insurance industry. It adds costs without adding value; it functions solely as a bureaucratic layer of interference between patients who need health services and the individuals and organizations providing them.

Establish a national single-payer mechanism for financing health care services. Base the enabling legislation for this mechanism on the following:"to protect, promote and restore the physical and mental well-being of residents of United States and to facilitate reasonable access to health services without financial or other barriers."

2) Pay for the national single-payer mechanism by a combination of the following:

a) Reduce spending in the Department of Defense by $100-200B over the next three years, and re-direct those cuts to funding the single-payer mechanism;

b) Return the income tax rate on incomes above $250,000 (individuals) and $400,000 (married couples filing jointly) to those rates that were in place in 1980;

c) Ditto on taxes for capital gains, and on income from dividends and interest, subject to an exclusion for those whose income from these sources is less than 10% of their total income;

d) Ditto on the inheritance/estate tax, with an exclusion for estates valued at less than $1M.

3) It seems that waving the magic wand is something that only the President, or somebody who had the President's ear, would actually get to do. So, as I (or the President I'm advising) waved the wand to get this party started, the following call to action would also be made:

a) Addressing health care in the U.S. in a meaningful and comprehensive way requires the mobilization and participation of every American, on a scale as great as the effort to fight WWII, meet the challenges of the Great Depression, and put a man on the moon - combined. It's a long-term, multi-generation effort that needs to touch every aspect of our lives, every day.

b) Along with the previously-stated measure to fundamentally adjust how health care services are financed, other areas of local, state, regional, and national policies in other spehers must take individual and public health into account. These include transportation, energy, agricultural, housing/development, labor, and environmental policies. Programs and activities in these spheres must be evaluated for their health impact, just as projects and activities are currently evaluated for their environmental impact.

c) A full-scale effort to combat obesity and hunger;

d) Comprehensive health education at every level of public schooling, including content on nutrition, physical and emotional fitness, sexuality, and reproductive health, along with opportunities for students to engage in community service activities in these, and related, topic areas.

e) A full-scale effort to increase the number and quality of medical and nursing school faculties, coupled with programs to support enrollment increases at schools of medicine, nursing, and other allied health professions.

f) Programs and incentives to identify and address underserved areas, both with regards to communities in need of improved health services, as well as health disciplines that are deficient in personnel.

g) An ongoing assessment and re-allocation of resources, to avoid and eliminate the kind of economically-unsound duplication of services often seen in urban areas with multiple tertiary care teaching facilities whose combined capacities exceed the needs of their service areas.

h) An ongoing discussion at all levels regarding end of life care, and the role of the health system and individuals to guarantee comfort, dignity, and family/community bonding at end of life, because as John Maynard Keynes said, "In the end, we're all dead."

That's my two cents/magic wand, anyway.

Anything less than what I've proposed (mandated?) is just frittering away along the edges, ultimately to little or no real effect. IMO

Barry Carol said...

I would give pretty good odds that Jerry’s recommendations regarding sharply raising taxes and tax rates on high income people would not affect him personally. It sounds like yet another example of the attitude toward taxation among much of the population attributed to the late Senator Russell Long which he characterized as “Don’t tax you, don’t tax me, tax that fella behind the tree.” Or, with respect to healthcare reform more generally, it’s reform healthcare by all means, but whatever you do, don’t cut me or ask me to make any sacrifices, financial or otherwise.

For the record, I think federal income taxation under President Clinton (39.6% top rate) struck about the right balance. If we went back to those rates, it would result in a material federal income tax increase for my family as would the taxation of employer provided health insurance which I also support.

Jerry said...

I post a comment containing over 600 words, and Barry responds to 2 of them.

Oh, well, at least is is a response.

Obama's already proposed returning to Clinto-era tax rates on the highest wage earners, and that generated plenty of demagoguery, too.

Personally, my portfolio includes shares of BRK-b, and I've always been interested in what Warren Buffett's had to say about taxes.

To paraphrase a recurring statement in his annual letter to shareholders, Buffett says he's happy when Berkshire's corporate income tax payment goes up, because it means that Berkshire's earnings have also gone up.

He's also pointed out that if the 150+/- largest corporations paid taxes at the rate that Berkshire does, there would be no need to tax any other corporation or individual to meet current federal spending and obligations.

Buffett is critical of the current system for "allowing him to pay a lower rate than his secretary and his cleaner."

Here's one account of Buffett's remarks on that subject.

Then again, that's just Warren Buffett.

Barry Carol said...

Jerry – I’m a Buffett fan too and have owned stock in Berkshire Hathaway for over 20 years. I’m very familiar with his comments about his effective tax rate vs. his secretary’s. He opposes eliminating the estate tax and so do I. The bulk of his income comes from capital gains and qualified dividends which are currently taxed at 15%. I seriously doubt that he would support a return to the marginal tax rates that were in effect in 1980 which were, I think, 50% on earned income (wages and salaries) and 70% on investment income (interest and dividends). That’s a different world from the Clinton era top rate of 39.6%.

That all said, it is important to note that Warren Buffett, through Berkshire Hathaway, built most of his wealth with the help of tax deferral, also known as “inside buildup.” He paid himself a modest salary of $100K, and the company never paid a cash dividend. Instead, profits were reinvested in the company. Since he owns over 30% of Berkshire, he was able to build his wealth without paying taxes on his pro rata share of Berkshire’s after (corporate) tax profits. Since he is also donating the bulk of his wealth to the Bill and Melinda Gates Foundation, he is not paying estate taxes either. While the Gates Foundation gift is admirable, he at least gets to choose who benefits from his largesse. With all due respect to Buffett, there is at least a bit of hypocrisy here.

Finally, I think you either misinterpreted his comment about corporate taxes or it’s just not accurate. According to the Congressional Budget Office (CBO), pretax corporate profits in 2006, a good economic year, were 13% of GDP. If that entire amount were taxed at the full federal corporate rate of 35%, it would have raised only about 4.5% of GDP. Total federal revenue is about 18% of GDP including roughly 10% of GDP from individual income taxes alone.

As it relates to healthcare and health insurance reform, there is no question that there is room to raise taxes on high income people within reason. It won’t get the job done by itself, however.

Anonymous said...

The entire discussion about which taxes to raise on whom and how fair it is, I find very irritating. Congress and Obama so far have done virtually nothing to address the medical cost side of the equation, including comprehensive payment reform and redesign of health care delivery. It's simpler just to raise taxes on people. This I find an act of both political cowardice and ignorance - the knowledge of how to do this is out there, well published, and has been discussed since well before the election. Not only that, but not doing it is killing patients through mistreatment, overtreatment and undertreatment. Even if it raises less $$ than raising taxes, it should still be included as an integral part of any "reform."
Sorry for the vent. I am just very disappointed.


Jerry said...

Here’s Buffett’s 2006 letter in pdf format.

This is from page 20 -

“Berkshire will pay about $4.4 billion in federal income tax on its 2006 earnings…Had there been only 600 taxpayers like Berkshire, no one else in American would have needed to pay any federal income or payroll taxes.”

I said “150 +/- corporations“ in error, but my point remains. Buffett pays his share without griping or dodging – a unique attitude when it comes to meeting obligations and fulfilling responsibilities.

Buffett also acknowledges the huge (essential) role that public institutions have played in his own life – you know, the kinds of things like public libraries, schools, state colleges and universities, probably even roads, fire departments, police. Things our taxes pay for.

nonlocal’s comment, that the President’s and several House committees’ reform proposals include ”virtually nothing to address the medical cost side of the equation” is in error.

Here’s the OMB FY2010 fact sheet as it pertains to health care –

Here’s the summary for HR3200, the House Energy and Commerce’s draft for health system reform (pdf) -

See Section IV. On page 3, “Controlling Costs.”

Those two are just for starters.

Anonymous said...

Excuse me Jerry; I spoke loosely. What I meant to say was that, in my opinion, the bill which we will eventually see will not contain a mechanism for the comprehensive redesign of health care delivery which I believe to be the only sustainable way to systemically reduce costs as well as increase quality. Thanks for taking the time to provide those links.


angienadia said...

The health care problem that we have now is complicated - many aspects of it needs to be fixed. I don't know the solution, but I think we should consider the following:

1. The current debate focuses so much on the payer that it misses other points, such as how costs are driven. Ultimately, only individuals pay for the costs of health care, through premiums if they pick private insurances, taxes if the public plan goes through, etc. The money comes from you and me, and right now most of what we are debating is on how it will be channeled to the payees. In the end, this debate is moot if we don't fix inflating costs driven by many factors, including the fee-for-service system, which is a major agency problem where agents (physicians) are also suppliers, and they almost always decide whether products are consumed (I can't imagine patients negotiating with doctors whether they need an MRI or a surgery).

2. Even a debate that focuses on reducing costs or on health care in general is still limited. Health care is in no way equal to health. Considering that the majority of health costs today stem from managing chronic diseases, health care is really a bandage on health already lost. By the time patients first present with a stroke, there is little medicine can do, when if only a fraction of the same resources is spent on public health initiatives affecting various root causes of health, we can prevent people from getting sick to begin with and improve health much more effectively. Similar points are put forth in this testimony:

The testimony also make a salient point about individual vs social responsibility in terms of health - it really speaks for people who most likely do not have resources to blog on the internet or explain to people that matter why they continue to consume unhealthy food and do not exercise.

Brenda said...

I know this has been up for a while, but I linked here from today's entry. I do agree that you would like to see everyone have access to affordable health care. However, point by point:

1. Good points except about the public plan. When I came to BI, I had a choice of the more affordable plan, or an expensive PPO. I had to choose the expensive plan if I wanted to keep my physicians, who are not part of Caregroup. It has nothing to do with medical care here, but it does have to do with continuity of care. Why transfer all of my medical records and start from scratch? I am fortunate to be able to afford this choice. If we had single-payer, or at least a public option, I would have been able to keep my insurance coverage AND my doctors.

2. Big give away to the insurance companies. Remember Medicare Part D? There is a reason insurance industry profits have skyrocketed.

3. I agree with you on this one.

4. Agree here as well.

5. Yes, primary care needs to be well-compensated and more available Nurse practitioners should be compensated just as well as physicians.

I have a different health care system background than what is provided in Boston. There are truly physicians and hospitals out there who make care decisions based on how they will make the most money. I have experienced this first hand as both a patient and a provider. Patients with good jobs, but no insurance were given more tests, kept longer in the hospital, and seen by more specialists because they would be billed for, and inevitably pay, the much, much higher standard rate. Some doctors looked at these patients and simply saw dollar signs. I am not making this up. The uninsured with low-paying jobs (or the undocumented) were given just enough care to meet legal requirements. That meant the anesthesiologists were conveniently tied up whenever one of these patients needed an epidural during labor. The L&D unit sometimes sounded like a torture chamber because of all the screaming.

I have also looked at some of the options for insurance coverage under the Massachusetts model. Out of pocket costs are horrendous in some of the options. And oh, if you are a legal immigrant in this state, then sorry--you are on your own.

Everyone needs to be covered. Insurance companies should not be given more money--they have plenty.

I think you are on the wrong side in this, Paul. It saddens me because I know how much you care about the patients in our facility. This is one time when I really hope you come out on the losing side.


Jerry said...

Well said, Brenda.

Anonymous said...

Paul I have to disagree with 3. My insurance premiums have skyrocketed over the past few years as my insurance company tries to compensate for inflated healthcare costs passed on to them by providers of the uninsured. Until a more equitable system is in place a tax exemption is the least they can do.

Ernesto said...

I think #2 needs a bit of tweaking. Over 70% of inpatient diagnosis are "preventable". Why subsidize bad behaviors like over-eating, smoking and exercise neglet? Require a mandatory physician office as part of the subsidy requirement? For over 12 years, congress has allowed employers to provide incentives to employees for healthy behaviors and yet employers I extremely hard to implement. I work in healthcare and having been trying to push incentives (like the ones Safeway does for their employees) and my employer is extremely reluctant because just like the government is extremely reluctant to call a spade a spade. Even though it costs $1,400 to cover a smoker, the maximum incentive you can give an employee is around $320for not-smoking, why doesn't incentive even come CLOSE to COST. Any intelligent life circling our planet would classify our health care system a disease care system. Once again, those of us that see a doctor each year, exercise, stop smoking are considered "non-factors" in the healthcare debate. Maybe when preventable disease is at the 98% level it might be worth looking into by the lawyers in washington. Nicotine addiction can be conquered in a few days, exercise can become a habit in 21 days, the solutions are easy but with zero attention to behavior, healthcare will never change, either, especially with our leader buffing away and congress/healthcare leaders ignoring healthy incentives.