In my job, I don’t just get to envision the possible in health care. I get to see the possible in action. As we look at how to improve health and health care in the Garden State, you, our members, often provide creative and powerful examples.

A favorite part of my job is the bird’s eye view I get of your work. I then have the opportunity to explore and share your innovations with others around the state. What can we learn? Can we scale your best practice? Can we spread those examples of strong leadership to make improvements that change lives?

Lately, as I’ve visited and worked with many of you, I’ve been in awe of how you are advancing health care in many ways.

  • At Cooper University Hospital, we spoke to the Maternal Fetal Medicine and Obstetrics leaders at Cooper, who provide care for pregnant women, many with high-risk pregnancies. While most hospitals in New Jersey have Cesarean rates over 30 percent, Cooper’s is just 19.4 percent. What struck me was how they described their culture. All the physicians with hospital privileges, whether employed by the hospital, the FQHC, or in private practice, have a spirit of mutual respect, love of evidence-based medicine, and the ability to work collaboratively. They meet regularly to share best practices, communicate regularly on an all-OB-GYN email, and share the goal of making sure that each woman who can have a vaginal birth has a vaginal birth. No physician is siloed, and communication is ongoing. And, there is transparency as they discuss all the patients together no matter who provides the care. I was inspired and eager to share their work with our Maternal Quality Improvement Collaborative.

 

  • In Cumberland County, we found a simple and fun way to support healthy eating. Through our Mayors Wellness Campaign and our grant from the United Health Foundation, Live Healthy Cumberland County created a local “Dining Week” with 35 restaurants offering healthy meal specials. Live Healthy Cumberland County worked with a local dietician to develop three healthy options for each restaurant, and the group gave the restaurants educational and promotional materials, such as placemats and vinyl decals to advertise the availability of healthy options in the restaurant window. Diners who selected the healthy options received the chance to win one of three $100 gift cards from a drawing. Live Healthy Cumberland will be sharing more of its work at our Population Health Breakfast on February 27th.

 

  • And recently I visited with Kyung Hee Choi, vice president in charge of Holy Name Medical Center’s Asian Health Services program. Now in its 10th year, the program works with more than 280 Asian-American physicians and 250 religious and community groups. Our state has the fourth largest Asian-American population in the United States, and, in Bergen County, Asian Americans account for more than 14 percent of the population. The program addresses the language and cultural barriers that might send someone to the emergency room instead of to a trusted primary care physician. We just started working with the hospital to create culturally appropriate materials for the Quality Institute’s Conversation of Your Life program that can be used by the Korean and Chinese communities. We want our materials to not just translate the words but to connect with different communities.

Please keep me apprised of the work you are doing to improve health care for the people of our state — and how you are doing more than just envisioning the possible but actually making it happen.

Stacey Flanagan, Director of the Jersey City Department of Health & Human Services, will be a panelist at the Quality Institute’s Breakfast on Population Health on February 27.  

 Jersey City is one of three New Jersey communities working with the Healthy Communities create Healthy Citizens (HCHC) initiative, funded by the United Health Foundation and the Quality Institute. One element of that work is Jersey City’s involvement in Aunt Bertha, a social services search and referral platform. Can you tell us how that works in Jersey City?  

 A little over two years ago, we started talking about the need for a one-stop source for resources in the non-profit world. In the non-profit world there can be a lot of turnover. How do we keep something updated? How can you get a database that is continually updated, web ready, accessible to all and reminds people to keep their information accurate and up-to-date? We were hoping for something that would grow as we grow. We began working with Aunt Bertha, which is designed to help our residents, providers and patient navigators search for social services in regards to food, shelter, health care, job training, financial assistance and more.

Can you describe your experience so far with Aunt Bertha?

We started with a soft launch six months ago with the vanity URL HealthierJCGetStarted.com. Now we are sharing it and asking people, ‘Please claim your listing and make sure all the information is up to date.’ We are reaching out to all kinds of organizations.

How did you encourage non-profit organizations to review their listings?

 We went through a list of 800 agencies across the county and called each one and said, ‘Do you still do this? What hours are you open?’ We made post cards with the Quality Institute to remind people to claim their agency. Quality Institute staff members also have been supporting our promotion efforts by providing Aunt Bertha presentations and trainings to social service providers in Hudson County. In March, we will launch our new health & human services department website, which will include a search box link to Aunt Bertha. Then, in April, we will provide monetary incentives to partners that have not only claimed their agency listing but have also signed up on the website to be a partner. In May, we will host our fourth annual Health Trust & Partnership symposium to continue to engage the health organizations across Jersey City to continue to leverage partnerships and promote Aunt Bertha.

 How have you now incorporated Aunt Bertha into the regular workflow of the health department?

 Through Aunt Bertha, we can see what the community’s needs really are. Are more people looking for affordable housing? Or looking for home health care providers? Then, we can reach out to organizations and say, ‘We want to develop a stronger partnership with you’ to ensure that residents are receiving the services they need. Asking people about their Aunt Bertha listing is the door-opening conversation.

How is Aunt Bertha helping residents of Jersey City?

People are saying, ‘This is really great. Things are faster. One click and I get what I need.’ It’s been a great way for us to reacquaint ourselves with agencies we haven’t talked to in a while. This allows us to follow up and see what people need and what they’re looking for.  They are trying to find the local food pantry, or they need help to pay for prescriptions, or affordable housing. We’re getting a more thorough picture of the needs of our community.

What is one thing that you would like to share about your work in population health with the Healthy Communities create Healthy Citizens initiative?

Collaboration is key to improving the lives of Jersey City residents, and we’ve accomplished this through the formation of Healthier Jersey City. If you want to learn more, you will have to attend the Breakfast on February 27th.

Dr. Richard J. Baron, President and CEO of the American Board of Internal Medicine and the ABIM Foundation, will deliver the Keynote Address at Innovation Showcase: Technology Tools for the Medical Neighborhood,” on March 15. Dr. Baron will discuss the origins of the Choosing Wisely campaign, a nationwide effort to reduce waste and overuse in health care. Read more about the campaign here.

How does Choosing Wisely connect with the move toward value-based health care?  

 Value-based health care is a move away from fee-for-service. In fee-for-service, there’s an economic incentive to do more. Doing more generates more revenue. In general, I believe physicians and clinicians are highly professional and try to do the right thing for patients. But we know a lot of what gets done is not evidence-based, not necessary — and exposes patients to risk. We want people to choose health care wisely, and Choosing Wisely helps clinicians and patients have conversations about what health care might not be necessary. The focus is not on money but on doing the right thing for patients.

You will be speaking at the Innovation Showcase. How can technology advance the efforts of Choosing Wisely?

 Choosing Wisely is a set of expert recommendations that come from folks with deep knowledge in each field. Committees of professionals with knowledge of the medical literature created the recommendations. They know what works and what doesn’t. How you move the recommendations into real life settings almost always involves some form of technology. We have the Choosing Wisely app. The app allows patients and physicians to easily search more than 500 recommendations. No one can carry all those recommendations around in their head. At the point of care, we also are seeing Choosing Wisely incorporated into Electronic Health Records. So if a doctor prescribes something against the recommendations, a prompt might come up that asks: ‘Do you really want to order this test, or this prescription?’ It is a way at the point of care for the patient and doctor to talk about what’s truly necessary for the patient.

If every clinician followed Choosing Wisely’s recommendations to eliminate unnecessary testing and treatments, what would that mean for American health care spending?

The campaign is focused on avoiding harm. Unnecessary care produces harm. Testing when it isn’t necessary also generates financial harm, especially for patients now that we increasingly live in a world of high co-pays and deductibles. The National Academy of Sciences says up to 30 percent of what we do in health care is waste. Since we spend $2.5 trillion on health care, 30 percent is a huge amount. We know in clinics where Choosing Wisely has been implemented into electronic health records we’ve seen a documented financial impact. Care that does not add value to patients gets done a lot less. The primary aim was never about reducing costs. Some have criticized us because even with Choosing Wisely there is still a lot of waste. It’s not the magic bullet for everything. But it is a highly effective tool.

Is the goal of Choosing Wisely to reach providers or patients?

It’s really aimed at both. If you talk to providers about why they do unnecessary things they’ll say that patients ask for it. ‘A neighbor with back pain got an MRI so I should get an MRI because of my back pain.’ But most people with back pain get better. The Choosing Wisely app supports the doctor who can say, ‘This recommendation shows you really don’t need that MRI.’ Patients sometimes may think the doctor is trying to save money because of a new health insurance contract or something. And the recommendations raise awareness to prevent the physician from, say, just prescribing antibiotics for a cold when that’s not the appropriate treatment.

Does following the recommendations mean doctors have more or less exposure to lawsuits?

We get that question a lot since litigation and malpractice is an ever-present risk for providers. Clinicians can get sued for anything. We know that doing more — if it’s the wrong thing to do — puts doctors at higher risk for lawsuits. It’s naive to think that doing more unnecessary tests and procedures will decrease litigation.

What will be the important takeaway from your keynote at the Innovation Showcase?

 I would love for this audience to be more aware of Choosing Wisely and the variety of tools connected to the campaign. There are so many things for primary care doctors to do these days. Screen for domestic violence. Firearms in the home. Appropriate preventive care. Everybody is busy. I know many physicians now have value-based contracts. Choosing Wisely gives doctors a better way to talk about low-value care without the conversation being financially driven. Bringing money directly to the bedside does not go well for physicians or patients. Our focus is better care. Having conversations around better care for patients is the pathway for success in value-based contracts.

At our recent Quality Breakfast, we recognized the ten New Jersey hospitals that received the Leapfrog 2017 Top Hospital designation. There was a common theme among the hospital leaders who spoke on our panel: The safety grade is not the goal.

The goal is “chasing zero.”

Work toward creating a culture of safety, they said, and inevitably the top safety grades and distinctions will follow.

The hospital leaders talked about not being satisfied with below average rates of, say, CLABSI, or central line-associated blood stream infections. Several of the top hospitals reported no CLABSI or no catheter-associated urinary tract infections for a year or even longer — measurements considered unthinkable just a few years ago.

They said the results come from hard work, including constant practitioner “huddles” to apply best practices, such as removing catheters the minute they are no longer needed. The hospital leaders described a constant focus on goals and a swift recognition of problems as they emerge.

The stakes are high. The top five health-care associated infections kill and harm patients and also cost the nation’s health care system more than $9 billion annually.

I remember when hospitals pushed back on Leapfrog and the public reporting of patient safety measures. Now, these hospitals, and most in New Jersey, voluntarily report to Leapfrog and embrace its role as a well-designed quality reporting system that helps hospitals improve care and patient safety.

“We used to say, ‘If you don’t measure, you don’t improve.’ Now we know it’s more complex: ‘If you don’t measure and publish, you don’t improve,’’ said John Bonamo, MD, MS, FACOG, Chief Medical and Quality Officer at RWJBarnabas.

The hospital leaders expressed no tolerance for physicians or employees who do not embrace quality improvement. Those days are pretty much over. Everyone, from nurses to housekeepers to food service staff members to surgeons, must work together to create a culture of safety on every level.

Our panelists represented CarePoint Health Bayonne Medical Center and CarePoint Health-Christ Hospital; Inspira Medical Center Vineland; Jefferson Stratford Hospital; Morristown Medical Center; Jersey City Medical Center, Monmouth Medical Center and Saint Barnabas Medical Center; and Virtua Voorhees Hospital. Capital Health Regional Medical Center was also a 2017 Leapfrog Top Hospital.

We are thankful that 94 percent of the hospitals in New Jersey publicly report to Leapfrog. In 2018, let’s get to 100 percent reporting and together keep chasing zero for the benefit of everyone needing care in the Garden State.

schwimmer-lg

Left-right, John Matsinger, DO, MBA, Executive Vice President, System Chief Clinical Officer at Virtua Health, representing Virtua Voorhees Hospital; John F. Bonamo, MD, MS, FACOG, Executive VP, Chief Medical and Quality Officer at RWJBarnabas, representing Jersey City Medical Center, Monmouth Medical Center, & Saint Barnabas Medical Center; Louis Brusco, MD, Chief Medical Officer, Morristown Medical Center; David V. Condoluci, DO, MACOI, Senior VP and Chief Patient Safety & Quality Officer, Jefferson Health New Jersey, representing Jefferson Stratford Hospital; Paul M. Lambrecht, MJ, MHA, CPHQ, FACHE, VP of Quality and Patient Safety, Inspira Health Network, representing Inspira Medical Center Vineland; Vijayant Singh, MD, Chief Hospital Executive at CarePoint Health Bayonne, representing CarePoint Health-Bayonne Medical Center and CarePoint Health-Christ Hospital; Linda Schwimmer, President & CEO, Quality Institute.

Published by Lilo H. Stainton on NJ Spotlight.

Healthcare experts have urged the Murphy administration to prioritize efforts to grow and sustain insurance coverage, better integrate behavioral and physical care systems, improve end-of-life planning, and boost the use of data and other technologies.

Those are among the recommendations outlined by the healthcare transition team for New Jersey Gov. Phil Murphy’s first one hundred days in office, according to a report released by the Democratic governor’s office in late January.

The 17-page report reflects broad goals to improve social equity and boost the state’s productivity — common themes in Murphy’s campaign last year — and includes a half-dozen priorities with detailed policy guidance, much of which echo recommendations made in the past by key members of the transition team. While New Jersey’s healthcare system is strong in many ways, significant racial and economic disparities remain when it comes to some conditions.

The authors also stress the need to protect existing healthcare programs, like the Affordable Care Act, which attract billions of dollars in federal funding to provide care for some of the state’s most vulnerable residents. Murphy has underscored the importance of defending against recent federal attacks on these initiatives and has appointed a number of department leaders with national experience to help with this strategy.

“Health is a prerequisite for full participation in the labor market and public life,” the report states. “A fairer economy requires that we invest in improving the health of the entire state’s population and address health disparities to ensure all New Jerseyans have access to quality, affordable healthcare and improved health outcomes.”

End of an era

In releasing the transition report, Murphy said the era of “ad-hoc policymaking” had come to an end. “We have thoroughly reviewed the Transition reports and have already started acting on some of the recommendations. We are excited to continue making progress and move toward a stronger and fairer New Jersey,” he said.

In fact, a number of priorities flagged by the transition team are already being addressed by the administration or the state Legislature, which must adopt measures to initiate several of the healthcare reforms. Efforts are underway to restore funding for women’s healthcare, to address costly out-of-network medical charges, and boost enrollment in the state’s Medicaid or FamilyCare program.

Healthcare programs in New Jersey are administered primarily by the Department of Health, which oversees public health, licenses facilities and — as of last fall — runs the state’s addiction and mental healthcare systems, and the Department of Human Services, which runs Medicaid, among other initiatives. Healthcare programs absorb roughly $20 billion annually, according to the transition report, including nearly $15 billion for Medicaid alone.

Dangerous changes

Some two-thirds of Medicaid’s funding comes from the federal government. Spending on the Affordable Care Act, much of which flows through Medicaid, has been a top concern for Republicans in Washington, D.C., leading to an ongoing effort to reduce the cost of these massive federal programs — changes Murphy and many others have said could be dangerous to the Garden State.

“The importance of Medicaid to its beneficiaries and to the entire system cannot be overstated. Any federal changes to this system will have significant cradle-to-grave care repercussions and will dramatically alter New Jersey’s overall healthcare system,” the report notes.

Murphy’s healthcare transition team included more than five dozen experts representing hospitals of all sizes, physicians, and public health professionals, mental health and addiction care providers, nursing homes, organizations serving individuals with disabilities, insurance companies, and other healthcare payers, academic and policy organizations, and community-based providers that work in some of New Jersey’s most challenging communities.

The group’s chairs included former state health commissioner Heather Howard, now at Princeton University, and Murphy’s nominee to lead the DOH, Dr. Shereef Elnahal, a former leader at the U.S. Veterans Administration.

Multiagency cooperation

In its report, the group calls for an overarching “health in all policies” (or HiAP) approach that, according to the American Public Health Association, requires leaders across multiple departments or agencies to work together to address underlying factors influencing health, like access to healthy food and safe homes, now known as “social determinants of health.”

The strategy can leverage “creative, cross-sector solutions” to address complex challenges without “crowding out” other priorities, the transition report notes. “Multi-agency strategies that engage external stakeholders and employ public-private partnerships are the next generation of health-promoting cost savers,” it states.

To help achieve this interdepartmental collaboration, the report calls for the state to create an Office of Healthcare Transformation to address issues that have in the past been handled by ad hoc committees established by the governor’s office. The entity could tackle complex efforts to improve Medicaid and the State Health Benefits Plan, which covers state workers, and establish and enforce statewide efficiency goals and other healthcare program targets.

This recommendation is one of several that mirror goals outlined in the New Jersey Health Care Quality Institute’s Medicaid 2.0, a blueprint for reform released nearly a year ago; Linda Schwimmer, the Quality Institute’s president and CEO, was also a chair of the healthcare transition team. It also stresses the need for a statewide database with insurance claims information to help policymakers identify trends and monitor costs — another issue favored by Schwimmer.

Addressing the opioid epidemic

The report also underscores the importance of addressing the state’s opioid epidemic, which killed more than 2,000 residents last year and became the top priority for former Gov. Chris Christie, a Republican. It calls for more education on the dangers of prescription drugs, expanding needle-exchange programs, investing in proven treatment programs, and organizing bulk purchases of overdose reversal agents like Narcan.

In addition, the report’s authors stress the need to better integrate mental health and addiction care — many patients are impacted by multiple diagnoses — and also coordinate these treatments with physical medical services. “New Jersey’s regulatory systems unnecessarily frustrate the implementation of integrated clinical care, leading to shortage of appropriate care for those in crisis, and for those whom crisis could be avoided,” it states.

The recommendations would build on efforts by Christie to improve services by reshuffling state oversight, calling for state officials to meet with advocates within the first 100 days. Within six months, they should clear a backlog of applications from providers seeking to integrate care programs, establish a working group to discuss reimbursement rates, and initiate efforts to create an up-to-date directory of treatment services.

Much of the report addresses strategies to expand enrollment in the state’s Medicaid program, which now insures some 1.8 million people, including nearly 500,000 who joined as a result of the ACA expansion. In his first week in office, Murphy signed an executive order calling on state agencies to study how they can promote and publicize access to these subsidized programs.

It also recommends the use of best-practice methods, especially to improve maternal care — an area in which New Jersey has fallen behind other states, in a country that significantly lags other western nations. The racial disparity in maternal death rates is among the worst in the nation, the report notes.

Medicaid pays for 42 percent of the births in the state and low-cost changes, like expanding prenatal care and codifying clinical practices, can go a long way toward improving outcomes, the authors stress.

Other efficiencies

Other efficiencies can come from better documenting and coordinating end-of-life care — Medicaid also funds 65 percent of nursing home care, which isn’t covered by Medicare, and advanced planning can significantly reduce costs at this stage. The transition team urged Murphy to build on the state’s existing efforts to institute a comprehensive program to track residents’ wishes for final treatments.

The report also calls for the state to review its Medicaid managed-care contracts, which cost the state billions each year, improve provider oversight, and consolidate all pharmaceutical purchases within one office; the state now spends $2 billion annually, after rebates, on drugs for Medicaid patients and government workers.

Published by Lilo H. Stainton on NJ Spotlight.

Lawmakers try to protect patients from unexpected healthcare charges but the partial fix they propose is opposed by physicians.

Support from the new governor and Assembly leadership has jumpstarted a decade-old debate on how to reduce the impact of out-of-network medical bills on New Jersey residents, despite the continued objection of some healthcare providers.

The Assembly Financial Institutions and Insurance Committee held the second of three planned hearings Monday, a nearly four-hour discussion of a proposal championed by the new speaker, Assemblyman Craig Coughlin (D-Middlesex). The bill seeks to better protect patients against surprise charges assessed by doctors or hospitals that are not part of their health insurance network.

The proposal — which only applies to bills generated by emergency or inadvertent situations — includes elements to require greater transparency by both doctors and insurance companies, to help patients understand what doctors and services are covered by their policy.

It also contains a more controversial element designed to further regulate the underlying out-of-network charges, which advocates have said impact some 168,000 Garden State residents annually. The latest version calls for arbitration, overseen by a state-appointed third party who would choose between final offers from providers and payers.

But some providers fear the cost-control mechanism, as written, will disadvantage doctors in their contract negotiations with insurance companies, and could drive some physicians out of state, further harming patients most in need of care. Without the threat of high out-of-network charges, providers have limited leverage when it comes to trying to craft in-network agreements with these insurance carriers, opponents said.

Weakens negotiating ability?

“We’re not looking for unreasonable out-of-network rates, but we need to have that negotiating ability to get reasonable (in network) rates to keep our doors open and provide those services for our community,” regardless of their ability to pay, stressed David Dafilou, chief administrative officer of Capital Health, a network with two hospitals, including a safety-net facility in Trenton. Both facilities are in-network with all major providers, he said.

“You’ve got to look at the long-term impact of that situation. With fewer providers, cost begins to rise also,” he added. “In that game of leverage between the payer and the provider, who is winning? Quite candidly, the health plan is winning, by far.”

Resolving the issue, which has been addressed through legislation in at least five other states, is a priority for Gov. Phil Murphy, a Democrat who took office three weeks ago. In its recommendations to the new administration, Murphy’s healthcare transition team claimed that some providers have “taken advantage” of the high out-of-network fees they can charge under the current law, a situation that adds as much as $130 million annually to premium costs, even though a growing number of providers are now in-network with most insurance companies.

While efforts to resolve the issue have attracted significant attention, progress on the issue was derailed by last year’s budget debate and the Legislature did not revisit the question when lawmakers returned to Trenton after November’s election.

Emergency-room protections

Under state law, patients who visit an emergency room are protected against paying anything more than their normal in-network charges — co-pays, co-insurance, or other out-of-pocket costs — for their care, even if they were treated at an out-of-network facility.

But a pair of Yale University researchers showed in a nationwide study that roughly 20 percent of emergency patients are still “balance billed” by physicians for any costs that the insurance company did not pay. Advocates note that, even if they aren’t legally responsible for the charges, the bill alone is stressful and upsetting and not beneficial to a healthy recovery. And unsuspecting patients may just pay it without complaining to the health insurer.

In addition, policy experts note that even when a patient isn’t responsible, higher charges add to the overall cost of care by driving up the cost for insurance companies, an increase that is reflected in higher premium prices. “We have to recognize that all parties in healthcare are economic players. That’s one reason this bill has been so disputed,” said Ward Sanders, president and CEO of the New Jersey Association of Health Plans, which represents insurance providers, and supports the bill.

The current version of the legislation (A-2390) has the backing of several major stakeholder groups, including the insurance industry and consumer advocates, which include patient organizations, business interests and labor unions. These entities insist a proposal that just requires greater disclosure from providers and insurance companies does not get to the heart of the problem.

Medical Society says problem overstated

“It’s not enough just to tell someone that, ‘Hey, you’re about to get a balance bill and it’s really going to stink for you and your family,’” said Linda Schwimmer, president and CEO of the Health Care Quality Institute, and a leader on the governor’s healthcare transition team. “There needs to be a system to resolve the issue.”

But physicians, for the most part, remain opposed to any effort to control out-of-network charges; the Medical Society of New Jersey has insisted the problem with surprise bills is overstated and that other changes in insurance contracting and state oversight are working to control the few egregious cases that remain. While outliers may still exist, the legislation shouldn’t be geared just to these “bad actors,” the group said.

The New Jersey Hospital Association has worked with the sponsors to fine-tune the measure but remains concerned about key elements of the mechanism outlined to resolve disputes between providers and payers.

Coughlin: all will ‘survive and prosper’

Neil Eicher, who heads government relations for the NJHA, said his membership is eager to resolve the issue, but stressed that hospital leaders did not quite know what to expect: the New Jersey legislation is the first in the nation to include hospitals in the payment-negotiation clause. (Unlike some states, New Jersey does not set hospital rates.)

Assemblyman John McKeon (D-Essex), who chairs the financial institutions committee and is a co-sponsor on the bill, urged Eicher to submit suggestions to address the industry’s two primary concerns — a mechanism to ensure some payment upfront when there is a dispute, and different benchmarks for resolving a billing debate, if needed. McKeon said he couldn’t promise any amendments, but he underscored the urgency among leadership to address the issue.

Coughlin, who testified early on, stressed that most of the stakeholders have worked hard to come as close as possible to an agreement. “Each has won and lost something in this,” the speaker said. “If enacted, I’m sure all will be able to survive and prosper.”

One point of consensus was that, regardless of the details, the legislation would only have limited impact. More than two-thirds of those with health insurance are covered under so-called ERISA plans, which are self-insured and regulated by the federal government, not state. (The proposal would allow these plans to opt in to the dispute-resolution mechanism to help resolve out-of-network billing questions, although it’s not clear how many would enroll.)

“This is not a perfect bill,” noted Assemblyman Gary Schaer (D-Bergen), another lead sponsor, who chastised providers and payers for not coming together to resolve the issue on their own, without help from the Legislature. “But it seems to me this is a very significant best effort to find a solution to a problem that everyone seems to agree there is.”