CEO SUMMARY: Here’s our current list of macro trends that affect clinical laboratories, updated from the last list in January 2000. One bold prediction is that Medicare, as we know it, is on the verge of a major meltdown. Employers and consumers are also new forces to be reckoned with by healthcare providers. Factors other than technology seem to be driving the fastest changes in healthcare today.
FOR THE FIRST TIME since THE DARK REPORT began presenting its list of influential laboratory industry trends, this year’s picks are mostly broad-based healthcare trends, affecting the entire healthcare system as well as the clinical laboratories that serve it.
This year’s list of ten clinical laboratory industry macro trends contains some surprises. At least seven trends are driving change across the entire American healthcare system—thus affecting clinical laboratories. Only three macro trends are specific to the clinical laboratory industry.
Across the broad range of healthcare services, I see clear and unmistakable signs that lead me to believe that the American healthcare system is about to begin an entirely new and different cycle. The changes wrought during this cycle will be just as deep and radical as those of the last cycle.
That last cycle lasted from about 1988 to 1998. During this period, managed care was the dominant change agent. The widespread adoption of the closed-panel, gatekeeper model HMO during that ten-year period caused deep changes to virtually every aspect of healthcare in the United States.
Because this managed care business model had many failings, it played out. By 1998, PPO enrollment was rising and HMOs were dropping onerous restrictions in an effort to retain beneficiaries and market share.
Now, after four or five years of relative quiet, I predict the American healthcare system has already entered the earliest stages of another change cycle. Economics will be the overarching driver in this cycle for a simple reason. Employers—as a major source of funding for healthcare services—must control the year-to-year double-digit growth of healthcare spending.
Cut Errors, Save Money
Employers are starting at the place where it is easiest to achieve cost savings: eliminating medical errors. This goal has another advantage; it is difficult for any hospital administrator or physician to be against the concept of “patient safety.”
From a cost-management perspective, employers view medical errors as economic “waste.” It is money expended to provide a clinical service that failed to meet quality standards. That is why the Leapfrog Group and similar employer consortiums have declared that documenting improvements to patient safety is a goal to which all healthcare providers must commit.
It sets up two desirable outcomes for the nation’s employers. First, reductions in medical errors will benefit patients. Second, the same reduction in medical errors will cut healthcare costs.
The “patient safety” movement also supports another goal I believe employers have for the American healthcare system. The nation’s largest corporations are showing exceptional unity in their intention that hospitals, physicians, and other healthcare providers adopt the management principles of quality that have proved successful for the world’s leading firms.
During the past two decades, the American healthcare system has virtually ignored the revolution in business management that has changed commerce worldwide. Less than 25 hospitals have ISO-9000 certification. At the end of 2002, probably 20 hospitals nationwide had a serious Six Sigma program under way.
Not surprisingly, I think you will see one theme woven through many of the ten clinical lab industry macro trends presented here. It is the need for laboratories (and all healthcare providers) to do a better job of collecting accurate and timely data about work processes and using this data to implement improvements which boost quality.
There is plenty of evidence that the American healthcare industry is entering a new cycle of radical change. Such change cycles are not accidental or serendipitous. They are driven by identifiable forces. It is my contention that the main force driving this new change cycle in healthcare are employers.
Employers are starting at the place where it is easiest to achieve cost savings: eliminating medical errors.
This year’s list of ten clinical lab industry macro trends are very different in character and impact than our lists from earlier years. It is my view that the forces about to pressure clinical laboratories during the next 12 months will have less to do with specific technologies and more to do with evolution occurring within the overall healthcare system.
That means clinical labs will have little ability to block or influence these trends, because they are occurring “upstream” from laboratory services. However, laboratories do have the opportunity to shape their destiny. These ten macro trends give perceptive lab executives and administrators early warning about the nature of coming changes. This useful business intelligence puts them ahead of the game, but only if timely action is taken.
Lab Industry Macro Trend # 1
Patient Safety and Reducing Medical Errors Is Clear Priority
EFFORTS TO IMPROVE patient safety within the American healthcare system will take center stage in 2003.
The most direct impact will be felt within hospitals, larger clinics, and skilled nursing (SNF) facilities. For that reason, hospital laboratories and those labs serving bigger physicians’ offices and LTC facilities will become directly involved.
Under the twin banners of “reducing medical errors” and “improving patient safety,” a powerful movement is gathering momentum. Various healthcare accreditation and certification bodies are already issuing revised requirements designed to address patient safety concerns.
For example, effective January 1, 2003, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) instituted a new program titled “National Patient Safety Goals.” This program has six specific goals and requires accredited institutions to implement 11 required actions.
During calendar 2003, laboratories will be required to devote time and resources to the subject of patient safety. It is a macro trend which is here today and requires immediate action. THE DARK REPORT identified this trend earlier last year. (See TDR, January 28, 2002 and July 15, 2002.)
It is important for laboratory executives and pathologists to understand that the “patient safety movement” is but one management theme connected to a more deeply-rooted trend: increasingly overt and direct actions by employers to change the American healthcare system in ways that lead to better quality outcomes while lowering the overall cost of care.
A closely-related theme and macro trend is the measurement, ranking, and public reporting of provider performance. (See Macro Trend No. 10, page 13.) Employers and consumers are asserting their right to know which hospitals and physicians get better outcomes.
The movement to improve patient safety is not a one-time blip on the radar screen for laboratories, hospitals, and physicians. All health providers are embarking on what will be a sustained program of continuous improvement.
Management systems will need to accomplish three goals. First, sources of medical errors must be identified. Second, the management system must have a mechanism that allows the provider to reduce the rate of medical errors over time. Third, the management system must be able to measure and document that the rate of medical errors is declining as a result of deliberate management actions.
THE DARK REPORT believes this will be a management day of reckoning for many healthcare administrators and physicians. The ability to manage in a sophisticated, knowledgeable way will become a key success attribute for all laboratories and pathology group practices.
Lab Industry Macro Trend # 2
Accreditation & Certification Requirements Undergoing Shift
EFFORTS TO IMPROVE patient safety will accelerate the work of a small band of champions who’ve quietly been pushing to reform healthcare accrediting and certification standards.
In recent years, certain dedicated individuals have diligently worked to imbed the principles of quality management into accrediting and certification guidelines. They were united in one goal: to bring into the American healthcare system the same kind of management philosophies and methods used successfully by the world’s greatest corporations.
THE DARK REPORT has tracked this little-noticed movement for several years. (See TDR, July 6, 1998.) Progress through these years has been painfully slow. But reaction to the Institute of Medicine’s (IOM) well-publicized report on the excessive number of medical errors is changing that situation. Making the right kind of reforms to accrediting and certification requirements is now a high priority for every healthcare governing body.
All these changes and reforms will have a simple and unifying theme. Healthcare providers will shift away from requirements to provide voluminous documentation that policies and procedures exist and are being followed (with little attention given to outcomes.)
Instead, emphasis will switch to measuring outcomes of work processes, with an additional requirement. Providers will also have to demonstrate (document) that: a) work processes are improving continuously toward desired goals; and, b) these improvements are attributable to deliberate and continuous improvements made to work processes.
One particular element of these reformed requirements represents a tectonic change in the management styles of many healthcare administrators. Accredited providers will have to demonstrate that they are regularly surveying the satisfaction of their patients and other users of their services, and that their patients are receiving increasingly better levels of service.
In short, the eventual consequence of these revamped accreditation requirements is that hospitals, laboratories, and physician groups will become customer-focused. Progressive laboratories and pathology groups that embrace these new management systems will gain competitive advantage as the impact of accrediting reforms ripples through the American healthcare system.
For guidance in understanding these new management perspectives, laboratory managers and pathologists need look no further than their largest vendors. For more than a decade, these companies have been evolving into customer-focused organizations. They understand the process—along with the predictable ups and downs that come with such change.
Lab Industry Macro Trend # 3
Employers Taking Direct Action To Control Healthcare Costs
FOR THE FIRST TIME IN DECADES, employers are taking a direct role in reshaping the form and structure of the American healthcare system.
THE DARK REPORT was first in the laboratory industry to identify this important trend. (See TDR, January 28, 2002.) One visible sign of this powerful trend was the Leapfrog Group’s public posting of hospital responses to questions about patient safety-related initiatives beginning January 12, 2002.
Further confirmation of this trend came on June 11, 2002. That day, the Midwest Business Group on Health announced its recommendation that corporate members should begin actively telling hospitals and physician groups how to operate their businesses.
One national newspaper characterized the Midwest Employers Group’s directive thusly: “an influential health-care group representing many Midwestern industrial giants is urging companies to crack down on medical costs through the same quality-control techniques they employ on the factory floor.”
Members of this group include large and influential corporations such as Bank of America, Ford, General Motors, Kraft Foods, Sears, and 3M. They are serious about reining in healthcare costs.
The Midwest Business group is telling their members to be more assertive and tell hospitals and physicians how to run their operations. The group is suggesting that hospitals set numerical targets for medical errors and punish low-performing hospitals and medical plans by withdrawing their business. It also wants companies to encourage hospitals and physicians to adopt “continuous improvement” types of programs to standardize treatment of common diseases and boost preventative care.
Providers need to pay attention to this employer trend. A failure to respond may mean loss of access to patients. Over the past seven years, Motorola has cut the number of health plans it deals with from 45 down to 25, based on performance. Motorola grades health plans on quality and customer satisfaction.
THE DARK REPORT observes that, since employers are the source of most healthcare payments, their insistence that hospitals and physicians provide accurate data on quality of outcomes, cost, and patient satisfaction carries clout. It is one reason why hospital administrators are suddenly acquiring a new interest in management tools such as Six Sigma and Lean. These tools not only produce this data, but help hospitals achieve higher levels of performance in quality, cost, and service.
This macro trend is closely intertwined with several others, such as improving patient safety and changes in provider accreditation and certification. Collectively, these trends are beginning to change the management systems in all classes of healthcare providers.
Lab Industry Macro Trend # 4
“New” Management Systems Arriving Within Healthcare
UNTIL 2003, the number of laboratories operating under a rigorous quality management system numbered in the low double digits.
That changed in 2002. For many reasons, some closely related to other clinical lab industry macro trends described in this issue, growing numbers of hospitals and hospital laboratories have begun to explore and embrace quality management systems like ISO-9000, Six Sigma, and Lean.
In recent years, THE DARK REPORT has chronicled the efforts of early-adopter laboratories to embrace and benefit from these management systems. Among public commercial laboratories, Quest Diagnostics Incorporated was first to earn ISO-9000 certification at several regional laboratory sites. (See TDR, July 6, 1998.) The lab company is now several years into a corporate-wide Six Sigma Program.
Within Kaiser Permanente, at least one laboratory division has earned its ISO-9000 certification. Kaiser Permanente Northwest Laboratories, in Portland, Oregon, has even designed a new lab facility using ISO-9000 principles. THE DARK REPORT believes at least 25 hospitals nationally are certified as ISO-9000 compliant.
Six Sigma and Lean management systems are working their way into hospital laboratories. At Grant Memorial Riverside Hospital in Columbus, Ohio, Sandy Hood became the first hospital laboratorian to earn the Six Sigma Black Belt designation. (See TDR, April 1, 2002.) Banner Health in Phoenix, Arizona now has laboratory Black Belts doing Six Sigma projects in its hospital laboratories.
Until now, most laboratories which adopted management systems like ISO-9000 and Six Sigma did so as a way to improve productivity and increase quality. These laboratories report great satisfaction with the outcomes and have no intention of abandoning these management systems.
Within the hospital sector, what is now giving quality management systems a boost is the drive to improve patient safety and reduce medical errors. Hospital and laboratory administrators recognize they must measure the quality of their outcomes, then take proactive steps year after year to improve that quality. These healthcare executives now recognize the value of management systems developed outside of healthcare in helping them achieve these results.
As noted on the previous page (Macro Trend no. 3), various healthcare accreditation and certification agencies are diligently working to incorporate the principles of modern management into their guidelines. This trend will further pressure hospitals, physicians, and laboratories to adopt the management philosophies infused in ISO-9000 and Six Sigma-types of management systems.
Lab Industry Macro Trend # 5
Provider Performance To Be Measured & Publicly Ranked
HOSPITALS AND PHYSICIANS have ardently opposed past attempts to measure performance or make public information about disciplinary action taken against doctors by regulatory agencies.
This time around, it’s a battle they’ve already lost. THE DARK REPORT predicts that measurement of provider performance will become commonplace. Moreover, providers will be ranked on various measures of clinical quality and operational excellence and these rankings will be posted where consumers can easily access them.
Examples of provider measurement are growing monthly. The National Committee on Quality Insurance (NCQA) which accredits health plans maintains a Web site that contains a program called the “Quality Dividend Calculator.” Based on HEDIS and other measurement data, the program provides employers and health plans with detailed estimates on how much money a company can save by using an accredited HMO.
California’s Department of Health Services (DHS) now issues “HMO Ratings.” These are available on the DHS Web site. Walgreen’s also posts them in its pharmacies. The ratings are based on statistically-valid measurements of several key HMO quality parameters.
Larger insurers in several other states are instituting incentive compensation programs to provide additional money to physicians who
score better on measures of patient satisfaction, HEDIS parameters, and other relevant factors.
In California, the Integrated Healthcare Association’s (IHA) physician incentive program is called “Pay for Performance.” Six of the state’s largest health plans are participating. The incentive is paid based on 50% clinical outcomes, 40% patient satisfaction, and 10% information technology usage. The program became fully operational on January 1, 2003.
In New York, it’s the Independent Health Association of Buffalo that offers physicians more income based on five measures. Hawaii Medical Service Association (HMSA), the state’s Blue Cross Blue Shield plan, has an incentive program that’s paid on a mix of measurements that include clinical and patient satisfaction scores, plus administrative processes that include electronic claims filing.
THE DARK REPORT was first in the lab industry to identify this important trend. (See TDR, January 28, 2002.) Laboratory executives and pathologists should carefully track the progress employers and providers make in measuring and rewarding physicians and hospitals who do a better job for their patients.
That’s because, before long, they will probably see the name of their laboratory or pathology group included in public performance rankings of like providers in their service regions.
Lab Industry Macro Trend # 6
Consumers Put Themselves Into Healthcare Driver’s Seat
CONSUMERS’ direct involvement in how healthcare is delivered to their children, their elderly parents, and themselves continues to grow.
It is hard to quantitate the year-to-year change in consumer behavior relative to healthcare services. But one overlooked fact is key to understanding why laboratories and pathology group practices should pay much closer attention to the needs of healthcare consumers.
According to the Institute for the Future (IFTF), a consulting think tank located in Menlo Park, California, about half of the yearly increase in healthcare expenditures is attributable to the use and cost of new technologies. It asks “is 15% of GDP our self-imposed ceiling on national expenditures on health and health care? If an additional 5% would buy proportionately better health, would we be willing to spend up to 20% of GDP on health?”
The IFTF’s conclusion is that, because consumers want better health, they will willingly pay additional money to access improved healthcare technologies. For this reason, healthcare spending will probably increase.
Moreover, IFTF believes our healthcare system is already evolving into a consumer-driven industry, one driven by demand, not supply. Most physicians, hospitals, and Medicare/Medicaid bureaucrats are not prepared to deal with the consumer as customer—and payer.
IFTF characterizes the consumer succinctly. “New consumers today demand choice, want lots of information, and insist on being treated with the same respect and courtesy that they receive at the Ritz-Carleton [pathologists—take note]. They have the analytic skills of a college graduate, a family income of at least $50,000, and computer skills and access to the Internet.”
IFTF continues: “Consumers expect to take control of their health by avoiding or preventing illness and by taking charge of their own healthcare [TDR italics]. Because a larger portion of healthcare costs is being shifted from employer to employee, the consumer as patient has suddenly become price-sensitive. Finally, consumers are demanding a Consumer Reports for health plans, hospitals, medical groups, and individual physicians. Clearly things are not as they used to be.”
Laboratories and pathology group practices have fair warning. A consumer-driven system of healthcare, based on what consumers demand, not what health professionals supply, requires that providers adopt a different mindset if they are to remain financially viable.
Because consumers spend their money rationally, it may not automatically be a bad thing if health- care spending climbs from year-to-year—but only if this increased spending represents consumers getting more benefits for their healthcare dollars!
Lab Industry Macro Trend # 7
Dwindling Supply of Med Techs Changing Laboratory Operations
IT IS WIDELY-RECOGNIZED that the number of technically-trained laboratorians will be inadequate to meet the needs of the laboratory
industry in future years. This situation is occurring for two primary reasons. One is demographics, the other is supply.
Much attention has been given to the fact that, of the certified medical technologists (MT) and medical laboratory technicians (MLT) working today in laboratories, a large portion are over the age of 40.
It is a demographic bulge that mirrors the Baby Boomer bulge. This demographic group is moving toward retirement in large numbers. At the same time, the supply of newly-certified lab techs remains inadequate to fill the number of open positions currently posted by the nation’s laboratories.
This situation is well-known to almost all laboratorians. What is less understood is the different impact this will have region-by-region across the country, as well as to the laboratory profession as a whole.
THE DARK REPORT believes that med tech staffing will not reach a crisis point—where certain laboratories in the United States must decline to perform tests because they have insufficient technical labor resources to do the work.
Instead, the economic forces of supply and demand will come into play. Many laboratory administrators already tell THE DARK REPORT they’ve raised med tech wages and enriched recruiting bonuses to attract new hires. In many cities around the United States, laboratory administrators from different labs are banding together to support local community college and university training programs—with both extra funding and help in recruiting candidates and pro- viding them on-the-job training opportunities. (See TDR, October 7, 2002.) These steps will increase the supply of trained technical labor for laboratories, although it will take several years to accomplish.
The other main strategy now used by laboratories to cope with a limited labor supply is to make existing technical labor more productive. One approach is to substitute automated instrument systems and reassign the med techs freed up to other areas of the laboratory.
Boosts to labor productivity can also be accomplished by intelligent redesign of work flow through the laboratory. Independent of laboratory automation, there are many ways to make technical labor more productive. This is exactly what the management systems like ISO- 9000, Six Sigma, and Lean have done for companies outside healthcare during the past two decades.
In site visits to laboratories throughout the United States, THE DARK REPORT sees these solutions coming into play. Higher wages, more astute workflow redesign, and shrewd use of targeted lab automation projects are becoming increasingly common.
Lab Industry Macro Trend # 8
Incremental Automation Finds Growing Favor in Laboratories
PROBABLY NO SINGLE AREA of lab management has been as frustrating as laboratory automation over the last decade.
Introduced under the banner of “total laboratory automation” (TLA) in the first half of the 1990s, the earliest attempts with first generation TLA equipment were often financial and operational disasters.
Over two-year and three-year cycles since the mid-1990s, diagnostic instrument manufacturers have introduced incremental improvements in TLA equipment, along with stand-alone solutions for task-oriented automation, modular automation, and workstation consolidation.
Judging by the sales of products which can be loosely described as “automated solutions” over the past 24 months, an expanding number of laboratories are taking first steps to restructure their lab operations and incorporate automation in their new workflow configurations.
A good term to describe this trend is “incremental automation.” That’s because laboratories are buying just one piece of the overall lab automation package. Once implemented, labs are free to pursue another automation project. But each of these “incremental automation” projects are much cheaper than the full TLA solution.
Most importantly, these incremental projects are easier to implement and the economic costs and benefits can be more accurately predicted. Each successful automation project makes it easier to automate other work processes in the laboratory in future projects.
In contrast to the “incremental automation” approach, the number of laboratories willing to convert to the full TLA solution remains tiny. THE DARK REPORT believes this is true for two reasons. First, most larger laboratories remain skeptical about their ability to successfully implement a cost-effective TLA installation.
Second, it remains difficult for any prospective buyer of TLA to get accurate, full, and reliable information about the costs, benefits, and ROI (return on investment) from the existing generation of TLA products. Neither existing customers nor vendors have been willing to publish rigorous data about the performance of these products in real lab settings.
Thus, many lab buyers assume, rightfully, that the lack of thoroughly documented information in the public domain means that the performance of existing TLA installations still has room for much improvement.
In the meantime, “incremental automation” is proving to be an effective way for labs to improve labor productivity, work around shortages of technical labor, and expand capacity to meet testing growth in their hospital or health system. THE DARK REPORT believes management systems like Six Sigma will encourage more lab automation, because such systems allow lab directors and pathologists to deploy such solutions with greater effectiveness.
Lab Industry Macro Trend # 9
Different Marketing Models For New Diagnostic Assays
HERE’S A TREND with the potential to radically change the way laboratories buy test kits and offer assays to physicians and consumers.
As this trend unfolds, it will shift the budget emphasis within clinical laboratories. It may alter the basic test menus offered by today’s higher-volume laboratories.
This trend fundamentally changes how new diagnostic technology is brought to the clinical market. Traditionally, most new test assays were marketed through the major diagnostic manufacturers. New assays were developed to run on existing instrument platforms and were offered, virtually without restriction, to any laboratory willing to buy the test and offer it to their physician-clients.
The new marketing model for diagnostic tests is radically different. It starts with a proprietary test that may be patent-protected. The objective is to maximize profits generated by the clinical use of this specific test technology. In many cases, the new test technology must be run on custom-designed instruments, a separate source of revenue to the manufacturer.
In most aspects, these diagnostic test developers are using the pharmaceutical industry’s marketing model. So, the diagnostic test company has its own sales force which visits physicians’ offices and “details” the doctors with information about the lab test and how to use it on their patients.
The diagnostic test company wants to build brand awareness for its lab test. Just as “Prilosec® ,” “Claritin®”, and “Viagra® ” have become well-known among consumers, the makers of “ThinPrep® ,” “TruGene® ,” and “OraSure® ” want similar consumer recognition for their lab tests.
To date, one of the best examples of this new diagnostic test marketing model is Cytyc Corporation’s ThinPrep test. It is patent-protected and has brand recognition with both physicians and consumers. It is a premium-priced test relative to the conventional Pap smear and, in the earliest stages of its market launch, only selected laboratory “partners” were allowed to buy the test and offer it to their lab’s clients.
THE DARK REPORT has covered this emerging trend in earlier issues. HIV mutation and viral load test assays have many elements of this new marketing model. (See TDR, June 24, 2002.) Hospitals and health system laboratories are already experiencing the budget-busting aspects of this esoteric testing business strategy. On pages 14-17 of this issue, THE DARK REPORT provides a detailed briefing on how specialty esoteric test companies are bypassing local labs and marketing high-priced, multi-panel tests directly to physicians.
For the laboratory industry as a whole, there are many troubling aspects involved in this new marketing model. As time passes, their full financial impact will be revealed.
Lab Industry Macro Trend # 10
Medicare’s Impending Meltdown Will Scramble Healthcare
MOST EVERYONE AGREES THAT Medicare has serious problems that require significant reforms as soon as possible.
THE DARK REPORT concurs, and is willing to go out on a limb and prophesy that a meltdown of the Medicare program as we know it today will happen soon, in as few as five years.
Medicare has become the dominant force in the American healthcare system for two reasons. First, it covers a growing number of the nation’s population, with aging baby boomers soon to swell that number at accelerating rates.
Second, Medicare’s regulations, policies, and price schedules for provider reimbursement have increasingly been incorporated by private payers into their own reimbursement criteria. Thus, major changes to the Medicare program immediately cause similar ripples throughout the private health insurance industry.
Medicare’s impending meltdown is rooted in the disconnect between Medicare’s pricing structure and reimbursement guidelines and the private marketplace. In an editorial published on December 31, 2002, The Wall Street Journal described Medicare as a “federal insurance program that evolved into a system of Soviet-style price controls in the 1980s. Medicare pays a fixed amount for a treatment, regardless of costs…”
Laboratories are familiar with the negative consequences of Medicare’s pricing structure. Part B lab test pricing is based on a 1984 menu of lab tests (that has never been updated in 18 years) which is reimbursed at well below Medicare’s median national price. In only three of the past 16 years has the lab fee schedule received an increase that equals or exceeds the CPI (Consumer Price Index).
Even as Medicare officials acknowledge the negative impact that recent reductions in physician professional fees will have, neither they nor Congress took action to forestall these cuts. In Oregon, THE DARK REPORT is hearing anecdotal stories about surprisingly large numbers of physicians giving service termination notices to their Medicare patients. These physicians are responding to lower Medicare fees by excluding Medicare patients from their practice.
Because Medicare has mutated into a bureaucratic price-fixing colossus, it has lost touch with the marketplace. Just as the Soviet Union collapsed 13 years ago, Medicare as we know it today is headed for a similar economic meltdown.
At a minimum, bureaucrats at Medicare will soon meet the buzzsaw of baby boomer consumers—who want physician choice and access to the latest technology. These consumers, as taxpayers and voters, will drive reforms to the Medicare/ Medicaid system we know today. What the final picture will look like is anyone’s guess. But choice and access to new healthcare technology will certainly be part of the post-reform Medicare scheme.