Steve Speil [00:00:04]:

I’m also very proud that even before the Affordable Care act was enacted, the Federation was the first major healthcare trade association to come up with a prototype for aca. We named it our Passport program, but it had all the features, many of the features that are in ACA today, with community rating, mandates, exchanges, all the elements of ACA that have led to tens of millions of people achieving coverage that they would otherwise not achieve.

Intro [00:00:50]:

Welcome to Hospitals in Focus. From the Federation of American Hospitals, here’s your host, Chip Kahn.

Chip Kahn [00:01:00]:

As the year comes to a close, it’s time to ponder the progress we’ve made and begin to prepare for the work ahead in 2025. To understand where we are today and the challenges and opportunities for healthcare and the hospital community ahead of us. It’s a helpful time to reflect on how far we’ve come and where we need to go. So we have a special guest today for this episode, this special episode, to look at the past and see whether past is prologue. Discussing the future. Steve Spiel, executive Vice President of Policy at the Federation, is retiring after an extraordinary tenure. With nearly four decades of healthcare policy experience, Steve has been a pivotal figure at the federation since 1997. Before he leaves to start his new chapter, Steve is taking time to look at the past and think about the future with us today and help us begin to think through the challenges that are necessary to sustain high quality, 24/7 hospital patient care into the future. Steve, thank you so much for being here today.

Steve Speil [00:02:16]:

You’re welcome, Chip. And thank you so much for having me.

Chip Kahn [00:02:19]:

So we’re gonna be setting context for thinking about the future. But before we get to that, I think it’s very important for our audience to understand who you are and where you came. I mean, you and I have been at the Federation for so long, both of us feel, probably feel like life began when we took the job working for the important hospitals that we represent, but frankly, both of us had lives before that. And let’s hear a little bit about yours and tell the audience what’s been important to you through your career as you came to Washington and got involved in health policy before the Federation.

Steve Speil [00:02:59]:

Happy to share that with you and the audience, Chip. You know, I could start with a conventional approach and talk about law school and work I did in Massachusetts. I’ll get into that in a second. But actually, when I was thinking about it, my career path actually started as a young teenager in the mid to late 60s, working 10 hours a day, six days a week as a dishwasher at Johnny’s Diner. Johnny’s Diner was the go to place in central New Jersey where I grew up. Somerville, New Jersey, the ultimate melting pot community back then. And buses that would travel west, I’m sorry, they would travel east to New York, would typically stop at Johnny’s Diner for breakfast, lunch, early dinner, whatever. And it was just remarkable to see the teamwork involved when a bus pulled up, the surge of activity, everything from the waitresses, the bus boys, Rudy who was considered the best short order cook in central Jersey, how everybody came together to beat the masses from the buses that came.

Steve Speil [00:04:13]:

And when I look back at that, that was kind of my first glimpse of how important teamwork is to the success of a hospital. So anyway, probably not what you expected to hear, but that was really important to me in terms of forging my work ethic and understanding teamwork and how that is the foundation for success in hospitals at the Federation and, and at all the other associations here in dc. So anyways, from there, of course I went to college and then followed that by deciding to get a Master’s of Health Administration in North Carolina. After which I decided, you know, if I really want to make my mark in public health, I think I need to do more and learn more. And that led me on a path to law school here in Washington D.C. at American University. There were very few health law programs back then. They didn’t have one.

Steve Speil [00:05:15]:

But they gave me an opportunity to kind of develop a flexible curriculum. So I worked actually days, first at FDA in the Office of Legislative and Congressional affairs for two years and my third year I was at EPA in the General Counsel’s office, graduated from law school. My first job was in Massachusetts in the Office of State Health Planning. Certificate of need was all the raids back then. There was federal money provided to states to develop statewide health plans that the Certificate of Need organizations would follow in terms of deciding who got to build a hospital, where, how big it was and all the rest of it. And Certificate of Need lives today in many states as well. Over time in Massachusetts I had increasingly responsible positions, culminating in my position as legal counsel to the Lieutenant Governor Evelyn Murphy in the Dukakis administration. Ultimately, she did not become governor and I then kind of migrated back to Washington D.C.

Steve Speil [00:06:23]:

taking a position doing health policy work for Adimit, which was then called the Health Industry Manufacturers association back in 1992, and ultimately leading to my position here at the Federation, which was run by Tom Scully back then in 1997.

Chip Kahn [00:06:44]:

So Steve, obviously a fulsome background to begin heavy duty work in health policy. You came to the Federation at a critical time back in the late 90s, right at the passage of the Balanced Budget act of 97 that touched so many parts of Medicare and really began many, many years of policy development, further policy development and, and maturing of Medicare and other programs. So let’s talk a bit about, because I want to talk about here overall, where we were and where we have come to. Let’s talk about in the late 90s in that, that period when you started here. You know what characterized that period?

Steve Speil [00:07:27]:

Well, thinking about the complexity of the world today, I could start by saying it was a simpler time, although it didn’t feel simple and innocent. There was basically one regulation a year, the IPPS rule. And it was a huge deal then and it’s a huge deal today. But it wasn’t nearly as complex as it is today. There was no quality program, there was no information technology, but there was the wage index and there was the outlier payment and there was the inflation update which were critical to hospitals ability to provide care to patients. So it was a much narrower scope compared today. But it was hugely important. It was a hugely important regulation.

Steve Speil [00:08:17]:

What was not so simple and it could foreshadow what we might see in 2025 and beyond was the BBA, the balanced budget act, which was enormously important to hospitals. There were massive cuts to payments across the board, creating incredible uncertainty and chaos in the industry. The BBA kind of, well, CBO underestimated the impact of the cuts to payments. And over the next two to three years there was subsequent remedial legislation that Congress enacted and bbra, for those who were around then and can remember exactly what that acronym stood for. But that is what I remember most about the late 90s here at the Federation was BBA in the aftermath.

Chip Kahn [00:09:14]:

Steve, I’d like our conversation to sort of take us from there to today. And I think you use the word complexity and I’ll put an exclamation point about that. And we play three dimensional chess today in dealing with all the different aspects of care delivery and financing that hospitals have to contend with. The hospitals you represent. Before we get there though, and thinking about this sort of as a continuum from the late 90s to where we are today, what were the high points of some of the issues that you dealt with over that period?

Steve Speil [00:09:53]:

Sure, happy to. But even before we get there, just to set a context for the increasing complexity, I want to go back to something. Peter Drucker, who was kind of the management guru back then, he’s no longer with US but what he said was really telling about hospitals then and today. And what he said was hospitals are, quote, the most complex human organization ever devised. And it’s hard to disagree with that. What is sort of ironic to me is he said that when there were much fewer regulations and burdens on hospitals as there are today, that was, you know, when he spoke, that cyber probably wasn’t even a word back then. And yet today, you know, hospitals face constant assaults from China, North Korea, Russia and others. So, you know, I think as we think about hospitals, we really need to think about the truth, the elemental and universal truth of Peter Drucker’s statement then.

Steve Speil [00:11:08]:

So over time, I’ve been so proud and honored to work for the Federation, the hospitals that I represent and that you represent. You know, we pay taxes and yet, you know, we’re ineligible for some of the important programs such as FEMA 340B, which were created to assist hospitals. But our hospitals today, the Federation hospitals, still do every bit the charity care and uncompensated care as all other hospitals along the way. In terms of some of the accomplishments that we at the Federation, working in unison with AHA and the other associations have achieved were, for example, ensuring that there would be a ban on new physicians on hospitals. There was a library of research showing how physicians own hospitals, kind of cherry pick patients, don’t do enough charity care, often do not have emergency rooms. They’re really not the full service community hospitals that that communities rely on today. So that was an accomplishment. I’m also very proud that even before the Affordable Care act was enacted, the Federation was the first major healthcare trade association to come up with a prototype for aca.

Steve Speil [00:12:38]:

We named it our Passport program, but it had all the features, or many of the features that are in ACA today with community rating mandates, exchanges, all the elements of ACA that have led to tens of millions of people achieving coverage that they would otherwise not achieve. I’m also very proud of the work that we have done over the years to assist rural hospitals. There’s been a series of legislative accomplishments to assist rural hospitals who are basically playing a game of inches. So back in MMA in 2003, we increased the DISH payment that rural hospitals get for treating low income and uninsured patients. Although it’s still stunning to me today that rural hospitals have a lower payment adjustment for treating a DISH patient than urban hospitals, I just don’t understand why there would be that type of differentiation. Hopefully, over time we’ll get some equity there as well. We’ve also done some things. And this is kind of in the micro world, we’ve created a single standardized payment which helps rural hospitals.

Steve Speil [00:14:01]:

We have helped rural hospitals in terms of ensuring the labor related share is lower for rural hospitals. Rural hospitals have a significant handicap when it comes to the wage index. And there’s more work to do. You know, aca, while it’s, you know, it’s famous for, you know, ensuring universal coverage, the other thing it did was to create a low volume adjustment that works. There was one created in 2003, but it was basically inconsequential. ACA kind of made it a real adjustment to help rural hospitals with the real challenges that they have. And over time it’s been extended. And that’s one of our challenges going forward, is to make sure that that gets extended again when Congress has the opportunity to do so.

Steve Speil [00:14:57]:

So anyway, those are some of the highlights, Chip, that resonate with me.

Chip Kahn [00:15:02]:

So many of these issues echo into the future, particularly issues related to ACA. And it was so important actually going back to 2006, which is almost 20 years ago, that it was our members who really drove the development of the healthcare passport that you’re talking about and how it really was to be modest about it. But it was a precursor at least to what ended up happening in 2009, 2010, with the ultimate enactment of what today is the Affordable Care act, the aca. So let’s talk about the landscape today and how it’s changed from your description of it in the late 90s, and what are the implications of that for so many issues.

Steve Speil [00:15:55]:

Change is a constant and adapt or die, as they say. But I would note three changes in particular, and they’re kind of environmental changes as well. One is, and it kind of harks back to what we were talking about earlier, that there was one major reg back in 97. There are multiple payment systems that hospitals have to deal with, each with its own set of rules and idiosyncrasies. The complexity is just, it can be unnerving if you let it. But, you know, you just have to take it in stride and do the best you can. So that’s one. The other is, and I’ll just make it as simple as possible, insurers don’t pay their bills.

Steve Speil [00:16:44]:

Back in 97, there was HMOs, and that led to challenges with the consumer responses with the consumer Bill of Rights and some other things. But it was nothing like it is today, where Medicaid is what, 70, 75% of patients are under a managed care organization, Medicare Advantage is at 54% of Medicare enrollees and projected to get up to 60, 70% over time. The denials, the delays, the downgrades, it is just mind boggling. And that is just a fundamental shift in the way hospitals and insurers interact and an entirely new challenge that hospitals have to deal with anyway. The army of researchers out there just constantly attacking hospitals with the same drumbeat of consolidation. Most of them are funded by groups with an ideological agenda. And it just becomes unnerving in many respects to have to respond to all of these studies, most of them saying the same things, some of them leading to absolutely absurd results, such as the quote unquote, peer reviewed study concluding that, you know, hospitals, hospital consolidation leads to suicide and drug abuse and drug addiction. I mean that’s.

Steve Speil [00:18:28]:

That to me is symbolic of how the environment has changed in a very negative way for hospitals.

Chip Kahn [00:18:35]:

You know, it seems sometimes like the kinds of researchers and billionaire advocates that you’re talking about live in an alternative reality to the one that we live in and the one that all of that Americans across the country experience every day. Members of their families or, you know, God forbid, they need hospital care and access to that. And if you look at our agenda for next year, it’s all about preserving that ready access. We feel very strongly that the important subsidies, the tax credits that were extended in the ACA exchanges that cover so many millions of Americans for a very affordable amount need to be extended. That the Medicaid program, particularly these state directed payment programs, need to be preserved so that Medicaid pays a sufficient amount. And you mentioned managed care as being so worrisome now, and managed care is such an important factor in Medicare and Medicaid. Why don’t you talk a little bit about that? And some of the things that we have to contend with today in terms of managed care, not just being, obviously the coverage on the private side, but now in terms of public programs really taking over from FIFA service, which was always the model that took primacy over most of your years at the federation.

Steve Speil [00:20:06]:

And one of the ironies of managed care is that the chassis for managed care is often fee for service payments. So, you know, value over volume is kind of a mantra now. I kind of think it’s overused to some extent. Everybody wants value, but the idea that fee for service is, you know, a villainous, in a way, encouraging oralization. I think people need to take a second look at that. Managed care is, in concept, makes a lot of sense. You want the right care to be delivered at the right Time in the right place. But the extent to which, you know, some of these insurers have people sitting in offices second guessing the judgment of a physician in consultation with the patient and the patient’s family as to what care is best, it is just.

Steve Speil [00:21:14]:

It’s an insult to physicians and a disservice to the way in which healthcare should be delivered and paid for. That is very disturbing. Fortunately, policymakers are paying attention to that. The report last week from one of the Senate committees showing demonstrating over time the explosion in denials for post acute care that insurers are making sheds light on this. OIG is looking at it. DOJ’s got some lawsuits going on, so hopefully there will be change in behaviors. CMS last year did the right thing and decided that seniors in Medicare Advantage ought to get the same protections as seniors in traditional Medicare with respect to midnight rule. If I can use a policy, there will monitor that over time.

Steve Speil [00:22:17]:

There may be some slight movement towards managed care companies complying with the rule, but we need to keep a very close eye on that and encourage CMS to kind of step up enforcement of that rule.

Chip Kahn [00:22:33]:

You know, at the beginning of your career with the Federation, you came in sort of in the wake of the passage of the Balanced Budget act of 1997. And that was an act that in the light of the threat to the future of the Medicare Part A trust fund and concern about federal spending, you know, went a long way, made a lot of deep cuts. Today the situation is not completely parallel, but next year there’s likely to be much discussion about reductions in spending because of concern about the deficit and federal spending generally. At the same time, though, the government, the nation is committed, should be committed to making sure that there’s access to care for those who are covered by Medicare. Can you talk a bit about your experience, sort of, in a sense, right after BBA 97 when hospitals had to contend with too deep a cuts. And what was sort of the response to that? That hopefully could be a bit of a warning to policymakers now that if they go too far, regardless of the best of intentions, it could have real effects in terms of the ability of hospitals to meet its 247 commitment to communities?

Steve Speil [00:23:55]:

Absolutely. And you know, 1997 was, although it seems somewhat like yesterday, a long time ago. And I don’t know that there’s anybody on the Hill now who remembers that time, but we do, hospitals do. And many hospitals are on the knife’s edge in terms of their ability to provide the care that communities need. That is actually probably the single biggest driver of hospitals integrating with one another in order to achieve economies of scale to increase quality, lower cost, and ensure access to the comprehensive suite of services that hospitals provide. So, you know, we just, we need to make sure that hospitals are aware of that. We need to meet the legislators where they are in their communities. And the federation’s got a pretty effective program that hometown hospitals, where we meet with members of Congress in the hospital to showcase the care that our hospitals are providing to communities.

Steve Speil [00:25:10]:

And hopefully that will build not just goodwill, but a clear recognition of the complexity, the costs involved. Hospitals are an aggregator of costs. We’re getting it from all sides. Pharma, medical device companies, labor, you know, is 50, 55% of the cost of hospitals. And you know, we need well compensated, well motivated employees to provide the care. So, you know, hope, hopefully we’ll be able to deliver those messages to Congress so that when it comes time for Congress to do what they’re going to do with respect to dealing with the debt ceiling and some of the other financial legislative issues, that hospitals are recognized as a key not just to providing care within the communities, but hospitals are often the economic engine of a community and a cut to hospital is a cut to the community.

Chip Kahn [00:26:15]:

You know, that’s so true. And I think when some of the policymakers look at policies like site neutrality, this issue of whether or not hospitals are paid would be forced to be paid the same as other settings. Hospitals are different than those other settings. Our patients are somewhat different and we have to meet all kinds of community demands which are appropriate 24, 7 and those other settings don’t. So I hope that whether it’s that policy or other potential policies that could be on the chopping block, that there’s a realization that if you pull those dollars out, you know, it will have ramifications. And that’s why back in the late 90s, early 2000s, the Congress had to come back and actually replace dollars that were taken away by BBA 97 because the effect on access was, was so great.

Steve Speil [00:27:14]:

Chip, that is so true. I’m so glad you mentioned that hospitals are unique, not just in the scope of services they provide, but as you mentioned, the types of patients that we treat, high acuity, high complexity, and is so different from what the care that is typically delivered at a physician’s office or someplace else. So I’ll say it site neutral. You know, it’s a lovely buffer sticker, but it hides the truth about the difference in care and the patient that hospitals provide and the patients that hospitals treat.

Chip Kahn [00:27:50]:

So, Steve, we spent time talking about our future agenda, which unfortunately we’ll have to contend with without you as you move on to your next chapter, as I said. But as we conclude here, what are your observations? What do you leave us with in terms of thoughts about the future of hospital care and our job to sustain that important care for communities?

Steve Speil [00:28:16]:

I’ll tell you, Chip, I am optimistic. I’m optimistic because I see how hospitals have responded in the past to challenges. I know how committed our hospitals and all hospitals are to the communities. They’ll always find a way to provide the care that communities across America expect and deserve. So I don’t know how we’ll do it. I remember over the years speaking with colleagues that I deal with in various companies and we’d sit there and Marvel’s like, how do they do it? How do our hospitals stay afloat and continue day in and day out to provide the care? But they always do it. And I am so humbled by what I’ve seen in terms of, you know, our hospitals and hospitals across the country, what they do. They’ll never give up, they’ll never waiver.

Steve Speil [00:29:18]:

They’ll always deliver regardless of the challenge.

Chip Kahn [00:29:21]:

Steve, thank you so much for your service over the decades and good luck.

Steve Speil [00:29:28]:

Thank you, Chip. It’s been an honor to be here working with you and on behalf of the Federation’s hospitals and all our hospitals.

Chip Kahn [00:29:39]:

Thanks for listening to Hospitals in Focus from the Federation of American Hospitals. Learn more@fah.org follow the Federation on social media at FAH Hospitals and follow CH@CHIP Con. Please rate, review and subscribe to Hospitals in Focus. Join us next time for more in depth conversations with healthcare leaders.

In his capacity as Executive Vice President of Policy, Steve Speil manages the Federation’s broad portfolio of payment policy issues. He serves as the association’s chief liaison on these issues with the Centers for Medicare and Medicaid Services and the Medicare Payment Advisory Commission. Working closely with the senior finance and policy executives in the Federation’s member companies, Steve develops and carries out both issue-specific and general strategic plans designed to advance the finance and payment related regulatory and legislative interests of the FAH. 

Prior to joining the Federation, Steve served as Associate Vice President, Policy Coordination and Communication for the Health Industry Manufacturers Association (now AdvaMed), the national trade group representing the medical technology industry. Before moving to Washington, Steve held a succession of increasingly senior management and policy positions in Massachusetts. During his time in the Bay State, Steve served as Legal Counsel to the Lieutenant Governor, Legislative Counsel for the Executive Office of Health and Human Services, Executive Director of the Disabled Persons Protection Commission, and Legal Counsel and Policy Director in the Office of State Health Planning. Steve also taught health law and policy as an Assistant Professor at Simmons College Graduate Program of Health Administration. 

At the federal level, Steve served in the Food and Drug Administration’s Office of Legislative and Congressional Affairs. He also worked in the Environmental Protection Agency’s Office of General Counsel. 

Steve earned a J.D. degree from American University’s Washington College of Law; a Master in Public Health degree in Health Administration from the University of North Carolina School of Public Health; and a Bachelor of Arts degree in Anthropology/Zoology from the University of Michigan.