The Numbers Behind Plastic Surgery

By Clive Riddle, February 21, 2013

The American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) has just released results of their annual membership study, which provides a wealth of information about what goes on their world.

Let’s take a peek, with some excerpts compiled from their study:

Cosmetic Procedures: The survey indicated 73% of all procedures were cosmetic  (versus reconstructive) in 2012, up from 62% in 2011. Non-surgical treatments made up two-thirds of all 2012 cosmetic procedures. The most common cosmetic non-surgical procedures remain BOTOX® and hyaluronic acid fillers, with the top three areas of the face most treated by injectables being the forehead (42%), cheeks (35%) and the lips (18%).

Volume and Fees: Member surgeons report performing an average of 945 facial cosmetic surgical, cosmetic non-surgical, reconstructive and revision procedures per surgeon in 2012. Facelifts command the highest average fee per procedure ($7,453, on average), followed by: hair transplants ($7,182), revision surgery ($6,542), and rhinoplasty ($5,541).

Women: 80% of all surgical procedures and non-surgical procedures are performed on women.  Two-thirds of women having procedures are mothers, primarily in their 40's and 50's. In 2012 the most common cosmetic surgical procedure for women was facelifts, followed by blepharoplasty, and rhinoplasty. The most common non-surgical cosmetic procedures among women were BOTOX®, hyaluronic acid injections and microdermabrasion, respectively.

Men: Rhinoplasty remains the most requested surgical procedure overall among men.  On average, 20% of male patients request plastic surgery as a result of their significant other having received plastic surgery. Men had a significant increase in Botox  (up 27% from last year - with hyaluronic acid fillers and microdermabrasion also among the most popular maintenance treatments ) while the number of Botox procedures among women was similar to 2011.

Age Groups: 28% of Facial Plastic Surgeons have seen an increase in cosmetic surgery or injectables in those under age 25. For both female and male patients under the age of 35, the most common procedure performed was rhinoplasty (53% females; 70% males), followed by BOTOX® (30% women; 13% men). For all procedures, except rhinoplasty, the majority were performed on patients between the ages of 35 and 60.

Race: The 2012 survey revealed that African Americans and Hispanics were most predisposed to have received rhinoplasty (80% and 65% respectively). Asian Americans were most likely to have blepharoplasty (44%) or rhinoplasty (41%), while Caucasians were more likely to have facelifts (40%) or rhinoplasty (39%).

Consumer Selection: Most patients get their information about plastic surgery online (57%) and are most concerned with the results of the surgery (40%) followed by concern over the cost (33%)  and recovery time (21%)when making their decision to undergo facial plastic surgery. Last year just 7% of prospective patients used social media to research doctors and procedures, down from 35% in 2011. However, there was a 31% increase in requests for surgery as a result of social media photo sharing.  Surgeons report that, on average, 22 women and 12 men that were dissatisfied with previous rhinoplasty surgery from a different office requested corrective surgery.

Tell Me the Good News Again

By Kim Bellard, February 13, 2013

This just in from CBO: federal health care spending has slowed dramatically, easing its impact on the federal deficit.  They are now projecting federal Medicare and Medicaid spending will be $200 billion lower in 2020 than they did three years ago.  And it is not just federal health spending:  according to CMS, 2011 marked the third consecutive year of relatively slow grow, increasing by 3.9%, which is modest for health care. 

Should we be breaking out the champagne to toast the victory?  Maybe not just yet. 

Economists aren’t sure if structural changes are finally taking place, or if much of the slowdown can be attributed to the recession and to consumers being more reluctant to spend any discretionary cash on health care.  There are some signs that the slowdown started before the recession, but there are conflicting signs that some portions of health spending are accelerating. 

For example, the CMS report cited increases in out-of-pocket payments as an area where spending was rising faster, but the Washington Post notes a contrary analysis by NPR’s Planet Money which suggests that the share of spending from consumer out-of-pocket payments is actually decreasing, dropping by nearly half over the last forty years.  Of course, that share is of a much large dollar amount, so the lower percentage may be of scant comfort.  Consumers probably don’t have the perception that their share is getting smaller, not with rise of high deductible plans, and some researchers, like Deloitte, would argue that the official numbers understate direct consumer spending by a wide margin.  So we don’t really know.

What everyone is waiting to see is what 2014 brings us, as several of the most significant ACA provisions – Medicaid expansion, health insurance exchanges, guaranteed issue health coverage, essential benefits, and federal subsidies for health insurance, to name a few – kick in.  None is without its problems. 

Medicaid expansion seemed like a no-brainer.  It promised to make eligibility for Medicaid much more uniform across states and between different pockets of the population, and it minimized the fiscal impact on states by the federal government picking up all the costs of the expansion in the first few years.  Some states are skeptical that the federal government is a reliable partner, and others oppose ACA on general principle, with the net effect that we still don’t have even a majority of states who have agreed to the expansion.  Without the expansion, some people won’t qualify for either Medicaid or subsidized coverage through the exchanges.  In other words, if you are the wrong kind of poor person, you may still be out of luck.

As for the exchanges (excuse me – “marketplaces,” as newly rebranded by HHS), according to Kaiser Family Foundation, as of February 12, only 18 states are planning to run their own exchange, another 6 are planning to run one in partnership with the federal government, and the remaining 27 are defaulting to a federally-run exchange.  Whether state, federal, or jointly run, if they are not already deep in the planning/building process, it’s worrisome as to whether they will be able to start online shopping for all those consumers beginning this October.  I’m not betting on a wonderful, Amazon-like experience come October.

The biggest problem with guaranteed issue and essential benefits is not the much debated controversy over contraception coverage, with its weird proposed compromise for “contraception-only” coverage, but rather is the concern that premiums could skyrocket, especially for younger people.  The combination of generally richer coverage and inclusion of people who previously could not obtain insurance, along with tighter age rating bands, may lead to doubling or even tripling of premiums for some consumers, report Politico and The Wall Street Journal.  Supporters of ACA note that the subsidies will largely offset most or even all of these increases, but disguising the true cost of things from consumers is a big part of the reason our health care system is in the mess it is in.  We should be aiming to bring down the cost of health care and health insurance, not simply offset it with other federal spending.

Last but not least, there are the subsidies themselves, which are the key to success in improving the number of people with coverage (not, as many think, the infamous mandate, which is probably too weak to force people to buy coverage they don’t want or don’t think they can afford).  The subsidies are already running into problems.  Unions fear that their health plans may become disadvantaged relative to subsidized coverage in the exchanges, and have asked the Administration to be eligible for similar subsidies, thus reopening the spending spigot.  Of course, there are a number of employer plans who could make the same request, although their political clout may not be as great as the unions. 

Employer plans face enough problems as it is, and the recent IRS rules that base “affordability under ACA guidelines solely on the cost for single coverage, not family coverage, are likely to complicate things further.  The IRS ruling spares employers from the nightmare of having to guess at a worker’s total family income, but also opens the door to employers contributing ever smaller portions towards family coverage.  We could end up with a Catch-22: rapidly shrinking employer contributions for dependent coverage make that coverage too expensive for many families, yet those same families would not be not eligible for the subsidies in the exchanges because of their eligibility for employer coverage.  I can already see the tear-jerking stories in Congressional hearings, although I’m not sure who Congress will try to pin the blame on.  Not themselves, of course.

And, of course, the sheer size of the subsidies – over $1 trillion through 2022 -- will become a tempting target for budget cuts should Congress and the Administration ever get serious about the deficit.  At the same time CBO delivered the good news about lower Medicare/Medicaid spending, they also disclosed that they were raising the estimates of the cost of the subsidy by over $200 billion over 10 years.  They also estimated that twice as many people – 7 million – will move from employer coverage to individual coverage through the exchanges.  Oh, and they also think fewer people will gain coverage through ACA at all, reducing their estimate to 27 million from their initial estimate of 32 to 34 million.  So there.

We have a long way to go before we can feel comfortable about how the health care system is changing.  The disturbing but, sadly, not surprising results of the recent study by Jaime Rosenthal and Peter Cram on the inability of consumers to obtain prices of hip replacement illustrate both the difficulty of obtaining prices for even a common surgical procedure, as well as the shockingly wide range of the prices they might be able to find.  If anyone thinks ACOs will make this better, I suggest they think again – assuming consumers will be able even find multiple ACOs near them from whom to seek competing prices, due to increasing provider consolidation.

And meanwhile we face the spectre of an explosion of health spending as baby boomers begin hitting peak health expense years, especially since they are already in worse health than their parent were at the same age, according to a recent study.  Living longer but in worse health and more demanding – not exactly a recipe for reduced health care spending in the years ahead.

I’ll go back to something I wrote a couple years ago: all health care spending ends up as revenue for someone.  Even care we might categorize as waste, unnecessary, or inappropriate counts towards some entity’s revenue.  We can make the health care system more efficient, more transparent, and more patient-centered, but at the end of the day controlling spending will mean controlling providers’ income.  To do that, one of three things has to happen: all providers end up getting less, some categories of providers fare worse than others (e.g., hospitals gain while nursing homes lose), or we start paying specific providers drastically less, or not at all. 

Personally, I think the fairest – although not the easiest -- way to control spending, and to improve the quality of care for patients, is to weed out underperforming providers, those who are delivering sub-par care (and we’re kidding ourselves if we think they don’t exist).  When we get serious about that, then maybe it will be time to start the celebration.

Who’s In: State Health Insurance Exchanges

By Cyndy Nayer, February 7, 2013

MCOL published the infographic that shows the participants (states) in health insurance exchanges (HIX), the monies invested, the managers of the exchanges, and the public v private efforts. To date:

• 19 states are expected to open an exchange in 2014.
• Over $3.5 billion has been invested in 47 states (including the District of Columbia).
• Private exchanges are developing, mostly through large consulting firms, health plans, and integrated delivery systems.
• 56% of people polled by MCOL think that health insurance exchanges will have a significant impact on health access and affordability.
• Update on Florida (not on the infographic): the first state to oppose the exchanges, is still considering the impact on the budget.

As health care reform spreads through the communities of the US, there is great hope that the insurance exchanges will, in a few short years, encourage more consumer-driven health management. What is happening, however, is the escalation of insurance premiums even before the uninsured are offered entry into the coverage marketplace. This will demand a much finer focus on keeping people in sync with their prevention, wellness, and chronic care management plans. It means that those who are proficient at health care purchasing–the self-insured employers–will need to keep a close communication package in place, encouraging appropriate use of services and screenings as well as attention to adherence to medical plans. Some employers have already shared that they will be offering a “step-up” insurance package to their beneficiaries, as they have reaped the rewards of value-based benefit designs and outcomes-based purchasing through the years. They believe that their commitment to a high-performing workforce will be continue, even if their employees and families enter the exchange marketplace.

ACO Directory 2013

By Claire Thayer, February 5, 2013

Need a resource on Accountable Care Organizations?  Today, HealthQuest Publishers announces the release of The Accountable Care Directory 2013. In this latest edition, you’ll find summary information for 321 selected ACOs, as well as a listing of 1,088 key persons with leadership or operational involvement with the ACO. Also included are Executive Profiles of Accountable Care executives and thought leaders, as well as indexes for easily referencing individuals and organizations included in this Directory.

Watch a one minute video at: http://www.healthsharetv.com/content/accountable-care-directory-2013

More info at: https://www.managedcarestore.com/yhlthqst/hqaco.htm

But Which Half?

By Kim Bellard, January 30, 2013

Advertising lore credits John Wanamaker, the department store magnate and marketing pioneer, with the famous quote: “Half the money I spend on advertising is wasted; the trouble is I don't know which half.”  It turns out he could have been talking about spending on health care.

The British Medical Journal, through their Clinical Evidence initiative, recently reported that they’d analyzed 3,000 medical treatments that had been studied in controlled, randomized studies.  It turns out that for half of those treatments, we have no idea how well they work.  Indeed, only about a third of the treatments were found to actually be beneficial or likely to be beneficial.  The rest are likely to be harmful.

Sadly, this does not come as a surprise.

We know we don’t know enough.  The vast number of medical treatments have never even been studied in a true clinical trial.  Worse yet, sometimes even when there is clear empirical evidence about which treatments are most effective, that information does not always sway physician behavior, or does so only very slowly (for example, see this study on the use of heart stents versus medication therapy).

There is no shortage of reports of unnecessary or even harmful care.  It’s even scarier when that care is associated with high costs.  In no particular order, one could cite recent controversies with spinal fusions, hip replacements, or chemotherapy drugs.   There can be lots of money at stake for manufacturers, drug companies, and health care providers.  That kind of money can distort the question of what is truly in the best interests of the patient.

Many employers, payors, and researchers have been pushing for “evidence-based medicine” for many years now.  EBM focuses on making sure that treatments have appropriate research to support their effectiveness, and in getting the word out about such treatments.  One of the many initiatives from ACA was the Patient-Centered Outcomes Research Institute, which is charged with conducting research to provide such evidence and funded by a $1 head tax on people covered by insurers.  And, of course, AHRQ probably is wondering why we need a new organization to focus on EBM, given their many efforts on effectiveness.

In time, this may all become much easier, as more patient data become electronic and more connected, and we can make more use of computing power to track what truly happens to patients under various courses of treatments.  I mentioned a couple examples of this in my last blog, citing Optum/Mayo’s new initiative and meta-research studies in lieu of clinical trials.  Another example comes from Archimedes Inc., a firm founded by David Eddy, who was one of the early pioneers of evidenced-based medicine.  Archimedes claims to use its advanced mathematics and computing prowess “to run clinically realistic virtual trials on any population and create compelling evidence to make decisions in health and economic outcomes research, policy creation, clinical trial design, and performance improvement.”  Apparently HHS thinks they can, as it hired Archimedes last year.

Most physicians I know are very bright, care very much about their patients, and work hard to stay current on the medical literature.  Unfortunately, the latter is virtually impossible to do, given the sheer volume of that literature.  Even when there are clear results about which treatment is truly the most effective, the research doesn’t usually come with a guide as to how physicians can implement the associated changes to their practice routines.  It’s as much of a question of change management as it is the evidence to make the change.

It would seem that the situation is tailor-made for clinical decision support tools, which seek to provide clinicians with information on treatment options, potential outcomes, and possible contra-indications at point-of-care.  Unfortunately, we may not quite be ready for them.

Last summer The Annals of Internal Medicine published a study on clinical decision support systems by Bright, et. al.  They did a meta-analysis of studies on CDSSs, and found ample evidence of their efficacy in improving process measures, but sparse results on their impact on clinical or economic outcomes.  Whether this is due to the limitations of the underlying studies, the CDSSs themselves, or how they were used by clinicians is unclear. 

Similarly, KLAS Research recently released results of their survey of health care providers on their satisfaction with clinical decision support tools.  The results cited a general level of frustration, especially due to lack of integration with EHRs and “alert fatigue” caused by ineffective targeting of alerts. 

Worst yet, according to new research from the University of Missouri, patients don’t seem to trust treatment recommendations from physicians who use CDSSs, believing them to be less capable than physicians who make decisions unaided.  Patients don’t even like it when physicians consult with other physicians before making a recommendation!  They think their doctor should know everything.  I blame television for this – on medical shows like Grey’s Anatomy or House physicians pull up the most obscure diagnoses and treatments strictly from memory, without ever having to consult any reference materials.  Nobody’s memory is that good. 

Clinical decision support systems aren’t going to replace doctors; they are simply tools to aid health care professionals, much as a stethoscope or a thermometer does.  One can imagine a future where CDSSs -- and EHRs -- fit seamlessly into patient visits, providing real-time, interactive information while with the patient.  The line between evaluation, documentation, and clinical decision support should blur, in order to more accurately diagnosis patients and determine the best course of treatment.  

In the meantime, it’s somewhat of a crapshoot.

A recent study by Deloitte indicates that 62% of Americans believe that, in fact, over 50% of U.S. health spending is wasted, which is up from the already high 51% in 2009.  The message about necessary spending may be getting out, but consumers may be getting the wrong idea – only 18% thought the problem was not using evidence-based treatments, versus 69% who blame fraud and abuse in the payment system.  In other words, the problem can be blamed on greedy crooks, not on well-meaning health care providers.  Defensive medicine and unnecessary paperwork were each also cited by about a third of respondents. 

I agree that fraud, defensive medicine, and inefficient administration contribute cause us to spend money we shouldn’t, and each should be addressed, but I suspect more of unnecessary spending comes from well-intentioned treatments that aren’t really best for the patients.  As professionals, health care providers should be more stringent about basing their treatment recommendations on evidence that truly supports them.  More importantly, as the people whose health is going to be impacted by those treatments, it’s incumbent on us to demand that evidence.

Maybe one day we’ll have Star Trek’s tricorder to non-invasively diagnosis or even Star Trek Voyager’s holographic doctor to treat.  Maybe someday nanobots will fix all our ills without our even being aware of their work.  All that is in the future.  For right now I’d settle for simply being able to know the odds that a recommended treatment will actually benefit me.

Mercer introduces new Mercer Marketplace

By Claire Thayer, January 28, 2013

Mercer now offers employers and their employees’ access to a new private benefits exchange, Mercer Marketplace.  The Mercer Marketplace includes over 20 types of benefits, allowing employees to construct a personalized portfolio with traditional core benefits as well as optional voluntary benefits. The new exchange includes qualified benefit designs available from multiple insurance providers. In addition, Mercer Marketplace can facilitate, but does not require, a move to a defined contribution funding.

Learn more at: http://www.mercer.us/articles/mercer-exchange-suite.

The Health Insurance Exchange Directory 2013

By Claire Thayer, January 24, 2013

Looking for contact information the new public and private health insurance exchanges? HealthQuest Publishers, from MCOL, just released a brand new 120+ page directory and database with contact information on health insurance exchanges throughout the country. This new Health Insurance Exchange Directory provides comprehensive contact information for all state-based public exchanges and public partnership exchanges as of January 2013 as well as a number of private exchanges.

Watch a one minute video about the Health Insurance Exchange Directory:

www.healthsharetv.com/content/health-insurance-exchange-directory-intro-video

The Health Insurance Exchange Directory includes a contact database and encompasses:

• Organizational Directory of 50 selected HIXs.  Contact and summary information along with a listing of 350 key individuals with leadership or operational involvement. Almost half of employees in the directory have email address listed.
• Executive Profiles providing contact and biographical information for 75 executives and thought leaders involved with Health Insurance Exchanges representing a wide range of organizations including exchanges, health plans, consulting groups, associations and others.
• Indexes for convenient navigation and reference organized six different ways
• Contact Database with all the information from the Organizational Directory and the Executive Profiles in an Excel spreadsheet. It includes tabs for Organizational Directory organizations, employees and Executive Profile employees.

Learn more at: www.managedcarestore.com/yhlthqst/hqhix.htm

Get Ready…ACA Superbowl

By Lindsay Resnick, January 23, 2013

Bring your A-game to both sides of the ball, it’s time to play game winning offense and defense. As ACA’s October 2013 open enrollment gets closer, winning health plans are focused on honing their direct-to-consumer marketing skills around retaining and acquiring membership.  It means getting into the Affordable Care Act game by protecting your base with tough defense, and preparing to put points on the board (aka new members) with aggressive offense.

DEFENSE: Retain the members you already have. Prioritize those that are the most valuable and create customized engagement strategies to keep them. Take a data-driven approach to understanding your most vulnerable “at risk” population within your Individual and Small Group businesses that can soon make individual choices.

Core objectives for health plan retention:

1. Maximize retention of existing membership in both on and off Exchange products by minimizing the potential to lose Individual and Small Group customers to competitors.
2. Leverage membership data and third-party intelligence to improve understanding of current Individual and Small Group customers.
3. Communicate a timely and relevant message to existing membership, employers, and distributors to support retention by improving member engagement and building brand loyalty.
4. Emerge as a trusted source for information regarding what health care reform is and what is means to those most impacted…Who’s eligible for what? What’s in it for ME?

OFFENSE: Get your share of the open enrollment “land grab”. Understand needs and attributes of various segments of new market entrants to optimize acquisition campaigns. Create on/off Exchange strategies to generate new leads and sales from individuals most likely to enter the market as a result of ACA’s disruptive events. Switching will be at an all-time high... make sure they switch to you!

Core objectives health plan acquisition:

1. Increase sales opportunities to enroll a larger percentage of the individuals across all segments likely to purchase through public/private Exchanges and, small businesses SHOP Exchanges (e.g., uninsured, disenfranchised small group employees, subsidy eligibles, new Individual shoppers).
2. Optimize and increase the use of database management and segmentation tools to improve targeting capabilities and gain a better understanding of the marketplace than your competitors.
3. Work in tandem with your product development team to identify various product acquisition paths, mapping current portfolio to a post reform products. These product acquisition paths will be the basis for determining messaging and sales strategies.
4. Deploy a new business direct response marketing tactics that blends push-based education with pull-based entry into your selling cycle. 

The future of health insurance belongs to the prepared.To achieve and sustain profitable growth, marketing strategies need to look very different going forward. They need to move from product-centric…see who buys it; to consumer-centric…understand how they engage.

Tomorrow’s health insurance consumer needs to be at the center of everything marketers do throughout the customer lifecycle.  An engaged consumer means connecting early and often, nurturing them into the sales cycle, keeping them involved through purchase, and delivering a superior customer experience. A balanced approach to customer retention and acquisition, supported by data-based intelligence and strong consumer engagement, will determine ACA winners.

"Faith is taking the first step even when you don’t see the whole staircase" - Martin Luther King

By Cyndy Nayer, January 22, 2013

The day before the 2nd inauguration of the President Obama, I have paused.  I’ve been thinking about the post I wrote last year at this time, with quotes of MLK and how they applied to my work, my vision, and, at the time, to the organization I had founded and built on evidence of health value innovation.  It’s no secret it’s been a tumultuous year for all of us.

This past year has been a year of conflict:  the dis-collaboration of the elected officials, the persistence of debt in the government, the modest recovery of the economy, the continuation of foreclosures, and so on.  Today, Twitter is alive with evidence of low to no health improvement from electronic medical records (EHR), the appearance of lack of remorse by Lance Armstrong, the noise of the NRA video with the Obama daughters, and so much more negativity.

On the opposite end, there was a call for Obama’s face to join Lincoln’s at Mt. Rushmore , the praise of Obamacare (ACA) [despite the unprecedented increases in insurance premiums for the 21-29 year olds], and the return of Hillary Clinton to Capitol Hill for updates on national defense.

This emotional rollercoaster is a ride this recession-weary country could well avoid.  So, today, I search for a hero who can help us refocus, that can help us restore our faith in in positive days ahead, and that will support our call to Capitol Hill and the White House to stop this battling and help us get the country back to work, get the kids healthy, and put our health system to top form and optimal outcomes.

I turn to a story, one more time, about Gabby Giffords, but not the PAC story (though, I’m so glad that she and husband Mark Kelley put their strengths into the efforts to protect our children and communities).  No, this time, it’s a message of facing demons and rebuilding on higher ground.

Gabby and Mark sat, on Nov 8, 2012, in a courtroom in Tuscon, AZ and faced her shooter.  Through her husband, Gabby told the shooter, “Today I am done thinking about you,”  and left the courtroom.  Her message to the press is that this is certainly not forgotten, but a resolution to move on.

Gabby is a true American hero.  We’ve struggled through her fight to live, her fight to walk, her fight to talk.  I’vedocumented the success of the recovery as a testament to all that the American health system does right.  The collaboration between health systems, the teamwork of the proficient care providers throughout the recovery, and her personal and very public messaging that yes, she’s getting better, and yes, she’s frustrated, and yes, it’s hard, and yes, she will persevere.

This is the message I’d like to hear from all of our elected officials.  America is a “do” country, not a “do not,” not even a “try” country.  For many years, when people tell me they are going to try something, I put a grin on my face and remind them of the famous philosopher Yoda, of Star Wars fame, who said “Do or do not, there is no try.”  America is that country, the DO country.

Need proof?  Check out this article  Apollo 40 years on:  how the moon missions changed the world for ever.  You will discover that innovation that supported the missions to the moon included (excerpt from the article):

Apollo 9 astronaut Rusty Schweickart’s ”mind-expanding view and the epiphany that it triggered led him to vividly appreciate the insanity of humans fighting over borders that were invisible to him from up there. ‘Hundreds of people in the Middle East killing each other over some imaginary line that you’re not even aware of, that you can’t see,” he recounted. ‘ And from where you see it, the thing is a whole, and it’s so beautiful,” he remembered of his view of Earth. “You wish you could take one in each hand, one from each side in the various conflicts, and say, ‘Look. Look at it from this perspective. Look at that. What’s important?’”  This later influenced astronomer Schweickart’s speech, later turned into an essay entitled “No Frames, No Boundaries,” was embraced by those at the conference, including Carl Sagan, who borrowed from for his uplifting poem Pale Blue Dot, published in his 1994 book of the same name.

The article goes on to document the increase in education funding that fueled the PhDs who developed the navigation system, the protective coverings, and so much more, all built on the faith that we could actually get a man to the moon, because President John F Kennedy declared it would be so.

Need more proof?  Stan Musial.  I have also paused today because Stan-the-Man has passed away.  I grew up in St. Louis.  I was at Stan’s last game in 1963.  I saw him often at Musial and Biggies, one of the best steak houses ever (it closed many years ago) and he never failed to give a smile, wave his hand, ask my little brothers for a handshake, or sign a napkin (or a Cardinal cap, which he more often than not was wearing).  I saw him 40 years later, still standing tall, still with that cockeyed grin, but a but stooped and a bit unsteady.  I wept today, because Stan Musial is the symbol of the Gateway to the West, of the St. Louis Cardinals, of the hope that St. Louis was in those years.  The years he played baseball were also the years of Dr. King.  I don’t think anyone would say those were collaborative years, no, but we did remarkable things, like missions to the moon, Medicare and Medicaid, and freedom to vote.  Our visions, our passions, while not always in sync, came together in sadness (the assassinations of John and Robert Kennedy, and of Dr. King) and in joy (the retirement celebrations of Stan-the-Man, the 1969 walk on the moon).

We never know how far our vision or our passion will reach.  We don’t know the depths of despair that some go thru during the frustration of reorganizing the vision, reformulating the steps, but never, ever losing hope of achievement.

I hope no one ever goes through what the parents at Newtown nor Gabby Giffords, nor the families of the now 900+ people who have been killed since the Newtown tragedy occurred must live with every day.  I hope I live to see the end of health system errors that cause needless suffering– in poor outcomes, in financial loss, and in family jobs–that we’ve all witnessed over the past years.

I say today that this is where I’m going:  to speed innovation that proves it is a solution to the gaps in care, gets people to better manage their own health, and puts the system into pro-active mode for healthier communities. At my lowest, I reach back to the heros, the Gabbys, the Marks, the Stans, the JFKs, the astronauts, the MLKs, and the many more who envision a bolder, grander, more compassionate America.  I refuse to give up my dream.  I will move forward on the faith that is my core, and I’ll take that first step, that 101st step, and I’ll hold your hand as you join me.

---

Lonny Dunn (@ProNetworkBuild)

1/12/13, 8:16 AM“The mediocre teacher tells. The good teacher explains. The superior teacher demonstrates. The great teacher inspires.” – William A. Ward

---

I share with you that tweet above that I think is so profound, and I hope it helps you, and those you love, find your way.  I pray, too, that those who guide our country find the will and the faith to solve for what is holding us back, not for personal interests, but for collective improvement. And, I include one more message below from the Twitter-sphere [apologies, I don't know who tweeted it]:

Don’t tell me the sky is the limit when I know there are footprints on the moon.

Be well, my friends, and travel with your head up and your eyes open and your passion in your hearts. Bless the USA, its leaders and its heroes.

Should We Spell ACO “CRM”?

By Kim Bellard, January 15, 2013

CMS released a list of 106 more ACOs, bringing the total of approved ACOs to over 250.  On the list there were some familiar names, and many organizations sponsored by familiar types of organizations.  It reminds me of how NFL coaches who get fired almost always get hired by another team – here’s a shout out to you, Norv Turner! – despite their demonstrated lack of success.  As the old saying goes, if you keep doing what you’ve been doing, why would you expect anything to be different? 

Don’t get me wrong; I hope ACOs prove successful.  I hope they help reform our health care system into a more integrated, cost-effective system that is centered around the patient.  Still, I wish we’d see some ACOs sponsored by organizations with more non-traditional orientations – an American Well or an athenahealth, for example.  And definitely wake me up when an ACO asks a company like Salesforce.com to help them.

Most of the approved ACOs are driven by hospitals or physicians, which should come as no surprise.  They’ve always been the center of our health care system, and will remain integral to it.  I was pleased to see, though, that Walgreens is also dipping its toes in these waters, leading three of the recently approved ACOs.  Walgreens’ ACOs may not prove any more successful than other ACOs, and will obviously still rely on hospital and physician partners, but at least they come at the problem with a much more retail orientation. 

ACOs are focusing on clinical integration, care management, financial risk management – really, all the things providers should have been doing all along but which they haven’t done such a great job at.  I’m wondering, though, if they are like the guy who only has a hammer, and thus sees all problems as nails.  Maybe instead of a care management problem, we have a CRM problem. 

CRM, for those not used to non-healthcare jargon, is “customer relationship management.”  It has many definitions and many applications, but at the risk of oversimplifying I’ll boil it down to this: knowing your customer, and using that knowledge to drive all interactions with that customer.  In health care (ACO), of course, the customer would be the patient. 

Here’s a set of things that would be true in a truly CRM-driven organization:

• A singular focus on earning and keeping customer loyalty;

• A customer database that can be accessed as needed throughout the organization;

• Each contact with the customer – at every touchpoint, with every representative of the organization – is informed by the existing information about the customer, and then becomes a source of new information about the customer;

• Contacts with the customer trigger rules-based algorithms that tailor what the organization wants stressed during the encounter, based on perceived (or expressed) needs and anticipated benefit to that customer – reminders, messages, additional services, etc.; 

• Contacts include both ones initiated by the customer and proactive ones initiated by the organization, with outgoing contacts being specifically targeted as to timing, purpose, type of media, and from whom;

• Contacts are, to the extent possible, tailored to customer preferences – e.g., physical visit versus virtual, mail/email/text/phone communication.

Now ask yourself: how many of the 250+ ACOs are likely to have all of these?  Most of these?  Any of these?  I have to admit that I’m not optimistic.  I mean – how many ACOs have an ACO-wide contact system?  How many ACOs even have a patient portal, especially one that incorporates both clinical and administrative information, from all ACO providers?    How many ACOs are even thinking about these kinds of things?

A physician in an ACO with a strong CRM platform would be up-to-date on what is happening with his/her patients, based on their own interactions, interactions the patients have had with other ACO providers, and even results of, say, home monitoring, especially for at-risk or chronically ill patients.  They’d be alerted immediately of an ER visit, potential adverse drug interactions, or test results from throughout the ACO.  Now we’re talking care management.

A recent report from Rand casts concern about how easy achieving any of this is likely to be for ACOs.  The report admits that HIT has fallen short on its promise, in large part because the various systems are neither interconnected nor easy to use, sad though that is to report.  It’s hard to do CRM with those kinds of barriers. 

Still, HIT provides so much promise for improving the health care system, in ways we’re only beginning to figure out.  For example, Optum and Mayo just announced Optum Labs, a collaboration that will pool their data and technology assets, with the goal to drive long term improvements to delivery and quality of care.  They’re not alone in this approach, with The New York Times recently reporting on researchers who plan to use electronic medical records to do medical research faster and more inexpensively.  HIT allows us to use data in ways paper records never could.

We’re in the era of Big Data, and the possibilities are as yet largely untapped.  CRM lives on robust data and targeted use of it.

I was also encouraged by an article by Linda Green and colleagues, which argues that our concerns about a physician shortage can be addressed by using alternative approaches towards delivering care, including “team” approaches, technological solutions and physician extenders.  The past does not have to be the future in terms about how patient care is delivered.  If anyone doubts that, they should read the recent survey by Harris Interactive about the use of retail clinics: some 27% of American adults have used such a clinic in the past year, up from only 7% in 2008.  Give consumers faster, easier options for care, and they will take advantage of them.

Of course, those options are not just bricks and mortar.  It should come as no surprise that the Internet plays an important role.  The Pew Research Center reports that 35% of U.S. adults have gone online to try to self-diagnose, which sometimes results in visits to providers and other times allows them to manage on their own.  Sixteen percent of online health information users have tried to find others on line with similar conditions, and 30% of internet users have consulted online reviews or rankings of health services or treatments.  Information is power, and more of that power is going to consumers.

Or take InTouch Health, which just won FDA approval for its “remote presence robot” that uses telemedicine to take care coordination to new levels.  Telemedicine is no longer exactly new, but FDA approval is a big deal.  Telemedicine promises – or threatens, depending on how one looks at it – to redefine what it means for providers to be available, and which providers.  Distance becomes less of a consideration.

Then there is the “mHealth” revolution.  Deloitte just issued their latest mHealth report, and sees a bright future: they expect some $305b in industry productivity gains over the next 10 years from mHealth solutions.  That’s a heck of a lot more than CMS forecasts ACOs may save, and it suggests that ACOs who aren’t incorporating a broad suite of mHealth and other technological solutions will do so at their own risk. 

At the end of the day, it’s not about these various slick technological solutions.  They just give us more options.  It is about doing the right thing at the right time in the right way for the right person.  If that’s not what CRM is for, I don’t know what is.  If that’s also not what we want from our health care system, again, I don’t know what is.

CRM is not easy to do, and it is rarely an all-or-nothing approach.  Even in the best case a CRM strategy can take years to implement, building incrementally.  It takes a committed, long term strategy to succeed with CRM.  And, as I see it, an ACO without a CRM strategy may not have a viable strategy at all.

PwC’s Top Health Industry Issues for 2013

By Claire Thayer, January 14, 2013

Last week, PwC’s Health Research Institute outlined their 10 Top Health Industry Issues to watch out for in 2013. Here’s a summary of their Top Ten issues culminated from recent survey of 1,000 consumers:

1.    States on the frontlines of Affordable Care Act implementation

Over the next year, state officials must decide how to run insurance exchanges, whether to expand Medicaid coverage, and what type of insurance market regulation is needed. The biggest challenge states may face in 2013 will be information technology.

2.    Consumer revolution in health coverage

Consumers’ rising voice on how they spend their healthcare dollars, coupled with state insurance exchanges, is prompting the health industry to compete on attributes similar to the retail industry: convenience, price and transparency. 

3.    Medtech industry braces for excise tax impact

A 2.3 percent excise tax on medical device companies takes effect on January 1, 2013, representing potentially $29.1 billion to the federal government over the next 10 years.

4.    Caring for the nation’s most vulnerable: dual eligibles

Dual eligibles – people who qualify for both Medicare and Medicaid – make up many of the 16 million people the ACA will add to Medicaid rolls by 2019.  The cost of care for duals is skyrocketing – much of it wasted due to a lack of care coordination between the two programs – and 70 percent of state Medicaid spending on duals goes to long-term care support services, such as nursing homes. 

5.    Bring your own mobile device: convenience at a cost

Doctors and nurses are bringing their own mobile devices to work, but many hospitals do not yet have a secure enough environment to protect sensitive patient information.  Sixty-nine percent of consumers surveyed said they are concerned about the privacy of their medical information if providers were able to access it on their mobile devices. 

6.    Goodbye cost reduction, hello transformation

With reimbursement resetting under the ACA and pressure from the federal budget crisis and price-conscious consumers, hospitals are scrambling to further reduce their costs.  HRI research found that 40 percent of consumers postponed care in 2012 because of the costs. 

7.    Customer ratings hit the pocketbooks of healthcare companies

Paying for performance will take on new meaning in 2013 as consumer reviews generate penalties and bonuses for hospitals and insurers. This could mean a bonus payout of more than $3 billion for insurers and a hold back of $850 million for providers in 2013.

8.    Meeting the new expectations of pharma value

Physicians, once the primary arbiters of pharma value, now have less say in payment decisions than insurers and large providers. The final hurdle in the long, expensive path to drug and device development is not regulatory approval, but rather reimbursement. 

9.    Bigger than benefits: employers rethink their role in healthcare

For nearly 70 years, employer-based coverage has been a cornerstone of U.S. healthcare - but healthcare and employers may not be inseparable.  With the Supreme Court ruling to uphold the ACA and the re-election of the President, employers have an opportunity to re-examine their long term role in providing healthcare coverage and explore alternative approaches provided by state and/or private exchanges.

10.    The building blocks of population health management

Medicare's accountable care organization and patient-centered medical home initiatives laid a foundation for improving population health, but other collaborations are fueling growth in population health management. 

For more details and to download the full report, visit: www.pwc.com/us/tophealthissues  

And You Thought Health Care Was Bad

By Kim Bellard, January 7, 2013

I’ve been thinking a lot of our educational system lately.  It may be the only part of our economy that makes me feel any better about our health care system.

Now, let me preface my remarks by admitting that whatever experience and expertise I may have with health care, I can’t claim the same for education (except as a student long ago).  Still, education and health care are two areas that most Americans feel very strongly about, recognizing that they are crucial for the well-being of the populace and of the country.  We should all care about what’s happening in both.  Unfortunately, we seem to have blinders on about how well either is performing.

The heath care statistics are perhaps better known.  I’ve covered some of these in previous entries, and won’t repeat all of them here.  In short, we spend way too much – far more than any other country – yet do not score at all well on most international comparisons of mortality or morbidity.  Whatever that extra spending is buying us, it does not appear to be better health.

The picture for education is surprisingly (and depressingly) similar.  We spend far more per pupil than other countries (although, unlike with health care, we’re not the highest as a percent of GDP), as reported by OECD.  Yet we aren’t getting good value for that spending, as our performance is at best middling compared to other countries (see, for example, the USC Rossier School of Education and The George Washington University).  And, according to a report from the Harvard Kennedy School recently, we’re not only scoring poorly but also we’re not gaining any ground on better performing educational systems in other countries.  In a global economy, that’s a race to the bottom, especially since some of our worst scores are in critical areas like math and science.

Most Americans might acknowledge that there are large parts of the public – especially the poor -- for whom both the health care and the education systems are failing, but the statistics for both systems indicate we’re all paying a premium for, at best, average performance.  That’s a sucker bet.

This caused me to start thinking about the ways in which the two sectors are similar.  Here are a few that strike me:

• Who Pays: Both sectors rely heavily on public spending.  Health care is roughly half public spending (even ignoring the “tax expenditure” for employer-based health insurance), while in education the public spending is much higher – over 70% for all levels and closer to 90% for pre-collegiate.  People may not be as vigilant about what they are getting when they think the government is providing the service as with services they buy directly.  However, most other countries have even higher proportions of public spending in both sectors.

• Local:  Most health care and most education is received “close to home.”  It’s certainly possible to get either health care or an education far away from home (as often happens with college), but that tends to be the exception; people tend to stick with what they know rather than seeking the best available.

• Variability: The Dartmouth Atlas has been preaching for decades about the variation in health care throughout the U.S., for reasons not explained by population differences but simply due to local practice patterns.  The variability of performance in the education system between states and between schools within the same state show a similar wide range of variability (indeed, the Harvard report indicated more variability between states within the U.S. as between the U.S. and other countries).  It’s possible to find the best care or the best education in the world within the U.S., but there is a certain geographic randomness to that which is very troubling.

• IT Transformation: Ironically, both health care and education were early adopters for IT – but for primarily for billing and administration, not for care delivery or teaching, respectively.  This is starting to change.  Health care has relied heavily on technology, such as MRIs or laser surgery, and the federal government is spending billions to encourage adoption of EHRs.  In the educational system, many classrooms are making good use of computers, even sometimes replacing textbooks with laptops or tablets.  Still, one would have to say that IT has not yet had the kind of dramatic impact on what the average doctor or teacher do every day as what workers in many other industries have seen, because they have not been forced to fundamentally reengineer their processes.

• Guild Mentality: For many, many decades both teachers and many types of health care practitioners – doctors, pharmacists, dentists, nurses – have generally been viewed with great respect by the public.  Unfortunately, those professions have had a tendency to incorporate the attitude that people outside their profession are not qualified to evaluate their performance.  This no doubt contributed both to the local variability and lack of IT transformation mentioned above.  Teachers have the added protection of unions that serve to further insulate them from outside pressure on performance, while doctors, pharmacists, and dentists have the strong barrier to entry of their advanced education and licensure requirements. 

• Lack of measurement: Historically, neither field paid much attention to measurement and certainly not to quantitative feedback loops for improvement.  Good teaching, like good health care, was seen as hard to define, especially since the full consequences of deficits in either may not fully emerge for years.  As a result, it’s been hard at best, and impossible in many cases, for consumers to view performance results to find the best teachers/schools or doctors/hospitals.  This is starting to change, such as through Meaningful Use requirements in health care and testing standards of No Child Left Behind/Race to the Top in education, but we have a long way to go before the average person can get actionable information on where and from whom to get the best education or health care. 

• Not Rewarding Excellence: For the past thirty or so years, both public and private payors have moved away from paying based on charges and more on using predetermined fee schedules. This had the (hopefully) unintended effect of rewarding health care providers for average, not actual, performance.   Similarly, in education, teachers’ compensation was largely driven by tenure; the longer one had taught, the more they were paid.  In neither sector was excellence rewarded or poor performance punished.  Health care is now creeping towards “value-based purchasing” and education towards various forms of pay for performance, but the new systems are not widespread nor do they generally comprise a significant portion of compensation.

One might expect that the professions involved would be leading the charge to measure and improve performance, and to reward excellence, but by and large that has not generally been the case.  In his recent book Class Warfare: Inside the Fight to Fix America’s Schools, Steven Brill noted a mentality where teachers’ unions treated criticism of any teacher as criticism of every teacher, and it struck me that the same is all-too-true for health care professionals as well.  We have to get away from that.  The fact is that there are better teachers and worse teachers, better schools and worse schools; better doctors and worse doctors, better hospitals and worse hospitals.  It is crazy that we as purchasers of these services are not demanding not only to know which are which, but also demanding the ability to take our children/ourselves – and our money -- to the best practitioners. 

Measuring quality in either health care or education is, indeed, hard to do, but better performance from both systems is absolutely critical.  We’ve not going to emerge from the 21^st century with the kind of country we expect unless we demand better performance.  Anyone want to bet which system reforms the fastest?

MCOL Blog | Key healthcare business trends to watch for 2013

By Claire Thayer, January 7, 2013

The 11^th Annual Future Care Web Summit will be held on January 24^th this year.  An expert faculty panel has been assembled to discuss a variety of pressing healthcare business trends to watch out for throughout the year. The live 90 minute webinar will feature thought leadership from PricewaterhouseCoopers on health reform and the 30 million newly insured, new Mercer research findings on employer health benefit trends, as well as Oliver Wyman research on ACOs. In addition, the Web Summit event includes three On-Demand presentations on the following topics: Accountable Care provider issues; private health insurance exchanges; and health cooperatives. Hope you can join us! http://www.healthwebsummit.com/futurecare.htm

TrendSoup: Ten Key Healthcare Business Trends for 2013

By Clive Riddle, December 19, 2012

There may not be a point to ranking the components in a collection of the top trends to impact the business of healthcare in 2013. It can be difficult to say what specific trend singularly will be the most important – beauty may be in the eye of the stakeholder. It would seem that top tier trends all converge and have some degree of effect on each other – kind of like the ingredients of a soup.

So here’s what this chef sees as the ingredient list – in no particular order – of the 2013 TrendSoup for the business of healthcare:

Exchanging Confusion with Public Health Insurance Exchanges

It is not too daring to predict a good deal of confusion will reign for all stakeholders involved with public health insurance exchanges during 2013, as everyone scrambles to prepare for HIX implementation in 2014. Guidance won’t be able to get produced fast enough; guidance won’t anticipate all the scenarios, and a monumental level of decisions and development must be delved into. It won’t be for the faint of heart.

Employer embrace of Defined Contribution Approach

Interest in private HIXs took off during 2012, and even though public HIXs were validated by SCOTUS and the November elections, it is clear that public and private exchanges can co-exist, and that mid-size and large employers are intrigued by utilizing private HIXs to facilitate a switch to defined contributions for health benefits, particularly for those still involved with retiree benefits.

Medicaid Matters: Implications for local Medicaid Plans

Size Matters. Therefore in healthcare, Medicaid Matters. Starting in 2014, the formerly uninsured will shift in sizeable numbers into the Medicaid system. Much attention has been given to the implications for national Medicaid plans – WellPoint acquired Amerigroup – all eyes are on the implications for Centene or Molina. But the real impact, and larger implications, may be spread over the blanket of local, publicly run Medicaid plans throughout the country. The question is – how will the Medicaid Surge transform the local plans?

Early Successes and Failures of Medicare ACOs

With any major new model of care delivery and payments, comes the buildup and the teardown.  So much has already been said about the hopes, dreams and aspirations for what ACOs can do for healthcare. In 2013, enough early experience will exist for Medicare ACOs, that the inevitable examples of big failures will emerge, with pundits and naysayers gleefully parading out their case studies, proclaiming that ACOs are a big bust. Similarly, there will be big successes that will emerge, with pundits and cheerleaders cheerfully parading them out as well.

Employer and Health Plan Embrace of Commercial Accountable Care Arrangements

The real ACO action around the country may be in how major national and regional health plans are investing in building and securing accountable care arrangements with provider organizations for commercial populations. Already a big deal in 2012 – the level of activity will continue to increase in 2013.

Integrated Healthcare Momentum

A greater  number of healthcare systems will either expand their integration efforts, or initiate such steps, with a particular emphasis on medical home development, accountable care arrangements, full system EHR, and some level of administrative capability to function as a payer, while not typically going so far as a licensed commercial health plan.

Hybridization of Employer Worksite Clinics

Onsite workplace clinics continue to gain in popularity among very large employers, to fulfill a number of objectives – reducing costs, improving access, reducing time off work for appointments, implementing a medical home, and many other strategies. But the concept appeals to a wide number of employers that can’t swing implementation due to their size, physical campus logistics, corporate capital constraints or a variety of other issues. 2013 will find development of more hybrid arrangements, such as shared sites between multiple employers or employer coalitions, TPA or health plan sponsored sites for large clients, mobile clinics rotating between sites and other arrangements.

The Convergence of EHR critical mass, readmissions and analytics

A much wider swath of the provider universe now orbits around EHR. Among other EHR implications, 2013 will find many more provider organizations mining their newfound trove of electronic data to conduct analytics, particularly for readmissions management strategies.

Medication Adherence Becomes a Bigger Target

Whether as part of wellness incentive programs, disease management programs, hospital readmissions management, or other care management initiatives; the realization will become even clearer in 2013 that medication adherence may the largest, lowest hanging fruit for stakeholders to focus on, with a wide range of approaches emerging to better address this long-standing issue.

Explosion of mHealth and Emergence of Breakthrough Apps

There’s an explosion of any kind of app, so it follows there’s an ongoing explosion of available healthcare apps. What will also shakeout in 2013 is that a handful of these mHealth apps will gain traction, go mainstream, and will be coming to an iPad near you, this New Year.

MCOL Blog | Latest Trends in the California Healthcare Market

By Claire Thayer, December 18, 2012

The Healthcare Crystal Ball: California in 2013

Join us on Wednesday this week as three leading experts discuss important trends in the California healthcare marketplace. This exciting event will touch upon all of the major hot topics, including: Health Insurance Exchanges, ACOs, Medical Homes, employer covered insurance, hospital and physician trends, ACA implementation, and more. We hope you'll join us to hear three of California’s most dynamic leaders in the healthcare industry: Steven T. Valentine, President of The Camden Group; Henry Loubet, Chief Strategy Officer for Keenan and Peter Boland, President at Boland Healthcare. Register at: http://www.healthwebsummit.com/pp121912.htm

AHIP’s Karen Ignagni Discusses Value-Based Payment Models

By Claire Thayer, December 10, 2012

Karen Ignagni, AHIP’s President and Chief Executive Officer, says that we need to move from paying clinicians and hospitals based on volume of services instead to a payment methodology based on the value of the services provided.  In this four-minute video, Ms. Ignagni discusses collaborative strategies that health plans and their provider partners are engaged in, in an effort to change the way payment is designed and delivered. 

To view the entire four-minute video on HealthShareTV: http://www.healthsharetv.com/content/karen-ignagni-president-and-ceo-ahip-discusses-value-based-payment-models

Members from Mars and Their Cars

By Laurie Gelb, December 10, 2012

You wake up one morning and decide gasoline costs are just too high. You want to begin filling your car's gas tank with water, which is, of course, much cheaper. You call your mechanic to find out if this is a good idea. He sadly tells you that it will not work. Chastened, you text your broker to invest in some alternative energy stocks.

What is unlikely about this scenario? Well, first and foremost, you have already internalized the fact that water will not run your car. You don't blame car manufacturers or your mechanic or even the oil producers for this. You don't call them biased and part of the IMF conspiracy. You recognize that what they all say (and consistently) is a fact and you proceed accordingly. In part, this is because you have abstracted at least of the chemical differences between gasoline and water, which will also help you recognize important safety hazards  like not throwing water on certain types of fires.

How much do your members and patients know about the vehicle they occupy 24/7-- their own body?  How much do you know about what they know? How many hopeful or destructive assumptions are they making, seeking information about, and/or simply acting on with no relevant evidence at all? Apart from transactional correspondence like enrollment and EOBs, the common thread within all your health communication can perhaps be described as attempts to drive behavior and choices that safeguard your customers' vehicles, if you will.

Unfortunately, health and disease management are often perceived in terms of being a cheerleader for fresh fruit snacks, when instead patients could most benefit from the calm, factual mechanic who leverages his customer's existing knowledge to improve understanding of the mechanisms that run your car. If you in a moment of extreme forgetfulness or frustration did ever call your mechanic and ask, "Why can't I use water in my gas tank?" he probably wouldn't begin his answer with, "For centuries, cars have been designed to utilize gasoline" or "Are you insane?" He'd probably say, "Carl, I realize it's tempting [empathy] but not only won't it work, it'll destroy your car's engine [clarifying stakes]. If you want to save money, have you thought about buying a car with better mileage or a hybrid? [positive alternatives] What are you driving now, that old Buick? [baselining]" And so on.

The bottom line: any mechanic or service provider...until we get to health care, education and a few other problem areas... that receives frequent customer calls and has a successful practice has likely learned how to communicate reasonably effectively while still driving repeat business and trust. And the auto/energy industries as a whole have largely succeeded in disseminating/reinforcing certain key bits of information on a pre-need basis. So the least sophisticated teenager knows not to pour water into a gasoline-powered engine, complete klutzes like me can put air in a tire or change a light bulb and life goes on.

Yet, with the stakes higher in medicine, people don't always dose analgesics correctly. Why? In part, we have failed to remain calm, neutral information providers in the face of human fear, anger, denial, confusion and vulnerability. Health care is no more the place for cheerleading or fear-mongering than the automotive world. Auto dealers do not post signs saying "Warning! Buying the wrong car could result in a fatal accident!"  even though technically it is true that car integrity/stability/maneuverability varies. Instead, they build a case across media channels, back it up with evidence and build its salience via brands. Which do you think is safer, a Volvo or a Lamborghini?

When a migraine or cerebrovascular event strikes, we want the patient to be responsible with OTC preps and seek care if/as needed. These are both pre-need education stories, but they only get internalized to the extent that they are believable. When they are dogmatic, on the order of "Are you insane?", contradictory, jargon-laden and/or confusing (sound familiar?), they cannot be internalized as early and often fail to drive outcomes.

So before you approve any more educational copy this week, you might ask your mechanic if it makes sense.

Healthcare Customer Service and Retention Concepts and Relevant Data Don’t Have to be Specific to Healthcare

By Clive Riddle, December 6, 2012

There can be a mindset within the healthcare industry that management of most core business functions need to be very healthcare specific in order to be relevant. Of course there is truth to that, but sometimes, those within the industry can use healthcare specificity as an excuse for performance levels that might not otherwise be acceptable in other service industries, or as blinders to ignore relevant knowledge and benchmarks that would undoubtedly prove beneficial to the healthcare organization. 

With this in mind, we call your attention to a study just conducted by Accenture, addressing customer service and marketing across ten service industries (including wireless phone, internet service, life insurance and retailers, but not including healthcare). The annual Accenture Global Consumer Survey  pulled together results from 12,000 consumers from 32 countries including the U.S. 

Here are some findings that should have applicability to healthcare, even if the data wasn’t healthcare specific:

• One in five consumers switched companies they buy from; 85% of consumers say the companies could have done something differently to prevent them from switching
• 67% pointed to having their customer service issue resolved during their first contact as a factor in switching
• 54% might have remained loyal if they had been rewarded for doing more business with their provider
• Broken promises are a top area of frustration for consumers, according to the survey: 63% indicate it’s extremely frustrating when a company delivers a different customer service experience from what it promised upfront
• 78% of consumers say they are likely to switch providers when they encounter such broken promises
• 65% are likely to switch when having to contact customer service multiple times for the same reason
• 65% are likely to switch when dealing with unfriendly customer service agents
• 61% are likely to switch when on hold for a long time when contacting customer service
• 48% say that, compared to 12 months ago, they have higher expectations of getting specialized treatment for being a “good” customer
• 50% say it is extremely important for customer service people to know their history so they don’t have to repeat themselves each time they call
• 31%  prefer companies that use information about them to make their experience more efficient from one step to the next; but only 24% said their service providers deliver tailored experiences 

Accenture found that, on average, consumers use various channels to learn about and select service providers, including:

1. Word of mouth, relied upon by 79% of consumers
2. Corporate websites, used by  71%
3. Online sources such as expert review sites, news sites and product comparison sites, used by 63% 

Robert Wollan, global managing director of Accenture Sales & Customer Services tells us “the sobering reality is that ‘tried and true’ strategies for customer acquisition, loyalty and retention are struggling to keep pace with consumers who are perpetually in motion, more technologically savvy than ever, and increasingly unpredictable. The news this year is that customers want to be loyal but customer service often fails to meet their expectations. In the digital marketplace, companies must improve social listening capabilities and apply predictive analytics designed to quickly identify and respond to potential customer issues before problems arise.”

PWC Health Research Adds Team Focused on Healthcare Policy and Regulatory Issues

By Claire Thayer, December 3, 2012

PwC’s Health Research Institute has announced the expansion of its health industry research arm to include a dynamic new team focused on healthcare policy and regulatory analysis.                     

Based in Washington, DC, the regulatory team will issue a weekly report and periodic in-depth examinations of major legislative and regulatory developments, providing analysis on the implications for organizations across the health spectrum, including insurers, providers, pharmaceutical and medical device companies, as well as employers and consumers. 

Benjamin Isgur, a director and former legislative director for the Texas House of Representatives will oversee the new team, comprised of:  Matt DoBias, Bobby Clark, and Caitlin Sweany.

For more information, read PwC’s press release at: http://www.pwc.com/us/en/press-releases/2012/pwcs-health-research-institute.jhtml

Wait – Health IT Increases Costs?

By Kim Bellard, November 29, 2012

Two recent reports challenge the prevailing conventional wisdom that increased spending on, and use of, electronic medical records and other clinical health IT will help control costs.  If these are true – and it’s too early to be sure – it may be because we’ve approached health IT in the wrong way.

Kaiser Permante looked at their experience in their Colorado plan for five years, comparing the utilization of 44,000 users of My Health Manager, Kaiser’s patient portal, to 44,000 non-users.  Pretty much across the board -- from office visits to ER visits and even inpatient stays, among other measures – the online users had higher utilization, and their utilization went up after gaining online access.  Kaiser’s portal allows for email consultation with their physician, but not only did that not deter some of these increases, the online users’ telephone calls per member were still actually higher than non-users.  

There’s more bad news for health IT proponents.  The New York Times recently reported that their analysis of Medicare data indicates hospitals are collecting more than $1billion more in 2010 than five years prior, in part because of how they have changed billing codes in the emergency room.  The Times associated many of these increases with introductions of electronic medical records in specific hospital systems, and asserts that some physicians outside the hospital setting are also using their EHRs to maximize billings.

The belief is that the EHRs can prompt physicians to code their documentation in ways that maximize payment, or to “cut and paste” documentation from other patient visits which might not accurately represent the services the patient received.   Some of these practices would be fraudulent, while others are just part of the ongoing arms race over up-coding.  Either way, the EHRs may be helping.

Raising yet another red flag, the HHS Office of Inspector General just issued a report warning that CMS does not have appropriate safeguards in place to monitor the EHR incentive program, either prior to the incentives being paid or once they’ve been paid.  The outcome could be fraud and/or less meaningful use than anticipated.

Meanwhile, a study on e-visits by Dr. Attev Mehrotra and colleagues had more mixed results.  It looked at visits for sinusitis and UTI for 4 primary care practices.  Their results found the e-visits resulted in significantly fewer tests being ordered for UTIs, but also a higher rate of antibiotics prescribed for both conditions.  The rate of follow-up care – a rough proxy for misdiagnosis -- was similar for e-visits and office visits.  The authors did not look directly at costs but their estimate was that e-visits may have led to lower costs per visit, taking into account the lower reimbursement for the e-visit itself.

For better or worse, EHRs would seem to be here to stay.  A recent survey by The Commonwealth Fund illustrates this.  CWF surveyed primary care physicians in 11 countries, including the United States.  Between 2009 and 2012, use of EHRs went up from 49% to 69% in the U.S.  Of course, seven of the other countries still are ahead of the U.S. in adoption rates, by as much as 30 percentage points.  And only Canada started from a lower point. 

More disappointingly, the U.S. ranks in the middle of the pack for “multifunctional HIT capacity,” with only 27% having EHRs that allow them to generate patient or panel information, or to give them clinical decision support.  We rank in the lowest third for ability to exchange patient information or test results with doctors outside their practice, with only 31% of U.S. primary care physicians having that ability.   We’re certainly not living up to EHR’s potential.

Consumers certainly appear ready for the new world.  OptumHealth recently found that three-fourths of consumers want online access to their records, although only 40% currently report such access, and 60% want to communicate with their physicians online.  Similarly, Manhattan Research found that 73% of American adults use online health information and tools, and 54% of online consumers are using the online resources in their choices of providers, treatments or services.  This is most pronounced for newly diagnosed patients.  This is good news, I think, although I’m still skeptical about how good the information is by which consumers may be making these choices.

Which leads me back to the Kaiser study and the NYT analysis.  The Kaiser results suggest to me that more engaged patients are taking advantage of the online resources, and at this stage of EHR evolution it doesn’t surprise me that those engaged patients are care-seeking.  As for the alleged up-coding the NYT warns of, to the extent the EHRs are prompting physicians to be more thorough, that’s a good thing; to the extent it is facilitating fraud, it must be fought.  The proof of the pudding is in the eating; in this case, how are patients faring with their treatment(s)?  This is where only EHRs offer us hope to give us better information, and why we can’t give up on them just yet. 

Many providers have embraced EHRs and health IT to improve their delivery of care, while others are still gamely trying to figure out how to do so.  Any provider that is not trying to re-engineer their processes may have a tough time in the coming years, so kudos to the ones aggressively taking advantage of technology to help patients.  Why taxpayers need to subsidize this kind of re-engineering, though, I’m less sure. 

It strikes me that the HITECH stimulus has compounded the provider-centric focus of our health care system.  It does, after all, pay providers for provider EHRs, and Meaningful Use for consumers is essentially only an after-thought.  The current incentives could mean that patients end up with access to disparate records at their various providers, and if they are lucky some of those provider systems may share data.  We should be expecting more than that.

We continue to think about patient data incorrectly.  A case in point was reported recently by The Wall Street Journal.  Long story short, Medtronic defibrillator devices now produce significant amounts of data wirelessly once implanted.  Medtronic shares the data with the patients’ cardiologists, and is now trying to further monetize the data through sales to payors or other entities, but does not see the patients as either customers or even entitled to the data.  That data is generated from those patients’ chests, mind you.  Medtonic and some physicians see the data as too complex for patients, but maybe they’re not thinking hard enough about how to make it useful to those patients.

Instead of HITECH, perhaps what we should have done was to stimulate the patient health record industry, transforming it from simple medical records to virtual health assistants.  These online assistants would take information from various providers’ EHRs, from the ever-increasing number and types of monitoring devices available, and from patient inputs, plus offer patients features like dashboards that summarize their health, suggestions for improving/maintaining their health, and assistance with choosing appropriate treatments and/or providers when necessary.  I bet IBM would see a potential role for Watson here.

A patient-centric health system would start an EHR initiative by analyzing what information patients need, and then determine what information was needed from the providers’ records to support that information.  Instead, we have provider-specific EHRs that can’t talk to each other and that patients often can’t understand – when they are fortunate enough to get access to them. 

As long as EHRs and health IT continue the provider-centered, provider-siloed approach of our current health system, I’m not holding my breath for them to really bend either the cost or quality curves.