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.

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition

Every business day, MCOL posts feature stories making news on the business of health care. Here are five we think are particularly important for this week: Trump Guts Requirement That Employer Health Plans Pay For Birth Control The Trump administration is rolling back the Obama-era requirement that employer-provided health insurance policies cover birth control methods at no cost to women. NPR Friday, October 6, 2017 Association Health Plans: A Favorite GOP Approach To Coverage Poised For Comeback Not even 24 hours after the latest “repeal and replace” proposal ran out of steam, Sen. Rand Paul (R-Ky.) ignited a new round of health policy speculation by predicting, during a cable news interview, impending Trump administration action on a longtime Republican go-to idea: association health plans. Kaiser Health News Friday, October 6, 2017 House passes GOP budget in key step for upcoming tax debate The House on Thursday passed a $4.1 trillion budget plan that promises deep cuts to social programs while paving the way for Republicans to rewrite the tax code later this year. The 2018 House GOP budget reprises a controversial plan to turn Medicare into a voucher-like program for future retirees as well as the party’s efforts to repeal the “Obamacare” health law. The Washington Post Thursday, October 5, 2017 Bill to Rescue Children’s Health Program Hits Snag in House Legislation to rescue the Children’s Health Insurance Program sailed through a Senate committee on Wednesday, but touched off a partisan conflict in the House, diminishing hopes that the popular program would be quickly refinanced. The New York Times Wednesday, October 4, 2017 Cigna says it won’t cover OxyContin prescriptions through employer plans The health insurer Cigna on Wednesday announced it will no longer cover OxyContin prescriptions for customers on its employer-based health plans, the second major announcement in two weeks from an industry group billed as an effort to slow the opioid epidemic. Stat News Wednesday, October 4, 2017 These and more weekly news items on the business of healthcare are featured in the MCOL Weekend edition, along with the MCOL Tidbits, and more, for MCOL Premium level members.

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition

By Claire Thayer, September 29, 2017

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition

Every business day, MCOL posts feature stories making news on the business of health care. Here are five we think are particularly important for this week:

CMS adds open enrollment period, offers regulatory relief for payers and members in wake of hurricanes

CMS has announced special open enrollment periods for all Medicare enrollees and some federal health insurance exchange consumers in the wake of hurricanes Harvey, Irma and Maria, along with other disaster-related policies to help insurance companies in affected areas.

FierceHealthcare. Friday, September 29, 2017

Senators close to bipartisan deal on health exchanges: Schumer

Two U.S. senators from both parties are close to finalizing a bipartisan deal to shore up the health insurance exchanges created under Obamacare, the chamber’s top Democrat said on Thursday.

Reuters. Thursday, September 28, 2017

Price took military jets to Europe, Asia for over $500K

The White House approved the use of military aircraft for multi-national trips by Health and Human Services Secretary Tom Price to Africa and Europe this spring, and to Asia in the summer, at a cost of more than $500,000 to taxpayers.

Politico. Thursday, September 28, 2017

Health crisis in Puerto Rico: Few hospitals have power or fuel, but public health officials fear the worst is yet to come

Only 11 of Puerto Rico’s 69 hospitals have power or fuel, leaving the few hospitals that are open to handle a surge of injured patients and those who need care for chronic conditions.

Fierce Healthcare. Wednesday, September 27, 2017

Anthem Says No To Many Scans Done By Hospital-Owned Clinics

Tightening the screws on pricey imaging exams, health insurer Anthem will no longer allow many patients to get MRI or CT scans at hospital-owned outpatient facilities, requiring them to use independent imaging centers instead. NPR Wednesday, September 27, 2017

These and more weekly news items on the business of healthcare are featured in the MCOL Weekend edition, along with the MCOL Tidbits, and more, for MCOL Premium level members.

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.”

Provider Data Accuracy – Continued Challenges for Health Plans

By Claire Thayer, September 27, 2017

Inaccurate provider directories continue to pose challenges for health plans both in terms of removing barriers to patient care as well as the monumental task of keeping track of network providers and managing all data elements associated with a single provider record.  Not only is the data constantly changing, consider this: documenting this information takes time as a detailed record can track up to 380 distinct line items, including service locations, billing locations, payment locations, specialties, certifications, affiliations, office hours, and languages spoken.  Regulations have been enacted on both the federal and state level on required data elements and timeliness of maintenance requirements, with penalties for non-compliance and regulations that vary widely from state-to-state.

This weeks’ edition of the MCOL Infographic, co-sponsored by LexisNexis, focuses on increasing challenges for health plans with data reporting and maintenance of provider directories:

 

MCOL’s weekly infoGraphoid is a benefit for MCOL Basic members and released each Wednesday as part of the MCOL Daily Factoid e-newsletter distribution service – find out more here.

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.

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition

Every business day, MCOL posts feature stories making news on the business of health care. Here are five we think are particularly important for this week: Of Cassidy-Graham’s four co-sponsors, only one has the support of his governor The latest Republican health-care bill gives significant power to the states. But several of the nation’s governors, including a handful of Republicans, aren't interested. The Washington Post Friday, September 22, 2017 CVS tightens restrictions on opioid prescriptions in bid to stanch epidemic CVS Health announced Thursday that it was limiting the amount and strength of prescription opioid painkillers it provides to patients taking the drugs for the first time, a step intended to help curb opioid abuse. Stat News Thursday, September 21, 2017 Graham-Cassidy Health Bill Would Shift Funds from States That Expanded Medicaid Senate Republicans' latest plan to overhaul the U.S. health care system ends with a massive shift of federal money from states that expanded Medicaid — and are largely dominated by Democrats — to those that refused to expand. NPR Thursday, September 21, 2017 Almost half of Americans favor single-payer healthcare system, poll finds Congressional Republicans may be trying once again to repeal and replace the Affordable Care Act with a more market-based approach, but a new poll finds that almost half of Americans favor a plan more in line with the single-payer offering served up earlier this year by progressive Sen. Bernie Sanders. Healthcare Finance News Wednesday, September 20, 2017 Amazon in talks with PBMs over pharma supply chain Amazon is reportedly communicating with pharmacy benefit managers about potential drug contracts, according to a Leerink Partners analysis cited by CNBC. Amazon has been hiring more healthcare leaders and expanding its drug and medical supply distribution in recent months, spurring rumors the online retailer is stepping into the pharmacy business. Becker's Hospital Review Wednesday, September 20, 2017 These and more weekly news items on the business of healthcare are featured in the MCOL Weekend edition, along with the MCOL Tidbits, and more, for MCOL Premium level members.

Need to drive MA plan membership? Don’t ignore your Marketing and Sales strategy

By Ben Kline, Business Development and Joel Andersen, Vice President, Marketing - Lumeris, September 19, 2017

After considerable due diligence, your organization has decided to launch a Medicare Advantage (MA) plan. You evaluated the market and current MA enrollment. You examined market competitors, such as provider-sponsored organizations, regional insurance firms, and large national organizations. You gauged potential competitor responses, trying to figure out if launching a plan would disrupt current market dynamics.

At this point, many organizations begin to shift their attention to enrollment and financial projections. As with any business endeavor, your organization needs to capitalize on its investment and understand where the membership threshold to breakeven lies. The sooner you can reach that membership threshold, of course, the better. However, many organizations fail to realize that the longer you go with low membership, the harder it becomes to garner traction. Meaning, your approach prior to launch and over the first year becomes increasingly important. You only have one chance to enter the market, and when you do, you want to capture your audience—providers, health systems, brokers, and consumers.

Based on our experience, most organizations underestimate, and often ignore, the importance of the sales and marketing strategy for launching a Medicare Advantage (MA) plan. Why? Some organizations that already manage insurance products in other lines of business may believe that traditional sales tactics will be sufficient for an MA launch. Others might think insurance marketing is purely an actuarial exercise and rely on the price point to drive membership.

From our experience in Medicare Advantage, two items are essential for growing membership:

1. Sales and marketing must be involved, and part of, the strategic planning process. They should be involved in all critical strategic decisions regarding the product launch, including advising on the design of your benefit plans.
2. A disruptive sales and marketing strategy helps you generate enrollment to ultimately win in your market. Successful plans pinpoint an unmet market need or gap in the market and leverage it—but this requires a highly tailored strategy.

Let’s walk through a common pitfall. In quite a few markets, we see the majority of new MA plans fall into the “me too” trap. They design their plans with a similar benefit structure and provider network to an existing MA product within the market. Their plan may have a slightly lower member cost share, but to the naked eye it appears identical to incumbent plans. To drive plan switching behavior among beneficiaries, you must provide a compelling reason to switch and those reasons must be visible to the consumer.

Many new MA plans also fail to realize that they are not just marketing against other market MA plans, but also against Medicare fee-for-service, Medicare Supplement insurance (Medigap), and standalone Prescription Drug Plans. While identifying competing benefit points is important, addressing the shortfalls of these other coverage options including how your plan addresses those shortfalls is critical. Educating the market on how your MA plan is innovative and transformative (and better than the status quo) can go a long way.

From here, it is critical to design a selling strategy that aligns with your sales channels. The more time you spend with your channel partners, the better. Handing off your new MA product to a series of brokers is not going to be enough. You will likely need to spend time educating your sales channel on Medicare Advantage, and the unique attributes of your plan. Moreover, how you design your product will dictate how you want to sell it. For example, you may have designed your product around a carefully crafted narrow network of providers. Narrow network MA plans call for an entirely different approach, and employment of classic MA sales and marketing approaches will often yield mixed results.

Medicare Advantage provides an attractive opportunity to deliver better care to seniors. To create a competitive advantage, don’t underestimate the power of a disruptive marketing and sales strategy.

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.

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition

Every business day, MCOL posts feature stories making news on the business of health care. Here are five we think are particularly important for this week:

Centrist Democrats Turn to Pragmatism, Seek Bipartisan ACA Fixes

While some progressives campaigned this week for “Medicare for all,” a group of moderate House Democrats aligned themselves with a more modest push to stabilize the Affordable Care Act, arguing that it could spur broader health care reforms in the future.

Morning Consult

Friday, September 15, 2017

CBO: ObamaCare uncertainty will lead to 15 percent hike in premiums

Premiums for ObamaCare's benchmark silver plans will increase by an average of 15 percent in 2018, the Congressional Budget Office (CBO) estimated in a new report released Thursday.

The Hill

Thursday, September 14, 2017

Sanders Offers Medicare-for-All Plan Backed by 16 Senate Democrats

Sixteen Senate Democrats are flirting with a single-payer health-care system, marking a shift within the party on what was once viewed as a politically treacherous issue that attracted little support from lawmakers.

Bloomberg

Wednesday, September 13, 2017

Stanford study: Three-quarters of opioid prescriptions written for 10 percent of patients

A new Stanford University study reveals a startling fact about the nation’s opioid crisis: A small minority of Americans account for the large majority of drug abusers.

Mercury News

Tuesday, September 12, 2017

Uninsured Rate Falls to Record Low Of 8.8%

Three years after the Affordable Care Act’s coverage expansion took effect, the number of Americans without health insurance fell to 28.1 million in 2016, down from 29 million in 2015, according to a federal report released Tuesday.

Kaiser Health News

Tuesday, September 12, 2017

These and more weekly news items on the business of healthcare are featured in the MCOL Weekend edition, along with the MCOL Tidbits, and more, for MCOL Premium level members.

Health Care's Juicero Problem

by Kim Bellard, September 8, 2017 Bad news: if you were still hoping to get one of the $400 juicers from Juicero, you may be out of luck. Juicero announced that they were suspending sales while they seek an acquirer. They'd already dropped the juicer's price from its initial $700 earlier this year and had hoped to find ways to drop it further, but ran out of time.  Juicero once was the darling of investors. They weren't a juice company, or even an appliance company. They were a technology company! They had an Internet-of-Things product! They had an ongoing base of customers! The ridicule started almost as soon as the hype. $700 -- even $400 -- for a juicer? The negative publicity probably reached its nadir in April, when Bloomberg reported people could produce almost as much juice almost as fast just by squeezing the Produce Packs directly. Moral of the story: if you want to introduce products that have minimal incremental value but at substantially higher prices, you're better off sticking to health care. Take everyone's favorite target, prescription drugs. As Donald W. Light charged in Health Affairs, "Flooding the market with hundreds of minor variations on existing drugs and technically innovative but clinically inconsequential new drugs, appears to be the de facto hidden business model of drug companies." As with prescription drugs, we regulate medical devices looking for effectiveness but not cost effectiveness -- and we don't even do a very good job evaluating effectiveness in many cases, according to a recent JAMA study.  Take robotic surgery, hailed as a technological breakthrough that was the future of surgery. A robotic surgical system, such as da Vinci, can cost as much as $2 million, but, so far, evidence that they produce better outcomes is woefully scarce.  Proton beam therapy? It's one of the latest things in cancer treatment, an alternative to more traditional forms of radiation therapy, and is predicted to be a $3b market within ten years. The units can easily cost over $100 million to buy and install, cost patients significantly much more than other alternatives, yet -- guess what? -- not produce measurably better results.  Last year Vox used 11 charts to illustrate how much more we pay for drugs, imaging, hospital days, child birth, and surgeries than other countries. Their conclusion, which echoes conclusions reached by numerous other analyses: "Americans spend more for health care largely because of the prices." We not only don't get a nifty new juicer from all of our health care spending, we don't even get better health outcomes from it.    Health care's "best" Juicero example, though, may be electronic health records (EHRs). Most agree on their theoretical value to improve care, increase efficiency, and even reduce costs. But after tens of billions of federal spending and probably at least an equal amount of private spending, we have products that, for the most part, frustrate users, add time to documentation, and don't "talk" to each other or easily lend themselves to the hoped-for Big Data analyses.  Many physicians might, on a bad day, be willing to trade their EHR for a Juicero.  Jonathon S. Skinner, a professor of economics at Dartmouth, pointed out the problem several years ago: "In every industry but one, technology makes things better and cheaper. Why is it that innovation increases the cost of health care?"  So we can make fun of Juicero all we want, but when it comes to overpriced, under-performing services and devices: health care system, heal thyself first. This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition

Every business day, MCOL posts feature stories making news on the business of health care. Here are five we think are particularly important for this week: Trump Administration Sharply Cuts Spending on Health Law Enrollment The Trump administration is slashing spending on advertising and promotion for enrollment under the Affordable Care Act, a move some critics charged was a blatant attempt to sabotage the law. New York Times Thursday, August 31, 2017 5 Outside-The-Box Ideas For Fixing The Individual Insurance Market With Republican efforts to “repeal and replace” the Affordable Care Act stalled, tentative bipartisan initiatives are in the works to shore up the fragile individual insurance market that serves roughly 17 million Americans. Kaiser Health News Wednesday, August 30, 2017 Pioneering Cancer Gene Therapy Gets Green Light — And $475,000 Price Tag The country’s first approved gene therapy — approved Wednesday to fight leukemia that resists standard therapies — will cost $475,000 for a one-time treatment, its manufacturer announced. Kaiser Health News Wednesday, August 30, 2017 Advisory Board to sell healthcare, education units in $2.58 billion deal Advisory Board Co said it would sell its healthcare business to UnitedHealth Group Inc’s Optum unit and education business to private equity firm Vista Equity Partners, for a total deal value of $2.58 billion. Reuters Tuesday, August 29, 2017 Majority of Voters Support Medicaid Work Requirements A majority of voters back the idea of tying Medicaid eligibility to employment status as the Trump administration weighs whether to give more states the power to impose work requirements on the government health program. Morning Consult Monday, August 28, 2017 These and more weekly news items on the business of healthcare are featured in the MCOL Weekend edition, along with the MCOL Tidbits, and more, for MCOL Premium level members.

Are you ready to meet the challenge of managing member identities?

By Claire Thayer, August 31, 2017

Healthcare consumers believe that their providers and health plans are taking measures to protect their digital healthcare data, yet a recent Accenture survey on Healthcare Cybersecurity and Digital Trust finds that one of four health care consumers (26%) has experienced a breach of their digital healthcare data, which may include their Social Security number, contact information, electronic medical record or health  insurance ID. And, of these, half were victims of medical identity theft.  Following a breach one-quarter (25%) of those experiencing a breach changed their healthcare providers, 21 percent changed their health insurance company, and 34% lost trust in the organization.

This weeks’ edition of the MCOL Infographic, co-sponsored by LexisNexis, highlights some of the issues and challenges involved in actively managing member identities and impact of security breaches: 

MCOL’s weekly infoGraphoid is a benefit for MCOL Basic members and released each Wednesday as part of the MCOL Daily Factoid e-newsletter distribution service – find out more here.

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.”

Medicare Advantage plans are rethinking member experience

Kristin Rodriguez, Health Plan Alliance. August 18, 2017

One of my favorite moments during our Medicare Advantage Value Visit, July 19-21 was when Melissa Smith, Vice President, Stars & Quality Innovations with Gorman Health Group said the highest performing health plans are the ones “making old school new again.” The point she was making? That which sets high performing health plans apart is the ability to execute at the member level.  The flavor of how health plans are tackling that member-level execution differed with each case study we explored during our time together last month, and yet the same theme presented again and again, with every conversation.  Elevating and protecting the member experience is paramount to ensuring strong market position, better outcomes and higher star ratings.

The “member experience” is a relatively new, hot topic for MA plans, though really it’s just a consolidation of the efforts we’ve been making for a long time, reframed into a global strategy that is bringing leaders from across the enterprise together to tackle challenging issues like these: making member facing materials more palatable, leveraging digital channels to enhance engagement, evaluating our MA portfolio with an eye on social determinants of health and guarding against chronic loneliness, building dashboards our provider partners actually care about, so they can deliver the care to those members that need it most, and, finally, ensuring appropriate payment so that we can finance that care.

The challenge facing all Alliance member health plans and our provider partners as we seek to “execute at the member level” are the barriers we and our members face, which have traditionally been outside any health plan’s influence or control.  With the industry transformation to value based purchasing and the steady march of quality ratings programs’ focus to outcomes and experience, health plans must drive care from the clinic to the community, and forge partnerships that empower care for the “whole person.”  Our MA members face crippling chronic conditions like depression and diabetes, not to mention persistent loneliness.  And even for our healthy senior population, ensuring a benefit mix that supports long term health and happiness can be challenging when it comes time to submit a bid that both differentiates your plan and is sustainable.

Experts like John Gorman agree that Medicare Advantage is a sound investment for health plans, with strong market growth providing solid opportunity for health plans looking to diversify and perhaps stabilize their portfolio.  To become a high performing MA health plan, however, organizations must be willing to identify and remove barriers preventing them from executing at the member level.  No matter what’s potentially holding you back, you can bet another Alliance member health plan is facing a similar challenge, or perhaps has even found a way to solve it. Through ongoing networking in-person and virtually, and by sharing our tools and lessons learned, we can help one another make “old school new again.”

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition

Every business day, MCOL posts feature stories making news on the business of health care. Here are five we think are particularly important for this week: Time Crunch Among Hurdles for Bipartisan Senate Push to Bolster ACA The leaders of a key Senate committee say they are cautiously optimistic about reaching a deal to shore up the Affordable Care Act’s individual marketplaces, but even with a bipartisan effort, it is far from certain whether they can hash out an agreement in time. Morning Consult Friday, August 18, 2017 EpiPen maker to settle on claims it overcharged taxpayers, agrees to have pricing practices reviewed Mylan will pay $465 million to settle claims that it overcharged states for its signature EpiPen, according to a Thursday Department of Justice press release. The company also signed an agreement with the federal government to enter into a review of its pricing practices. Stat News Thursday, August 17, 2017 Express Scripts to limit opioids, concerning doctors The nation’s largest pharmacy benefit manager will soon limit the number and strength of opioid drugs prescribed to first-time users as part of a wide-ranging effort to curb an epidemic affecting millions of Americans. Stat News Wednesday, August 16, 2017 Federal deficit will soar to $194 billion, premiums spike 20% if Trump nixes cost-sharing subsidies, CBO report says The federal deficit will soar by $194 billion over the next nine years and gross premiums for silver plans, the most popular, would spike 20 percent higher in 2018 and 25 percent higher by 2020 if President Trump follows through a proposal to eliminate the cost-sharing subsidies that allow low-income consumers to purchase and afford health plans on the individual ACA insurance exchanges, a report from the Congressional Budget Office said. Healthcare Finance News Tuesday, August 15, 2017 CMS cancels two mandatory pay models and scales back a third The CMS on Tuesday said it will toss two bundled payment models and cut down the number of providers required to participate in a third, citing providers' requests to have more input in the models' designs. Modern Healthcare Tuesday, August 15, 2017 These and more weekly news items on the business of healthcare are featured in the MCOL Weekend edition, along with the MCOL Tidbits, and more, for MCOL Premium level members.

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

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition

Every business day, MCOL posts feature stories making news on the business of health care. Here are five we think are particularly important for this week: Trump Plans to Declare Opioid Epidemic a National Emergency President Trump said on Thursday that he was preparing to officially declare the United States’ worsening epidemic of opioid overdoses as a national emergency, accepting an urgent recommendation from a national commission that he appointed. The New York Times Thursday, August 10, 2017 Early 2018 marketplace rates vary widely across states Health insurers selling individual plans next year on the federally operated marketplace, HealthCare.gov, have until Wednesday to finalize their rates. But early filings provide a good look at how the ACA marketplace is shaping up for 2018. Modern Healthcare Thursday, August 10, 2017 Bipartisan health policy coalition urges Congress to strengthen the ACA An unlikely coalition of liberal and conservative health-policy leaders is calling on Congress to strengthen the existing health-care law in a variety of ways to help Americans get and keep insurance. The Washington Post Wednesday, August 9, 2017 Taking A U-Turn On Benefits, Big Employers Vow To Continue Offering Health Insurance The shrinking unemployment rate has been a healthy turn for people with job-based benefits. Eager to attract help in a tight labor market and unsure of Obamacare’s future, large employers are newly committed to maintaining coverage for workers and often their families, according to new research and interviews with analysts. Kaiser Health News Tuesday, August 8, 2017 Large employers increasingly leaning on value-based contracts Instead of looking to reduce demand by shifting costs to employees, large employers are increasingly hoping to constrain health insurance cost growth through value-based contracts with providers, according to a survey released Tuesday by the National Business Group on Health. Modern Healthcare Tuesday, August 8, 2017 These and more weekly news items on the business of healthcare are featured in the MCOL Weekend edition, along with the MCOL Tidbits, and more, for MCOL Premium level members.

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).”

Health Care's Kodak Moment

by Kim Bellard, July 26, 2017

For those of us of a certain age, a "Kodak moment" connotes a special event that should be captured by a photo.  For younger generations, the term probably doesn't mean anything, because they don't know what Kodak is.  That's why, for some, "Kodak moment" has come to suggest a turning point when big companies and even entire industries can become obsolete. 

Health care could soon be at such a point.

Anthony Jenkins, a former CEO of Barclay's, recently warned that banks could face a Kodak moment soon.  He said they're already seeing a "Uber-moment," where smartphones and contractless cards are transforming the industry.  "The Kodak moment is completely different," Mr. Jenkins explained.  "That’s where customers realize there’s a totally better and different way of doing what they want to do, and the incumbent becomes obsolete."

In a separate speech, Mr. Jenkins elaborated that, due to new technologies, "we can imagine total transformation of the banking system."  He predicted banks have 5 to 15 years to face these challenges, or become irrelevant to their customers.

The "good" news, he added, is that: "Banks can avoid that, but they have to act now, and what they really need to do is think about innovation, but also transformation, doing something radically different."

For "bank" or "banking system" feel free to substitute "doctor/hospital" or "health care system"

Incumbents all-too-often grow protective and/or fail to take advantage of new opportunities.  The irony of disruption, Mr. Jenkins noted, is that it is "actually a great growth opportunity," and that "incumbents are best positioned to seize disruptive opportunities."  

Health care has a number of legacy problems that make it ripe for disruption.  Innovators look at these problems and see opportunities.

The opportunities -- or, threats, depending on one's point-of-view -- on health care's horizon are numerous.  They include:

• Digital health makes real-time information and communication feasible, such as with wearables and telehealth.
• Big Data will help us finally understand what is happening with patients and predict with better accuracy how we can manage our health.
• Robots will take over health care tasks/jobs that humans either don't want to do or lack the required precision to do.
• Artificial intelligence (AI) will be able to make sense of all that Big Data and all the various research studies, and can serve to either augment or, at least in some cases, replace physicians.
• 3D printing will allow us to replace an ever-increasing number of body parts, even systems, and do so with unprecedented speed and affordable cost.
• Nanotechnology will allow us to monitor and maintain us down to a cellular level.

Meanwhile, traditional health care companies -- from providers to middlemen to manufacturers to insurers -- are waiting with some trepidation to see what 21st century behemoths like Amazon or Apple are going to do in their space.  

Disruption might come from innovators within the health care industry, but it might also come from unexpected sources -- and in unexpected ways.  Kodak didn't take digital photography seriously enough, and it certainly wasn't expecting smartphones as the new camera.  

Health should have a number of the old-fashioned Kodak moments -- the birth of a child, a miraculous recovery, achievement of a health goal, and so on.  Whether health care organizations or even the entire health care system suffer the other kind of Kodak moment depends on how (and when) they respond to the disruptive opportunities now available to them.