WIDC: Supreme Court holds the key to the future of the ACA

Sesh SarathyOne of the highlights of the Fuqua Week in DC (WIDC) course was hearing from Mr. Lyle Denniston, who has been covering the Supreme Court for 57 years and writes for scotusblog.com, about how the Supreme Court has handled the ACA. He gave our group a comprehensive history of court’s decisions regarding the ACA, including insights on the NFIB (National Federation of Independent Business) vs. Sebelius case from 2012. Interestingly, he was the first to correctly report the verdict of the NFIB case; channels such as CNN and Fox, in a rush to break the news, incorrectly reported that the Supreme Court had ruled that the ACA was unconstitutional.

Denniston spoke to our group at length about the upcoming battle in the Supreme Court – King v. Burwell – on whether the federal government can extend its program of subsidies to buyers of health insurance in federally operated exchanges in 34 states. According to him, if the court decides to limit subsidies only to the state-run exchanges, it would result in the complete unraveling of the ACA.

At the heart of the King v. Burwell case are four words in the ACA: “established by the State,” and the future of the ACA will depend on how the nine justices interpret those words. When the subsidies were setup, Congress wrote that it would apply to exchanges “established by the State.” But if a state did not setup an exchange, can it still receive federal subsidies? The plaintiffs in King argue that the ACA authorizes federal subsidies only for individuals who purchase insurance on state-established exchanges and not for those who do so on exchanges established by the federal government.

While to the casual observer, it may seem preposterous that the healthcare of several million people could be held hostage by “four words” in the ACA, Denniston explained the history and nuance behind how justices view the constitution and interpret law. Some judges believe in textualism – that a law’s ordinary meaning should govern its interpretation, as opposed to looking at the legislative intention behind passing that law. Other judges take a more holistic view, known as the purposive approach, and look at legislative intent as well consider relevant materials such as speeches given in Congress, committee memos and reports, white papers, etc.

Denniston gave our group some extremely interesting tips on what to look for ahead of the Supreme Court ruling on King v. Burwell. Chief Justice Roberts and Justice Kennedy are considered to be the “swing votes,” and the other justices are expected to vote along ideological lines. But Denniston admitted that very few, if any, were able to correctly predict the outcome of the NFIB case. Oral arguments in the King case will be heard on March 4th 2015 and the final decision will be made on the last week of June 2015.

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Duke University Hospital Experiential Learning Practicum: New Perspectives on Primary Care

Jessica DennisBefore coming to Fuqua, I worked as a strategy and operations consultant and advised pharma and payer companies. My interactions with healthcare industry clients inspired me to pursue the Health Sector Management (HSM) Certificate at Fuqua, but after just a few days at HSM Bootcamp, I realized how little I knew about the drivers of the industry.

The Duke Hospital Experiential Learning Practicum (DUH ELP) gave me the opportunity to learn more about the care delivery side of healthcare. Throughout the semester I worked on a project for Duke Primary Care (DPC), a network of roughly 40 offices encompassing primary care, urgent care, and pediatrics. The DPC Chief Operating Officer oversaw my project and included me in DPC’s Performance Improvement group meetings.

In the past few years, the introduction of new technology as well as the need for more streamlined and coordinated care has helped DPC become more efficient but also challenged employees at each practice to take on new responsibilities. The lines between clinical, clerical, and administrative tasks have become increasingly blurred as employees are required to interact with both the patient and the patient’s electronic medical record. My project for the semester was to support DPC in its effort to clarify roles and responsibilities for key managerial positions at the primary care practices.

Each practice relies on a team of health care administrators, practice medical directors, and nurse managers to manage patient flow and clinical operations. I surveyed and interviewed each of these groups to understand the current state of their leadership responsibilities as well as their perspectives on an ideal future state. The final product was a matrix view of roles and responsibilities that each practice could use as a reference for decision-making and delegation.

In addition to working with DPC, I also had the privilege of shadowing three different leaders within Duke University Hospital. I shadowed the Vice President of Emergency Services and learned about hospital’s training and preparation for potential Ebola patients. I spent a half day with the Chief Operating Officer of the Patient Revenue Management Organization understanding the impacts of the Affordable Care Act on Duke and other large hospitals throughout the state. Finally, I met several members of Duke’s Center for Community Health, a unique group that works to improve access and affordability of healthcare services in several North Carolina counties.

The most important lesson I learned from this experience goes far beyond the trends, frameworks, and statistics of the provider setting; instead, I learned to appreciate the complexities of a large healthcare system. Within the sector, within each system and even within departments of the same system, leaders constantly face competing demands, conflicting interests, and gray areas, but all are seeking the same objective: delivering the best possible care to patients. Advances in technology, policy, and innovation support that objective, but they also introduce new challenges to the system. Addressing those challenges will be complex, but the DUH ELP is one of many HSM experiences that prepares my classmates and me to continue onward with our main objective: pushing the limits of our abilities to positively impact the healthcare industry.

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WIDC: This Class is the Jewel of Fuqua’s HSM Program

Gay WehrliThank you for a fantastic week in DC. When I began the WEMBA program I predicted my two top experiences would be the Term 6 Coach K Basketball experience and the Health Policy Class in DC. My prediction was 110% correct. Through this class and week in DC, I learned a tremendous amount about the ACA and its challenges, health insurance exchanges, the challenges of healthcare policies, and the roles in healthcare for Government, Government organizations and Non-government organizations.

This truly was a phenomenal week and one that every HSM student should attend. I am still reveling in my new found knowledge, in meeting the phenomenal speakers, and in entering buildings, old and new, that house our Nation’s healthcare leaders. The DC experience and memories will remain with me for years to come. This class is the jewel of Fuqua’s HSM program.

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Why Business Students Should Care About Policy

Hunter SinclairIf you’re a business student and you want to work in healthcare, you’re going to need to understand at least a little bit about healthcare policy. While Americans take pride in their “free-market” healthcare system, government sources pay 55 cents out of every healthcare dollar spent in the United States…and there are a lot of healthcare dollars spent in the United States (far more than any other country in the world).

During Duke’s Week in DC trip, speakers from across the healthcare industry talked about a number of different ways that healthcare policy changes could have a dramatic impact in 2015. For example, a number of our speakers talked about the upcoming King v. Burwell Supreme Court case and the potential $36-65B annual impact that this decision could have on the industry. We also heard about the potential repeal of the medical device tax (a $4B annual impact on the medical device industry). We even heard a few speakers talk about the potential of non-profit hospitals to lose their long treasured tax-exempt status as the number of uninsured patients falls drastically in some states (Not-for-profit hospitals are exempted from paying $20B in sales, property and income taxes each year).

While all the issues I mentioned previously are important, I feel that the most emblematic topic we discussed this week was the Sustainable Growth Rate (SGR) or “Doc Fix”. I’ll spare you the gory details, but Congress passed a law in 1997 that was designed to rein in healthcare costs. This sounds great in theory, but Congress has prevented its own rule from being enforced 17 times. The latest delay in enforcement expires on March 31, 2015 and many in Washington are optimistic that Congress won’t “waste a good crisis” and will issue a permanent Doc Fix. The proposed fix attempts to transition physician payment away from fee-for-service towards a payment system that rewards higher quality and better outcomes.

The reason I feel that the SGR debate is so emblematic of the week is because it highlights the best and worst parts of healthcare policy. The worst part of healthcare policy is that it is constantly changing, heightens uncertainty and often doesn’t factor in unintended consequences for those in the industry. The best part of healthcare policy is that it can be used to redesign the largest healthcare system in the world towards a system that rewards better care (instead of more care) and offers opportunities for entrepreneurs like Privia Health and Evolent Health to do well (make money) while doing good (saving lives).

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HSM Bootcamp: An Enriching Experience

Elena BraunHaving spent the first part of my career at a generic pharmaceutical company, I had a reasonable understanding of what it takes to get a product to market and really enjoyed the challenge pharmaceuticals presented. I knew that post MBA, I wanted to go back into the industry so I came to Fuqua primarily for the HSM program. My goal was to round out my expertise in the US healthcare market, but what I didn’t realize was how much was left to learn and just how quickly that education would begin.

On the first day of bootcamp, our professor, a medical doctor by trade, asked the class to always consider the question “who is going to pay”?  This was totally new to me. In generics, the answer to that question was simple and consistent- everyone would be willing to pay because we were the most affordable option. But the story on the branded side was much different. In order for providers to pay, or doctors to recommend new products, innovators must present a case for incremental benefit.

This was just the first of my “ah-ha” moments during bootcamp. Between lectures and casual conversations with my classmates, I learned how big the market was not just in the United States, but globally. I was tested and challenged to go beyond my experience, asked to leverage my own interactions with the health system, and pushed to think critically about how health, social and societal factors, as well as cost, play into decisions. We examined healthcare around the world to see what worked, what didn’t, and perhaps most importantly, why there is no “one size fits all” model.

Once the week wrapped up, I spent some time reflecting on the conversations and discussions I participated in during boot camp. I compared the takeaways to my professional experience and reexamined my interactions with the healthcare system. Amazingly, the question of “who is going to pay” was central to everything I had experienced, I just didn’t have the right framing to realize it. Personally, I had been making tradeoff decisions about visiting the doctor when the cost was my personal time. Professionally, I realized that our customers had been choosing between the long trusted brand name and a lower cost generic.

With even more distance between bootcamp and now, I can cite two significant changes in my world view.  First, on a more tactical level, I approach healthcare situations by trying to first understand the flow of money through the system. Secondly, on a more macro level, I have tried to step back from problems and consider different framing of the question. Overall, the bootcamp was extremely enriching and I am thrilled I attended.

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HSM Student Travels to South Africa on a Fuqua Gate Trip

Liz MeinertAs a first year student, I had the opportunity to complete a Global Academic Travel Experience (GATE) course on South Africa that culminated in a two-week trip to South Africa over spring break. Over the course of two weeks, we spent time in Cape Town, Durban, the Entabeni game reserve, and Johannesburg. The trip was a once in a lifetime opportunity to venture to the other side of the world and experience an emerging, but strong economy with an incredibly rich, but complicated, social and political history. I was also interested in learning more about South Africa’s healthcare system, given widespread HIV and tuberculosis (TB) prevalence that further complicates care delivery. The trip definitely did not disappoint!

Our main class assignment required us to develop a business plan for a particular industry prior to our trip, and then write a follow-up assessment to evaluate its actual potential based on our company visits, cultural tours, and the trip overall. Given my impending summer internship at athenahealth, I chose to focus my paper on electronic medical record adoption and implementation in South Africa.  Several factors complicate the South African healthcare landscape:

  • The system varies in both its breadth and depth across the private and public sectors.  While the state provides primary care and accounts for 40% of all healthcare expenditures, the private sector currently provides care for 80% of the total population[i].  This divide between the private and public sectors has led to widespread disparities in access to healthcare services–an underfunded, understaffed public health sector provides care to lower income individuals, and a private health sector employs 80% of all providers and targets middle to higher income individuals[ii].
  • Secondly, the burden of infectious disease, particularly HIV and tuberculosis, adds additional complications to this dichotomous system.  Currently, the South African life expectancy hovers around 53 years of age as a result of these two infections and their complications; 60% of South African TB patients are also HIV+[iii]. This translates to approximately 1,000 deaths per day due to AIDS.[iv] Mother-to-child transmission is also a significant area of concern, as 30% of pregnant women were found to be HIV+ as of 2011[v].  By comparison, tuberculosis affects approximately 1% or 500,000 South Africans,[vi] translating to the second highest rate of new tuberculosis cases in the World and the highest rate of drug-resistant tuberculosis in Africa.[vii] The drug resistance adds another complicating factor that also significantly increases medical costs; further, it is almost certainly driven by varying levels of adherence to medication regimens due to sporadic and inadequate access to care.

Post-Trip Assessment:  While on the trip, I had the opportunity to see a few medical facilities, and visit the traditional Zulu Muthi market in Durban. However, the most interesting “reality check” for my business plan was a front page, Johannesburg newspaper article titled “Is there a doctor in the house?” , centered entirely on the shortage of doctors and nurses in South Africa. By the numbers, South Africa only graduates half of the physicians it needs on an annual basis: 1,200. This, for a country of approximately 52 million individuals. Additionally, the average age of a specialist is 55 years [2].

Numerous factors were discussed as part of the rationale, including a lack of interest in the medical profession, mass exodus of South African physicians to other countries, and insufficient capacity at medical schools that prevents taking on larger class sizes.[viii] Additionally, private hospitals are not allowed to train medical students, so training is restricted to public hospitals, further decreasing the national recruitment pipeline. There has been movement to lobby for government approval of training in private hospitals, but thus far has not been successful despite significant support from the private hospitals.

Given this dramatic shortage of physicians, my final assessment was that it may be early for South Africa to consider full-scale EMR adoption. EMR adoption would require governmental support, via potential subsidization and regulation, and it seems that their efforts would be better focused on insuring sufficient clinicians to care for South Africa’s citizens. However, I do think adoption of a point-of-care app could be a great resource for training medical students in general. Access to the latest technology could change the perception of the profession and also incentivize the younger generation to consider treatment options and resources that may be “outside the box”.

Overall, the opportunity to vet my business plan was an important lesson in applying the business skills I learned throughout my first year at Fuqua. But most importantly, the trip was an amazing experience!


[ii] Ataguba, John Ele-Ojo. “Health Care Financing in South Africa: moving toward universal coverage.” Continuing Medical Education. February 2010 Vol. 28, Number 2

[iii] Ibid





[viii] Ibid.

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HSM Student Travels to China on a Fuqua Gate Trip

Maria McLemoreI spent the first two weeks in May on the China GATE trip, along with 95 other Fuqua students.  GATE is an opportunity to learn about global business by visiting enterprises operating abroad – on the China trip, we visited both American and international companies operating in industries across the spectrum.  While in China, some students, including more than twenty HSM folks, had the opportunity to visit the Shanghai offices of British pharmaceutical company GlaxoSmithKline (GSK).  At GSK, we learned not only about the company’s business model in China (including some discussion over its recent bribery scandal), but more importantly, how the pharmaceutical industry operates in China.

Pharma in China is flourishing.  As a component of its socialist market economy, the State Council of China publishes five-year plans to outline significant economic initiatives.  The 12th five-year plan, published in March 2011, establishes the “biomedical” sector as one of its seven key industries to grow China GDP.  The plan broadly defines the biomedical sector as anything from small-molecule pharmaceuticals to more complex biological products, vaccines, medical devices, and diagnostics.  Historically, government backing has significantly accelerated the growth of designated strategic initiatives, and the biomedical industry is not expected to be an exception. The central government has pledged to spend 20 billion yuan ($3 billion)[1] specifically on innovative medicine, the cultivation of new varieties of genetically modified organisms, and on the prevention and control of infectious diseases. Since the State Council published the plan, various ministries—including the Ministry of Health, the Ministry of Science and Technology, and the Ministry of Industry and Information Technology—have contributed their own 12th five-year plans to develop the biomedical industry.  The biomedical prioritization is expected to generate 1 million jobs in these five years alone.

However, like any industry, the pharmaceutical industry in China is not without its challenges.  The GSK visit enlightened us to a variety issues borne out of the biotech expansion that present both challenges and opportunities for foreign drugmakers operating in China.  For example, quick growth has overburdened regulators, slowing the approval process for drugs.  The Chinese regulatory agency, the SFDA, is understaffed and underfunded, resulting in a backlog of new drug applications that can take up to five years to be approved.  Current regulatory processes require that all marketed drugs in China be approved by the SFDA (i.e. there is no reciprocity based off approval from the FDA or the EMA, for example).

A second issue is that, in order to be successful, foreign drugmakers must partner with Chinese companies via joint venture.  China’s 12th five-year plan encourages the biomedical industry to look outside China to gain best practices from industry leaders, begetting partnering and consolidation and creating opportunity for multinationals looking to enter or expand presence in China.  China incentivizes multinationals to seek joint ventures simply by the promise of an easier operating environment – it is widely suspected that the Chinese government looks more favorably, in terms of drug approval and reimbursement, upon multinationals operating jointly with local companies. Currently, all the top 20 pharmaceutical companies in the world have set up joint ventures or wholly owned facilities in China, suggesting that market conditions have never been more attractive or competitive.  However, in pursuing JVs, multinational cede autonomy to the partner organization, a challenge for many big pharmaceutical companies that are accustomed to dominating smaller partners.

A third issue is reimbursement for drugs, which continues to be a major problem in China, not only for GSK but for other major pharma companies.  China’s public health insurance programs covers 90% of the population, but coverage is not extensive.  The formularies are particularly selective, and those drugs that do get coverage are often not covered in full.  Over 30% of healthcare costs in China are borne by the patient as out-of-pocket expenses, and prices for drugs on government programs’ formularies are under immense pressure.  This causes prices for drugs that are not covered to skyrocket, and become out of reach for even wealthy Chinese.

Ultimately, the success of the 12th five-year plan for the biomedical industry will depend how well China aligns the viewpoint and needs of its many different stakeholders to foster policies that better support innovation and quality.  Progress could be slow due to the existing infrastructure and the hub-and-spoke nature of Chinese government, however, the eagerness of foreign multinationals to enter China is promising.  The road will not be easy for them, either: they will want to increase their investments across the value chain, step up their core capabilities, and explore creative ways of reaching new customer segments through partnerships.   Despite the challenges, the future is bright and promising growth suggests that the biomedical industry will continue to be a focus, even beyond these five years.

[1] GaBI http://www.gabionline.net/Biosimilars/News/China-s-5-year-biotech-investment-fires-clear-warning-to-US

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The HSM Journey: An international health care professional’s perspective of the first year MBA

Itai RikovitchAfter working with an Israeli medical devices Startup Company and negotiating several due diligence processes with top US corporations, I gained preliminary exposure to the US health care arena.  This experience triggered my decision to explore the US healthcare industry and better understand the various stakeholders’ roles and incentives. After thoroughly researching the various health care related top MBA programs, it was clear that Fuqua Health Sector Management (HSM) would be the best fit for me. The elements of the HSM program at Fuqua that made it a natural choice for me are: (1) the high level of industry interest within the class (25% of my MBA class participates), (2) a highly diverse class profile including 47% internationals, and (3) the proximity of Duke University Hospital.

My initial perspective as an international entrepreneur of the US health care industry was that it is an attractive, straight forward “6 steps to entry market”: “Develop your idea, get your device to work, know your competition, gain FDA approval, find a strategic partner and either scale up or divest.”  It took 48 hours into the HSM Bootcamp for me to realize how complex, but exciting, the US healthcare industry is and how different it is from the small scale, single payer, system I came from.

A lot has been written about innovation in Israel (e.g. the best seller Start-up Nation: The Story of Israel’s Economic Miracle by Dan Senor and Saul Singer) and the majority of bio technology and medical devices executives who regularly attend Fuqua events mention Israel as an innovation hub that fuels the US healthcare incumbent corporations. The level of attention the Israeli medical device and bio technology markets get is high and I always feel like I am able to communicate the differences in perception inside and outside of class.

My first year in the Fuqua HSM program has helped me to bridge previous industry understanding gaps and to gain the required foundations for my upcoming internship with a large medical devices company as a business development and strategic innovation intern. We have held multiple discussions about the possible reasons why the Israeli entrepreneurship market usually does not scale and commercialize its innovation and US corporations and start-ups do. Professor Ridley’s Health Care Markets Class, which covers the various trends and business models of the industry, was an essential part of the knowledge I gained. In addition, my view of the changing health care landscape was enriched through the various key opinion leaders that Professor Jeff Moe invites to speak as part of the required first year Health Care Seminar.  The HSM program leadership creates the ultimate environment to fully capture the breadth and depth of the US health care market as I complete the transition from the Israeli innovative market to the fast- paced and complex US healthcare industry.

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FCCP Project: Real World Client Experience Helping a Regional Medical Center

Sydnor GammonAs an applicant to business schools in the fall of 2012, I knew that I wanted to pursue a career in healthcare consulting.  I worked in clinic administration for an academic medical center where I found my passion for discovering and implementing best operational practices across healthcare systems.  Healthcare consulting represents an opportunity to do just that.  In learning about the Fuqua School of Business, I quickly realized I could gain the tools I needed to be a successful healthcare consultant at Fuqua through the HSM program and the wide variety of learning opportunities.

One of the many experiences where I could explore a career in healthcare consulting was through the Fuqua Client Consulting Practicum (FCCP).  My original goal for participating in the FCCP was to obtain real world client experience as practice for my summer internship. FCCP offers a wide variety of projects that span many disciplines and functions, including several in health management.  The FCCP faculty does their best to match students with their top project choices and I secured mine.

I am on a team with two other Fuqua MBA students and a Duke Master of Public Policy student.  Our project involves helping a regional medical center decide how to best aid an adjacent county whose local hospital has closed, leaving 9000 citizens without easy access to medical care.  While my initial motivation for taking an FCCP course was to better understand the world of healthcare consulting, this project has offered an additional experience. I have learned a great deal about the public health landscape in the U.S. and the challenges in addressing disparities in healthcare access and affordability.

To help our team develop a strategy for our client, the FCCP faculty lead weekly courses during Spring 1 that introduce important themes in consulting, such as client relationship management, data gathering tools, and strategic implementation tactics.  My team’s faculty member has expertise in the healthcare consulting field and we meet regularly with him to discuss our project’s challenges. As a team, we also meet weekly to work on project deliverables and for videoconference calls with the client to update him on our progress.

Our work has required creative approaches from the team.  Much of the data that we need to make a sound recommendation is unavailable, requiring that we make substitutes.  We also have encountered challenges as circumstances at the client side have evolved, causing us to shift our understanding of the problem.  Because our project relates to public health issues, we have had to consider local politics and the perspectives of various regional stakeholders, adding an extra layer of complexity to navigating the organizational dynamics of our client.  While our project has proved challenging, our professor reminds us that it is not unlike a real world client consulting experience where consultants must navigate organizational dynamics, political environments, and evolving client demands.  In this way, I have been able to fulfill my original goal of joining FCCP to gain client experience.

With five weeks left on the project, I am eager to deliver a recommendation that will be valued and useful.  I have appreciated my FCCP experience as a “learning by doing” application of classroom teachings and as an opportunity to expand my understanding of the health sector.

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HSM Highlights of Fall 1 and 2

Heather LangermanFall Terms 1 and 2 were a busy and exciting time in the Health Sector Management (HSM) program, with weekly academic seminars, the November healthcare conference, and the December Town Hall meeting. These events kept us busy, engaged, and constantly learning.

Each Wednesday morning during Fall 1 and Fall 2 the entire HSM first-year class attended a seminar led by a different prominent player in the healthcare management field. For example, we heard from Richard Bartlett and Krishna Udayakumar from the Duke-based International Partnership for Innovative Healthcare Delivery. They both spoke about SalaUno, a center that provides affordable cataract surgeries in Mexico. In another seminar, Paula Garrett from Eli Lilly spoke about the power of consumer insights and segmentation by using Cialis as a case study. These seminars were a highlight of my week— I had the opportunity to catch up with my HSM classmates and participate in lively conversations about current issues facing the world healthcare market. The speakers and our discussions were very informative.

The November Duke Healthcare Conference was a day packed with speakers and networking. For me, the most interesting parts of the conference included the closing keynote by Jeff Henderson, the CFO of Cardinal Health, and a session on health insurance exchange implementation featuring panelists, some of whom were HSM alum, from Blue Cross Blue Shield, Deloitte, the State of North Carolina, and Aon Hewitt.

The day concluded with a networking session for first years where we were able to interact with panelists and ask follow-up questions, as well as learn more about internship opportunities at various healthcare firms. I was thrilled to be able to speak with alumni from some of my top-choice firms for my summer internship. I left the healthcare conference grateful for the strong Fuqua HSM alumni network. I valued the opportunity to learn from alumni working in various aspects of the healthcare sector who shared unique insights about their work by serving as conference panelists or while interacting during the networking event.

In December, a group of HSMers gathered on a Friday evening for a “Town Hall” event right before Fuqua Friday to hear from Dr. Brian Caveney, Vice President and Medical Director of Blue Cross Blue Shield of North Carolina. This session was an informal question-and-answer discussion in which Dr. Caveney discussed changes in the health insurance marketplace that resulted from the Affordable Care Act (ACA). It was fascinating to hear about these changes from the payer perspective. I had read frequently about payers’ reactions to the ACA in the news, but hearing about these issues firsthand gave me additional context to better understand the situation. I have been able to apply what I learned during this talk in subsequent HSM classwork and even in my internship interviews.

With so many healthcare topics in the news and rapid changes in the industry, it’s beneficial to have healthcare events on campus to keep me in the loop on what’s happening in the real world. I think that the analytical perspective we get from these events—and the HSM program as a whole—provides the tools we need to be future managers and decision-makers in the healthcare field.

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