A Visit to Planet Gawande

By Clive Riddle, June 22, 2018

We still don’t know much at all about what the heck the Amazon-Berkshire-JPMorgan healthcare triumvirate will be doing. But we do now know who will be running it. The renowned Dr. Atul Gawande has been appointed its Chief Executive Officer, effective July 9th.

 The announcement quotes Atul: “I’m thrilled to be named CEO of this healthcare initiative. I have devoted my public health career to building scalable solutions for better healthcare delivery that are saving lives, reducing suffering, and eliminating wasteful spending both in the US and across the world. Now I have the backing of these remarkable organizations to pursue this mission with even greater impact for more than a million people, and in doing so incubate better models of care for all. This work will take time but must be done. The system is broken, and better is possible.”

Amazon’s Jeff Bezos says “we said at the outset that the degree of difficulty is high and success is going to require an expert’s knowledge, a beginner’s mind, and a long-term orientation. Atul embodies all three, and we’re starting strong as we move forward in this challenging and worthwhile endeavor.”

For those who don’t already know all there is to know about Atul Gawande, let’s take a quick visit to Planet Gawande and check out the man who will be commanding the mystery ship Amazon-Berkshire-JPMorgan.

Atul’s website homepage succinctly provides this description: Atul Gawande is a staff writer for The New Yorker, and author of four books; (2) Atul Gawande practices general and endocrine surgery at Brigham and Women’s Hospital; and (3) Atul Gawande is Executive Director of Ariadne Labs, a joint center for health systems innovation. Of course, item #3 will require editing. As the already updated Ariadne Labs website announces “Atul Gawande transitions to Chairman and becomes CEO of new health care organization.”

What are Atul’s roots? He was born in 1965 in “Brooklyn, New York, to Indian immigrants to the United States, both doctors. His family soon moved to Athens, Ohio, where he and his sister grew up, and he graduated from Athens High School in 1983.”

As an undergraduate and in medical school, he dived into the worlds of politics and healthcare policy. He volunteered for Gary Hart's and Al Gore's presidential campaigns. He served a health-care researcher for Rep. Jim Cooper (D-TN). He became Bill Clinton's healthcare lieutenant during the 1992 campaign. He served as senior HHS advisor after Clinton's inauguration and directed one a committee in the Clinton Health Care Task Force, before returning to medical school, re3ceiving his MD in 1995.

During his residency his career as a writer launched with Slate, and soon he was writing essays for the New Yorker. His June 2009 New Yorker essay, The Cost Conundrum was widely read and influential,  in which he compared the health care of two towns in Texas to show why health care was more expensive in one town compared to the other.. He continues to occasional whip out New Yorker Essays, with these being the titles of his works during the past 18 months:

• Curiosity and What Equality Really Means, The New Yorker, Jun 2, 2018
• Is Health Care a Right?, The New Yorker, Oct 2, 2017
• How the Senate’s Health-Care Bill Threatens the Nation’s Health, The New Yorker, Jun 26, 2017
• Trumpcare vs. Obamacare, The New Yorker, Mar 6, 2017
• Trumpcare, The New Yorker, Feb 27, 2017
• The Heroism of Incremental Care, The New Yorker, Jan 23, 2017

He has also written more technical papers and studies in journals including the New England Journal of Medicine and has authored four books:

• Being Mortal: Medicine and What Matters in the End (2014)
• The Checklist Manifesto: How to Get Things Right  (2009)
• Better: A Surgeon's Notes on Performance (2007)
• Complications: A Surgeon's Notes on an Imperfect Sciences (2002)

Of Gawande’s most recent book, Malcolm Gladwell wrote, “American medicine, Being Mortal reminds us, has prepared itself for life but not for death. This is Atul Gawande’s most powerful – and moving – book.”

Of course, the platforms from which Gawande has drawn the experiences and perspectives that he writes about is from being a clinician, researcher and academian. He practices general and endocrine surgery at Brigham and Women's Hospital in Boston, Massachusetts. He is a professor in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health and the Samuel O. Thier Professor of Surgery at Harvard Medical School.

His outside affiliations have included Ariadne Labs where he has been Executive Director, Lifebox, Safesurg.org, WHO Safe Surgery Saves Lives initiative and the Center for Surgery and Public Health.

Ariadne Labs might be the most instructive, in regard to the approaches Guwande might take in his new gig. Ariadne Labs is a joint center between Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, founded in 2012 by Gawande and others.

Here’s more about Ariadne Labs direct from their website – which says their mission is “to find solutions to some of the most complex problems in health care, including life-threatening errors in surgery, maternal and neonatal mortality, failures in end-of-life care, and fragmented and ineffective primary health care systems. Leveraging a network of expertise across the Harvard-Brigham system, Ariadne Labs’ designs, tests, and spreads simple solutions to address failures in health care delivery worldwide.”

Here’s what Ariadne Labs lists as its more prominent innovations:

• The Surgical Safety Checklist, developed in collaboration with the World Health Organization, shown to reduce post-surgical deaths and complications by 47 percent worldwide.
• OR Crisis Checklists, a compendium of 12 checklists to guide surgical teams through critical lifesaving steps when sudden emergencies occur in the OR. In simulation testing, Ariadne Labs demonstrated that when the checklists are not used, clinical teams completed only 77 percent of lifesaving steps in an emergency. When the teams used the checklists, they completed nearly 100 percent of lifesaving steps.
• The Safe Childbirth Checklist, developed with the World Health Organization to address the major causes of maternal and neonatal mortality. Implemented with Ariadne Labs BetterBirth Program of peer-to-peer coaching, the intervention has demonstrated significant improvement in the quality of care during labor and delivery in low-resource settings.
• The Delivery Decisions Team Birth Project, a solution package aimed at reducing C-section rates in the U.S. by improving communication between clinicians and laboring women, defining the basic care women in labor should receive and prioritizing women’s preferences for care. The project is being tested with tens of thousands of patients across the United States.
• The Serious Illness Conversation Guide, a structured tool to help clinicians and patients have meaningful conversations about what matters most to patients. The guide is the centerpiece of the Serious lllness Care Program, a systems-level intervention to ensure that all patients with serious illness receive care that aligns with their goals and values.
• The Primary Health Care Vital Signs, a global data resource for measuring and monitoring the strength of primary care systems in countries around the world, developed with the World Bank, WHO, and the Bill and Melinda Gates Foundation as part of the global Primary Health Care Performance Initiative.

We’ll all stay tuned to see what happens next on Planet Gawande.

Healthcare Organization Mobile Device Use: Check That Pager

By Clive Riddle, June 15, 2018

The list of benefits derived from mobile device use by clinicians and staff at healthcare organizations is a long one. But the challenges exacted comprise a worrisome list topped by privacy and cybersecurity concerns. Organizations who promote or allow BYOD (Bring your own device) of course have significantly enhanced concerns.

So in this context its worthwhile to take a gander at the eighth annual Spok survey report: Mobile Strategies in Healthcare Results Revealed. The good news is that 57% of healthcare organizations surveyed have developed a documented mobile device strategy. The bad news is 43% have not.

They respondents say these are the challenges they are facing

• Wifi coverage – 51%
• Cellular coverage – 40%
• Data security – 34%
• Compliance with BYOD policies – 34%
• IT support – 29%
• Mobile adoption rates – 28%

For those with a strategy, here’s the top seven components included:

1. Mobile management and security - 56%
2. Mobile device selection - 51%
3. Integration with the EHR - 48%
4. Infrastructure assessment (wireless and mobile) - 45%
5. Clinical workflow evaluation - 43%
6. Device ownership strategy (such as BYOD) - 34%
7. Mobile app strategy (in-house, third-party, hybrid) - 29%

How well are these policies enforced? 39% said extremely well, 33% said well. 24% weren’t sure and an honest 4% said poorly. With respect to validating compliance, 48% use education, 42% gather data from the devices, 37% seek feedback from the end user, 23% take surveys, and an honest 21% said they aren’t doing any validation.

With respect to devices they organization supports, 74% said smart phones, 69% wifi phones, 56% onsite pagers, 54% tablets, 45% wide area pagers, 22% encrypted pagers, 12% voice badges and 6% wearables.  

Perhaps the biggest surprise I found in the report was this passage: “Pagers are still a mainstay in healthcare. Despite the growth of other communication tools, they remain at a relatively high level of use as other mobile devices complement them (without necessarily replacing them altogether). In fact, onsite pagers are the most popular communication option for non-clinical care team members such as housekeepers, transport techs, and phlebotomists.” For non-clinical staff 54% listed some type of pager as their primary communication device (onsite 40%, wide area 10% or encrypted 4%/) Wifi phones came in at 15% and smartphones at 14%.

The 260 Page 2018 Annual Medicare Trustees Report and the Part D Rx Share of the Pie

By Clive Riddle, June 7, 2018

This week CMS released the 2018 Annual Medicare Trustees Report, which provides a financial/actuarial analysis of the current state of the Medicare Fund, and projections regarding the Fund solvency going into the future.  The big takeaway always emphasized from the report is at what year in the future will the Fund become insolvent, but there really is a lot of historical information in the report worth a gander.

In regard to when the Fund is projected down, we are told the “Trust Fund will be able to pay full benefits until 2026, which is three years earlier than last year’s projections, attributable to adverse changes in program income. The Trustees project that total Medicare costs (including both HI and SMI expenditures) will grow from approximately 3.7 percent of GDP in 2017 to 5.8 percent of GDP by 2038, and then increase gradually thereafter to about 6.2 percent of GDP by 2092.”

But in addition to the voluminous portion of the report dedicated to projections taking us to near the end of the century, there’s plenty of history and present tense buried in the 260 page report as well. Here’s a snapshot from the report of Medicare in 2017:

It’s interesting to look out what portion of the expenditures are from Part D. On a gross basis, $100.1 Billion in Prescription Drug expenditures out of $702.1 Billion in benefits represents 14.3% of benefit expenditures.

But not all beneficiaries have Part D coverage, so that’s not an apples to apples percentage.

Looking at 2017 benefits for Part A, Part B, Part C and Part D combined, total benefits were $702.1 Billion, of which 29.9% ($209.7 Billion) was spent through Part C, the Medicare Advantage program. Given the analysis doesn’t break down the benefit expenditure categories for the contracting Part C Medicare Advantage plans, here’s a breakdown of the Regular Medicare expenditures including Part D (backing out Part C):

• Hospital:  43.6% ($197.9 Billion)
• SNF: 6.2% ($28.3 Billion)
• Home Health Care: 4.1% ($18.4 Billion )
• Physician Fees: 15.2% ($69.1 Billion)
• Prescription Drugs (gross adjusted): 13.5% ($61.6 Billion)
• Other: 17.4% ($78.8 Billion)

Regarding the Gross Prescription Drugs adjustment: You will note the above Prescription Drugs total $61.6 instead of the $100.1 Billion in the above snapshot. That’s because the Medicare Advantage Part C enrollees with Part D enrollment were backed out, given that the other benefit expenditure categories didn’t include a breakdown from Part C. So the Part C enrollment in Part D plans, as a percentage of total Part D enrollment – taken from the December 2017 Medicare Advantage/Part D Contract and Enrollment Data Summary Report - was extrapolated (61.5% of Part D Enrollees are not enrolled in Part C; 61.5% of $100.1 Billion in total Prescription Drugs expenditures = $61.6 Billion.)

But the only problem with stopping there, is not all regular Medicare beneficiaries are enrolled in Part D. There were 43.2 million PDP enrollees at the end of 2107, while there are 58.5 million total Medicare beneficiaries. Of the 15.3 million 2017 beneficiaries with no Part D, 1.9 million were from Part C, leaving 13.4 million regular(non-part C)  Medicare beneficiaries with no Part D, and 26.2 million with Part D, out of a total 39.6 million regular Medicare beneficiaries. Now if we extrapolate 66% (26.2/39.6 million) for regular Medicare with Part D, from the other benefit expenditure categories (reducing the expenditures by one third for the other categories) we can get an apples to apples look.

This will reflect the percentage benefit expenditures extrapolated for Regular Medicare beneficiaries with Part D coverage:        

• Hospital:  40.7% ($130.6 Billion)
• SNF: 5.8%  ($18.7 Billion)
• Home Health Care: 3.8% ($12.4 Billion )
• Physician Fees: 14.2% ($45.6 Billion)
• Prescription Drugs (net adjusted): 19.2% ($61.6 Billion)
• Other: 16.2% ($52.0 Billion)

19.2% of the Medicare benefit pie for prescription drugs, get us a lot closer to the Milliman analysis just conducted for AHIP in the commercial population, which found Rx representing 23.3% of total costs including administration. If we add in the extrapolated portion (66%) of the $8.2 Medicare administrative expenses from the above snapshot, the regular Medicare prescription drug portion represents 18.9% including administration.

Anthem, IngenioRx and Taking a Total View of the Prescription Drug Trend

By Clive Riddle, June 1, 2018 In the crossover worlds of national pharmacy chains, PNMs and health plans, we have witnessed the emergence of CVS-Aetna , Cigna-Express Scripts, and the UnitedHealthGroup’s OptumRx fueled by its 2015 acquisition of Catamaran, plus the rumored Walmart Humana pairing. Meanwhile, Anthem took a somewhat different approach, starting their own PBM from scratch instead of acquiring or merging with someone on in the Rx aisle. Thus last October Anthem announced the launch of IngenioRx, which will assume Anthem’s PBM business when its current commitments expire in 2020. IngenioRx, thus sidelined for another year and a half – and looking to improve its visibility while gearing up – just released just released a Drug Trends Report in the same style as other national PBM reports, not letting the fact that it not yet operational serve as a roadblock. Instead, they focused reporting on the current Anthem book of business that they will be serving. With that in mind, here’s what they shared for Anthem’s 2017 commercial population, emphasizing they were examining the total drug trend, including medical benefit and prescription benefit utilization, unlike many reports from others that are only positioned to report on the prescription benefit experience: ·         21% of Anthem’s total drug spend was administered via the medical benefit,, and 79% via the pharmacy benefit. For specialty drugs only, the breakdown was 42% medical benefit and 58% pharmacy benefit. ·         Anthem’s total drug trend was 2.0%, comprised of -4.6% non-specialty drug spend and 9.9% specialty drug trend. ·         Anthem’s 2.0% total drug trend drivers included 5.6% inflation, 1.2% new drugs costs, -0.8% reduction in utilization, and -4.0% decrease in costs due to management approaches. For non-specialty drugs, inflation was 4.9%; for specialty drugs inflation was 6.5%. Carving out the prescription benefit to independent PBMs in the health plan world created three inefficiencies: (1) inability to manage the total drug trend due to some drugs administered through the medical benefit, as IngenioRx points out; (2) doesn’t allow for optimal coordination of care between the prescription and medical treatment components; and (3) creates duplication of administrative resources required in administering eligibility and reporting for the two components. If IngenioRx remained just an in-house PBM for Anthem, taking the total drug trend management view will be easier, But Anthem’s IngenioRx will be a stand-alone PBM, pursuing other business as well, and requiring its own separate administrative systems, making taking a total view for the Anthem book of business a little more challenging.

Six Things To Know From Deloitte Research on Health Plan Government Business

By Clive Riddle, May 18, 2018 This week, Deloitte Center for Health Solutions’ Andreea Balan-Cohen, Ph.D., and Maulesh Shukla gave a presentation on Medicare Advantage and Medicaid Managed Care Trends: Deloitte Research in a live HealthcareWebSummit event. The basis for their discussion was Deloitte Center for Health Solutions analysis of financial performance trends in the US fully insured health plans market between 2011 and 2016. This research series was divided into three chapters: Chapter 1, published in December 2017, provided summary observations on overarching developments in the market. Chapter 2, published in March 2018, focused on trends in health plan government programs, specifically Medicare Advantage and Medicaid managed care. Chapter 3, forthcoming later this month, will focus on trends in the commercial individual and commercial group lines of business. Here’s six key findings they shared on U.S. health plans’ government business: 1.     Government programs accounted for a large and growing share of health plan revenue and underwriting gains. 2.     The Medicare Advantage business experienced significant top-line growth and bottom-line volatility, including a notable decline in underwriting performance in 2014 and 2015. 3.     In Medicaid managed care, aggregate plan revenue increased steadily between 2011 and 2016, and underwriting performance grew impressively before retrenching in 2016. 4.     The largest Medicare and Medicaid plans by national revenue captured a disproportionate and growing share of industry underwriting gains. 5.     Medicare Advantage performance variation widened beginning in 2014; smaller plans and newer entrants experienced substantial headwinds. 6.     Medicaid managed care markets exhibited widening performance variation at the company and state levels beginning in 2014.

The Disconnect with Consumers and Health Plan Costs

By Clive Riddle, May 11, 2018 eHealth this week released a new eleven page report: Costs and Consequences in the ACA Market: A Survey of Individual and Family Health Insurance Consumers, presenting findings from more than 1,700 consumers who purchased their ACA-compliant plans via eHealth that included:  (1) “Consumers’ idea of a fair price is hard to find in today’s market;” (2) Policyholders aren’t willing to pay extra for key ACA benefits;” and (3) “Voters are bringing health care frustrations to the mid-term elections this fall,” (66% said it was one of their top three issues.) Consistent with a number of previous studies, there is a significant disconnect between consumers sense of where healthcare prices should be in the market, and what they actually are. Health reports that the average individual monthly premium cost during the last open enrollment was $400,  Only 3% surveyed felt $400+ was a fair price. Only 9% felt $300+ was fair. Only 25% felt $200+ was fair. So what is fair? 38% felt premiums should be $100 or less. Another 36% felt $200 or less was fair. The disconnect carries over consumer sense of the value of specific benefits. 61% want mental health benefits, 60% want maternity care and 55% want birth control coverage (which are all ACA required), but only 25%, 24% and 16% respectively, want to pay for them. Even emergency room benefits experience this disconnect: 80% want the benefit and 54% are willing to pay for it. ACA compliant HDHPs are prevalent in the ACA marketplace, and continue to gain the large group environment as well. Benefitfocus this week released a new eleven page survey report: The State of Employee Benefits 2018 - Industry Edition that examined benefit trends for four sectors: education, health care, manufacturing and retail, with an emphasis on examining the impact of HDHPs in each sector. Benefitfocus found that regarding HDHP prevalence by sector: ·         Education: 50% of employers offer HDHPs compared to 23% in 2016. ·         Healthcare: 73%% of employers offer HDHPs compared to 56% in 2016. ·         Manufacturing: 88%% of employers offer HDHPs compared to 54% in 2016. ·         Retail: 76%% of employers offer HDHPs compared to 55% in 2016. ·         All Industries: Healthcare: 70%% of employers offer HDHPs compared to 58% in 2016. When large employers offer other type plans and HDHPs side by side (many employers do not offer both), the HDHP employee enrollment rates by sector were: Education: 34% (30% in 2016); Healthcare: 27% (23% in 2016); Manufacturing: 29% (46% in 2016); Retail: 40% (27% in 2016) and All Industries: 35% (40% in 2016). What would drive such different results by sector? Employee premium HDHP contributions compared to last year decreased 27% in Education, increased 4% in healthcare, increased 46% in manufacturing, increased 20% in retail, and increased 4% overall for all industries. So just as in the individual marketplace, much comes down to price, even though there is a disconnect in the value that price reflects.

Welcome to Lifestyle Medicine

By Clive Riddle, May 4, 2018 

The May issue of Circulation includes the research article: Impact of Healthy Lifestyle Factors on Life Expectancies in the US Population, which presented findings from a study that aimed “to estimate the impact of lifestyle factors on premature mortality and life expectancy in the US population.” 

Using data from previous studies they defined five low-risk lifestyle factors

1. never smoking
2. ≥30 min/d of moderate to vigorous physical activity
3. moderate alcohol intake
4. a high diet quality score (upper 40%)

The study “estimated hazard ratios for the association of total lifestyle score (0-5 scale) with mortality,” and used available national public databases to estimate life expectancy by levels of the lifestyle score, examining mortality of 42,167 adults. 

They found the females who adopted all five of these low risk factors would at age 50 live 14.0 more years that those who adopted zero of the five; and that men at age 50 who adopted all five would live 12.2 years longer than those who adopted zero. They “estimated that the life expectancy at age 50 years was 29.0 years for women and 25.5 years for men who adopted zero low-risk lifestyle factors. In contrast, for those who adopted all 5 low-risk factors, we projected a life expectancy at age 50 years of 43.1 years for women and 37.6 years for men.” 

With these findings in mind, let’s stop by the American College of Lifestyle Medicine (ACLM), established several years ago as “the professional medical association for those dedicated to the advancement and clinical practice of Lifestyle Medicine as the foundation of a transformed and sustainable healthcare system.” They tell us that “Lifestyle Medicine involves the use of evidence-based lifestyle therapeutic approaches.” 

ACLM and Blue Shield of California have just announced a collaboration “to provide Lifestyle Medicine continuing medical education and other training tools to the nonprofit health plan’s in-network healthcare providers.” They tell us that “with this new collaboration, Blue Shield becomes the first health plan to offer its in-network healthcare professionals access to discounted ACLM courses, membership, conference registration, board certification review coursework and registration for the American Board of Lifestyle Medicine exam.” 

In November last year, ACLM announced the first physicians and health professionals to be board-certified in the field. They also have developed True Health Initiative (THI), “a coalition of world-renowned health experts committed to cutting through the noise and educating on only the evidence-based, time-honored, proven principles about lifestyle as medicine. The ultimate mission of the THI is to eliminate as much as 80% of all lifestyle-related chronic disease through lifestyle as medicine.”

Nine Things to Know Jump Out of Leapfrog Hospital Safety Grade Report

By Clive Riddle, April 27, 2018 In May talk of frogs would lead one to the annual Calaveras Jumping Frog Jubilee (check out www.frogtown.com). But in April, talk of frogs leads one to The Leapfrog Group, who just released the spring 2018 edition of the Leapfrog biannual  Hospital Safety Grades. Leapfrog tells us their “grading assigns “A,” “B,” “C,” “D” and “F” letter grades to general acute-care hospitals in the U.S., and is the nation’s only rating focused entirely on errors, accidents, injuries and infections that collectively are the third leading cause of death in the United States.” Here’s nine things to know from the Leapfrog report card results they have shared: 1.     Five “A” hospitals receiving this grade for the very first time this spring had an “F” grade in the past 2.     46 hospitals have achieved an “A” for the first time since the Leapfrog Hospital Safety Grade began six years ago 3.     89 hospitals receiving an “A” at one point had received a “D” or “F” 4.     Of the approximately 2,500 hospitals graded, 30 percent earned an “A,” 28 percent earned a “B,” 35 percent a “C,” six percent a “D” and one percent an “F” 5.     The five states with the highest percentage of “A” hospitals this spring are Hawaii, Idaho, Rhode Island, Massachusetts and Virginia 6.     Rhode Island, Hawaii, Wisconsin, and Idaho once ranked near the bottom of the state rankings of percentage of “A” hospitals but now rank in the top ten 7.     Hospitals with “F” grades are located in California, Washington, D.C., Florida, Iowa, Illinois, Maryland, Michigan, Mississippi, New Jersey and New York 8.     There are no “A” hospitals in Alaska, Delaware or North Dakota 9.     Impressively, 49 hospitals nationwide have achieved an “A” in every grading update since the launch of the Safety Grade in spring 2012 In addition to staterankings, you can search for specific hospital safety results at their webaite: http://www.hospitalsafetygrade.org

Long Term ACO Impact: Medicare vs. Medicaid vs. Commercial

By Clive Riddle, April 12, 2018 Commercial accountable care – value based payment arrangements between purchasers and providers seem to be spreading virally. States Medicaid accountable care initiatives are proliferating.  Will Medicare continue to consumer the greatest share of healthcare stakeholder attributed ACO patients and financial resources?  The April issue of Accountable Care News Thoughtleaders Corner ask a panel this question: “Which type of ACO activity will have more impact on stakeholders in the long term: Medicare, Medicaid  or commercial?” Kirit Pandit, Co-Founder & Chief Technology Officer of VitreosHealth responds that “I think Medicare ACO activity will have the most impact in the long term based on where incentives are maximized. Fully capitated plans such as Medicare Advantage and managed Medicaid plans will have the highest incentive to reduce costs and maintain high quality scores. This is where ACO activity will produce the best outcomes. The per member per month costs are high to make it attractive for providers to participate in these performance-based contracts.  However, compared to Medicare ACOs, Medicaid has higher churn rates. This makes it challenging for the providers to manage these members with a long-term perspective. If the churn rates are high, chronic care management activities will not have enough time to impact patient behavior and outcome. So the Medicare ACO plans that are fully capitated and have minimal member churn will have the highest impact.”  Michael Millenson, President, Health Quality Advisors; adjunct associate professor of medicine at Northwestern University’s Feinberg School of Medicine and author of the book Demanding Medical Excellence has this to say: “Right now, it’s synergistic. Medicare is by far the nation's largest payer, but joining an ACO is voluntary. However, Medicare’s clout and standardization are critical. On the other hand, Medicaid and private payers can both push their programs on providers (a state or large employers can choose only ACOs) and be much more innovative. Statutorily, CMS could switch all Medicare to ACOs without additional congressional authorization. If that ever happens – with implicit Congressional approval and definitely in the long term – this question will have answered itself.”      William DeMarco, Founder and President, Pendulum HealthCare Development Corporation, which has advised a wide range of ACO clients shares that “We think after all the dust settles, Medicare will offer the biggest impact on stakeholders. This considers total dollars and the fact that 10,000 Baby Boomers turn 65 every day and total cost of care will continue to rise ahead of inflation – so it will always be a big number. Medicaid will continue to be in a constant state of change on a state-by-state basis, but will slowly follow the ACO transition that may very well lead to more Special Needs and Dual-Eligible strategies being promoted by states and offered by insurers, as well as provider-led health plans that see the advantage of receiving a large capitated sum from Medicare and Medicaid for eligible patients. I say this based upon the number of Section 1115 waivers being sought to permit states to offer above and beyond Medicaid benefits through ACOs and CCOs. Commercial will always be in transition, as self-funded and fully insured are finding big deductibles do not work and the fiduciary accountability starts to weigh heavily on many of the purchasers of care. What employers are interested in are ACOs that can manage the active workers and retirees at a predictable cost. Health plans and insurers are seeing their profitability is linked with these ACOs that can take partial or full risk for the medical portion of the premium, and this allows the health plan to improve administrative cost savings – plus predict total cost of care.” So, some collective wisdom seems to point towards Medicare continuing to hold the strongest magnetic force attracting ACO activity.

The PBM side of CVS

By Clive Riddle, April 6, 2018 Assuming the CVS acquisition of Aetna clears all final hurdles, perhaps the most attention given to the merged company is in respect to the retail synergies. But the CVS Caremark PBM also deserves considerable attention. After all, Cigna’s big merger recently announced with Express Scripts was purely a PBM play. With that in mind, its interesting to poke through the just released 14-page CVS Health Drug Trend Report 2017. Similar to Express Scripts previously released 2017 report, the CVS Health report was certainly positive, and they touted that drug prices for clients  rose “at a minimal 0.2 percent, despite manufacturer price inflation near 10 percent.” But it must be noted that the touted 0.2 percent increase was just for prices. There was 1.7% cost growth due to utilization, yielding a total pmpy drug trend in 2017 of 1.9%, still quite a positive trend. Here is additional data CVS shared about their client experience in 2017: ·         While CVS drug price growth was 0.2%, the manufacturer AWP inflation rates were 9.2& for traditional brands, 8.3% for specialty brands, and 0.4% for generics. ·         The CVS generic dispensing rate was 86.1%. ·         CVS traditional and specialty brands accounted for 14% of prescriptions dispensed, but 69% of pharmaceutical spend. ·         The CVS specialty trend consisted of 3.7% price growth plus 9.2% utilization cost growth for a total 12.9% 2017 specialty trend. ·         CVS gross client costs pmpm were 108.42 pmpm in 2017 compared to $104.10 in 2016. ·         For CVS Clients with managed formularies, costs were $88.94 pmpm compared to $87.43 pmpm in 2016. ·         The managed formulary differential in overall drug trend for 2017 resulted in a 1.7% trend with managed formulary clients compared to 4.2% trend for other clients. ·         42 percent of CVS Health commercial PBM clients spent less on their pharmacy benefit plan in 2017 than they had in 2016. ·         For clients aligned with the company's managed formularies, drug price declined by 0.1 percent, in 2017, as compared to the overall 0.2 percent drug price growth. ·         Member out of pocket costs pmpm declined from $11.99 in 2016 to $11.89 in 2017. ·         In 2017 24% of members had zero out of pocket costs (no claims), 49.4% of members had out of pocket costs under $100, 14.6% had out of pocket costs between $100-$299, 5% had out of pocket costs between $300 - $499, 4.3% between $500-$599 and 2.7% above $1,000.

Wal-Mart and Humana: How Healthcare on Wall Street Imitates Hollywood

By Clive Riddle, March 30, 2018 Hollywood notoriously chases a hot movie trend with much more of the same – imitation being the most sincere form of flattery.  Wall Street when it comes to healthcare continues to flatter Hollywood by imitating this strategy as best they can. In the 1980s, public hospital companies rushed to acquire health plans. They subsequently rushed to spin-off or otherwise unload them. That’s how Humana become just a health plan company. In the 1990’s, the PPM industry was born as integrated delivery systems where split up, giving birth to PhyCor an others who subsequently flamed out. More recently, on the heels of ACA implementation, the mantra was to increase clout to succeed in the Marketplaces and expanding Medicaid and Medicare Advantage programs. Aetna announced the Humana acquisition and Centene announced the HealthNet acquisition within a day of each other in early July 2015. Three weeks later Anthem announced the Cigna acquisition. Then in February 2017, Aetna-Humana and Anthem-Cigna separately announced on the same day the death of their proposed mergers, thanks to DOJ opposition, and in Anthem-Cigna’s case, merger indigestion. Additionally, the new Trump administration and Republication Congress’ zeal for Repeal made the merger’s marketplace strategy seem moot. But a year later a new blockbuster movie formula has developed. There is Amazon style retail market disruption looming over the pharmacy sector in particular but the rest of healthcare as well, and the specter of the mysterious Amazon-BershireHathaway-JPMorgan healthcare venture. There is the outcry over pharmaceutical costs, and the questioning of the PBM sector’s role.  From this backdrop the CVS-Aetna merger emerges in early December.  Then early this month Cigna announces their Express Scripts acquisition. And now the Wall Street Journal and many others report Walmart is in early stage acquisition talks with Humana. WSJ notes the annual revenue of WalMart is $500 billion and Humana’s is $54B, compared to $185B fir CVS, $61B for Aetna, $42B for Cigna and $100B for Express Scripts. Will the Walmart-Human movie deal get inked? Will any of these new projects make it through production and get released? And what sequels and similar projects are under development?

Animal Farm Meets Health Care

By Kim Bellard, March 23, 2018 In George Orwell's classic Animal Farm, the animals revolt against their human masters, and establish a classless society with the inspiring principle, "All animals are equal."  As events play out, their society devolves into a dictatorship with a ruling elite, and the principle becomes "All animals are equal, but some are more equal than others." This, surprisingly, makes me think of health care.   I am old enough to remember when maternity coverage was at best only very limited even in employer group health plans.  It took the Pregnancy Discrimination Act (1978) to require them to treat maternity the same as any "illness," and, even then, individuals plans often did not include it until ACA required it.  Similarly, coverage for mental health was typically skimpy until the Mental Health Parity Act (2008) required parity. Preventive services were usually only available for (the small percentage of) people enrolled in HMOs, until network-based managed care plans grew more widespread in the 1990's.  The same happened with prescription drug coverage, which used to only be available to the minority of people with "major medical" coverage. It took the Affordable Care Act to standardize what "essential benefits" should be included in health plans. For services like dental, vision, or hearing, not so much.   Evidently, some services are more equal than others. We've managed to push our rate of people without health insurance to around 11%, but it's more than double that for dental insurance, and worse yet for vision coverage.  For seniors, the figures are significantly worse.  The real question should be, why do we have separate coverages for services like dental or vision, especially when many lack them? This matters.  According to NCHS, 14% of Americas report hearing trouble, 9% vision trouble -- and 7% have no natural teeth left (25% for those over 75).  There is a well documented link between oral health and our overall health, yet a study found that dental care had the highest financial barriers to care, compared to other health services. If you break a bone, you'll see a doctor; if you break a tooth, you'll see a dentist.  If you have problems with your throat, you'll see a doctor; if you have problems with your gums, you'll see a dentist.  If you want to correct your vision with glasses, you'll see a optometrist; if you want to correct it with Lasik, you'll see a physician. Specialization is understandable, as most physicians end up doing, but I have to wonder why some types of specialization start at the beginning of training, rather than after the basic medical training (see my previous article on balkanized medical education). We accept all this because, well, that's the way it always has been.  That doesn't mean it makes sense, or that it is best for our health. We each only have one body.  Although some health issues are fairly specific, we are increasingly realizing that many are systems issues involving multiple parts of the body.  It's time to stop drawing artificial distinctions between what care we get, who gives it to us, and how those professionals get trained.  Health is not equal to health care.  Health care should not be limited to medical care.  We need to get past "historical accidents" and focus on what is best for our health, and our care. Unless you actually do believe that all health services, and all health care professionals, are equal, but some are more equal than others. This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

National Healthcare Measures: A lot of Improvement Overshadowed By Obesity and Diabetes

By Clive Riddle, March 16, 2017 On this Ides of March the CDC National Center for Health Statistics released Selected Estimates Based on Data From the January-September 2017 National Health Interview Survey with great data covering measures fifteen different selected topics. We selected a key statistic from ten of the topics to share below. What’s striking is that despite our marked improvement in most topics during the past two decades, the percentage of persons reporting they had excellent health didn’t improve (although half a percentage point better than ten years ago, it is two percentage points lower than twenty years ago.) The culprits in the case must be due in a large part to the fact we living large(er). Two topics below in which increasing percentages aren’t a good thing are obesity and diabetes, but increase we did. We can make policy and administrative changes that impact the percentage of people with insurance, access  care, receive vaccinations, promote exercise and promote smoking cessation. Obesity and Diabetes seem  tougher to tackle. ·         Percentage of persons without health insurance coverage: 2017  9.0% | 2007 14.5% | 1997 15.4% ·         Percentage of Persons With a Usual Place to go for Medical Care (Age adjusted):  2017  88.1% | 2007 86.5% | 1997 86.3% ·         Percentage of persons of all ages who failed to obtain needed medical care due to cost at some time during the past 12 months (Age Adjusted): 2017 4.4% | 2007 5.8% | 1997 4.5% ·         Percentage of adults aged 65+ who received an influenza vaccination during the past 12 months (Age Adjusted):  2017 70.6% | 2007 66.8% | 1997 63.1% ·         Percentage of adults aged 65 and over who had ever received a pneumococcal vaccination (Age Adjusted):  2017 69.9% | 2007 57.8% | 1997 42.6% ·         Prevalence of obesity among adults aged 20 and over (Age Adjusted):  2017 31.4% | 2007 26.6% | 1997 19.5% ·         Percentage of adults aged 18 and over who met 2008 federal physical activity guidelines for aerobic activity through leisure-time aerobic activity (Age Adjusted):  2017 54.8% | 2007 42.0% | 1997 43.3% ·         Prevalence of current cigarette smoking among adults aged 18 and over (Age Adjusted):  2017 14.3% | 2007 19.7% | 1997 24.6% ·         Percentage of persons of all ages who had excellent or very good health:  2017 66.5% | 2007 66.0% | 1997 68.5% ·         Prevalence of diagnosed diabetes among adults aged 18 and over: (Age Adjusted):  2017 8.4% | 2007 7.5% | 1997 5.3%

Perhaps Accenture’s Surveyed Consumers So Willing To Share Healthcare Data Should Read Accenture’s CyberSecurity Survey Report

By Clive Riddle, March 9, 2018 Accenture has just released a 12-page report with findings from their 2018 Consumer Survey on Digital Health in which they conclude that “Growing consumer demand for digital-based health services is ushering in a new model for care in which patients and machines are joining doctors as part of the healthcare delivery team, and that  “consumers are becoming more accepting of machines — ranging from artificial intelligence (AI), to virtual clinicians and home-based diagnostics — having a significantly greater role in their overall medical care. “ Here’s some survey response highlights shared in the report: ·         19% have already used AI-powered healthcare services, with 66% of these consumers likely to use AI-enabled clinical services ·         Consumer use of mobile and tablet health apps has increased from 16% in 2014 to 48% currently. ·         44% have accessed their electronic health records in patient portals over the past year, with 67% of these consumers seeking information on lab and blood-test results; 55% viewing physician notes regarding medical visits, and 41% looking up their prescription history ·         The use of wearable devices by consumers has increased from 9% in 2014 to 33%t currently. ·         75% view wearables  as beneficial to understanding their health condition; while 73% cite them helping engage with their health, and 73% also cite monitoring the health of a loved one ·         90% are willing to share personal data with their doctor, and 88% are willing to share personal data with a nurse or other healthcare professional. ·         72% are willing today to share with their insurance carrier personal data collected from their wearable devices has increased over the past year, compared to from 63% in 2016. ·         47% are willing so share such data and with online communities or other app users today, compared with 38% in 2016. ·         38% are willing to share data with their employer  and 41% with a government agency Interestingly while consumers seem to trust sharing their data most with their doctor and clinical professionals much more than their health plan, another Accenture survey recently released on healthcare cybersecurity found that while overall 18% of healthcare organization employees were willing to sell confidential data to unauthorized parties for as little as between $500 and $1,000; there was considerable disparity between plans and provider offices: 21% from provider organizations would sell confidential data compared to 12% from payer organizations.

Peter Kongstvedt on the Amazon Healthmarket, Coming Soon to an Alexa Near You

By Clive Riddle, March 2, 2018

Lendedu released survey results this week on consumer acceptance if Amazon ventured into several financial related markets including virtual currency, banking, lending, investment and insurance. Their survey involved polling 1,000 consumers who purchased something from Amazon within that past 30 days.

In the insurance arena, consumers were asked about Life, auto and health insurance: “If offered, would you be open to the idea of using the listed insurance product created by Amazon?” For health insurance, 35.8% said yes, 31.3% said no and 32.9% were unsure. 41.6% of the consumers who were Amazon Prime users said yes. Acceptance for auto insurance was nine percentage points higher and life insurance was two percentage points higher.

Just over a month ago, most everyone in the healthcare universe got excited or at least paid notice when AmazonBershireJPMorgan healthcare was announced. Of course some such as Sam Baker cautioned in Axios that “We don't know what they're even trying to do” and that “other big companies have tried something similar.”

A month later AmazonBershireJPMorgan healthcareis still a blank canvas that we’re allowed to paint our own perceptions into. Healthcare media reported on the Lendedu survey results with headlines such as 35.8% of Americans would use an Amazon health insurance plan.

The national treasure of healthcare wit and expertise that is Peter Kongstvedt, MD FACP had this to say in response (including footnotes) to these headlines:

“Who wouldn’t be eager to sign up for an undescribed health plan, for which we can imagine it to be low-cost, super-convenient, available through Alexa, delivered in your home by the same day, and come with unlimited music and video streaming?* Few if any barriers to achieving this. Merely need to tell hospitals, physicians, and drug manufacturers what they will accept as payment in full and their obligation to meet Just-in-Time delivery, and they will all fall all over themselves to be in the Amazon HealthMarket.® ”

* PrimeHealth® 12-month subscription required, renewable at PrimeHealth’s sole discretion. Treatment options and bandwidth limitations may apply. Offer only available in U.S. states and territories. Acceptance denotes consent with all EULA Terms and Conditions including your Blood oath to forever abandon WalMart® and Apple® iTunes®.

The State of the Uninsured and Health Insurance Coverage

by Clive Riddle, February 23, 2018 The National Center for Health Statistics has just released updated health insurance coverage estimates from selected states using 2017 National Health Interview Survey data.  Here are seven things to know about their findings for the first 9 months of 2017: 1.     28.9 million (9.0%) persons of all ages were uninsured, not significantly different from 2016, but 19.7 million fewer persons than in 2010. 2.     12.7% of adults aged 18–64, were uninsured, 19.5% had public coverage, and 69.3% had private health insurance coverage. 3.     4.4%  of adults aged 18–64 (8.6 million) covered by private health insurance plans obtained their coverage through the federal or state-based exchanges. 4.     Adults aged 25–34 were almost twice as likely as adults aged 45–64 to lack health insurance coverage (17.3% compared with 9.2%) 5.     4.9%  of children aged 0–17 years, were uninsured, 41.9% had public coverage, and 54.6% had private health insurance coverage. 6.     The percentage uninsured decreased significantly for all age groups from 2013 through the first 9 months of 2017, ranging from –6.2 percentage points for ages 45–64 to –10.7 percentage points for ages 18–24. 7.     43.2% of persons under age 65 with private health insurance were enrolled in a high-deductible health plan (HDHP) compared to 39.4% in 2016 However, as a warning sign that 2018 may see slippage in these insurance coverage, the Minnesota Department of Health just issued an ominous press release, indicating that “last year Minnesota saw one of its largest, one-time increases in the rate of people without health insurance since 2001. The uninsured rate rose from 4.3 percent in 2015 to 6.3 percent, leaving approximately 349,000 Minnesotans without coverage.”

Employees Feel Their Own Health Plan is Better Than Most Others

By Clive Riddle, February 9, 2018 Surveys have consistently shown over the years that the public generally ranks Congress low in esteem, but their personal Congressman is held in higher regard. Health Plans, like Congress, have been a favorite target as well, but similarly – people tend to like their personal coverage more than how they view health plans overall. AHIP has just released a 42-page report of findings from their national survey “The Value of Employer Provided Coverage” that not only reinforces this phenomenon – in which respondents rank their own plan higher than their overall view how health care is covered, but also makes the case that consumers place employer provided coverage in higher regard than the nation’s health coverage system as a whole. On top of that, there is perhaps less angst about the nation’s health insurance system overall than one might have thought. 63% were satisfied with the nation's current health insurance system, and 31% were dissatisfied. 71% were satisfied with their own health plan, and 19% were dissatisfied. 60% felt their personal cost was reasonable and 29% felt the cost was unreasonable, while 66% felt the cost was unreasonable for Americans as a whole. 52% described their deductible as reasonable, while 36% said it was unreasonable. However, for those dissatisfied with their plans, 82% cited costs as the main reason. 72% say they are adequately informed about health insurance benefits under their plan, yet only 20% understand that employers average paying above 75% of the total costs. In other findings from the survey: ·         71% remain concerned the cost of health care will continue to rise ·         56% prioritize comprehensive benefits while 41% prioritize affordability of plans. ·         46%said health insurance was a deciding factor in choosing their current job ·         56% support keeping employer provided coverage tax free, and 13% oppose ·         58% prefer increased market competition while 42% support increased government involvement to address costs ·         Prescription drug coverage (51%), preventive care (47%), and emergency care (47%) rank among the benefits that matter most.

AmazonBerkshireJP Healthcare: Think About Kaiser

By Clive Riddle, February 1, 2018 After Amazon, Berkshire Hathaway and JPMorgan Chase issued their press release this week regarding their employer based healthcare partnership, healthcare stock portfolios went into a tailspin and a lot of smart people have had something to say about what this venture might become. But where there is consensus is that what we do know is what we don’t know, as right know the venture is a dot to dot healthcare coloring book where no lines have been connected yet and we haven’t even been issued our crayons. The press release, while void of details, espouses technology solutions. Learned speculation surrounds their replacing PBMs, going whole hog into self-insurance, promoting telemedicine and much more. The New York Times quotes Segal Group’s Ed Kaplan: “Those are three big players, and I think if they get into health care insurance or the health care coverage space they are going to make a big impact.” Paul Demko in Politico writes that Amazon's new health care business could shake up industry after others have failed. But while citing some optimism, he also reports that ““ ‘We’ve seen these deals before,’ said Sam Glick, a partner in the health and life sciences division at Oliver Wyman. He cited Walmart and Intel as two companies that have sought to provide health care for employees while cutting out the insurance middleman. ‘It’s not news that jumbo employers are frustrated with escalating costs and lousy experiences in the health care system.’ “ A great tweet from Yale Health Economist Zach Cooper tells us "I do hope Amazon, JP Morgan, & Berkshire succeed. Health care is wildly inefficient However, it’s a bit like Mayo Clinic, Cleveland Clinic, and Partners Health coming out and saying they don’t like their computers so they’re going to form a new IT company." An Axios post by Sam Baker cautions “A new health care behemoth? Not so fast.” He reminds us “We don't know what they're even trying to do” and that “other big companies have tried something similar.” While like Sam Glick, we can point to less than stellar results from a number of other corporate forays into this arena, if we peek further back into time, we can also point to Kaiser, whom Sam Baker mentions in his post. Let’s take the wayback machine to 80 years ago: In 1933, Sidney Garfield MD establishes prepaid plan to fund care for his Contractors General Hospital and clinic providing care to workers on the Los Angeles Aqueduct. In 1938 Henry J Kaiser recruits Dr. Garfield to establish prepaid clinic and hospital care for his Grand Coulee Dam project in Washington. In 1942, at the request of Henry Kaiser, Dr. Garfield expands program to Kaiser-managed shipyards and Kaiser’s steel mill. In 1945, Permanente Health Plans opens to the public in California, in addition to serving Kaiser employees. Kaiser and their clinically integrated health care is often cited now as an example of a better system than much of the rest of American healthcare. Perhaps Amazon et al should take a long look at the Kaiser experience, and consider directly providing some levels of care enhanced by technology, instead of just relying on technology alone.

2018 CMS Medicare Shared Savings Program: 43 Previous ACOs out, 124 New ACOs In

By Clive Riddle, January 19, 2018

CMS recently published 2018 Medicare Shared Savings Program information.  After comparing the listing of 561 2018 MSSP participants to the 480 2017 participants, we found 43 2017 ACOs have exited the program for 2018, and there are 124 new ACOs for 2018.  Caravan Health has sponsored 15 new ACOs, and Community Health Systems is sponsoring 14 of the new ACOs.

Here’s the list for the 43 ACOs exiting the program:

1. Accountable Care Coalition of Mount Kisco (CT, NY)
2. Accountable Care Coalition of Western Georgia (AL, GA)
3. ACO of East Hawaii (HI)
4. Advanced Premier Physicians ACO (CA)
5. APCN-ACO (CA)
6. ApolloMed Accountable Care Organization (CA, FL, HI)
7. Arkansas High Performance Network ACO of FQHC (AR, KY)
8. Arkansas HIgh Performance Network ACO (AR)
9. Bay Area Medical Associates ACO (CA)
10. Bluegrass Clinical Partners (FL, KY, TN)
11. Care Covenant (TX)
12. Catholic Medical Partners-Accountable Care IPA (NY)
13. CHRISTUS Louisiana ACO (LA)
14. CHWN ACO (IL)
15. Collaborative Health ACO (MA)
16. Community Health Accountable Care (NH, NY, VT)
17. Connected Care (MI)
18. Cornerstone Health Enablement Strategic Solutions (NC)
19. Health Leaders Medicare ACO Network (LA)
20. Indiana Care Organization (IN)
21. Kansas Primary Care Alliance (KS, MO)
22. KCMPA-ACO (KS, MO)
23. Mary Washington Health Alliance. (VA)
24. Mercy ACO (AR, MO)
25. MHT-ACO (GA, MI, OK, SC, TX)
26. Midwest Quality Care Alliance (KS, MO)
27. NEQCA Accountable Care, (MA)
28. North Jersey ACO (NJ, NY)
29. OneCare Vermont Accountable Care Organization (NH, VT)
30. Oregon ACO (OR, WA)
31. Palm Accountable Care Organization (FL)
32. Physicians Accountable Care Solutions (CA, CO, CT, IL, NY, OH, PA, UT, WV)
33. Physicians Collaborative Trust ACO (FL)
34. Primaria ACO (IN)
35. Primary Care Alliance (FL)
36. Revere Health (AZ, UT)
37. Shannon Clinic (TX)
38. South Shore Physician-Hospital Organization (MA)
39. SPACO (FL)
40. Torrance Memorial Integrated Physicians (CA)
41. UW Health ACO, (WI)
42. VirtuaCare (NJ)
43. Western Maryland Physician Network (MD, PA, VA, WV)

And here’s the list of the 124 new ACOs joining the program for 2018:

1. Accountable Care Coalition of Alabama (AL)
2. Account. Care Coal. of Community Health Centers (AR, DC, FL, IL, KY, MD, MI, RI)
3. Accountable Care Coalition of New Jersey (NJ)
4. Accountable Care of Nevada (NV)
5. Accountable Care Organization of Aurora (IL, MI, WI)
6. ACO West Virginia (PA, WV)
7. Acorn Network (IL, IN, MI)
8. Adventist Health Accountable Care (CA)
9. Adventist Health System ACO (FL)
10. Alabama Physician Network (AL)
11. Aledade Accountable Care 22 (OH, PA)
12. Aledade Accountable Care 25 (NJ)
13. Aledade Accountable Care 35 (LA, MS, TN)
14. Aledade Accountable Care 37 (MD, TN, VA, WV)
15. Baptist Health/UAMS Accountable Care Alliance (AR, TX)
16. Baptist Physician Partners ACO (FL, GA)
17. Bethesda Health Quality Alliance (FL)
18. Boulder Valley Care Network (CO)
19. Bridges Health Partners ACO (PA)
20. Caravan Health ACO 11 (AL, GA, IL, KY, NM, NV, TX)
21. Caravan Health ACO 12 (MN, WI)
22. Caravan Health ACO 13 (MA, NY, VT)
23. Caravan Health ACO 14 (ID, MN)
24. Caravan Health ACO 15 (IA, MN, NE, SD)
25. Caravan Health ACO 16 (AL, TN)
26. Caravan Health ACO 17 (OR)
27. Caravan Health ACO 31 (OK)
28. Caravan Health ACO 32 (OK)
29. Caravan Health ACO 33 (OK)
30. Caravan Health ACO 34 (OK)
31. Carolinas HealthCare System ACO (NC, SC)
32. Cascadia Care Network (WA)
33. Centrus Health of Kansas City (KS, MO)
34. CHSPSC ACO 1 (AL, FL, LA, MS)
35. CHSPSC ACO 10 (FL)
36. CHSPSC ACO 12 (GA, NC, SC, VA)
37. CHSPSC ACO 13 (PA)
38. CHSPSC ACO 14 (TN, WV)
39. CHSPSC ACO 15 (KY, TN)
40. CHSPSC ACO 16 (OK)
41. CHSPSC ACO 17 (FL)
42. CHSPSC ACO 2 (IN)
43. CHSPSC ACO 21 (AL, FL)
44. CHSPSC ACO 6 (TX)
45. CHSPSC ACO 7 (AR, LA, MO, OK)
46. CHSPSC ACO 8 (AK, AZ, NM, NV)
47. CHSPSC ACO 9 (IN)
48. Coastal One Health Partners (CA)
49. ColigoCare (NJ, NY)
50. Community Health Center Network Of Idaho (ID, OR, WA)
51. Community Healthcare Partners ACO, (IL, IN)
52. Connected Care of East Tennessee (AL, GA, TN)
53. Connected Care of Middle Tennessee (TN)
54. Connected Care of Mississippi (MS)
55. Connected Care of West Tennessee (MS, TN)
56. CPSI ACO 2 (CA, CO, GU, ID, ND, OR, SD, WA)
57. CPSI ACO 3 (GA, MS, NC)
58. CPSI ACO 7 (IA, IL, NE, WI, WV)
59. CPSI ACO 8 (AR, LA, MO, TX)
60. Crestwood Regional Healthcare Alliance (AL)
61. CVACC (VA)
62. DMH Health Network (IL)
63. DOCACO GULF COAST (FL, SC)
64. Einstein Care Partners (PA)
65. Family Choice ACO (CA)
66. Foothill Accountable Care Medical Group, (CA)
67. Genesis Physicians Group (TX)
68. Health Alliance ACO (DC, MD, VA)
69. Healthcare Quality Partners (NJ, PA)
70. HealthChoice (AR, MS, TN)
71. Heritage Valley Healthcare Network ACO (OH, PA, WV)
72. Holy Name Medical Center ACO (NJ)
73. HP2 (GA)
74. Independent Physicians Accountable Care (CA, CT, FL, SC, TX, VA)
75. Inspire Health Partners (IN)
76. Intermountain Accountable Care (NV, UT)
77. Keep Well ACO (IL, KS, MO)
78. KENNEDY HEALTH ALLIANCE (NJ)
79. Kootenai Accountable Care (ID, WA)
80. McFarland Clinic, PC (IA)
81. McLeod Healthcare Network (NC, SC)
82. MHC Accountable Care Organization (KY, OH, WV)
83. MHN ACO (IA, IL, NE, SD)
84. MSHP ACO (NY)
85. MultiCare Connected Care (WA)
86. NCH ACO (FL)
87. NorthShore Physician Assoc. Value Based Care (IL)
88. OhioHealth Venture (OH)
89. Orange Accountable Care Organization (FL, MD, NJ, NM, PA, TX)
90. Pacific Private Practice Network, Inc (CA, TX)
91. PathfinderHealth (AZ)
92. Physician Partners of Western PA (PA)
93. Physician Performance Network of Arizona (AZ)
94. Primary Comprehensive Care ACO (IL, NC)
95. PRIMARY PARTNERS (FL)
96. PRIME ACCOUNTABLE CARE WEST (AZ, CA, IL, NV)
97. Privia Quality Network Gulf Coast II (TX)
98. QHI ACO (CA, CT, IL)
99. Renaissance Physicians Accountable Care (TX)
100. Riverside Health Source (VA)
101. Rush Health ACO (IL)
102. Saint Francis Hospital Medicare ACO (AR, IL, MI, MS, TN)
103. Select Physicians Associates (AL, FL)
104. SIGNATURE NETWORK (VA)
105. Space Coast Independent Practice Association (FL)
106. St. Dominic Medical Associates (MS)
107. St. Luke's ACO (IL, MO)
108. St. Luke's Medicare ACO (NJ, PA)
109. St. Tammany Hospital ACO (LA)
110. Steward National Care Network, (FL, MA, NJ, OH, PA)
111. The Iowa Clinic, P.C. (IA)
112. The Ohio State Health ACO (OH)
113. Treasure Coast Integrated Healthcare (FL)
114. UC Davis Health ACO (CA)
115. UC Irvine Health Accountable Care Organization (CA)
116. UC San Diego Health Accountable Care Network (CA)
117. UCSF Health ACO (CA)
118. UMC Accountable Care (NM, TX)
119. United Physicians ACO (MI)
120. University Health ACO (TN)
121. UPQC (NV, UT)
122. Valley Medical Group-Renton (WA)
123. VillageMD Chicago ACO (GA, IL, IN, KY, TN)
124. White River Health System Clinically Int. Network (AR)

Accenture’s Advice to Pharma: It’s The Evidence, Stupid.

By Clive Riddle, January 12, 2018 Remember when Bill Clinton’s first presidential campaign mantra was “it’s the economy, stupid”?  Accenture advises the pharmaceutical industry to substitute evidence for economy in that equation and focus more on evidence-based solutions than products or brand. Accenture has just released 16-page report: Product Launch: The Patient Has Spoken in which they conclude “brands are not major influencing factors when patients consider new pharmaceutical products. More than two-thirds (69 percent) of patients surveyed said the product’s benefits – i.e., treatment outcomes – are more important than the brand itself, with less than one-third (31 percent) citing a strong affinity to brands in a healthcare setting.” Accenture tells us that for the report, they commissioned a survey of 8,000 patients in France, Germany, the U.K. and the U.S across eight therapeutic areas – immunology, cardiology, pulmonology, neurology, oncology, rheumatology, endocrinology and eye disease. Respondents represented three main age demographics: baby boomers, Gen Xers and millennials. Accenture shared the following findings: When patients were asked which factors influence their healthcare product and treatment decisions: ·         66% cited the doctor/physician relationship ·         55% indicated the ability to maintain their current lifestyle ·         53% said ease of access to the care they’ll need ·         But just 31% listed brand loyalty or popularity, and this ranked twelfth out of 14 influencing factors The report notes that patient perspectives include: ·         38 % said they feel very knowledgeable about new or existing products coming to market for their condition ·         25 % reported having either very limited or no knowledge of new products that might be suitable for them ·         48 % believe that their doctors discuss the full range of product options with them ·         44 % feel that they have significant input into their treatment selection ·         63 % said they want to be involved in such decisions ·         47% said they’ve thought about switching their treatment at some point ·         62%of those who think about switching end up doing so So if it isn’t product and brand, what does drive patient treatment choice decisions? Accenture says “despite survey results showing that many patients look online for information about new treatments, physicians remain the primary influencer of their treatment choices. In fact, the reason patients cited most often for switching treatments was a recommendation from their physician (cited by 81 percent of patients who switched treatments), followed by proven benefits compared to current treatment (79 percent) and fewer side-effects than their current treatment (78 percent).” Regarding demographics, the survey “findings also identified differences in attitude and behavior by age group, with younger patients more likely than older ones to understand which treatments are available—and switch treatments when they believe there’s something better. For instance, while physician recommendation was the most-cited reason across all age groups for switching treatment, Millennials are almost twice as likely as Baby Boomers to be influenced by people posting alternative treatment options on social media.” Of course what the report doesn’t focus on regarding treatment decisions is the role of insurance coverage, cost-sharing and formularies. But Accenture’s message in this value based era should still resonate. Accenture’s Jim Cleffi, a co-author of the report, tells us “given the significant budgets pharmaceutical companies devote to driving brand equity in the marketplace, our report findings should be a strong signal to the industry that launch strategies need to change. Patients in our study made it clear that outcomes matter most which means that pharma companies should focus their launch strategies and communications more on patient value and impact versus the brand—and do so in a much more precise and personalized way. Reallocating parts of launch budgets to programs that resonate the most with different patient segments would not only better meet patients’ needs and deliver better outcomes, but likely provide the companies with better ROI.” Accenture provides pharma two recommendations in the report: 1)    Bring an outcome – not just a product – to market. Patients value outcomes over brands, so instead of launching just products, pharmaceutical companies should start launching evidence-based solutions, or products with services as a secondary offering. This will require collaborative data-sharing – between patients, providers and payers – along with advanced analytics to generate robust insights and delivery via digital channels. This mindset should begin at the clinical trial-stage so it informs new launch strategies and full commercialization. 2)    Make it personal and precise. One size no longer fits all; pharmaceutical companies need to understand patient sub-segments and develop value-driven launch strategies tailored to each segment. Harnessing advanced analytics and other new technologies that leverage the proliferation of health data will help enable companies to modify launch strategies that make new treatments more relevant to patients while also driving better-informed resource and investment allocations.