Ten Large Objects on the Highway to Healthcare in 2018

By Clive Riddle, January 5, 2018

We find ourselves suddenly situated in 2018. How did that happen? Where did 2017 go, and for that matter, 2016 and its younger siblings? A Meat Loaf ballad once lyricized how Objects in the Rear View Mirror Appear Closer Than They Are. With apologies to AC/DC - on the highway to healthcare, here are ten large objects that demand our attention to stay focused on the road ahead and not in that fabled rear view mirror:

Merger Mania

In 2015 three health plan mega mergers were hatched, but only the Centene-HealthNet one made it out of the nest, and no other mega deals immediately followed suit. Will the late 2017 CVS-Aetna and hospital mergers such as CHI-Dignity signal more major activity in 2018, such as the rumored St. Joseph-Ascension merger? The answer should be a big yes for hospitals and other providers. In the health plan arena, look for additional players to pursue out of the box approaches such as CVS-Aetna (see below.)

CVS/Aetna and Multi-Level Integration

CVS will become a distribution center for applicable Aetna products. Aetna will become a distribution system for CVS products. CVS will further build upon its base retail clinics to become a direct care delivery system for Aetna. It’s a different kind of integrated delivery system than traditional hospital-medical group-health plan integrated systems, but integration it is, all the same, at multiple levels.

Amazon and the Decline of Retail Pharmacies

Especially coming off the holiday season, we read reports on the continuing rise of online shopping and decline of brick and mortar retail. Mail order pharmacy has been around for decades but has been focused on maintenance meds. Now that Amazon has mastered rapid on-demand delivery and has filed for pharmacy licenses in various states, and can deliver the other non-prescription products typically purchased at retail pharmacies – the rush is on. Major retail pharmacies will try mightily to enhance their own online offerings or partnerships.

Consumer Embrace of Technology

Private practice physicians aren’t so wild about the demands of EHR, and are skeptical at times about all things new bright and shiny, but numerous surveys indicate consumers are enthusiastic about the range of advances in healthcare technology that touch them. Consumers have plenty to be grumpy about in healthcare – but their embrace of technology will continue to drive demand for telehealth, e-visits, apps, portals, wearables, and new treatment options.

Searching For Value in Value Based Care

In the business of healthcare, we love to give birth to innovative approaches in healthcare delivery and payment arrangements, and after a honeymoon period, we tend to eat our own. Studies are published that indicate the new approach doesn’t deliver on results. A chorus of naysayers rises. And then we rightly or wrongly move on to something else. Health Affairs recently published a study concluding that Medicare ACO program savings were more the result of patient selection than care efficiencies. Other studies have begun to question various value based care arrangements. Given the growing popularity of value based care, and the intrinsic notion that the proposition makes sense, there is much at stake for value based stakeholders to continue to demonstrate the true value in their arrangements.

All Things Healthcare CyberSecurity

Hackers are as plentiful and resilient as crabgrass. Healthcare provides fertile hacking ground. The challenges in cybersecurity will grow larger, not smaller in 2018. More data breaches, and ransomware and other intrusions will occur and disrupt. A greater portion of healthcare resources will have to be deployed from every budget.

Deploying Social Determinants of Health

SDOH has been around for some time, but in 2018 it will be put into practice for population health initiatives by healthcare organizations and health plans on a significantly wider scale, driven by analytics and innovative new approaches.

Ho-Hum Impact of Trump Health Insurance Reforms

Moving insurance plans offerings across state lines and promoting association health plans won’t make much of a dent in the individual health insurance market in 2018. Don’t count on these initiatives to drive much business.

The Certainty of Uncertainty

Uncertainly was the word of the year in 2017 as the ACA teetered on a year-long tightrope. The tax reform individual mandate axe further muddies the water, as well as threatened Medicaid funding and more in 2018, but then there are the November 2018 elections, and who knows what that will bring.

Fulfilling the Promise of Analytics

SDOH is just one of a spectrum of initiatives that analytics is driving that wouldn’t have been feasible in their current form earlier this decade. Analytics is helping to shape solutions for the Opioid crisis, healthcare identify management, and interventions throughout population health, readmissions management, complex case management, to name a few. Serious analytics requires no small sum of resources and scale, but the returns are mounting and will bear even more fruit in 2018.

Looking A Little Deeper into CMS National Health Expenditure Report

By Clive Riddle, December 20, 2017 The CMS Office of the Actuary recently released their annual National Health Expenditure Data, current and historical through 2016. We thought we’d take a slightly deeper look at data released to expand upon the publicized highlights. CMS found that ”in 2016, overall national health spending increased 4.3 percent following 5.8 percent growth in 2015.” For comparison PwC in their annual Behind The Numbers medical cost trend report pegged the number at 6.8% in 2015; 6.2% in 2016; 6.0% in 2017 and project 6.5% for 2018. Of course overall national health expenditures measured by CMS are not an identical universe to how PwC measures medical cost trend. The portion of national GDP that healthcare consumes has been one of the most used comparative measures of healthcare to the overall economy. CMS found that “During 2014 and 2015, the health spending share of the economy increased 0.5 percentage point from 17.2 percent in 2013 to 17.7 percent in 2015. Health care spending grew 1.5 percentage points faster than the overall economy in 2016, resulting in a 0.2 percentage-point increase in the health spending share of the economy – from 17.7 percent in 2015 to 17.9 percent in 2016.” Looking back into CMS historical files, in 1966 healthcare consumed 5.7% of the national GDP. In 1976 it was 8.1%. In 1986: 10.3; 1996: 13.3%; 2006: 15.5%; and last year to 17.9%. CMS reports that “private health insurance spending increased 5.1 percent to $1.1 trillion in 2016, which was slower than the 6.9 percent growth in 2015.” Private insurance comprised 22% of national health expenditures in 1966, 25% in 1976, 29% in 1986, 32% in 1996, and 34% in 2006 as well as 2016.   Regarding Medicare, CMS states “spending grew 3.6 percent to $672.1 billion in 2016, which was slower growth than the previous two years when spending grew 4.8 percent in 2015 and 4.9 percent in 2014.  Medicare comprised 4% of national health expenditures in 1966, 13% in 1976, 16% in 1986, 18% in 1996, 19% in 2006 and 20% in 2016 For Medicaid, CMS says “expenditures grew 3.2 percent in 2016, while federal Medicaid expenditures increased 4.4 percent in 2016. The slower overall growth in Medicaid spending was much lower than in the previous two years, when Medicaid spending grew 11.5 percent in 2014 and 9.5 percent in 2015.” Medicaid comprised 3% of national health expenditures in 1966, 10% in 1976, 9% in 1986, 14% in 1996 and 2006, and 17% in 2016. CMS tells us that overall “out-of-pocket spending grew 3.9 percent to $352.5 billion in 2016, faster than the 2.8 percent growth in 2015.  Additionally, 2016 was the fastest rate of growth since 2007 and was higher than the average annual growth of 2.0 percent during 2008-15.”Examining out of pocket expenses as a percent of overall health expenditures, we found the percentage has decreased from to 48% in 1960; 33% in 1970; 22% in 1985; 15% in 2000 and 11% in 2016. CMS reported that “retail prescription drug spending slowed in 2016, increasing 1.3 percent to $328.6 billion. The slower growth in 2016 follows two years of significant growth in 2014 and 2015, 12.4 percent and 8.9 percent, respectively” Looking back at historical files for Rx total spending, percentage of overall healthcare spending and the percentage paid out of pocket for the past six decades, we found: 1966: Total $4.0 Billion | 8.6% of Total Health Expenditures | 90.2% paid out of pocket 1976: Total $8.7 Billion | 5.7% of Total Health Expenditures | 74.7% paid out of pocket 1986: Total $24.3 Billion | 5.1% of Total Health Expenditures | 64.8% paid out of pocket 1996: Total $68.1 Billion | 6.3% of Total Health Expenditures | 35.6% paid out of pocket 2006: Total $224.1 Billion | 10.4% of Total Health Expenditures | 22.9% paid out of pocket 2016: Total $328.6 Billion | 9.8% of Total Health Expenditures | 13.7% paid out of pocket.

Recent Uber and Lyft Healthcare Transportation Collaborations

By Clive Riddle, December 1, 2017 

Yesterday (November 30th) Cigna-HealthSpring reported on its collaboration with Lyft for medical transportation of Medicare Advantage members. They stated that "more than 14,500 transports have occurred through this collaboration. Since its introduction in May, 92 percent of Cigna-HealthSpring customers using Lyft have made it their preferred transportation option, according to customer surveys. On average, participants are waiting less than eight minutes for Lyft to take them to or from their appointments." They explain that "the service is for ambulatory customers in non-emergencies only and is only available to Cigna-HealthSpring customers whose benefit plan includes supplemental non-emergent medical transportation coverage through Access2Care at no additional cost. Participants need to contact Access2Care to establish Lyft as their designated transportation provider." 

I decided to check out what other developments have occurred during the past month regarding Uber, Lyft and medical transportation collaborations. 

The AHA during November published a nice 27-page report in their Social Determinants of Health Series on Transportation and the Role of Hospitals. In their chart summarizing transportation strategies, they state that “When transportation is unavailable, health care systems may need to provide transportation directly to patients and staff,” and their recommendations include that hospitals “partner with ride-sharing companies like Uber or Lyft.” 

A November1st Catholic Health World article Ministry systems tackle transportation barriers for vulnerable patients, that included these four examples of Uber and Lyft healthcare transportation collaborations: 

• “St. Vincent Charity Medical Center in Cleveland launched a program in the spring to provide free transportation via the ride-sharing company Uber to patients undergoing addiction treatment in the hospital's Rosary Hall Intensive Outpatient Program.....Between June and September, 30 new clients logged 507 Uber rides, and 29 clients achieved 100 percent participation in the group and individual counseling sessions. In the 30 days before launch, Rosary Hall had 76 percent client participation in group sessions and 62 percent client participation in individual counseling sessions. “
• “Trinity Health of New England has pinpointed pickup and drop-off locations exclusively for Uber riders to and from its five hospital campuses in Connecticut and Massachusetts that can be selected on the Uber smartphone app so the driver knows exactly where to deliver or meet a patient. Uber rides also can be scheduled through each hospital's website....Trinity also uses Uber to transport select patients from its Mandell Center for Multiple Sclerosis in Hartford, Conn., for services at nearby Saint Francis Hospital and Medical Center.”
• “St. Louis-based Ascension was the first health care system to form a partnership with Lyft. Since February, Ascension has put agreements in place in 21 of its markets, and Lyft has provided more than 8,000 rides.....Ascension staff members use Lyft's concierge platform to schedule the rides.”
• “Broomfield, Colo.-based SCL Health announced last month that it is collaborating with Lyft to make nonemergency on-demand or scheduled transport available to its vulnerable patients living in the front range of the Rockies near Denver.”  

The Advisory Board Care Transformation Center Blog featured this post on November 28^th:  5 ways MedStar's nurse-inspired partnership with Uber has paid off, starting off by telling us “Since 2016, Uber has announced partnerships with MedStar Health, Hackensack University Medical Center, and Boston Children's Hospital. Lyft has announced partnerships with transportation service organizations National Medtrans Network and Logisticare, as well as BCBSA. Why have these organization, among others, turned away from more traditional van or cab service? We learned a bit more about MedStar's arrangement with Uber to try and figure it out.” They cite these key benefits of the Medstar/Uber partnership: Patient Transportation Service is now faster; Service is more reliable; Service is less expensive; Clinic staff workflow is more manageable; and Analytics on MedStar transportation support offer new opportunities. 

But there are concerns patients are beginning to use Uber and Lyft in emergent situations. The CBS affiliate in Cincinnati reported on November 9th on The "Uberlance" trend: People turn to Uber to offset high hospital transportation costs.  They tell us that “the new trend is forcing Uber drivers to act as first responders. The drivers asked to not have their identities revealed, but they still wanted to tell their stories of what is now being referred to as ‘Uberlance.’ ‘I said to him ‘why didn't you call an ambulance?’ His hand was bleeding. He goes ‘because you're quicker and you're cheaper,’ said ‘Johnny’, an Uber driver. ‘I've had people get in my car, they're dizzy, they don't feel well, their chest hurts,’ said ‘Brian’, an Uber driver. Drivers say passengers opt for Uber over an ambulance for speed and cost.” 

Despite these concerns of patients taking matters in their own hands and using Uber or Lyft to avoid dispatching an ambulance, some EMS, healthcare and health plan organizations are proactively pursuing such arrangements for urgent care visits to avoid use of ambulances in non-emergencies.  The San Diego Union Tribune on November 5^th ran the story San Diego exploring new emergency response model amid ambulance crisis, stating that EMS officials there were seeking “an alternative model where non-emergency patients could take a taxi or Uber to a clinic or urgent care facility and get reimbursed by private insurers, Medicare or Medi-Cal.” The article cites that “Anthem Health Insurance recently announced it will start covering such alternative modes of transportation in 2018.”

The State of Medicaid in the States

by Clive Riddle, November 8, 2017 Mark Farrah Associates has just released their Mid-Year 2017 Medicaid Market and Enrollment Trends report which cites national Medicaid coverage was “74.3 million as of June 2017. This represents approximately 17.5 million more covered lives, a 31% increase, when compared to the population of Medicaid recipients prior to Affordable Care Act (ACA) implementation.” They fix Medicaid managed care enrollment nationally at 48.6 million, and tell us “total year-over-year managed Medicaid grew by only 187,000 members, a substantial difference from the 3.6 million increase between 2Q15 and 2Q16. Most of the top five managed care companies– Centene, Anthem, UnitedHealth, Molina and Wellcare – did however, experience enrollment increases. Among the leaders, Centene commanded 12% of the Medicaid market share as of second quarter 2016, enrolling approximately 6 million members. Anthem and UnitedHealth increased year-over-year membership with both attaining 11% market share. Molina and WellCare rounded out the top five Medicaid managed care leaders accounting for 7 and 5 percent market share, respectively. These top five Medicaid companies control 45% of the overall Medicaid Managed Care market.” Meanwhile, CMS Administrator Seema Verma this week gave a major speech discussing “her vision for the future of Medicaid and unveiled new CMS policies that encourage states to propose innovative Medicaid reforms, reduce federal regulatory burdens, increase efficiency, and promote transparency and accountability.” CMS reports that Verma emphasized “her commitment to ‘turn the page in the Medicaid program’ by giving states more freedom to design innovative programs that achieve positive results for the people they serve and pledged to remove impediments that get in the way of states achieving this goal. She announced several new policies and initiatives that break down the barriers that prevent state innovation and improvement of Medicaid beneficiary health outcomes.” CMS touts that they have published new public website content that reflects “CMS’s willingness to work with state officials requesting flexibility to continue to provide high quality services to their Medicaid beneficiaries, support upward mobility and independence, and advance innovative delivery system and payment models.” Veema emphasized their “commitment to considering proposals that would give states more flexibility to engage with their working-age, able-bodied citizens on Medicaid through demonstrations that will help them rise out of poverty.”  In shorthand, this means that states have a path to impose work requirements on applicable Medicaid beneficiaries and deny continued coverage for those that do not comply.  Other changes CMS shares include: ·         Allowing states to request approval for certain 1115 demonstrations for up to 10 years; ·         Providing for states to more easily pursue “fast track” federal review ·         Reducing certain state 1115 reporting requirements; ·         Expediting SPA and 1915 waiver efforts through a streamlined process and by participating in a new “within 15-day” initial review call with CMS officials. ·         Developing “Scorecards that will provide greater transparency and accountability of the Medicaid program by tracking and publishing state and federal Medicaid outcomes.” Meanwhile, the question of the day is what to make of the Maine election results this week approving Medicaid expansion, with their Governor subsequently stating he will block implementation.

Three Recent Studies and Three Different Perceptions of Value Based Payments

by Clive Riddle, November 3, 2017 Three different recently released studies addressing value based payments fuel three different perceptions: (1) value based payments have solid momentum; (2) that hospitals view value based care is growing more slowly than anticipated; and (3) physicians prefer FFS systems to value based care. The Health Care Payment Learning & Action Network has just released a report with survey results indicating “29% of total U.S. health care payments were tied to alternative payment models (APMs) in 2016 compared to 23% in 2015, an increase of six percentage points.” The Network states that “the survey collected data from over 80 participants, accounting for nearly 245.4 million people, or 84%, of the covered U.S. population.”   While 29% of payments were value based and totaling “approximately $354.5 billion dollars nationally” in 2016, the Network determined that 43% of payments were “traditional FFS or other legacy payments not linked to quality” and 28% was “pay-for-performance or care coordination fees.” Deloitte recently released results from their 2017 Survey of US Health System CEOs which includes are chapter on Population health and value-based care that provides these insights: ·         “Survey participants say the transition to value-based care is happening, but at a slower rate than initially anticipated. Still, many of the CEOs report that they are developing and expanding innovative delivery and payment models, and are focusing on MACRA and physician activation. ·         “Many CEOs also are looking into strategies to generate physician buy-in and encourage behavioral change, which will help them be better prepared for the transition to population health and value-based care.” ·         “Many of the surveyed CEOs express concern about operating under two different payment systems—FFS and value-based care—and having misaligned incentives. Moreover, moving towards population health and bearing financial risk likely will require a large patient population.” ·         “Many CEOs who previously had acquired and invested in physician practices report being more engaged and prepared for MACRA implementation than other survey respondents. “ ·         “In our survey, some respondents indicate they are using tools including clinical integration, employment contracts with incentives, ACOs and risk-sharing agreements, among others to better activate physicians in care delivery transformation.” Meanwhile, Bain & Company recently released their Front Line of Healthcare Report 2017, in which they surveyed 980 physicians and concluded that “more than 60% of the physicians we surveyed believe it will become more difficult to deliver high-quality care in the next two years as they struggle to cope with a complex regulatory environment, increasing administrative burdens and a more difficult reimbursement landscape. After years of experimentation, physicians now want evidence that new models for care management, reimbursement, policy and patient engagement will actually improve clinical outcomes. Without it, they see little reason to alter the status quo and move toward widespread adoption.” Specific to physician receptivity toward value based care, Bain found that physicians very much prefer FFS if they had their druthers: “More than 70% of physicians prefer to use a fee-for-service model, citing concerns about the complexity and quality of care associated with value-based payment models. Fifty-three percent of physicians say that capitation reduces the quality of care, and most see little advantage from pay-for-performance models either. Further, many believe their organizations are not sufficiently prepared for the shift to value-based care.”

CVS, Aetna, Retail Integrated Delivery Systems and the Strange World of Frenemies

by Clive Riddle, October 27, 2017

As widely reported, including in the Wall Street Journal, CVS is making a very serious bid to acquire Aetna for more than $200 a share, equating to $66 billion. The most often cited drivers behind this deal include:

• CVS’s strategic response to Amazon’s potential entry into the pharmacy business
• CVS strategic response seeking growth outside core business, after antitrust regulators rejected Walgreens/Rite Aid merger
• Aetna strategic response seeking growth outside core business after antitrust regulators rejected Aetna/Human and Anthem/Cigna mergers
• Aetna would serve as significant source of members for CVS PBM division, customers for CVS pharmacies and patients for Minute Clinics
• CVS and Aetna’s strategic response to competitors aligning health plans and PBMs such as UnitedHealth acquisition of Catamaran

Much attention has been given to initiatives for integrated delivery systems between hospitals and medical groups that take on purchaser functions. Does this signal a different focus – on retail integrated instead of clinically integrated systems - bringing together pharmacies, retail clinics, health care coverage, wellness services, patient engagement and care coordination?

But Wall Street experts remind us that doesn’t mean this deal is a sure thing.  Things could fall apart simply due to details in the financial terms, or because of new changes in direction by competitors or in the overall market. The Street quotes Jeremy Bryan, a portfolio manager at Gradient Investments, a minor CVS shareholder: "There's just no case study for this. There could be regulatory hurdles. But we have cautious optimism." The Wall Street Journal states “The deal almost surely would attract close scrutiny from U.S. antitrust enforcers who have expressed concern about health-care consolidation.”

Assuming however there is a clear path forward for CVS and Aetna, the question remains for them what lies in wait for them down the road? A few potential concerns include:

• Would the deal jeopardize the recently announced Anthem/CVS relationship whereby CVS will service Anthem’s new PBM?
• Would the deal drive other competing health plans away from the CVS PBM and pharmacies?
• What if CVS is counting on Aetna becoming a more significant force in Medicare Advantage to drive CVS PDP business, and Aetna fails to deliver?
• What if the Trump Administration and Republican Congress succeed in further scaling back Medicaid, causing Aetna’s significant investment in Medicaid business to erode and become a drag on CVS overall performance?
• What if Aetna focuses its pharmacy and retail clinic network offerings on CVS locations, and loses market share to competitor plans with broader offerings?

On the other hand, maybe the deal wouldn’t cause competitors to blow up relationships with CVS or Aetna. The Washington Post quotes Adam Fein, president of Pembroke Consulting: “This is part of the strange world of the health insurance and PBM industry. Many companies are frenemies.”

A Dozen Things To Know About The Trump Healthcare Executive Order and Elimination of CSR Payments

by Clive Riddle, October 13, 2017 1.       Attorney General Jeff Sessions issued a legal opinion to HHS and the Treasury Department that that money appropriated to HHS “cannot be used to fund” Cost Sharing Reduction (CSR) payments.   2.       The Trump administration has filed notice to the U.S. Court of Appeals for the D.C. Circuit, “that the Department of Health & Human Services (HHS) has directed that cost-sharing reduction payments be stopped because it has determined that those payments are not funded by the permanent appropriation for ‘refunding internal revenue collections.” they were not formally appropriated by Congress.   3.       Health Plans still have to provide marketplace subsidized discounts to low-income customers. Without CSR reimbursement, one must assume participating plans will raise premiums as soon as feasible.   4.       A CBO report indicates the decision to end CSR payment payments is likely to cost the federal government more than making the payments due to ACA required subsidies to cover anticipated premium increases.   5.       The health plans most impacted by the CSR elimination include mostly Blue Cross and Blue Shield companies and insurers focused on Medicaid, such as CenteneCorp. and Molina Healthcare Inc.   6.       CSR lawsuits are likely. Impacted health plans may sue. The Hill reports attorneys general from California and New York say they are prepared to sue the Trump administration to protect health-care subsidies that the White House said would be cut off.   7.       As Sam Baker, Axios healthcare editor posts, “Congress can solve this. University of Michigan law professor Nicholas Bagley, an expert on this issue, told me that if Congress appropriates the money for these subsidies, they would begin flowing again immediately.”   8.       The Trump Executive Order does not equate to immediate changes. As healthcare policy expert Timothy Jost posts in Health Affairs, the Executive Order “is a direction to draft rules. Under the Administrative Procedures Act these agencies will first have to publish proposed rules and then receive and respond to public comments before publishing the rules in final form. The fact sheet accompanying the order acknowledges that regulations will proceed through notice and comment rulemaking. This will likely take months. Indeed, rulemaking will likely be proceeded by studies by the affected departments, and any proposed and final rules will likely have to be reviewed by the Office of Management and Budget. Therefore, changes are unlikely to affect plans beginning on January 1 of 2018, although some changes may take effect mid-year.”   9.       The executive order instructs the Department of Labor to expand the availability of association health plans under the Employee Retirement Income Security Act of 1974 (ERISA).   10.   The executive order instructs the Departments of Labor and HHS to pursue expanded Availability of Short-Term, Limited‑Duration Insurance.   11.   The executive order instructs the Departments of Labor, Treasury and HHS to increase the usability of HRAs, to expand employers' ability to offer HRAs to their employees, and to allow HRAs to be used in conjunction with nongroup coverage.   12.   As Timothy Jost notes in another Health Affairs post, small employers already received expanded ability regarding HRAs in 2016, when “Congress adopted in Title XVIII of the [21st Century] Cures Act a new type of arrangement, the Qualified Small Employer HRA (QSEHRA), that is effectively an exception to the HRA prohibition, but only for small employers — employers that have fewer than 50 full-time equivalent employees and therefore are not subject to the large employer mandates. These employers may pay or reimburse employees through a QSEHRA for premiums for health insurance that qualify as minimum essential coverage.” Thus the Executive Order would have more impact on larger employers.

The Impact of Time and Money on The Physician – Patient Relationship

by Clive Riddle, October 6, 2017 The “physician-patient relationship remains strong but cost may challenge its future,” is the headline takeaway offered by The Physicians Foundation, who just released findings from their second biennial patient survey. Their 45-report discuss analyzes survey responses from a nationally representative sample of 1,747 adults, ages 27-75, who had two visits with the same doctor in the past year. We are told “89 percent of consumers are fearful that the rising cost of healthcare will adversely impact them in the future. In particular, over half (56 percent) of patients say the cost of prescription drugs and pharmaceuticals directly contributes to rising healthcare costs. In fact, because of cost, 25 percent of patients surveyed said they did not fill a prescription and 19 percent have skipped doses of their medicine…..Fifty seven percent of healthcare consumers feel they are one sickness away from being in serious financial trouble. And 75 percent of consumers are concerned with their ability to pay for medical treatment if they were to get sick or injured, an increase from the first survey issued in 2016 when 62 percent were concerned.” What do consumers think is driving increased costs? The Foundation says “eighty-eight percent of consumers look to pharma companies and the way they price drugs as the main reason for rising healthcare costs. Other factors that consumers feel contribute to rising healthcare costs include absence of free markets (24 percent) and fraud (23 percent).” 33% of consumers say they have debt because of medical costs, with 30% of those with debt owing $5,000 or more. Time is the other major concern. The Foundation states that “only 11 percent of patients and 14 percent of physicians report that they have all the time they need together. This signals a significant challenge to providing high quality care, especially when 90 percent of patients feel the most essential element of a quality healthcare system is a solid physician-patient relationship.” The Foundation goes on to report that “65 percent of patients feel that time is always or often limited with the physician, however only half of physicians feel similarly. Yet the same number of patients (53 percent) and physicians (52 percent) are of a common mindset in terms of workload – believing physicians to be at full capacity.”  But despite the pressures from time and money, 95% of patients said they were satisfied with their overall primary doctor relationship, including 64% who said they were very satisfied. 5% said they think about changing their primary doctor all the time, and 15% said they thought about that often.

Studies on Prescription Drugs and Social Media

By Clive Riddle, September 29, 2017

Given that prescription drugs are perhaps the most direct-to-consumer marketed U.S. healthcare service, and pharmacies perhaps the most retail oriented distribution of health care services, social media would seem to have the greatest influence on pharmaceuticals than other healthcare sectors. PrescribeWellness this week released results of its 2017 Pharmacy Social Media Survey, which "looked at how Americans choose their pharmacy, what pharmacy services they most value, and their interest in interacting with their neighborhood pharmacists online and through social media."

Here’s what the shared from their findings:

• 37% look to Google when looking for a pharmacy, versus 34% relying on word of mouth
• Another 18% look to Facebook to choose a pharmacy
• 32% look for a pharmacy with a useful website
• 78% would consider following their pharmacist on social media— and 48% already do
• 42% percent wish their pharmacist were more active on social media.
• 47% say their preferred social network for interacting with their pharmacist is Facebook
• 15% prefer Twitter in this regard and 12% prefer Instagram (12 percent)
• 34% are interested in their pharmacist’s website
• 25% would be interested in a pharmacy email newsletter.
• 54% would be more inclined to use a product that their pharmacist recommended on social media

Respondents say the top benefits of following their pharmacist on social media include:

• Deals and promotions – 58 percent
• New offerings or services – 39 percent
• Healthcare news – 37 percent
• Relevant news and tips about health and wellness – 37 percent
• Seasonal vaccine reminders – 31 percent

62% use their pharmacy’s website, with 61% using the site for refill requests; 47% for online orders; 29% for medication reminders; 29% for a medication list; 20% for online appointments; and 19% to access messages from their pharmacists, 40% say their pharmacy has a mobile app, which they use to place refill requests (48%), receive refill reminders (38%) and place orders (38%).

Moving on from pharmacies to pharmaceutical companies, earlier this year, the Journal of Medical Internet Research published to paper: Direct-to-Consumer Promotion of Prescription Drugs on Mobile Devices: Content Analysis, which sought to “investigate how prescription drugs are being promoted to consumers using mobile technologies. We were particularly interested in the presentation of drug benefits and risks, with regard to presence, placement, and prominence.”

Of the mobile communications they examined, 41% were product claim communications, 22%) were reminder communications, and 37were help-seeking communications (includes information about the medical condition but not the drug name. 69% linked to branded drug websites indicating both benefits and risks, 25% linked to a landing page listing benefits but no visible risks, and 6% linked to a landing page listing risks but no visible benefits.

The Frontiers in Pharmacology journal last December published the article Perspectives for the Use of Social Media in e-Pharmamarketing which among other things concluded that "in November 2015, American Food and Drug Administration (FDA) has encouraged the use of social media to improve communication and information exchange in health promotion and public health (U.S. Food and Drug Administration Social Media Policy, 2015). Foreign studies show that one in four interactions with doctor, patient, and healthcare providers in the United States is a digital contact. Patient education through social media is therefore an opportunity for the pharmaceutical industry to gain confidence in the company and increase the awareness of consumer when choosing a product. In this way, customer acquires knowledge about health, diseases, and treatment. In various social media channels it is possible to find information on any drug. This information is available on: websites of a manufacturer, social network brand fanpages, portals for white staff specialists. According to a study, conducted by Comscore, patients who are familiar with drug brand website often followed the recommendations for its use (20% of patients). Internet advertising also influenced the use of a drug (13.5% of patients; ROI Media, 2016). E-pharmamarketing activities in social media and in the network tend to increase. It is estimated that in the year 2016 the US pharmaceutical companies allocate for this purpose 2.48 billion dollars.”

NCQA Releases 2017-2018 Health Plan Ratings

By Clive Riddle, September 22, 2017 The National Committee for Quality Assurance (NCQA) has just released its 2017-2018 Health Insurance Plan Ratings. NCQA reports that they evaluated 1,429 health plans and rated 1,062: 498 private (commercial), 386 Medicare and 178 Medicaid. NCQA’s ratings are based on a scale of 1.0 to 5.0, and they state their system is similar to the CMS Star Rating approach for Medicare Advantage plans. NCQA tells us that “the overall rating is the weighted average of a plan’s HEDIS and CAHPS measure ratings, plus accreditation standards (if the plan is accredited by NCQA), rounded to the nearest half point. Accreditation standards are given 10 percent of the weight of the valid HEDIS and CAHPS measures that a plan submits. The overall rating is based on performance on dozens of measures of care and is calculated on a 0–5 (5 is highest) scale in half points. Performance includes three subcategories (also scored 0–5 in half points): Consumer Satisfaction, Prevention and Treatment.” If you really want to get into the weeds regarding their methodology, you can click here to review their 16-page methodology report. NCQA share that the “Top Ten States with the Highest-Rated Health Plans (receiving a 4.5 or 5.0 out of 5 rating) for Three-Year Average: 1.     Massachusetts 2.     Rhode Island 3.     Maine 4.     New Hampshire 5.     Wisconsin 6.     Minnesota 7.     Hawaii 8.     New York 9.     Vermont 10.  Iowa NCQA also tells us that “high and low performers Are rare: of the 1,062 rated plans, 103 (10%) received a top rating of 4.5 or 5.0 out of 5. Twenty-three (2%) earned the ratings of 1.0 to 2.0. Digging into their website, we compiled this list of health plans with 5.0 overall ratings for Private, Medicaid or Medicare: ·         BCBS MA (Private) ·         Johns Hopkins US Family MD (Private) ·         Kaiser Northern California (Private) ·         Tufts MA, NH, RI (Private) ·         Jai Medical Systems MD (Medicaid) ·         Group Health Plan MN, WI (Medicare) ·         Gundersen Health Plan IA, WI (Medicare) ·         Kaiser Southern CA (Medicare) ·         Kaiser Northwest OR, WA (Medicare) ·         Kaiser Washington (Medicare) ·         Kaiser Hawaii (Medicare) ·         Medical Associates Health Plan WI (Medicare) ·         Medical Associates Health Plan IL, IA (Medicare) On the flip side, here’s the plans we identified with ratings of 2.0 or less: ·         Cigna NM  (Private 2.0) ·         Cigna Utah (Private 2.0) ·         Connecticut General NM (Private 2.0) ·         Human Puerto Rico (Private 2.0) ·         Anthem BCBS Nevada (Private 2.0) ·         Triple S Salud PR (Private 1.5) ·         UnitedHealthcare of Texas (Private 1.5) ·         Tokio Marine Pacific Guam (Private 1.0) ·         Union Health Service IL (Private 1.5) ·         Aetna Better Health IL (Medicaid 2.0) ·         Family Health Network IL (Medicaid 2.0) ·         Health Plan of Nevada (Medicaid 2.0) ·         South Florida Community Care Network (Medicaid 2.0) ·         Aetna Better Health NJ (Medicaid 1.5) ·         Community Care Alliance IL (Medicaid 1.5) ·         Cook Children's Health Plan TX (Medicaid 1.5) ·         Affinity NY (Medicare 2.0) ·         Atrio (Medicare 2.0) ·         Community Care Alliance IL (Medicare 2.0) ·         Elderplan NY (Medicare 2.0) ·         Gateway KY, NC, OH (Medicare 2.0) ·         Group Health Inc. NY (Medicare 2.0) ·         Inland Empire CA (Medicare 2.0) ·         Meridian IL (Medicare 2.0) ·         United Healthcare of New York (Medicare 2.0) ·         Virginia Premier (Medicare 2.0) ·         VNS Choice NY (Medicare 2.0) To be fair to the above plans rated 2.0 and less, there were 367 NCQA evaluated but did not rate due to only partial or no data available – and it is quite possible that a number of these would have received low ratings as well.

Nine Things to Know About Current Opioid Misuse from a New SAMHSA Report

By Clive Riddle, September 15, 2017

The HHS agency  SAMHSA (Substance Abuse and Mental Health Services Administration) has released a new 86-page report: Key Substance Use and Mental Health Indicators in the United States: Results from the 2016 National Survey on Drug Use and Health, which among other things provides an updated peek at opioid misuse during the past year.

 

Here’s nine things to know from the report:

1. In 2016, approximately 11.8 million people aged 12 or older misused opioids in the past year,         representing 4.4 percent of this population.

2. About 891,000 adolescents aged 12 to 17 misused opioids in the past year, representing 3.6 percent of adolescents.

3. About 2.5 million young adults aged 18 to 25 misused opioids in the past year, representing 7.3 percent of young adults.

4. 8.4 million adults aged 26 or older misused opioids in the past year, representing 4.0 percent of this age group.

5. In 2016, approximately 11.5 million people misused prescription pain relievers in the past year, making it the predominant means of opioid misuse.

6. Among people aged 12 or older in 2016 who misused prescription pain relievers in the past year, the most commonly reported reason for their last misuse of a pain reliever was to relieve physical pain (62.3 percent.)

7. 53.0 percent of people who misused pain relievers in the past year reported that they obtained the pain relievers the last time from a friend or relative.

8. Another 36.8 percent of people who misused pain relievers in the past year indicated that they obtained pain relievers the last time through prescription

9. Another 6.0%  people who misused pain relievers in the past year bought the last pain reliever they misused from a drug dealer or stranger.

Fighting Over Who The Healthcare Punching Bag Should Be: Health Plans vs. Pharma

By Clive Riddle, August 25, 2017

Earlier this month the Doctor-Patient Rights Project released Not What the Doctor Ordered: Barriers to Healthcare Access for Patients an eighteen page report presenting consumer survey results regarding health insurance coverage denials. The Project issued statements in conjunction with the report including from Stacey Worthy, Executive Director of Aimed Alliance and one of the Project’s founding members, who said “our research reveals a hidden healthcare crisis. The current debate about healthcare reform has focused on getting more Americans covered. Yet, the real crisis is among patients with chronic illnesses who tell us that insurance is worthless when their insurance providers withhold coverage of essential treatments prescribed by a doctor.”

The Project highlighted that the survey found:

• Insurance plans denied treatment coverage 24% of patients with a chronic or persistent illness or condition
• 41% of these patients denied coverage were denied once, while 59% were denied multiple times.
• 55% of those denied treatment said they were denied a prescription medication
• 41% of those denied treatment said they were denied a diagnostic or screening test
• 24% of those denied treatment said they were denied a medical procedure
• 53% of those denied coverage for a treatment of a chronic or persistent illness appealed the denial
• 49% of those appeals were ultimately successful
• 70% of the denied treatments for chronic or persistent illnesses were for conditions described as “serious
• 43% were for treatment of patients described as “in poor health”
• 29% of patients initially denied coverage reported that their condition worsened
• 34% denied coverage had to put off or forego treatment altogether

What isn’t clear at all in the report, is what the overall denial rate was for the 1,500 consumers surveyed. One wonders why that information wasn’t shared. The report focuses on denials for those responding that they had a chronic or persistent medical illness or condition, or on types of denials for the overall population surveyed.

The report tells us that 55% of the denials were for prescriptions, with 37% of these for formulary exclusions, while 12% required prior authorization, 9% required step therapy and 5% involved therapeutic substitutions. It becomes less clear from the report what portion of these denials still resulted in an alternative covered prescription, or ultimate coverage of the requested prescription after qualifying conditions were met.

The health insurance industry counters that runaway prescription costs are what we should be focusing on. The Blue Cross Blue Shield Association, AHIP and others have regularly produced reports highlighting the prescription cost problem. AHIP, for example one month ago posted Myth vs. Fact: What’s Behind Drug Prices on their website, in which AHIP goes about “fact-checking some of the pharmaceutical industry’s main arguments for why they have to charge hundreds of thousands of dollars for a course of treatment.” They cite reports and articles to support statements including: “High prices have little or nothing to do with drugs’ innovation or efficacy for patients”; “Pricing is based on what already exists, and competitors use shadow pricing to drive each other’s prices higher”; and “Instead of promoting true medical advances, a common business strategy in the pharmaceutical sector is to buy the rights to older drugs and then immediately jack up the prices.”

Morning Consult wrote about the dustup between the two sides this week, stating that health insurers are “alleging it [the Project Report] is part of a campaign by the pharmaceutical industry to distract the public from rising drug prices,” and that “Insurers say the coalition [Project] is tied to pharmaceutical companies.” The article quotes AHIP: “Big Pharma initiated another long-rumored political ad campaign in its attempts to distract from skyrocketing drug pricing, AHIP spokeswoman Cathryn Donaldson said in an email Monday, adding that instead of spending money on advertising campaigns, pharmaceutical companies should address high prescription drug prices.”

The article also quotes the other side punching back: “PhRMA spokeswoman Holly Campbell said pharma companies spend 20 percent of their revenue on research and development, fueling economic growth and bringing patients new treatments. In contrast, the insurance industry invested $0 in R&D and instead spend nearly 20 percent of premium dollars on administrative costs, she said in a Monday statement.”

Employer Surveys Project 2018 Cost Increases in the Five Percent Range

by Clive Riddle, August 11, 2017 The National Business Group on Health has released results from their Large Employers’ 2018 Health Care Strategy and Plan Design Survey, which projects the total employer cost of providing medical and pharmacy benefits to rise 5% for the fifth consecutive year in 2018. The total cost of health care is estimated to be $13,482 per employee in 2017, and is projected to increase to $14,156 in 2018, with employers funding 70% of these costs. What is driving cost increases? The most often listed top driver was specialty pharmacy (26%) and 80% of employers ranked this among the top three cost drivers. Similarly, last week Willis Towers Watson released preliminary findings from their 22nd annual Best Practices in Health Care Employer Survey, which found that "Employers expect health care costs to increase by 5.5%* in 2018, up from a 4.6% increase in 2017." The NBGH 2018 survey also produced this grab-bag of interesting employer survey responses regarding health benefit strategies, regarding telehealth, onsite care, value based care, and CDHP: ·         96% will make telehealth services available in states where it is allowed next year ·         56% plan to offer telehealth for behavioral health services ·         20% of employers are experiencing employee telehealth utilization rates of 8% or higher ·         21%s plan to promote ACOs in 2018, and another 26% are considering offering them        ·         54% will offer onsite or near site health centers in 2018         ·         88% expect to use Centers of Excellence in 2018 for certain procedures         ·         40% of employers have incorporated some type of value-based benefit design ·         18% will use value-based benefit design to steer employees toward telehealth in 2018 (16% in 2017) ·         66% of companies will offer medical decision support and second opinion services in 2018 ·         90% will offer at least one Consumer Directed Health Plan (CDHP) in 2018. ·         40% of employers will offer a CDHP as the only plan option in 2018, compared with 35% this year ·         28% pair a HDHP with a Health Reimbursement Arrangement

More on Medicaid Satisfaction: J.D. Power finds Medicaid Members More Satisfied Than Commercial Plan Members

by Clive Riddle, August 4, 2017 Recently, we  posted about The July 10 , 2017 Research Letter published in JAMA, A National Survey of Medicaid Beneficiaries’ Expenses and Satisfaction With Health Care, which found that “Medicaid enrollees gave their overall health care an average rating of 7.9 on a 0 to 10 scale. Forty-six percent gave their Medicaid coverage a score of 9 or 10, while only 7.6% gave scores under 5.” We noted these relatively high satisfaction levels occur despite a study published in the May 2017 Health Affairs: Outpatient Office Wait Times And Quality Of Care For Medicaid Patients which found Medicaid patients were 20 percent more likely than others to wait 20 minutes or longer. We also noted Medicaid managed care satisfaction rates were also measured last summer, under a survey commissioned by AHIP, which found 87 percent were satisfied with their Medicaid coverage and benefits. This week J.D. Power published a 2017 Managed Medicaid Special Report, which concludes that “Medicaid recipients are more satisfied with their coverage than traditional, commercial health plan members.” Their study measured “overall satisfaction with managed Medicaid organizations based on six factors (in order of importance): provider choice; coverage and benefits; customer service; cost; information and communication; and claims processing. Satisfaction is calculated on a 1,000-point scale.” The study found that: ·           Overall managed Medicaid satisfaction averaged a 784 score ·           The Medicaid average score was 78 points higher than the commercial health plan score for 2017 ·           Medicaid enrollees indicate provider choice as the most important factor of overall member experience ·           In contrast, commercial members list coverage and benefits as the key driver of satisfaction ·           42% of Medicaid managed care members deferred medical treatments due to cost ·           40% of Medicaid managed care members avoided buying prescription medications due to cost Given that Medicaid is administered and differs at the state level, the study addressed state differences, and reports that “Medicaid recipients in states where a dominant regional plan or a plan that owns a health system have the easiest access to doctors and hospitals, underscoring the importance of building robust networks and focusing on coordination of care between providers. Iowa, Tennessee, Arizona and Indiana have the easiest access to doctors and hospitals, compared with the other states included in the study.” The report also share that “the states with the highest levels of satisfaction among Medicaid recipients are Utah (885), Iowa (859), Colorado (854), Arizona (840) and Virginia (840). The lowest-performing states in terms of overall recipient satisfaction are Kansas (683), Mississippi (686), Delaware (716), New Jersey (728) and California (731).”

State Employee Benefit Plans Provide Insight Into Overall Group Benefit Trends

By Clive Riddle, July 20, 2017 The Summer 2017 edition of Data, Segal Consulting’s publication providing research findings on public sector employee benefits, presents findings from their 2017 State Employee Health Benefits Study. As states are one of the largest employers, and their benefit decision making is directly impacted by policy makers, monitoring the pulse of state employee benefit plans provides insight into benefit trends for group coverage as a whole. Andrew Sherman, Segal’s National Director of Public Sector Consulting, tells us “health benefits have become more important to state leaders as the cost of coverage outpaces overall inflation, placing budget pressure on health plan funding and underscoring the need for ongoing cost-management efforts. Examining what other states offer can be helpful for these leaders when they make difficult decisions about potential changes in coverage.” The 23-page issue exclusively presents their study which involved a review of the websites for all 50 states and the District of Columbia in the fourth quarter of 2016, capturing medical, prescription drug, vision and dental plan information, as well as wellness and tobacco-cessation programs, including 105 PPOs/POS plans, 83 HDHPs/CDHPs, 149 HMOs/EPOs and five indemnity plans. One insight from the study was “there are stark geographic discrepancies to where it is offered. According to the study, 13 Southern States offer HDHP/CDHPs, compared to just two in the Northeast. They are offered in eight states in the Midwest and seven in the West.” This equates to 22% of the states in the Northeast, 76% in the South, 67% in the Midwest and 54% in the West offering consumer driven plans. Single premium increases averaged 8% for HMO/EPO plans, 10% for PPO/POS plans and 14% for HDHP/CDHP plans. The average single monthly premium was $780 for HMO/EPO plans, $713 for PPO/POS plans and $563 for HDHP/CDHP plans. Single deductibles averaged $194 for HMO/EPO plans, $483 for PPO/POS plans and $1,997 for HDHP/CDHP plans. For the prescription benefit, single copayments averaged $9 for generic, $29 for brand formulary, $53 for brand non-formulary, and $101 for specialty drugs.

Medicaid Patient Satisfaction: High Despite Naysayers and Longer Wait Times

By Clive Riddle, July 13, 2017 The July 10 , 2017 Research Letter published in JAMA, A National Survey of Medicaid Beneficiaries’ Expenses and Satisfaction With Health Care, and authored by researchers at the Harvard T.H. Chan School of Public Health frames the issue like this”: “some policymakers have argued that Medicaid is a broken program that provides enrollees with inadequate access to physicians. While numerous studies demonstrate that Medicaid increases access to care, the literature has less frequently focused on patient satisfaction among Medicaid enrollees themselves. We analyzed a newly released government survey examining Medicaid beneficiaries’ experiences in the program.” Co-author Michael Barnett, assistant professor of health policy and management at Harvard Chan School, tells us “the debate on the future of Medicaid has largely marginalized a crucial voice: the perspective of enrollees. Our findings confirm that Medicaid programs are fulfilling their mission to provide access to necessary medical care.” The authors used the Medicaid Consumer Assessment of Healthcare Providers and System (CAHPS) survey administered by CMS. Here’s their summary of results: “Medicaid enrollees gave their overall health care an average rating of 7.9 on a 0 to 10 scale. Forty-six percent gave their Medicaid coverage a score of 9 or 10, while only 7.6% gave scores under 5. Ratings were similar in Medicaid expansion and nonexpansion states (7.8 vs 7.9; P = .54). Ratings were slightly higher for older adults and dual-eligible beneficiaries, but similar in the fee-for-service and managed-care groups. Overall, ratings ranged from 7.6 to 8.3 across all demographic groups.” Access was also addressed:  physician access, 84% of enrollees reported that they had been able to get all the care that they or their physician believed was necessary in the past 6 months, and 83% reported having a usual source of care. The mean percentage of beneficiaries able to get all needed care was significantly higher in Medicaid expansion states than in nonexpansion states (85.2% vs 81.5%; P < .001). Overall, only 3% of enrollees reported not being able to get care because of waiting times or physicians not accepting their insurance. Two percent reported lacking a usual source of care because 'no doctors take my insurance.' This level of patient satisfaction comes despite a study published in the May 2017 Health Affairs: Outpatient Office Wait Times And Quality Of Care For Medicaid Patients which found Medicaid patients were 20 percent more likely than others to wait 20 minutes or longer, with the median Medicaid wait time for Medicaid patients 4.6 minutes past their scheduled appointment time, compared to 4,1 minutes for the privately insured. 18 percent of visits for Medicaid patients has a wait time of more than 20 minutes, compared to 16.3 percent for privately insured patients. The concern stated with the study is the wait time would impact the Medicaid satisfaction rates measured in the CMS Consumer Assessment of Healthcare Providers and System (CAHPS). Yet the new survey findings would indicate otherwise. Medicaid satisfaction rates were also measured last summer, under a survey commissioned by AHIP, which found: ·         87 percent were satisfied with their Medicaid coverage and benefits ·         Medicaid managed care plan member had higher satisfaction with their benefits (85 percent) in comparison to those enrolled in traditional Medicaid fee-for-service programs (81 percent); ·         9 percent) said they are dissatisfied with their coverage; and ·         83 percent were highly satisfied with their level of access to doctors when needed.

Healthcare 2017 Viewed Through Brokers’ Lens

by Clive Riddle, July 7, 2017

With the onset of the ACA at the start of this decade, if one asked how brokers would view the world of healthcare seven years later, some would have answered “who cares – they will become irrelevant.” But flash forward to 2017 and here they are, continuing to play the role they have always played, even though the landscape has certainly shifted. Despite disintermediation, public exchanges, technology and a host of other challenges, brokers remain at bat, swinging away.

BenefitsPRO has just released they annual broker survey, with responses from 350 brokers representing the spectrum of industry sectors. One might have thought brokers of all people, would firmly be in the camp of ACA repeal, 50% “would like to see the ACA retained and repaired, while 28 percent prefer a gradual repeal and replace, and 22 percent want it repealed and replaced immediately.”

One insight is that brokers business has evolved so that the public exchange market isn’t a material part of their business. When asked, “how have state exchanges’ struggles impacted your business,” 48% said there was no effect, 35% replied it hurt a little or significantly, and 17% said it helped a little or significantly.” The individual market has gravitated away from brokers, with 34% not involved, 37% reporting minimal demand, and less than ten percent stating “enrolling individuals on the public exchange is worth the effort.” Private exchanges aren’t a dominant force at this point, as “nearly 6 in 10 of those responding say they do not have a private exchange partner for enrollment and benefits administration.”

While technology has facilitated some disintermediation, brokers continue to attempt to enhance their value offering a personal touch that online tools can’t offer. The survey report noted that 53 “percent of respondents say meeting in a group setting at the worksite is the primary enrollment technique, while 36 percent cited one-on-one meetings in the workplace. However, 39 percent say their top method is using an electronic enrollment tool independently.”

But losses of individual and other health insurance market share have been offset by growth in the voluntary benefit sector, with 57% identifying with the statement that “they will use voluntary benefits to offset anticipated commission losses from health insurance this year.”

Looking toward the future, consolidation looms large, just as in all other healthcare sectors, as “27% expect their organization to acquire or merge with another broker/agent organization,” while 14% “ look for another broker/agent to acquire their organization” and “14% also say their company will leave the health insurance brokerage business.”

Brokers focus for the future includes 84% “promoting ancillary insurance coverage,” 58% “promoting health plan consumer engagement and health and wellness programs,” 43% “promoting third-party consumer engagement and health and wellness programs, while 53% will be concerned about the threat of “the new wave of disruptive companies entering the industry.” A particular innovation they are concerned with is payroll companies with direct benefits distribution, with 57% viewing this a concerning.

A virtual tour of new studies on virtual visits

By Clive Riddle, June 23, 2017 The Advisory Board reports that “up to 77% of consumers would consider seeing a provider virtually—and 19% already have,” according to just published results from their Virtual Visits Consumer Choice Survey of 4,879 U.S. consumers, “designed to better understand the tradeoffs that consumers make when they need different types of care.” The survey found consumers “would be willing to consider a virtual visit in each of the 21 primary and specialty care scenarios tested,” with over 70% of respondents interested in “a prescription question or refill, pre-surgery and select post-operation appointments, receiving ongoing results from an oncologist, and ongoing care for chronic condition management. Select pregnancy checkups, weight loss or smoking cessation coaching, dermatology consults, and psychologist consults also ranked among top offerings.” The survey also addressed consumer telehealth concerns, with 21% citing care quality as their top concern, “followed by the provider not being able to diagnose or treat them virtually (19%), meaning they would have to go to the physical clinic anyway. Only 9% of respondents said they had no concerns about virtual visits.” The current issue of Annals of Family Medicine includes the article “Patient Perceptions of Telehealth Primary Care Video Visits, in which co-authors from the National Academic Center for Telehealth, Thomas Jefferson University conducted “in-depth qualitative interviews with adult patients following video visits with their primary care clinicians at a single academic medical center.” They found that “all patients reported overall satisfaction with video visits, with the majority interested in continuing to use video visits as an alternative to in-person visits. The primary benefits cited were convenience and decreased costs. Some patients felt more comfortable with video visits than office visits and expressed a preference for receiving future serious news via video visit, because they could be in their own supportive environment. Primary concerns with video visits were privacy, including the potential for work colleagues to overhear conversations, and questions about the ability of the clinician to perform an adequate physical exam.“ The May 1, 2017 North Carolina Medical Journal includes the article A Clinical Pharmacist in Telehealth Team Care for Rural Patients with Diabetes which describes a study of the “diabetes telemedicine program funded by the Health Resources & Services Administration and Kate B. Reynolds Charitable Trust was offered in 13 sites in eastern North Carolina, including federally funded Community Health Clinics. A telemedicine team offered interdisciplinary care in the primary care provider's (PCP's) office without the patient needing to travel. The interdisciplinary team included a clinical pharmacist, dietician, behavioral therapist, and physician specializing in diabetes. The PCP referred the patient to 1 or more disciplines depending on the patient's needs. The program targeted underserved rural adults with uncontrolled type 2 diabetes.” The study found that “92% of telehealth patients were ‘very satisfied’ with their care and 83% agreed that telemedicine made it easier to get care.” Referring physicians (vs direct consumer demand) may indeed be the potential driving force for telehealth, at least in rural settings. The current issue of the Journal of the American Board of Family Medicine includes the article Family Physicians Report Considerable Interest in, but Limited Use of, Telehealth Services. A survey of 1,557 Family Practitioners found "15% reported using telehealth services during 2014, and that FPs using telehealth were:  26% more likely to be located in a rural setting; 40% more likely to work in a practice with <6 FPs; 22% less likely to work in a privately-owned practice; and 76% less likely to provide general primary care to patients. Of the FPs using telehealth: 22% used it 1-2 times, and and 26% using it 3-5 times; 55% used telehealth for diagnosis and/or treatment; 68% used telehealth to refer patients to specialists; and 28% used telehealth to refer patients to mental health providers. Still, a rosy future telehealth market is projected according to Hospital & Health Systems 2016 Consumer Telehealth Benchmark Survey results released this month, with health systems cited as a primary driver. They report that “seventy-six percent of U.S. hospitals and health systems either have in place or expect to implement a consumer telehealth program by 2018. Drivers for the rapid adoption growth include the desire to improve access to care, improve care coordination, increase efficiency, prevent readmissions and expand population health programs. In addition, 69 percent of organizations that currently have consumer telehealth programs are planning to expand their offerings, and 76 percent of organizations without consumer telehealth indicate it is a high strategic priority for their organizations.”

A Dozen Takeaways From PwC’s Medical Cost Trend: Behind the Numbers 2018 Report

By Clive Riddle, June 16, 2017 PwC’s Health Research Institute has released Medical Cost Trend: Behind the Numbers 2018, their twelfth annual report projecting the growth of private sector medical costs in the coming year and identifying the leading trend drivers. The findings are largely based upon PwC’s annual Health & Well-being Touchstone Survey results, which draws from responses of 780 employers from 37 industries, and have also just been released. Here’s a dozen takeaways from this year’s 32 page Behind the Numbers report, and 114 page Touchstone Survey report: 1.       PwC’s HRI projects a 6.5 percent growth rate for next year, a half percentage point increase from the estimated 2017 rate.   2.       This growth rates steadily decreased from 11.9% in 2007 to 6.5% in 2014, and has fluctuated slighly above or below that figure since then   3.       PwCs provides this definition of their projected medical cost trend: the “increase in per capita costs of medical services that affect commercial insurers and large, self-insured businesses. Insurance companies use the projection to calculate health plan premiums for the coming year.”   4.       PwC's HRI has identified three major inflators expected to impact medical cost trend in the coming year: (A) Rising general inflation impacts healthcare. As the U.S. economy heats up, a rise in general inflation during 2016 and 2017 will likely put upward pressure on wages, medical prices and overall cost trend in 2018; (B) Movement to high-deductible health plans is losing steam. The wave of growth in high-deductible health plans, employers' go-to strategy in recent years to curb health spending, may be plateauing; and  (C) Fewer branded drugs are coming off patent. Employers may have less opportunity to encourage employees to buy cost-saving generics in 2018.   5.       PwC's HRI has identified two major deflators expected to impact medical cost trend in the coming year: (A) Political and public scrutiny puts pressure on drug companies. Heightened political and public attention could encourage drug companies to moderate price increases; and (B) Employers are targeting the right people with the right treatments to minimize waste. They are doubling down on tactics such as prescription quantity limits and exploring new technologies such as artificial intelligence to match people with the best treatment.   6.       The report also cites these healthcare drivers affecting the 2018 cost trend:  Technology and treatment innovation: Provider and Plan Consolidation; Government regulation; and Evolving Payment models.   7.       The report allocated these proportions of costs by component for 2018: Pharmacy 18%; Inpatient 30%; Outpatient 19%; Physician 29%; Other 4%   8.       The Touchstone Survey cites that “Medical plan costs have continued to increase, but employers expect that the rate of increase will start to slow. Plan design changes contributed towards slightly lower-than-expected increases in 2016;” and that “the average increase in 2016 was 6.8% before plan design changes and 3.6% after plan design changes. In 2017, participants expect to see a 6.0% increase before plan design changes and a 3.2% increase after plan design changes.”   9.       The Touchstone Survey notes that “participants appear to be in a "wait and see" mode – rather than considering broader and more transformational changes, they continue to use traditional cost-shifting approaches to control health spend;” and that “57% of participants expect to continue to increase employee contributions in the next three years, while 38% (29% for Rx) plan to increase employee cost-sharing through plan design changes.”   10.   The Touchstone Survey finds that “participants are increasing contributions in the form of surcharges for spouse, domestic partner and dependent coverage. This may be contributing towards a decrease in enrolled family size and slowing the rise in net employer spend.”   11.   The Touchstone Survey also finds that “participants are utilizing High Deductible Health Plans (HDHPs) more and Preferred Provider Organizations (PPOs) less, although PPOs remain more popular among employees. PPOs are the highest-enrolled plan 44% of the time, compared to 46% in 2016 and 60% in 2009. HDHPs are the highest-enrolled plan 34% of the time, up from 32% in 2016 and 8% in 2009.”   12.   The Touchtone Survey found that employer interest in population health is strong but private exchange interest is waning. They report that “79% offer wellness programs compared to 76% in 2016, and 63% offer DM programs compared to 56% in 2016;” while  “8% of participants are considering moving their active employees to a private exchange; 2% have already done so. Interest seems to have dropped off as the discussions on public exchanges and ACA have increased. However, 36% of participants who offer retiree medical coverage are considering moving pre-65 retirees to a private or public exchange.”

Centura Health Shares Strategies for Reducing Readmissions in Bundled Payment Arrangements

By Clive Riddle, June 9, 2017 Two experts from Centura Health, the Colorado based healthcare system shared their organization’s strategies in reducing readmissions in bundled payment arrangements for total hip and knee replacements, as part of a panel presentation in a HealthcareWebSummit event held this week on “Advanced Strategies in Appropriately Reducing Bundled Payment Arrangement Readmissions.” Centura’s Kristen Daley, Group Director – Value Based Programs, and Brenda Lewis, RN, MBA-HCM, CCM, ACM Group Manager – Care Coordination started by providing context from the literature for total hip arthroplasty (THA)  and total knee arthroplasty (TKA): ·         5.6% of THA and 3.3% of TKA require Readmission within 30 days of discharge ·         Unplanned Readmissions Costs for Medicare Patients = $17.5 Billion/Year ·         THA costs: $17,103/Readmission ·         TKA costs : $13,008/Readmission Daley and Lewis reminded us that elevated patient risk factors for these readmissions come from increased age; male gender; african american race; and medical co-morbidities including obesity, chronic pulmonary disease, bleeding disorders, cancer history, and psychiatric illness. They cited the leading complication for readmissions is infection: (12.1% of unplanned 30 day readmission) and the many other causes including: systemic: pulmonary, cardiac and circulatory; joint specific:  dislocation, fracture, malposition; hematoma, falls; failure to mobilize; increased pain and social determinants. They noted 50% of these readmissions are unrelated to the patient’s index arthroplasty. Here is Daley and Lewis’ summary of their readmissions reduction strategies: ·         Team Approach: All Providers and Caregivers Engaged, Communicating, and on the same page ·         Every Patient receives preoperative medical evaluation/optimization by Perioperative Hospitalists ·         Perioperative Hospitalists round post-op and collaborate on discharge with the Surgeon ·         Robust Care Coordination Program ·         Prepare Patients for Efficient Discharge ·         Front-Load Discharge Planning ·         Partner with Acute Case Management Team ·         Promote use of Preferred Partners ·         Extend Patient Management Post-Discharge They have undertaken the following to prepare patients for the transition from hospital to home: ·         Begin Education Preoperatively and Re-emphasize throughout Hospitalization ·         Embed Care Coordinator into Joint Education Class ·         Utilize LACE Tool to Assist to Identify Risk of Readmission (The LACE index identifies patients that are at risk for readmission or death within thirty days of discharge) ·         Provide Detailed Discharge Instructions ·         Educate patients on Wound Care, DVT Signs ·         Help patients with understanding Pain Management ·         Emphasize importance of Post-op Rapid Mobilization and Physical Therapy