Emails at the heart of cross-channel marketing to engage customers

By Claire Thayer, May 30, 2013

Targeted emails are highly effective in terms of end-user engagement, be it consumers or professionals.   According to thinkcomputers.org, in 2013, mobile devices are projected to become the most common tools for accessing the Internet.  In addition, cloud packaged data and analytics are expected to accelerate in 2013 with mobile access to these sources of information.

Email remains an important and powerful means of communication, and according to Experian UK, sits squarely at “the heart of cross-channel marketing.” In April 2013, Experian UK cited research by digital agency Steel, “more than a third of consumers read marketing emails on their mobile, which rises to 55% among 18-34 year olds; a high proportion of many marketers’ target audience. It could be argued that the added functionality that comes with mobile – location based services, the always on mentality, the more obvious call to action – makes for a better, more targeted email experience than that of the desk top. But then what mobile makes up for in engagement, it can lack in delivering true creativity. Both certainly have their benefits. The challenge for email marketers is to ensure that their campaigns render correctly on whichever device the consumer uses to open their email. Whichever way you look at it, email is not dead.”

Check out Digital Trends 2013: Email back in the Spotlight In 2013: http://www.experian.co.uk/blogs/latest-thinking/2013/04/digital-trends-2013-email-back-in-the-spotlight-in-2013/ as well as the MobileGovBlog at http://howtomobile.apps.gov/.

We have lots ideas to help you with your cross-channel marketing efforts – ask us about them!

Recalculating Health Care Spending Projections

By Claire Thayer, May 22, 2013

A new study published in the May 2013 issue of the journal Health Affairs projects that health care spending during the next 10 years will actually be as much as $770 billion below predictions. Here's an abstract from this article.

Despite earlier forecasts to the contrary, US health care spending growth has slowed in the past four years, continuing a trend that began in the early 2000s. In this article we attempt to identify why US health care spending growth has slowed, and we explore the spending implications if the trend continues for the next decade. We find that the 2007–09 recession, a one-time event, accounted for 37 percent of the slowdown between 2003 and 2012. A decline in private insurance coverage and cuts to some Medicare payment rates accounted for another 8 percent of the slowdown, leaving 55 percent of the spending slowdown unexplained. We conclude that a host of fundamental changes—including less rapid development of imaging technology and new pharmaceuticals, increased patient cost sharing, and greater provider efficiency—were responsible for the majority of the slowdown in spending growth. If these trends continue during 2013–22, public-sector health care spending will be as much as $770 billion less than predicted. Such lower levels of spending would have an enormous impact on the US economy and on government and household finances.

More info:

If Slow Rate Of Health Care Spending Growth Persists, Projections May Be Off By $770 Billion. David M. Cutler and Nikhil R. Sahni. content.healthaffairs.org/content/32/5/841.abstract?=right

To view the Table of Contents of the current issue: content.healthaffairs.org/content/current

Trimtabs Applied to Health and Health Care Reform

By Cyndy Nayer, May 21, 2013

I’ve been reviewing some of my saved quotes and notes, such as the notes on trimtabs, as the airwaves heat up with IRS, AP and all things HCR (health care reform). The road to repositioning health as the goal can be a long uphill struggle, and as I continue to speak around the country and counsel employers large and small, the strain is showing. It’s time to discuss trimtabs.

It’s certainly no secret that I’ve lived most of my life in St. Louis, home to the Missouri Botanical Gardens, a world-renowned horticultural center and leader in rainforest research and environmental change.

The centerpiece and brand of the Mo. Botanical Gardens is the Climatron, a geodesic dome, the building with the smallest footprint and the largest capacity. This is the building of Buckminster Fuller, who has built many geodesign domes, which, according to his research, is the strongest building on earth, withstanding hurricanes, tornadoes, and earthquakes. You’ll note from the picture that it resembles a honeycomb curved into a shell-like structure. The intersection of the cells means that, like a honeycomb, the physical stress on the structure is equalized across all of the cells. This I learned many years ago when the Climatron was built. Bucky understood that design signals the human intention, and his intention was to live well and leave the world better when he was gone.

Buckminster Fuller was a scientist and a man who loved sailing. He understood trimtabs as the mechanism that cause rudders to move. Trimtabs are small surfaces connected to the trailing edge of a larger structure (such as a rudder) that stabilise the boat or aircraft in a particular desired attitude without the need for the operator to constantly apply a control force. This is done by adjusting the angle of the tab relative to the larger surface. In simple terms, it means that by adjusting the trimtab, or tabs, the rudder on a boat can make a series of small adjustments with less effort than trying to push the rudder against the enormous force of the water.

In Bucky’s own words:

“Something hit me very hard once, thinking about what one little man could do. Think of the Queen Mary — the whole ship goes by and then comes the rudder. And there’s a tiny thing at the edge of the rudder called a trimtab. It’s a miniature rudder. Just moving the little trim tab builds a low pressure that pulls the rudder around. Takes almost no effort at all. So I said that the little individual can be a trimtab.”

Bucky takes the concept of trimtabs further, by noting, “Society thinks it’s going right by you, that it’s left you altogether. But if you’re doing dynamic things mentally, the fact is that you can just put your foot out like that and the whole big ship of state is going to go.” He was determined to use design to improve lives; he used the familiarity of culture to make change feel familiar, less threatening, and easily adoptable. He developed solar panels to heat the geodesic domes, and even these have morphed to many more uses, including protecting turtles where they nest. In many ways, his description of the enormity of a small bit to move the Queen Mary is the embodiment of all of his work. Each of us, in our own way, has the ability to affect the course of boats, of ocean liners, of our hometowns, and of health care in America.

I’ve had the honor and good fortune to address health plans, small businesses, and large businesses over the past few weeks, literally from coast to coast. The travel is tiresome, but the amazing need for information on patient and employee engagement, health care reform, and, most importantly, WIIFM (What’sInItForMe) is never-ending. Sharing the stage or the panel with other innovators is such a pleasure. Yet, sometimes we forget in our enthusiasm to share that those who are listening need us to slow down just a bit, walk away from the acronyms, and catch them up on what we know.

It’s that rare moment when any of us can be trimtabs to the audience, to change their course and their affect from one of powerless victim (THEY are doing this, and THEY have no idea of the kinds of hassle and money this is causing me) to one of expert seafarer, with a new and clearer eye on the horizon. I love those moments.

On the road or in the air back to home base, I have the chance to review notes and consider concepts that will help attendees and readers of this blog to manage the stress that occurs with substantive change.

• Moving from a sick-care system to a true health care system is not easy. Neither is changing the course of the Queen Mary.
• Moving from incentives to intrinsic behavior change is not easy. Neither is pulling lobsters behind a trawler when the wind is in your face.
• Identifying key components of change and then enacting the changes through legislation is not easy. Neither is turning those beautiful white sails on the sailboats at the beach.
• Finding that there were items left unconsidered, or, finding them with gaping holes or costs that were unanticipated is not easy. Neither is moving great seas out of the way in order to make it home safely.

We are on a journey for better health outcomes in this country. We are creating a platform where more people can access health insurance and, in the end, health care. We trust that by creating a wider group of engaged, healthier people, our businesses and our communities can stabilize and grow to productivity and prosperity again. And our course causes some to fear, some to claim “this is mine and cannot change,” much like the wild seas attempt to claim the sailboat.

Paramount to our efforts must be engaging folks across the spectrum of health care interventions, from exercise and purchasing healthy foods to trust in a safe-care system delivered with consideration of the patient and the family. As Dr. Toby Cosgrove, CEO of Cleveland Clinic said in an IOM post recently, “We must do everything transparently and with the patient fully engaged. We must provide value and pay for outcomes.” This is a fundamental shift in how we pay for health care; it’s new and unknown, and therefore causes tension that we may not have anticipated. But it’s the course we are on so that we can get home to health and safety.

So as I have traveled these past few months, and I’ve seen the weariness and, yes, the fear, I’ve thought about Bucky and went back to my notes that I keep for inspiration. Trimtabs are a fantastic frame for the work occurring across this country, and, if we can remain committed to getting home–creating a healthier person, healthier businesses, healthier communities–then we will have succeeded. We can identify the gaps and fill them with innovation and purpose. We can take the steps, singly or in concert, and embrace the change in course so that we can achieve our goals.

The man who designed geodesic buildings to save the environment, who invented the word “synergy,” said, “Call me Trimtab.” And R. Buckminster Fuller considered the role of trimtabs and his work (you can see a video of Bucky here and here). He thought trimtabs and the efforts each of us can contribute would lead to a better course for the better lives of all. He liked the concept so much, he had it engraved on his headstone.

Games (Some) People Play

By Kim Bellard, May 13, 2013

I have to admit that I am a child of the television age, with movies as a close second.  I never really got into video games, like PacMan, Tetris, Mario Brothers, Call of Duty, Grand Theft Auto or even Madden NFL, and am only now belatedly becoming addicted to Angry Birds.  As I suspect is true of many of us old health care pros, I am also late to the potential revolution that video games offer for health care.  I’m glad others in the field have been paying more attention.

The video game industry is not for teenagers, and its size is shocking – it dwarfs the music industry, and, depending on which source one uses, either has surpassed or soon will surpass the movie industry.  It’s helping to drive the chip, PC, and mobile phone industries; none can afford to fail to deliver the speed and video quality that modern gamers demand.  We’re talking about a soon-to-be $70 billion industry here; still only a fraction of the health care industry, but much bigger, for example, than spending on health IT. 

The video game industry itself faces its own challenges; for example, the era of game consoles may be ending, as more gaming is done on mobile devices and with other options for player control.  That’s not to say the era of video games is passing, but rather that it continues to change rapidly.  Hand-held games were revolutionary when first introduced, as were game consoles, PC-based games, the Wii controller, Kinect, to name a few.  Video game companies who do not innovate can find themselves quickly left behind.  This “evolve-or-die” mindset is one that I wish was more prevalent in health care, whose attitude is more often “we know best” and/or “not too fast!”

Always looking ahead, the Robert Wood Johnson Foundation started its Games for Health project back in 2004.  They have given grants of over $9 million, and have an active conference and information sharing presence in the health/gaming intersection.  They’re not just spurring development of games and games technology, but also funding research on the games’ effectiveness through their Health Games Research program. 

The research is showing some results.  There are many reports about the health benefits of video games, such as a recent study that found video games can slow or even reverse mental decay, and a broader list of positive impacts that include motion skills, stress reduction, pain relief, vision and decision-making skills.  Apparently, both seniors and kids can benefit. 

An example of how game principles can be applied in health care is Mango Health, which turns the problem of medication management into a game, complete with rewards that can be turned into gift cards or charitable donations.  It is not the first or only such example, but is illustrative of the potential games offer.

The Entertainment Software Association, perhaps sensitive about criticism that violent videogames can have adverse impacts, prominently touts video games’ role in health care (along with family life, art, the economy, education, social issues, and the workplace – boy, these guys really are defensive, aren’t they?).  Two of the key areas it cites are in rehabilitation and in training.  For example, USC’s Institute for Creative Technologies researchers developed Jewel Mine to provide customized rehabilitation to people with a variety of neurological and physical injuries.  Other efforts use out-of-the-box gaming systems, like Wii or Xbox, to make rehab more enjoyable.  And there is an organization, Games4Rehab, that tries to tie users, developers, clinicians, and researchers together in this area.

One of the innovators in training that ESA cites is the University of Maryland Medical Center’s Advanced Simulation, Training, Research, and Innovation Center (MASTRI).  MASTRI has been working for over six years now on high tech simulation and training for health care.  Even ONC is using video games for training, as is Darpa (in their case, mobile medical training for first responders). 

One recent study found that surgeons who used the Wii – not on any specific medical games but just using standard Wii games -- outperformed their peers in laparoscopic simulators, due to improved spatial attention and hand-eye coordination.  My favorite study, though, was the one that found gamers did better at simulated surgery than medical residents.  Maybe the wrong people are doing those kinds of surgeries.

Surprisingly, payors haven’t all been late to this particular game.  Humana, in particular, was a pioneer, focusing on video games as far back as 2007.  Aetna  and United have joined the movement, and last year the Wall Street Journal summarized various insurer efforts.  One senses they’re not quite sure what they should be doing, but don’t want to get left behind.

People have coined the term “gamification” to include game-like features into non-game pursuits.  Author Jane McGonigal wrote a fascinating book called Reality Is Broken, the subtitle of which is “Why Games Make Us Better and How They Can Change the World.”  She doesn’t confine herself to video games, nor does she talk much about their applications for health care, but the mind-set she describes -- which include overcoming obstacles, rewards, collaboration, interaction, voluntary participation, and feedback -- is very much something people in health care should be incorporating more. 

The health care system does often seem like a maze, but it’s not one that most people have any fun navigating, nor one where many people emerge thinking they are winners.  This is an industry where, for example, use of outdated communications technologies like pagers waste an estimated $8.3 billion annually.  This is an industry that demanded, and is getting, hundreds of billions of dollars from the federal government to bring their medical records into the 20th century (and I mean that), largely still in siloed, mainframe EHRs that can’t talk well with each other and whose requirements for “Meaningful Use” are being delayed again.  It is not, in short, an industry that would seem an early adaptor of the lessons video games can teach.

Video games are no panacea for health care.  Not everything is a game, not everything should be approached like a game, and not everyone likes games.  Still, there are a couple of important lessons we should draw from them:

• To each his own: for a not insignificant and growing portion of the population, games are a familiar and preferred medium.  If we want to educate, motivate, and influence behavior for that segment, game-like approaches are the way to go.  The likelihood of reaching serious gamers through, say, a telephonic disease management program would seem to be very low.  The point is not to use video games for everything for everyone, but to use the right media for the right populations.  We now have lots of options to reach people, including not just games but also social media, text, email, mobile.  The challenge to providers, health systems, and health plans is to figure out how to best use each tool for which portion(s) of the population.   
• Take advantage of the technology and design:  Video games are in an arms race for better experience, and, as with arms races, there can be spillover benefits to other sectors.  High quality simulated images (even 3-D), on-demand, motion-sensing, multimedia, multi-person, and, above all, relentlessly interactive – all describe modern game capabilities and should be describing applications for health care, even if not used for games themselves.  Maybe health care organizations should hire fewer mainframe programmers and more game designers to work on their B2C efforts. 

Excuse me, but I better go play some games…for my health, of course!

It Depends on the Outcome: Payments for Providers – Benefits for Consumers

By Clive Riddle, May 10, 2013

Two separate studies released this week took the pulse of the outcomes-based financial landscape in healthcare at different ends of the spectrum: Availity released a sixteen-page white paper: Health Plan Readiness to Operationalize New Payment Models for providers, while the Midwest Business Group on Health released a twenty-page report: Employer Survey on Incentives, Disincentives & Outcomes-Based Incentives for employees.

The Availity study was conducted by Porter Research in the fourth quarter of 2012, involving interviews of 39 health plans. 82% of the plans consider payment reform a ‘major priority. 90% expect value-based payment models to impact their top three business objectives ( 46% expect a ‘major’ impact, while 44% anticipate ‘some’ impact.)

That doesn’t mean value based payments are mainstream today.  Just 20% say value-based models

support more than half of their businesses today.  But 40% predict that in three years, value-based models will support more than half of their businesses; and nearly 60% forecast that more than half of their business will be supported by value-based payment models in the next five years. And, of those, 60% are at least mid-way through implementation.

While the ACA uses Medicare as a primary tool to promote provider payment reform, the marketplace seems to be focusing health plans even more on the commercial side. More than 75% say they are focusing value-based payment efforts on their Employer Group plans, compared to 54%  for Medicare plans  and 46% and 44% citing Medicaid plans and Individual plans..

Availity noted that “transitioning to payment models that base compensation on outcomes requires physicians and health plans to exchange new kinds of information – different than what is required under today’s predominant fee-for-service arrangements. 90% of health plans agree that automating the exchange of ‘new’ information required under value-based payments is critical to success, with 85% saying the highest value will come from real-time exchange, though less than half have real-time capabilities.”

Meanwhile, the Midwest Business Group on Health employee incentive study was conducted during April 2013, with responses from 94 self-funded employers that represented multiple industries and locations around the US.  They found that “80% of responding employers are utilizing some form of incentives, with 41% using or planning to use outcomes-based incentives to increase engagement and participation as well as motivate healthy behaviors in employer-sponsored programs.”

Here MBGH findings from the study regarding outcomes-based Incentives:

• Employers responded that 13% are already offering outcomes-based incentives and 28% are planning to launch programs over the next one to two years, while 40% indicated interest, but need more information.
• Of those currently offering outcomes-based programs, 54% tie incentives to both outcomes-based measures (i.e. meeting specific targets such as BMI of 25) and improvements in outcomes (i.e. percentage decrease in BMI), versus one or the other.
• Onsite clinical screening programs are used by 94% of employers as the way to capture biometrics with the top measurements being: 86% blood pressure, 81% BMI, 73% cholesterol, 68% glucose, and A1c and waist circumference tied at 59% each.
• Employers said that 18% are experiencing participation levels of over 90% for outcomes-based programs; while the majority (60%) is experiencing participating levels of 40 to 80 percent.
• Employers indicate that 98% of employee feedback is “somewhat positive” to “very positive.”
• Degree of difficulty is notable with 95% of employers finding some level of difficulty in implementing an outcomes-based program.

Also, MBGH shared this data regarding the overall offering of incentives/disincentives:

• Of the 18% of employers who reported not offering incentives or disincentives, 53% indicated the reason was that it was not part of their corporate culture and 47% are not sure it works.
• For those employers offering incentives, 62% reduce premiums, 38% use gift cards and 35% offer merchandise.
• Of those employers that use disincentives, 43% increase employee share of premiums for non-compliance and 14% have higher plan deductibles or out of pocket fees.
• Activities that most employers’ incented included biometric screenings (70%) and health risk assessments (78%), with the greatest disincentive (78%) being used for tobacco use.
• The monetary value of incentives programs varies widely, with $250-500 for 27% of those offering programs, $100-250 for 22% of employers and $500-1,000 for another 22% of companies.
• Employers indicated that 71% found their incentive strategy was “very successful” or “successful” and 45% viewed their disincentive strategy as “very successful” or “successful.”
• With the Affordable Care Act (ACA) in 2014 allowing employers to increase their incentives from 20 to 30 percent of total coverage, almost 67% said they are “very likely” or “likely” to do so and almost 36% are “not very likely” or “not likely.” For tobacco users, the ACA allows employers to increase the value from 20 to 50 percent, with employers indicating 48% “very likely” to “likely” and 52% “not very likely” to “likely.”

CMS Releases hospital specific charges for more than 3,000 hospitals

By Claire Thayer, May 8, 2013

Today, CMS announced the release of hospital-specific charges for the more than 3,000 U.S. hospitals that receive Medicare Inpatient Prospective Payment System (IPPS) payments for the top 100 most frequently billed discharges, paid under Medicare based on a rate per discharge using the Medicare Severity Diagnosis Related Group (MS-DRG) for Fiscal Year (FY) 2011. These DRGs represent almost 7 million discharges or 60 percent of total Medicare IPPS discharges.

For these DRGs, average charges and average Medicare payments are calculated at the individual hospital level. Users will be able to make comparisons between the amount charged by individual hospitals within local markets, and nationwide, for services that might be furnished in connection with a particular inpatient stay.

Access reports from here:

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/index.html

Anchors Aweigh!

By Clive Riddle, May2, 2013

In MCOL’s current issue of ThoughtLeaders, the question was asked “Which provision of the Affordable Care Act do you feel has had the greatest degree of success thus far with regard to implementation and achieving its objectives?”

The sage, and always insightful Peter Kongstvedt, MD, provided a response with an intro that demands repeating in part here, because it is that good:

Peter opens his reply with: “The answer to this or any other question must always be preceded with a question: Who’s asking? In other words, how successful or effective something is depends on who is defining success or effectiveness. The following table illustrates this:”

Person	Thing	Effectiveness
Drunk Don, drowning after diving into a pool	Inflated inner tube	Life-saving, thank God
	Gallon of water	No thanks, I take mine neat
	200 pound anchor	Is this a case of Murder?
Desert Pete, far from civilization without his mule or canteen	Inflated inner tube	In the desert? Useless
	Gallon of water	Life-saving, thank God
	200 pound anchor	In the desert? Worse than useless
Yachtsman Biff on his unmoored sloop, foundering off the lee shore of a rocky isle	Inflated inner tube	May need it if can’t anchor yacht
	Gallon of water	May need if need to abandon ship
	200 pound anchor	Life-saving, thank God

The wisdom of Peter’s anchor analogy is not only humorous, it is quite profound.  We all need to keep Drunk Don, Desert Pete and Yachtsman Biff in mind as we tackle the spectrum of healthcare issues stretching out from here to the horizon, with the understanding that whether we’re talking about reform policy issues, readmissions management, health plan marketing segmentation, performance analytics, wellness incentives, and on and on…. the needs, solutions, outcomes and metrics are not one size fits all. Populations, geography, situational scenarios..they all matter.

Peter expanded on his ThoughtLeaders response in his own blog, which is highly recommended reading. I urge you to click now and check out the KvedtBlog from PR Kongstvedt Company!

Comprehensive Assessment of ACA Factors That Will Affect Individual Market Premiums in 2014

By Claire Thayer, May 1, 2013

A new Milliman report, prepared for and at the request of AHIP, outlines how the Affordable Care Act’s (ACA) coverage expansion, new benefits, and market reforms will impact individual market health insurance premiums in 2014. The 27 page report highlights how some provisions will increase premiums while others will make health care coverage more affordable for consumers. The report estimates that those eligible for subsidies will receive financial assistance in 2014 to cover, on average, 40 percent of the premium for the silver plan, and as much as 94 percent for those with the lowest incomes. Read more on AHIP's Center for Policy and Research web site: http://www.ahip.org/MillimanReportACA2013/

Boston: Coincidences, Complexity, Continuity, Care

By Cyndy Nayer, April 25, 2013

America's Freedoms Are Our Vulnerabilities

There is no doubt that the terrorism of the Boston Marathon 2013 was heart-stopping, heart-rending, and a cruel reminder that America's freedoms are also our vulnerabilities.  It's also a bit ironic that, because of a family emergency, both of my daughters had flown down to our house and were with us when the bombs went off.  Why is this important enough for me to mention here?  Because if my older daughter hadn't come down to help, she would have been exactly at the finish line where the bomb went off. Coincidence?

I don't believe in coincidences.

The week, and the socialmediasphere, have been resplendent with coincidences, the most poignant of which was the story of the couple who both were in the health care provider space, both came to cheer the runners of the marathon, both had a portion of their left legs blown off in the explosion.  They were separated by the blast, and they remain separated in different hospitals, but they are recovering and they are talking by phone to each other (see below for how you can help).

Who were the terrorists, what was their motivation, what will happen to the survivor, I have to leave to the sleuths and judicial systems to discover and decide.  My work is to uncover the learnings that we can all ingest to fortify our health promotion and business recovery.  Here are some thoughts.

1.  Boston has terrific hospitals, prepared for trauma management.  I've managed many fitness events, and, of course, a key component was the clinical staff onsite.  They volunteered their time for running injuries, dehydration, and the sort.  Some of them on April 15 had seen combat duty in Afghanistan and Iraq, and they were able to flip into mash-unit mode quickly.  All of the injured who made it to the hospitals have survived, albeit many have much rehabilitation to work through.

2.  Boston has moxie and motivation.  Bostonions have been described recently as gritty, defiant, and strong, and this makes great sense since this is the birthplace of the American Revolution--the shot heard round the world--and of the freedoms that would coalesce into the US Constitution.  When the explosions came, the runners ran INTO the crowds to help those who were hurt, ran to the hospitals to give blood (another 2.5 miles after their 26.2 mile run), and reached out to one another.  They may fight like family, but when the pressure is on, Boston is one big supportive family. For more on the grittiness of Bostonians, and a chuckle, click here to see Colbert's Report for April 16, one day after the bombs.  

3.  Boston finishes what it starts. Samuel Adams (not the beer, but the revolutionary) said, “Nil desperandum, Never Despair. That is a motto for you and me. All are not dead; and where there is a spark of patriotic fire, we will rekindle it.” There were people around the nation, and now, around the world (London) running races for Boston over the past 10 days, and there will be more.  There are calls for boosting the economy and taking Boylston Street back--it opened today--and for helping those who were locked out of their homes and businesses for these days.  This is the Boston that warned of the Red Coats, rode the Freedom Trail, waited 86 years for the Red Sox pennant.  When folks were hurt, people did what they could:  one woman baked oatmeal chocolate chip cookies for the police/troopers/FBI/ATF, etc. to eat when the 2nd suspect was arrested.  Grit and defiance demand food, too, after all.

4.  Boston wears its patriotism and small-town love proudly.    Read this excerpt from one of the London marathoners, who also ran in Boston:

“I had a hard day out here,” said Neynens, who wore a 2013 Boston Marathon hat during his London run and finished in 2:48:09. “I was hurting, but obviously I was not hurting near as much as the injuries that I saw, people who lost their legs. I finished for all those people who were hurt and those people who couldn’t finish last Monday...

There was a banner we passed around Mile 25 that said, ‘Run if you can. Walk if you must. But finish for Boston.’ That meant a lot to everybody. It was great to see the support of everybody out there for the runners and for Boston."

 There were lessons for health, healthcare, and healthcare reform, too.

1.  Interoperability of electronic medical records could have been a problem.  In the marathon were runners and family-watchers from around the world.  What if there were a diabetic runner who, because of the bombings, was delayed in his/her sugar control?  There are so many other "what ifs" that the message is clear:  we need to quickly find a way to make these EMR-EHR-PHR talk to one another for the safety and security of the providers, patients, and communities.  We cannot afford to waste time finding a knowledgeable relative when life hangs in the balance.  [I wrote about this lack of interoperability in my post "EHR Is Speechless"].  There is no magic about data, the rules engines can be preserved as proprietary to each company, but the data must be accessible.

2.  Teamwork. Who will ever forget the masses of security forces closing in on the final suspect?  Or the video of the Chief of Police of Watertown MA saying his troops were never trained on counterterrorism, so they just did what was they thought was right?    Those of us riveted to the scenes will remember the ATF, FBI, fire departments, EMT, Boston police, State Troopers, and so many more.  But how many noticed that hot food was brought by the NY-NJ Port Authorities?  How many could ever forget the cheers and singing and clapping by the Watertown citizens when the ambulances and security cars crept slowly back into the city?  Now, imagine those kinds of teamwork in communities of care, with warm "handoffs" from primary care (Watertown police) to specialists (BPD, ATF, FBI, MA troopers) to recovery and long-term care (Red Cross, Boston Globe, and so many other watch-dogs and care providers).  Everyone had their job and new exactly what they had to do.

3.  Continuity and safety.  Recently I saved an article on the rates of hospital infections in the US compared globally, sent to me from my colleagues at MCOL.com.  Because of the trauma training, the warm handoffs, and the sense of accountability, continuity is a given in Boston.  It's the accountability that will guard the injured, the fallen and the recovery.  There's a new sense of "we share in this," and it's this sense that carry Boston through.  That's the real message of accountability:  we all own at least a portion of the problem, whether it's economic recovery or health promotion, and we all have a responsibility to step up to manage our community better.

Of course, in the land of the Red Sox, with the frame of David Ortiz' opening moments in Fenway Park, and the surprise visit from Neil Diamond to lead Sweet Caroline, the poignant moments caused tears and love and hugs.  For us who weren't in Fenway, or Boston, or Watertown, I treasure the picture that went viral on twitter and other social outlets:

 I don't think there are any coincidences.  I abhor terror, bloodshed, violence.  But these moments that I've called out remind me, and I hope all of us, of the goodness of people.  Who could possibly convey it better than Fred Rogers?  We needed to hear his words, "Look for the helpers," right then, right at that moment.  It opened our hearts and made us feel safe again, and we spotted more helpers and lavished praise, because we all needed to heal.

And then Boston Daughter (who had returned to Boston) sent me an email and a picture that she took, the one that starts this blog post, the site that amazed and tore and then opened her heart.  She told me she couldn't sleep, walked to the memorial Monday morning at 5am to pay her respects, and left her pink running shoes because she wanted to be part of the healing, too.

If you want to be one of the helpers, here are two ideas for you for donations.  There are many more, I simply had intersections with each of these here:

If you, like me and my Boston daughter, are an avid fitness participant, then you may want to make a purchase at @unitedwestride UnitedWeStride will donate all the proceeds from the purchase AND AN ADDITIONAL DOLLAR

@JetBlue  I audaciously sent a tweet on 4.22 to @JetBlue asking for serious discounts to Boston so we could boost the economy--I'm betting others did, too. On 4.23 I received an email with serious discounts.  Help those most affected by the Boston tragedy through The One Fund Boston, and JetBlue will match up to $100K. http://www.jetbluegives.org

 I hope peace comes to those who mourn and to those who heal.  I hope strength comes to our leaders and our protectors.  I hope our communities come together for health.

ACOs now serve 14% of Americans

By Claire Thayer, April 22, 2013

ACOs now serve 14% of Americans according to new research by Oliver Wyman, an increase of 40 percent since August 2012.  This research study finds that the total number of patients in organizations with ACO arrangements with at least one payer—both Medicare and non-Medicare—is now between 37 and 43 million, up from 25 to 31 million—or roughly 14 percent of the population.  If you're in need of Accountable Care decision support analytics, Verisk Health has a white paper that you might find interesting – download directly from this link: http://www.veriskhealth.com/markets/providers/accountable-care-organizations

Sebelius Says

By Kim Bellard, April 16, 2013

If I was HHS Secretary Kathleen Sebelius, I think I’d be asking for a pay raise, or maybe a (verbal) flak jacket.  Of course, there’s probably no money for them.

Sebelius is front and center for any developments with ACA, and she has been a very visible spokesperson for the controversial legislation.  I don’t know whether she actually believes all the things she says, or is just a loyal soldier for the Obama Administration.  Either way, the news about ACA seems like a slow drip of continued bad news, and I fear that the news is going to keep getting worse before it gets better.

Latest up was the request, included in the Administration’s 2014 budget, for an additional $1.5 billion to run the health insurance exchanges for the 26 states who have opted to have the federal government run their exchanges, plus another seven that are to be jointly run.  That’s far more than had been originally expected, which means much more work for HHS.  Congress refused a similar request for just under $1 billion last year, and is likely to view this request equally skeptically.  

In testimony before the House Ways and Means Committee last Friday, Secretary Sebelius vowed that the exchanges will be up and running by the October 1 deadline, but admitted there’s no backup plan in case she’s wrong.  Presumably she’s lined up someone to blame in case she’s wrong.

Curiously, even though far fewer states are planning to run their own exchanges, HHS expects their grants to those states to be more than twice as much as they estimated last year – some $4.4 billion instead of the earlier $2 billion.  HHS doesn’t need to ask Congress for this money, but the increase certainly raises eyebrows.  Twice as much for half as many states?

The Washington Post recently pointed out that, even though ACA is arguably the signature accomplishment of the Obama Administration, the President’s recent budget proposal doesn’t do anything to spell out its expected costs.  They are spread out through the budget and not always cleared spelled out.  Cynics might argue that the budget deliberately obfuscates the costs to avoid drawing attention to how much they are.  CBO had recently estimated, for example, that the subsidies are now expected to be much more expensive than originally forecast.  Some of that is because health insurance premiums are expected to be higher than expected – the Administration had promised they would drop due to ACA, something Secretary Sebelius now acknowledges isn’t going to be the case.

The Administration has already started to cut corners on how the exchanges will operate.  They recently announced that employees of small employers who get coverage from the exchange will not initially get options of health plans; they will be limited to a single option.  I’ll be waiting for the other shoes to start dropping about what else they will be cutting back on.  Maybe they can start with their complicated application… 

Then there is Medicaid expansion, which is not going well at all.  I’d previously written on this, and the situation isn’t getting better.  The Arkansas approach, which relies on purchasing private insurance, was seen to be a potential solution for wavering states, but the Arkansas House recently failed to approve the approach.  Similarly, in Ohio, Gov. Kasich faces rebellion from his own party on his support for their version of expansion.  The number of states who have not opted to expand Medicaid should, ironically, hold down the projected federal spending, but it is not clear how the Administration is scoring the impact of those states’ reluctance.

ACA used employer coverage as a continued cornerstone for source of coverage – remember “if you like your health plan, you will be able to keep your health plan”? – but that cornerstone is weakening.  The Robert Wood Johnson Foundation recently detailed what has long been known: employer coverage has declined drastically over the past few years, dropping 10 percentage points nationwide from 1999/2000 to 2010/2011.   Some states saw even worse results, led by Michigan with a 15.2% decline.  And that was before ACA’s biggest impacts. 

Optimists are pointing out that there is no sign yet of employers planning to drop coverage or cutting back on full time hours to avoid their 2014 mandate requirements, but I think their optimism is premature.  Even if 70% of benefit professionals say their companies would “definitely will” keep health coverage, as cited by the International Foundation of Employee Benefit Plans survey, that number is still alarmingly low, and those same professionals are coming to be more pessimistic about how much ACA has been increasing their costs. 

Similarly, quoting the recent Minneapolis Federal Reserve survey results -- which indicated 89% of employers hadn’t shifted full-time employees to part-time – as good news seems slightly Orwellian.  Eleven percent is a lot for something that hasn’t happened yet, and the Fed notes that the 89% didn’t exactly say they wouldn’t in the future. 

When one adds up the various things that are becoming visible problems about ACA, the list starts to get long.  For example, the tax on employer plans, the medical device tax, and the affordability test for large employers’ contributions to dependent coverage have all come under fire in the past few months.  And let’s not forget that the Class Act was the first part of ACA to go, with Secretary Sebelius killing it back in fall of 2011. 

According to Kaiser Family Foundation’s latest survey, three years after the passage, over half of Americans report they don’t understand how ACA will impact them, and a plurality still oppose the law.  One wonders how many members of Congress who supported ACA originally would still vote for it if they had a second chance. 

One way or the other, we’re going to put putting increasing numbers of people in the exchanges in 2014 and beyond, which will increase the strain on them and will increase the cost of subsidies.  Maybe that’s not so bad, but we better go into 2014 with our eyes open about the difficulties the system may face.  No matter what Secretary Sebelius says.

53% percentage of young adults using social media for healthcare reviews

By Claire Thayer, April 15, 2013

PWC's Health Research Institute released a new report on consumers’ experience in seeking health related information as well as effectiveness of healthcare ratings and reviews.  When consumers in the study were asked on their sources of healthcare reviews, the HRI survey finds that Consumer Reports topped the list of sources, with 43% respondents who have read reviews indicating that they have used the well-known products review source to look for health-related information.  Not surprisingly, there are generational differences too. Consumers age 65 and older prefer government sources for their health-related information, while consumers 18-24 prefer reviews on blogs or social media sites such as Facebook or online patient discussion forums.  For more information about HRI's report - Scoring healthcare: Navigating customer experience ratings, click here: http://www.pwc.com/us/scoringhealthcare

Health Sector Economic Indicators – Altarum Institute

By Clive Riddle, April 12, 2013

Altarum Institute each month issues Health Sector Economic Indicators Briefs through its Center for Sustainable Health Spending. The brief cover health care spending, utilization, prices, and employment, and are worth perusing each time. 

Altarum’s Charles Roehrig, Director of the Center, had this to say about their current assessment of health care in the economy:  “Health spending has remained at about 18 percent of gross domestic product since mid-2009, but health employment continues to slowly increase as a share of total employment.  Expanded coverage under the Affordable Care Act should push these figures upward, but an improving economy will push in the other direction as non-health spending and jobs accelerate. We look forward to tracking how these forces play out.”

Here’s the current pulse of the health care economic sector from Altarum’s just issued April briefs, which incorporate February and March 2013 data:

• National health care spending in February 2013 grew 3.9% relative to February 2012
• Health care price growth rose to 1.7% in February 2013 compared to February 2012, two-tenths above January 2013 reading
• This was still the second lowest rate of price increase since 1.3% growth recorded in December 1997.
• The 12-month moving average price growth at 1.9% in February 2013 is the lowest since the same figure recorded in November 1998.
• In February 2013, health spending increased to a seasonally adjusted annual rate of $2.89 trillion, slightly higher than its value of $2.88 trillion in January.
• The health spending share of the gross domestic product was steady at 18.0% in January 2013, up from 16.4% at the start of the recession in December 2007.
• Health spending by category in February 2013: Hospital – 32%; Physician & Clinical – 19%;  Prescriptions – 10%; Nursing Home – 5%; Dental – 4%; Home Health – 3%; Other personal healthcare – 11%; Other health spending – 16%
• Year-over-year, hospital prices rose to 2.6% in February (from 2.0% in January). Physician and clinical services rose 0.8%, barely above the low 0.6% January print.  Prescription drugs saw price growth tumble to 0.8%, from 4.0% as recently as August 2012, and the lowest since 0.7% in June 2007.
• Implicit per capita health care utilization averaged 1.3% growth over the last 12 months.
• Health care employment rose by 23,000 jobs in March 2013, somewhat below the 24-month average increase of 24,000
• Health care represented 10.74% of total employment in March 2013, compared to 10.67% a year ago and 9.49% in December 2007.

Getting Healthy

By Cyndy Nayer, April 1, 2013

In January 2013, US News published a report on why Americans aren’t healthier and gave us the concept of a health lag.  In fact, the gap between America’s health status and that of other industrialized nations is a 30-year trajectory of lower outcomes.

Last week, Modern Healthcare published a review of Kaiser Family Foundation findings in which the highest hospital readmissions were directly correlated to the unhealthiest counties in the US.

On the same day as the MH-KFF release, I was privileged to receive a tweet on patient engagement that highlighted the blog of Gilles Frydman  on PatientDriven.org, which highlights the real engagement and outcomes of patients who seek to understand their conditions and treatment by conversing with others.  The point here is in the definition of engagement, per the blog, “An engaged patient is someone deeply involved in the scientific understanding of their disease, fully aware at all times of the entire spectrum of available therapeutic options. It requires a set of learning, cognitive and psycho-social tools that can only be acquired by conversing often with a real network of peers who are similarly involved in this complex endeavor.“ 

This, says the author, is exactly opposite of the current definition of patient engagement as used by HIT, care professionals, benefits personnel, and service providers:  “the engagement flows from the various professional stakeholders of the health care system to the patients. It is a direct extension of the concept of consumer engagement.”

It’s exactly the discussion I am most involved in, most of the time, in which the (choose one) doctor/ IT developer/ hospital administrator/ national thought leader talks about patient engagement as the patient behaving according to the “guidance” he/she is provided.  But what if the guidance reaches the patient at the same time she is dealing with her teenager who had a car accident, or her husband who may lose his job? What if the “guidance” is a follow-up visit or test, but the office isn’t open late when she is off work? What if the “guidance” is the purchase of a pharmaceutical that she either can’t afford or that may cause side effects for her?  What if she simply didn’t understand the instructions or, three months later, is feeling better and stops the medication or falls off her nutrition plan?

Unfortunately, the problem here is that the engagement and persistence (which, by definition is part of engagement) did not occur because people have other parts to their lives than the body parts with issues.  They have financial needs, emotional needs, social needs, even transportation needs that interfere with engagement. While the most-influential people in the patient’s life, according to surveys, is the clinical “face” (doctors, pharmacists, nurses, etc.), these people do not follow the patient everywhere, and others in her sphere of influence take precedence.

Emergency department visits drop when medical practices extend hours. There are examples of patient engagement strategies that work and that translate directly to saved dollars.  In surveying more than 9,500 people with steady sources of care, the Center for Studying Health System Change focused its results on 1,470 individuals who had tried to contact their primary care practices after normal business hours in the past year. The study, published online in Health Affairs on Dec. 12, found that nearly 21% had difficulties reaching their physicians after hours, and those who reported more difficulty accessing after hours had higher rates of emergency department use (37.7%  and higher rates of unmet medical needs (13.7%).

As I’m on my relentless pursuit of solutions that deliver better health outcomes, I have to  emphasize this, re-emphasize it, and then state it many times more.  Those who doubted the power of value-based benefit design or outcomes-based clauses did not fully understand the suite of services and, what I call surround-sound messaging, that is necessary for patient engagement in health.

We cannot be paternalistic, nor maternalistic, in making health the end goal.  We have to meet people where they are and stop treating body parts separately (you know, hypertension over there and depression over here and diabetes…).  We have not only organize in patient-centric efforts but, perhaps more importantly, in patient-driven circles.  This is the success of the senior-citizen breakfasts that promote Medicare health plans, of the breast-health discussions that occur in churches and hair salons, and of the Dr. Oz and Dr. Phils of the world who reach through social media (including TV) to their audiences.

Transparency will only matter if the patient is seeking healthcare.  If, instead, she is seeking a carpool for her kids or the money for rent, then transparency of treatments may not be as meaningful, if it’s on the radar at all.  ”Entitlement programs,” as Medicare and Medicaid are increasing called, cause splits in peer groups and often in the same family, pitting seniors against young working adults in the “subsidy” allotment.

These are not directly related to the delivery of treatment from the health system, but they are distractions to the patient decisions.  If the incentives to the prescriber are different than the incentives to the patient, the patient will more often seek the treatment recommended by the doctor, as this is the trusted relationship.  In survey after survey for many years, the clinician advice trumps the insurance benefit advice, yes, but it also relieves the patient of asking price or quality or convenience questions of the physician.  To this point, in my March 15 2013 I sent out the Health Affairs link to the Kaiser study showing that consumers do not want to be responsible for their healthcare costs, and they don’t want their doctors to be responsible, either.  

If we want to close the health valley that we are in, if we want to use the amazing healthcare resources in our country wisely and widely for all of us, then we have to stop this narrow focus of hospital v doctor v benefit plan v pharmaceutical manager v insurance and get back to the basics:  making healthcare understandable, actionable, and most of all, relevant WITH the patient not TO the patient.  Patient engagement IS the holy grail for healthcare and health improvement.  But it can’t be done around the patient, it must be done with the patient fully present and asking questions and envisioning the future of his or her health.  If he or she can’t see it, he or she can’t achieve it.

If Kaiser Is Not the Answer, What Is the Question?

by Kim Bellard, March 28, 2013

The New York Times recently published an interesting article, “The Face of Future Health Care,” that raised questions about whether even a model like Kaiser is delivering what we need to reform our health care system.  It’s the old “be careful what you wish for…” dilemma.

After all, Kaiser could be considered a prototype for what ACA wanted when it created Accountable Care Organizations (ACOs).  It is a fully integrated hospital-physician organization, delivering care and managing risk with salaried physicians and other health care practitioners, and its own hospitals.  Hospitals all over the country are rushing to build their own versions, buying up physician practices at a record pace – one survey indicated that 52% would do so this year, while another predicted 75% of physicians would be so employed by 2014.

Kaiser may not have been the first integrated delivery system, nor are they the only one, but they certainly are the largest and have been around for decades.  With all those decades, though, one would expect they would be dramatically lower in cost, and that is not generally the case.  San Francisco public radio station KQED did a report “Why Isn’t Kaiser Less Expensive?” last spring.  In their report, critics accuse Kaiser of shadow-pricing, while Kaiser’s CEO George Halvorson insists they don’t and are usually at least 10% cheaper.  That’s nothing to brag about: with even 1% lower annual trend, they should have gotten 10% cheaper in these early years of the 21^st century alone.

All this is not to pick at Kaiser.  I have long admired models like Kaiser, Geisinger Health System, Group Health Cooperative of Puget Sound, Intermountain Healthcare, or The Mayo Clinic.  It just seems intuitively obvious that like an integrated system, without the same incentives to overtreat that are pervasive elsewhere, should produce better results.  Each of the systems has been fairly successful in their core markets, although less so the further away from home they get, yet none are delivering radically different cost or quality results than other providers.

And, really, why should they?  They only have to be a little better each year than their competition.  The new mantra in health care is “value-based purchasing,” but we’re a long way from there.  The Catalyst for Payment Reform reports that only 11% of payments to doctors and hospitals are based on performance, while the Commonwealth Fund reports that less than 1% of health insurance premiums was spent on quality improvement in 2011.  This is disappointing but hardly surprising.  Most purchasers are buying with essentially house money; that is, someone else’s money. 

The biggest sources of health coverage are Medicaid, Medicare, and employer-sponsored health insurance.  The persons covered under all of these are largely shielded from the true cost of that coverage.  Medicaid is funded entirely by taxes, Medicare is also largely tax-funded, even when considering beneficiaries’ lifetime contributions, and, of course, employer coverage has the tax preference.  The “tax expenditure” for employer health insurance is, by far, the largest such expenditure – more than twice as large as the mortgage deduction, for example.  It’s all just compensation to employers; money “contributed” to employee benefits is simply money not spent on employee wages.  The tax preference helps shield employees from how much is being spent on their behalf, and it creates a huge disparity with people buying individual coverage, who receive no tax break.

ACA doesn’t equalize the tax preference, but it does introduce a vast set of new subsidies for individual coverage.  The Society of Actuaries has recently reported that individual premiums may be 32% higher due to ACA, joining the chorus of warnings about what may start happening in 2014.  Even HHS Secretary Sebelius now acknowledges they may be higher, but notes that the new subsidies will offset much of these.  While I think it is good public policy for more people to be covered and for economically disadvantaged people to get assistance in making coverage affordable, I worry greatly about creating a large new class of people sheltered from the true cost of health insurance.  It’s making a bad situation much, much worse.

Steve Brill has gotten much deserved attention for his lengthy and insight Time article “Why Medical Bills Are Killing Us.”  Brill painstaking walks through the crazy world of health care prices, especially their inconsistency between payors.  Some have used his work to call for single payor or other rate-setting, while I would argue that the system is a symptom of what happens when no one is paying enough attention to prices.

Frankly, I question whether the ACO/integrated delivery system is going to be the solution to our health care mess.  Hospitals are like factories: full of capital-intensive equipment and expensive to operate unless run at capacity.  Yet they aren’t really run like modern factories in terms of management practices, as a recent study in JAMA pointed out.  Similarly, physicians and other health care providers have some definite income expectations and fixed overhead obligations. 

All too often, combining hospitals and other providers in integrated delivery systems may be more about consolidating market power or assuring current revenue levels than about improving the cost and quality of the care for patients.  One AEI scholar recently pointed to the “humongous monopoly problem in health care,” and that’s with ACOs still in an early stage.  AEI is not the first to cite this issue, as I’ve written about previously, but I still don’t think enough attention is being paid.

We’re moving quickly to a health care system that features geographic provider monopolies or cartels, consumers too shielded from costs, and a regulatory environment that creates larger barriers to entry for new competitors in either delivery or financing of care.  That’s the perfect storm for a disaster. 

For radically different results, we’ll need radically different approaches.  Clayton Christian wrote about disruptive innovation in health care over ten years ago, and yet we’re still waiting to see it.  It may mean breaking the health/medical connection that HMOs led us to try to integrate in health coverage, giving consumers more fiscal accountability for the former while still protecting them from catastrophic expenses that can result from intensive medical interventions.  It should mean putting more of the data and technology – like mobile apps -- in the consumers’ hands, as advocated by people like Eric Topl (The Creative Destruction of Medicine) or Joe Flowers, and using that data to measure performance and help prescribe treatment. 

We’ve had a very paternalistic health care system, with health care experts telling us what care we need and other experts choosing coverage for us.  Let’s hope we can change that.  We need consumers engaged, taking responsibility, and demanding accountability from providers.  We need new types of competitors, using 21^st century technology and science, to help consumers manage and finance their health needs.

We have to make sure that legislation and regulations focus on what’s best for the patient, not necessarily for existing health system entities, in order to help ensure we don’t stifle innovation (e.g., FDA regulation of mHealth).  The facts that traditional Medicare benefit design is still largely based on 1960’s Blue Cross Blue Shield designs, or that, generally speaking, you can’t use telemedicine to consult with an expert physician in a different state due to licensing or coverage restrictions, amply illustrate the problem. 

Whatever the future health system looks like, it won’t look like what we have today.  Dinosaurs were remarkable effective for hundreds of millions of years, but the environment dramatically changed and they became extinct.  A lot of the dinosaurs that have historically been the basis for our health care system will become extinct in the new health care environment, or evolve beyond recognition.  As with evolution, it will be messy, proceed with many false starts, and produce unexpected winners.

Personally, I can’t wait to see what the future looks like.

The Alzheimer's Elephant

by Clive Riddle, March 22, 2013

There are so many large, aging elephants in the national room: Social Security, Medicare and Alzheimer's to name three leading the herd. They keep growing larger - we can see it happening in real time - and we've seen it coming for quite some time. Decades ago Ken Dychtwald coined the term Age Wave, referring to the massive shift and implications of the ballooning senior segment of our population.

Robert Egge, the Alzheimer's Association's VP of Public Policy has this to say about Alzheimer's: "Alzheimer's disease steals everything – steadily, relentlessly, inevitably. With baby boomers reaching the age of elevated risk, we do not have time to do what we have always done. The National Institutes of Health needs to reset its priorities and focus its resources on the crisis at our doorstep, and Congress must fully fund implementation of the National Alzheimer's Plan to solve the crisis."

The  Alzheimer's Association this week released 2013 Alzheimer's Disease Facts & Figures, an annual report – this year spanning 71 pages – designed to serve as “a statistical  resource for U.S. data related

to Alzheimer’s disease, the most common type of dementia,  as well as other dementias.”

Here’s some ten key points to consider about the state of Alzheimer's one can glean from the report:

1. Alzheimer's disease is the sixth leading cause of death in the United States and is the only leading cause of death without a way to prevent, cure or even slow its progression.
2. 1 in 3 seniors dies with Alzheimer's or another dementia.
3. Based on 2010 data, Alzheimer's was reported as the underlying cause of death for 83,494 individuals
4. In 2013 an estimated 450,000 people in the United States will die with Alzheimer's.
5. Among 70-years-olds with Alzheimer's disease, 61% are expected to die within a decade. Among 70-year-olds without Alzheimer's, only 30% will die within a decade.
6. More than 5 million Americans are living with Alzheimer's disease.
7. Without the development of medical breakthroughs that prevent, slow or stop the disease, by 2050, the number of people with Alzheimer's disease could reach 13.8 million.
8. In 2012, there were more than 15 million caregivers who provided more than 17 billion hours of unpaid care valued at $216 billion.
9. Due to the physical and emotional toll of caregiving, Alzheimer's and dementia caregivers had $9.1 billion in additional health care costs of their own in 2012.
10. The total payments for health and long-term care services for people with Alzheimer's and other dementias will total $203 billion in 2013, the lion's share of which will be borne by Medicare and Medicaid with combined costs of $142 billion.

Here's a breakdown provided in the report of 2013 Health and Long-Term Care Services expenditures by source:

• Medicare: $107 billion (53%)
• Medicaid:  $35 billion (17%)
• Out-of-Pocket Costs: $34 billion (17%)
• Other Sources - private insurance / uncompensated - $27 billion (13%)
• Total: $203 billion

We’ve all heard the trope “an elephant never forgets.” The irony is, we as a nation are conveniently forgetting the elephant in the room that that in the long term, will rob us of our capacity to remember. 

Medicaid Is Different…Isn’t It?

By Kim Bellard, March 14, 2013

Let’s be honest: since its inception, Medicaid has been the unwanted stepchild of the health care system.  It serves a diverse set of populations that other public and private programs have historically ignored, its health outcomes are no better and possibly worse than not having insurance at all, its payments to providers generally rank lowest of all payors, and its coverage varies widely between states and all-too-often is skimpy despite its broad coverage requirements.  And yet ACA wants to pour more people into this creaky vessel, sweetened by the inducement of increased subsidies to the states for the first few years. 

Some states are thinking there has to be a better way.

Supporters of ACA are crowing about the fact some prominent Republican governors, such as Arizona Gov. Jan Brewer or New Jersey Gov. Chris Christie, have come out in support of expanding their Medicaid programs as allowed by ACA (with a nudge from the Supreme Court).  They should be looking harder at states like Arkansas and Ohio.

Arkansas asked CMS if they could use the expansion dollars to fund buying private insurance, in the exchanges, for its Medicaid population.  No just the newly eligible population, mind you – the entire eligible population.  Much to some experts’ surprise, CMS approved this approach, citing premium support flexibility allowed by ACA and previous laws.  This approach still has to be approved by the Arkansas legislature, which so far has been receptive. 

Other states are not far behind.  Ohio, whose Republican Gov. John Kasich drew national headlines by supporting the expansion, is proposing a hybrid model that would put only the newly eligible population into private insurance via the exchanges, so that anyone over 100% of the federal poverty level can get coverage there.    

Wisconsin has an even more unusual twist.  Its Medicaid coverage already covers many residents over 100% of the poverty level, but is frozen to new adult enrollees due to budget issues.  Gov. Rick Walker wants a trade-off: Wisconsin would cover everyone under 100% of poverty in its Medicaid program, while anyone above that – including those now eligible for Medicaid – would get coverage (and subsidies) through the exchanges.  Connecticut is considering a similar move.

States like Florida are watching closely.  Its Governor, Rick Scott, shocked supporters by reversing his position and coming out in favor of the expansion.  The Florida legislature was not too thrilled about this seeming support for Obamacare, but finds the Arkansas approach intriguing.  Florida had already moved to putting its Medicaid enrollees in managed Medicaid plans, so the Arkansas approach is a closer fit philosophically.

In theory, CMS can approve such approaches if the cost and the coverage are comparable, but early indications are that they are taking a liberal (or would that be conservative?) interpretation of those requirements.  The Kaiser Family Foundation just released a brief outlining the various requirements and options for the premium assistance model, in case anyone is that deeply interested.  Some pundits think that if the Arkansas approach is implemented, that approach will spread quickly.

Two things I liked about ACA – and they may be the only two things – were that it ensured anyone could get coverage and that all of the lowest income people had subsidized coverage.  The way it did so, though, made an already complicated situation worse.

Consider a person scraping by just under the poverty level.  They now manage to get Medicaid coverage, with its limited cadre of participating providers and specific set of benefits.  That coverage is increasingly likely to be delivered through a private managed Medicaid plan.  Then they get a raise and start making enough money to get above 138% of FPL – so they are off Medicaid, and have to switch to another insurer through the exchange, with some public subsidies to help defray the cost.  They probably will lose some benefits, such dental or vision, but also probably would have a much broader set of providers from whom they can get care.  Then maybe they get a new job, whose employer offers health benefits.  They lose their exchange coverage, as well as the subsidies, and there’s no guarantee that the employer coverage will either be as good as the exchange coverage or that the employer subsidies will be anywhere close to the exchange’s subsidies (especially for dependent coverage).  If they lose that job, well, it may be back to the Medicaid coverage.

Honestly, Rube Goldberg would have enjoyed this set-up.

A recent analysis by HealthPocket suggests that less than 2% of health plans meet the recently released essential benefit standards.  I suspect that many of those plans may have been individual policies rather than plans offered by large employers, but ACA requirements like pediatric dental and vision are virtually never offered by even the best health plans (although may be available via accompanying dental or vision coverage).  It is not clear to me why someone who earns 137% of poverty should get dental and vision for all family members, while someone who earns 139% and lacks employer coverage gets only the pediatric coverage for children, and someone with employer coverage may lack those benefits entirely.  Is this coverage important or not?

I’m not advocating that all plans should include full dental and vision, but, come on, this jumping back and forth between sources of coverage/type of benefits/amount of premium subsidy is crazy. 

We have to remember that Medicaid really serves three distinct populations (as illustrated by this nice Kaiser Family Foundation graphic): the poor (some of them, anyway), the elderly needing custodial care, and individuals with severe disabilities.  Most of the spending goes to the latter two populations.  Maybe we should be thinking of splitting out the ongoing care support aspects of the program from the more traditional health insurance components of the program.  That would allow for a much more seamless source of coverage and care. 

When I read that the supposedly simplified, one-step application process may require a 21 page application, it feels like the canary dying in the coal mine: I fear the whole thing is going to crumble under its complexity.  I don’t know if the Arkansas approach of putting everyone in the exchange will end up being implemented, or if it would prove to be actuarially equivalent, but it makes a lot more sense to me than the patchwork quilt of coverage ACA sets in motion.

High Deductible PPO Plans Versus CDHPs

By Clive Riddle, March 8, 2013

United Benefit Advisors has just released results of their annual health plan survey, with responses from 11,711 employers sponsoring 17,905 health plans nationwide, with results applicable for small to midsize companies. The survey includes a focus on Consumer Driven Health Plan (CDHP) vs. PPO comparisons of premiums, deductibles and enrollment. Their study found that “Consumer-driven health plans (CDHPs) -- high-deductible health plans (HDHPs) often paired with health savings accounts (HSAs) or health reimbursement accounts (HRAs) -- are not achieving long-term savings greater than what would be reached by raising the deductible on traditional PPOs.”

Unlike most national large employer benefit consulting firms, UBA – whose survey concentrated on smaller firms – is not bullish on account based plans, and would rather place their bets on straight PPO plans with a higher deductible. Although one could argue, it might be easy to make a stripped down high deductible PPO health plan yield immediate lower costs than a CDHP that has account administration costs, up-front wellness benefits and other bells and whistles. That doesn’t necessarily mean the PPO HDHP would be the best long term solution for an employer’s and employee’s objectives, unless immediate premium costs is the only concern.

UBA CEI Thom Mangan tells us “Employers are turning to CDHPs as a cost-cutting solution against the relentless upward spiral of health care costs. However, our research shows that small-to midsize businesses in particular, who may be considering these plans may first want to consider increasing the deductible on the plans they already have to achieve the same initial savings. Or, prior to implementing a CDHP plan, employers should build a culture of health and wellness in their workplace that drives employee behavior towards quality, low cost medical care and prescription drugs.”

Here’s some of the data UBA has shared from their findings:

• Nearly 60 percent of the 11,711 employers surveyed said they plan to offer a CDHP in the next five years
• PPOs remain the dominant plan type with 61.7 percent of U.S. employee enrollment
• The greatest savings of a PPO over a CDHP was achieved with a deductible of $2,000-$2,999, where PPO cost per employee was $7,811 and CDHP was $8,859, a savings of $1,000 per employee.
• Savings created by CDHPs over the plans they were replacing or HSA, averaged 1.75 percent in 2012, a significant reduction from prior years.
• Enrollment also decreased to 15.6 percent (a 1.8 percent decrease from 2011), and nationwide enrollment among employers with 1,000 or more employees dropped substantially from 15.9 percent in 2011 to 11.3 percent in 2012.
• The area of the country that has seen the biggest increase in CDHP growth is Minnesota, which saw the percent of employees enrolled in CDHPs increase from 15.5 percent in 2010 to 37.1 percent in 2012, a rate 18.4 percent higher than the national average in those same years.
• Other areas with rapid CDHP growth include Indiana, Virginia and the Northeast region. The only western state to see CDHP popularity increase was Oregon, where percent of employees enrolled in CDHPs increased from 12 percent in 2010 to 20.3 percent in 2012.
• Overall, CDHP enrollment in the west is the lowest in the country with only 7.7 percent of employees covered, a slight increase from 7 percent in 2011 and 4.6 percent in 2010. HMOs account for 31.3 percent of the market in the west.

Involved But Not Committed

By Kim Bellard, February 28, 2013

There’s an old joke about the difference between bacon and eggs: the chicken is involved, but the pig is committed.  Perhaps the problem in health care is that when it comes to being engaged in our own health, most of us are chicken.  Maybe the wrong people have been cooking.

Patient engagement -- along with its many synonyms, such as shared decision-making or consumer-directed care – continues to be a favorite strategy for many health pundits.  I am biased towards it myself, although exactly what it means, or will mean in the future, is not entirely clear.

The prestigious journal Health Affairs recently devoted an entire issue to the topic.  In one study, Judith Hibbert and colleagues reported that patient activation scores help predict costs: lower activation levels were tied to higher costs, even after adjusting for risk.  A separate study, also by Hibbert, reviewed the literature and concluded that patients with higher activation levels had better health outcomes and care experiences, although the evidence was more inconclusive about the effect on costs. 

The trick, of course, is how to “activate” patients – is it all self-motivation, or can providers and other third parties (such as employers) encourage it?

One common method to influence patient engagement is an employer wellness program.  A recent National Business Group on Health survey reports that almost 90% of employers offer wellness-based incentives, spending an average of over $500 per employee on the programs.  Employers are getting tough too: 15% directly tie health plan eligibility to a health activity such as taking a risk assessment or biometric screening.  Almost two-thirds already tie employee contributions to completing such activities.  And 41% include, or plan to include, outcomes-based measures (e.g., lowering blood pressure) as part of the program.

Another strategy employers are using is increased employee cost-sharing, such as in consumer-directed health plans (CDHPs).  Critics accuse them of simply shifting costs to employees, but there are plenty of studies that indicate they may actually change employee behavior and help control costs.  For example, Cigna recently claimed that their CDHP members improved their health risk profile 12% while their health cost trend was 13% lower than traditional members.  Cigna CDHP members were also more likely to take health risk assessments, to use cost and quality tools, to choose generic drugs, and to seek preventive care. 

Consumers may be starting to take cost into account, but they don’t like it.  A study by Sommers, et. alia, reported on focus groups of insured patients.  The focus groups indicated that patients don’t like cost considerations to be part of health care decisions, and revealed that several stereotypes remain all-too-common, including that more expensive care is better care, and choosing more expensive care is some sort of victory over insurance companies (not realizing that, in the end, they and other insureds pay for that care).  Patients still don’t really know how to weigh risk versus cost. 

We treat health care costs much like we treat the deficit: costs come from other people, cuts should come from other people, other people should pay, and, oh-by-the-way, let’s think about it tomorrow.  That has to change. 

One thing that offers new hope for patient engagement is that the options for it have never been broader or more robust – mobile, electronic records, telemedicine, and social media, to name a few.

There are estimated 40,000 mobile health apps.  It seems you can get an app to do just about anything you can think of, plus many things you probably hadn’t.  The health apps vary widely not only in purpose but also in audience and quality.  A company called Happtique has just introduced a certification for health apps that will hopefully give consumers a better comfort about which apps to use, or for physicians to know which to recommend to patients.  They see the program not as a rating mechanism but as kind of like a Good Housekeeping seal of approval, assuring that at least a set of minimum standards have been met.  This could spur adoption.

It does appear that physicians are joining the mobile revolution, according to CompTIA.  Their recent survey indicated that one in five physicians is using a medical or health-related app daily, and 62% expect to be regular users with a year.  The trick will be how they incorporate them into their practice, for patient care and/or patient engagement.

EHR/PHRs provide yet another option to engage consumers.  To date, consumer adoption of PHRs have been disappointing, to say the least – even when they are available.  A recent study by Ritu Agarwal and colleagues, aptly titled “If We Offer it, Will They Accept?”, explores this issue and concludes that use depends on a number of factors – not just existing consumer preferences but also satisfaction with the patient-provider relationship, provider support for patient use of the PHR, and specific communication strategies to encourage use.  HITECH funding and “meaningful use” requirements may drive availability of patient EHRs, but persuading patients to use them will require some effort.

Telemedicine seems be exploding, both in terms of easing of regulation and in terms of payor coverage, so it is not surprising that there are a plethora of companies making their mark in this space.  These include American Well, Cardiocom, HealthSpot, NowClinic, or Virtuwell, to name just a few.  These may not provide your personal physician, but they offer physician expertise at your convenience – 24/7, from your house or even mobile device, not restricted to a physician’s hours.  That’s got to help improve patient engagement.

The IOM just hosted a workshop on partnering with patients, and one of the conclusions was that physicians and health systems need help in developing those skills, plus they may need additional incentives to engage in the kind of dialogue patient engagement requires (why am I not surprised?).  When you think about it, though, relying on physicians, or even nurses, to drive patient engagement doesn’t seem realistic.  We can spend time and resources on training them, but we still face the barrier of the projected shortages in both professions (physician, nurse), especially with the baby boomers just starting to crash the Medicare barrier.  Primary care providers may just be too scarce, especially in rural and other already underserved areas.  Not everyone agrees with these dire forecasts, but the point remains, though: the health professional to patient ratio doesn’t scale well into an era of higher patient engagement.

And maybe it doesn’t need to.  Maybe it really is up to us as patients to take responsibility.  Fortunately, we still don’t have to go it alone.

Social media, for example, may not even rely on a provider-patient model.  Health care providers are still trying to figure out social media.  An infographic by Demi & Cooper advertising/DC Interactive Group suggests that only 26% of hospitals use social media (most commonly Facebook), while over 80% of individuals 18-24, and 45% of those 45-54, would share health information via social media.  Meanwhile, Patientslikeme has been breaking new ground for social media use in health care for many years now, using patient-to-patient expertise and experience.  We’re only begun to scratch the surface of what patient engagement looks like in a social media world.

Artificial intelligence could be the real game changer in patient engagement.  IBM has made a big bet on AI in health care via Watson, and a recent study from Indiana University reaffirms that use of AI has the potential to both improve outcomes and lower costs.  Widely available health content on the Internet started this ball rolling, but health care professionals start to look like just another option – a preferred option, to be sure, but no longer the only option – to getting health information, advice, perhaps even diagnoses.  And I’ll have to save discussion of robotic surgery for another blog…

We’re already got a mobile stethoscope app, remote monitoring options for conditions like diabetes or blood pressure, medication and other reminder apps, and increasing ability for AI to evaluate and diagnose.  Who needs health coaches or even physicians to drive patient engagement?  Maybe in the not-too-distant future the model for patient engagement will increasing look like patients simply using their mobile devices: i.e., when Siri marries Watson.

At the end of the day, the person who has to be committed to patient engagement has to be the patient.

AHIP Announces Launch of new Health System Change Initiative

By Claire Thayer, February 25, 2013

The AHIP Foundation has announced the launch of a new Health System Change Initiative - the Institute for Health Systems Solutions (IHSS). The priorities of the new Institute will focus on:

• Access: Using innovation to improve health care delivery and payment reform
• Innovation: New ideas to improve access
• Smart Regulation: Regulation that creates the fewest unintended consequences

More information, including links to Insights & Resources and News & Activities may be found here: http://www.healthsystemssolutions.org/