1. Donor Recognition Reception
November 15, 2012
Sue E. Mooney, MD, MS
Alice Peck Day Memorial Hospital
Good Evening and Welcome! Thank you for coming and most importantly, thank you for your
ongoing support of APD. I am delighted to see so many of you here this evening. I must confess,
I am a little intimidated by what I have been asked to accomplish with this talk because Melanie
has asked me to spend the next 20 to 30 minutes sharing with you my thoughts about our
National healthcare system and where it is headed. My anxiety stems from the fact that I can
do that in less than a minute – the National healthcare system is a complete mess and no one
knows where it is going – which leaves a whole lot of time to fill… However, as I gathered my thoughts and sat down at
my computer to write, I realized that I actually have a lot to say about our healthcare system and I have plenty of ideas
about where APD should go. Now I am worried that 20 to 30 minutes is too short a time. Hard to win with this
assignment. As an aside, I also told Melanie that I was not going to show any PowerPoint slides and that I did not have a
title for the talk, but as I prepared (at the last minute), I changed my mind. Sorry, Melanie. I hope I am not driving you
crazy and Thank You and your staff for doing such a nice job with this event tonight. So, even though it is not on the
program, the title of this talk is “Learning
to Block and Tackle in the age of Hail Mary
Medicine” and I will start with a
digression, a story and my first slide.
The digression involves telling you a little bit about myself – I am a
really competitive person. I like to watch people compete, I
personally like to compete. I even dream about competing.
Competition is in my DNA. I have mellowed with time, but anyone
who has ever watched me watch a sporting event knows that mellow
is a relative term. By the way, this is a picture of a Princeton
University Soccer Player and I am proud to announce that my former
team has made it to the second round of the NCAA tournament which
began this afternoon at 5 PM. Go Tigers!
Now on to the story: Two summers ago, my partner, Tish and I
decided to take our boys to the Maine coast for a brief summer vacation. Hedging our bets against bad weather, we
decided to stay in Portsmouth at a Residence Inn. Our plan was to hop across the bridge to the beaches in York and
Oqunquit with the option of in-town activities in the case of inclement weather. Mother Nature’s plan was to dish up
the worst possible 4 day stretch of weather known to man with non-stop torrential downpours, gail force winds and
occasional hail. By day three we were all a little cranky – you can only go to the Dover children’s museum and the hotel
pool so many times before you start to re-think the whole “let’s go to the beach vacation idea”. And then we noticed
the building next door to the hotel. It was modern and colorful – industrial but in a new age, hipster kind of way. We
got curious and decided to pile the kids in the car for an investigatory spin around the block (yes, I know the building was
right next door but refer back to the comments about the weather and then add in that my kids were eight and three at
the time and you can understand the impulse to drive rather than walk the 100 yards between the buildings). What we

2. found was the Red Hook Brewery. Now, you may question the wisdom of this next move, but we immediately pulled in
and signed up for a tour. Yes, you heard me right. We took our kids on a brewery tour. Desperate times call for
desperate measures. And we all had a ball. We saw really cool machinery, learned a lot about yeast and hops and
barley, decided that the bottling room was way too
loud and figured out that wrestling in the halls during
the beer tasting is frowned upon. The grownups in
our group also learned that Red Hook is part of a
publicly traded company called Craft Brewers Alliance
(Ticker Symbol BREW, for anyone who is interested).
One of my hobbies is investing small amounts of
money in small companies. I like to read the financial
statements and follow the performance (for me, this
is a little like a sporting event, so you can refer back
to my previous comments). When we got home from
our soggy vacation, I did my research and ultimately
ended up buying 250 shares of BREW. My
appreciation of this small company has been turned
into tangible support. I feel good about investing my money in this way. I enjoy owning a small piece of a local company
that makes a product that I like with a corporate structure that I can understand. I like the brewery and I want to
support it. My shares have also appreciated a fair amount since I bought them, which doesn’t hurt.
By now, I am guessing that you are sitting there wondering where this is going and what this has to do with healthcare.
I want to assure you that there is a point and that I am not just revealing some, small personal details about myself to kill
time. I am trying to tell you that I am a very competitive person and a hard core Capitalist. Which I think you need to
understand in order to hear what I have to say next, because it may not be a popular thing to say: In my opinion,
competition and Capitalism are at the very heart of what is wrong with the US healthcare system.
Start with history: In
Profit
the US, we don’t have
a rational healthcare
system. We have a
Occupational Health
conglomerate of
Medical Admits
competing healthcare
Obstetrics
RAMCCC
organizations. This is
WCC
Breakeven
ECF
SNF
ICC
especially true in
ER
urban areas with large
GI endoscopy
Pharmacy
Neurosurgery
Hand Surgery
Urology
Ophthomology
Dermatology
ENT
SWSNF
Orthopedics
Gynecology
Podiatry
General Surgery
Plastic Surgery
Radiology
Surgery Clinics
Pain
Sleep Lab
Anesthesia
Lab
Rehabilitation
populations. Each
organization has to
make decisions about
which services to
provide to the
community. Different
services are Loss
reimbursed at
different levels –
obstetrics, pediatrics, psychiatry, primary care are reimbursed poorly (often at rates that are below cost), while other

3. services like orthopedics, cardiology, neurosurgery and interventional radiology (to name a few) are reimbursed well
(often at rates well above cost). (This is an old slide that I have used at APD to illustrate the point. The services on the
left make enough money
for the hospital to cover the services to the right of the slide) I have no idea who created this system, but I do think that
it says a lot about our societal values and we could spend the whole of our time together today talking about that, but
we won’t. Facilities cover the cost of providing poorly reimbursed services by beefing up services that are lucrative.
Maintaining or increasing market share in the financially “good” stuff and dumping the financially “bad” stuff becomes a
winning financial strategy. (This is fundamental – people really do respond to financial incentives – Healthcare
executives and Doctors are not exceptions to this rule) In any given region, decisions about what services to offer are
strongly influenced by money, not societal need. Hence the crisis in mental health care services, the closing of Birthing
Centers and Nursing Homes and the oversupply of surgical subspecialists and interventionists which often leads to the
overuse of interventions with equivocal benefit. Additionally, the system pits facilities against one another. If System A
builds an MRI that attracts patients and supports the Neurosurgery service, then System B better build one fast because
a system that loses a highly reimbursed subspecialty risks financial collapse. In business, competition leads to
innovation and lower prices. Consumers’ benefit. In healthcare, something more interesting happens. Supply creates
demand. The concept of supplier induced demand has been well described by healthcare researchers and there is clear
evidence that it drives up system cost. Competition has created an irrational “arms race. We have 20 MRI scanners in a
region that, objectively, really only needs two and we use all 20 of them. Each time we run the scanner, we generate
more revenue for our institution, because, currently, we are paid for each task we do. We are not paid to keep you well
or even, quite frankly, to heal whatever it is that ails you. From the standpoint of the overall system, it is worth
remembering that an organization’s revenue is also the system’s cost – hence the higher our revenue, the higher the
overall cost of healthcare.
Everyone in healthcare understands this dance. But none of us can give up the (metaphorical) scanner, because to do so
now, given the current “fee for service” paradigm, is akin to committing financial suicide. This is complicated stuff and I
have not even mentioned the Federal Trade Commission and their historical stance that competition must be preserved
in order to protect consumers.
The concept of supplier induced demand fascinates me because I don’t think that there is an easy answer to the
question – why are we using all 20 of the scanners mentioned above, if we really only need two – is it really just because
Doctors are ordering tests and performing procedures we don’t need in order to make more money? Yes, the payment
system and the regulatory environment are problematic and, yes, there is some evidence that there are Doctors who are
defrauding insurance companies – cardiologists have been caught doing catheterizations on people who don’t have
heart disease – but I believe that outright fraud is rare and that the answer to why we are using all these scanners (and
tests and interventions) is complex. Yes, Doctors do respond to financial incentives but they also really want to help
their patients. They believe that what they are doing is of benefit to their patient and they are also very responsive to
patient’s desires, demands and expectations.
In the US, if you have insurance, you have access to the most sophisticated and amazing healthcare the world has ever
seen. We have immediate access to specialists, tests, drugs, and heroic interventions with limited chance of success.
You have back pain without neurologic signs – the MRI scanner is available this afternoon, the co-pay is reasonable and
the insurance company picks up the rest, so let’s just get the test to be sure that we are not missing anything. We seek
reassurance and we want to eliminate all risk. You are at the end of your life because the cancer you have is too
aggressive and too advanced but an experimental treatment that someone, somewhere tried in a lab might help. It’s
fourth and long with the game on the lin e, so we throw the “Hail Mary” – because everyone remembers Doug Flutie

4. and the “Miracle in Miami”. If you don’t catch this reference,
after the talk, just grab any sports fan in the room. They will
know what I am talking about…
But what of the people without insurance? The evidence is
clear. A lack of insurance translates into a lack of access to
healthcare. The uninsured are like the kids standing outside
FAO Schwartz at Christmas, unable to get what they really
want. Or perhaps a better analogy is to say that they are like
the barefoot, homeless man on a winter night outside the
cobbler’s store. Unable to get what he really needs. Without
healthcare insurance (and let’s face it, no one can afford
healthcare without insurance) you are largely cut off from all that we have to offer. As I said before, I am a Capitalist, if
you can’t afford to buy Red Hook Beer, so be it, but somehow this whole topic is much more difficult when it comes to
healthcare.
Over the past few days, I have been wrestling with a question – I have long held the belief that healthcare is a
fundamental human right, but lately I have been asking myself “why do I believe that?” “What are the moral
underpinnings of that statement?” I have not yet formulated a clear answer – other than to say that I wholeheartedly
believe that a just society does not condemn its weakest members – children, disabled people and the mentally ill, for
example – to a lifetime of increased suffering purely because they lack the financial resources to change their fate. (As
an aside, I have learned a great deal about life from the two children that we adopted from the slums of Guatemala
City).
But aside from morality and ethics, I can argue this on another level. As a society, we deny the uninsured basic
healthcare (because realistically, they can’t afford it) but when they show up in the ED with end stage diseases or even
minor issues that could be addressed more cheaply in an office setting, we go all out. Cost be dammed. The net result,
Medical bankruptcy for them, cost-shifting for you and I and hospitals that are perpetually on the verge of financial
collapse due to un-reimbursed care. Those of us who are in healthcare, who truly understand how this system works
are pretty convinced that we have collectively, as a society, lost our minds. Those of you who aren’t in healthcare, can’t
fully understand it because it can’t really be this ridiculous and the politicians who are making the rules are a whole
‘nother story. Back to the beginning. This system is a mess and no one really knows where it is going.
We have a system that is perfectly designed to lead to increased costs, we have perverse incentives and a heroic vision
of doing everything we can, because to do less is to admit defeat. We are providing care in the worst possible way – at
the 11th hour in bits and pieces through EDs and unnecessary hospitalization AND we are paying for it in the least
efficient way possible. It comes down to this: as a country we need to decide: If healthcare is a right, then let’s pay for it
in a rational way. If it is not a right, then let hospitals and healthcare providers turn away those who cannot pay. I
suspect very few are comfortable with this but let’s put it out there, because this middle ground of having it both ways is
untenable and unsustainable.
As you all know, I am new to my role as President and CEO of this institution and, after hearing the beginning of this talk,
you are probably wondering why I took the job. I have been asked that many times in the past few months – usually in
the context of someone testing my sanity, and my reply has been consistent. “This is a fabulous time to be a leader in
healthcare. How often in life do you get a chance to really make a difference and to be a part of creating something
new? This is what opportunity looks like”.

5. So, where do we go from here? Dr. Kerr White, a
Dartmouth Alum and early Health Services
Researcher observed that for every 1,000 people at
risk of disease, only 100 are admitted to a general
hospital and only 10 are admitted to a tertiary care
facility. Ironically, still today, the vast majority of
our resources are spent on hospitals that are
incentivized to compete with each other, which, in
healthcare, has the paradoxical effect of raising
costs, not lowering them.
Building on Dr. Kerr’s work, I believe that we need to stop setting ourselves up to win the game with a long shot pass. As
all sports fans know, most games are won by the team with excellent fundamentals. We need to learn to block and
tackle. Healthcare systems need to stop competing and
start collaborating. We need to make decisions about
which services to provide based on what the local
community needs, rather than what insurance will pay for.
Blocking and tackling in healthcare looks like going after
the roots of our obesity epidemic, managing chronic
diseases like diabetes and hypertension, and preventing
COPD through tobacco cessation programs. Blocking and
tackling is ultimately about promoting health and wellness.
When we focus on the fundamentals by shifting resources
to the population at risk instead of the population in the hospital, we will begin to rationalize this insane, irrational non-
system. There is much to be gained by focusing our efforts on the 1,000 people at risk, rather than the few in the
hospital. And, ultimately, this strategy will be cheaper. APD is perfectly positioned for success in the future because we
have always been about the community. If a rational healthcare system looks like a pyramid, we are a part of its
foundation. The work ahead includes defining what that means. Personally, I firmly believe that any services that can
be effectively, efficiently and safely provided in a community setting, should be provided in a community setting.
Defining those services, ensuring that they are of high quality and that they meet the needs of those we serve is my top
priority.
At the beginning of this talk, I told you some things about myself that I think are important. I am a very competitive
Capitalist who has come to understand that, when it comes to healthcare, these impulses need to be examined and
perhaps rechanneled.
If there is a light in this darkness called the healthcare system, it is this. I am not alone in this thinking. There is a
growing consensus in the Upper Valley that we, as a community, need to come together to solve this enormous puzzle
called healthcare. Whatever your political persuasion, whatever your socioeconomic status or religious leanings – we all
have “skin in this game” and the solutions will come from within us. I had a recent conversation with some of my
colleagues from the Dartmouth Institute and they asked me what I was most proud of regarding my work as a leader at
APD. I was, at 1st surprised and unable to answer because I don’t tend to think about such things – After a few minutes,
I said “Starting the right conversations…”

6. In retrospect, I think I got that answer right. Preserving the best of what is, facing the reality of what’s broken and
finding solutions will require all of us. There will be many conversations – within our institution, with DHMC and other
regional providers, but most importantly with you, the members of the community that we serve. I believe that we start
here, today. I really don’t want to change the whole system – it is too big and too broken – I just want to make this
small piece of it, APD, a little bit better. And I know that I cannot do this alone, but I can start the conversation. So,
think of this talk as an invitation – an invitation to give of
yourself and to add your voice to the growing chorus of voices
that will shape the future of a local, sustainable, healthcare
system for our community.
Thank you for your attention and continued support of APD.