Benchmarking Employer Onsite Health and Fitness Centers

By Claire Thayer, December 13, 2011

MCOL’s Healthcare Web Summit announces the Benchmarking Employer Onsite Health and Fitness Centers, scheduled for Thursday, January 19^th from 1:00 PM to 2:30PM Eastern. Regardless of size, every employer needs comparisons in their efforts to design, manage and expand the capabilities and performance of their worksite health and fitness centers. This session will provide attendees with the results of surveys intended to help employer-sponsors of such facilities benchmark against others.

More information: http://www.healthwebsummit.com/nawhc011912.html

Employer Positions on Health Reform: Measuring a Moving Target

By Clive Riddle, December 8, 2011

A multitude of studies continue to measure and monitor employer reactions to health reform. The big question typically included in surveys has to do with the employers likelihood of continuing to provide group health coverage. Findings have not been altogether consistent, some studies like McKinsey’s estimate earlier estimated 30% of employers would drop coverage once Health Insurance Exchanges became available, while others estimate a far lower number.

Gfk Custom Research North America this week released findings from such a study (surveying 502 private sector companies) that seems to land in the middle ground, and thus might be a reasonable assessment of employer’s current state of mind. Here’s what Gfk found overall:

• 56% of employers surveyed are likely to continue to offer employer-sponsored health insurance after health care reform is fully enacted
• 12% of benefits decision-makers say they would be very or somewhat likely to drop coverage
• 32% are unsure what they will do

But the important thing to emphasize when bandying about such numbers is the size of the employers surveyed. Gfk notes that “only four percent of decision-makers surveyed from those companies with 500 or more employees considering terminating coverage completely. In addition, decision-makers who say they are familiar with health care reform are less likely to foresee their dropping coverage (7 percent, versus 15 percent among those not familiar).”

In fact, given that HIXs (Health Insurance Exchanges) are being designed to target small businesses in addition to individuals, it is not a bad thing – and one should expect – that employers in that sector would be considering dropping their own group coverage in favor of the exchanges.

The survey also found that employers don’t believe reform will save anyone money:

• 11% believe costs of health benefits will increase more slowly than if no reform had passed
• 51% think costs will increase more rapidly because of reform.
• 38% are not sure about the effect of health reform on future costs.

Ten Trends to Tend to in Two Thousand Twelve

By Clive Riddle, December 1, 2011

Alliteration abounds inside the MCOLBlog crystal ball. What trends and issues will significantly shape the business of health care in 2012? The MCOLBlog crystal ball knows all, sees all, and now tells all:

1. Supreme Court Affordable Care Act decision and presidential election will either cause chaos, or be impetus to for those waiting on sidelines to get moving
   
   If the Supreme Court knocks down just the Insurance mandate, a mess will ensue. If the Supreme Court knocks down the entire Affordable Care Act, supreme chaos will ensue. How to handle all the midstream programs and initiatives, how to undo some things that perhaps can’t be undone? Confusion will reign for awhile in this event, as detailed guidance won’t be handed down the same day as the court’s decision. To whatever degree stakeholders perceive the outcome of the presidential election will change - or keep - the administration, Affordable Care Act implementation activities could grind to a halt or hasten the pace. Should the Supreme Court validate the Affordable Care Act, and should the current administration be re-elected, the stakeholders who have chosen to sit on the sidelines will be pushed to get more than their toe in the water of the deep end of the pool.


2. Attempts to dodge the bullets of Automatic Medicare Payment Cuts will consume Providers lobbying resources
   
   So the SuperCommittee failed. HFMA cites that as result, and barring a subsequent agreement,  “Medicare provider payments would be reduced by up to 2 percent, while Medicaid would be spared. Hospitals would likely see an estimated $63 billion in Medicare cuts through 2021, while physician reimbursements would be reduced by $25 billion, according to forecasts by the Centers for Medicare & Medicaid Services.” Conventional wisdom is that some agreement will be reached in 2012 to avert a Medicare provider disaster, but this will be at the expense of consuming the waking hours and legal & regulatory budgets of hospital, physician and related providers and their industry associations.


3. Significant resources will be allocated towards the holy grail of reducing preventable hospital readmissions
   
   Purchasers, whether they be Medicare, Medicaid or Commercial, are driving the readmissions train through hospitals in the form of value based payment arrangements, compliance requirements, and other structures. Hospitals are generally onboard, but the question remains where the train is headed. Can- and will - true improvements in quality and utilization be achieved; and how will this be accomplished? A lot of money and resources will be spent by hospitals, medical groups, vendors and purchasers in this pursuit. The jury is still out on the ROI – MCOL’s own October 2011 stakeholder e-poll asked “do you feel the current level of national attention and initiatives regarding hospital readmissions will ultimately result in significant reductions in avoidable readmissions?” 40% answered yes, 49% maybe and 11% no. The same e-poll indicated “Identification and Case Management of High At-Risk Patients” as the top choice as the single most important factor in reducing overall hospital readmission rates. The problem for 2012 is in identifying the high risk patients. A recent JAMA article by Devan Kansagara MD et.al. concluded that “most current readmission risk prediction models that were designed for either comparative or clinical purposes perform poorly.”


4. Hospital Systems will ramp up physician integration initiatives
   
   Many hospital systems are already at various points down this path. 2012 will see them taking steps forward, not backward, and increased traffic from new travelers. Nearly three-fourths of physicians surveyed by PwC “are already in financial relationships with hospitals, and more than half said they want to move closer financially.”


5. The shift to Value Based Provider Payments will be in full swing
   
   It isn’t just about ACO payment arrangements. Value based provider payments are to officially be named the flavor of the year at all employer, health plan, government and provider network restaurants in 2012.


6. ACO progress will occur in Commercial  health plan initiatives
   
   ACO development slowed in 2011 until the Medicare Shared Savings Program Final Rule was issued, and offered somewhat more favorable conditions for at least some stakeholders, and now the brakes have been lifted from a number of provider Medicare ACO initiatives. But the timetable for these programs is longer, and the real hub of ACO activity in 2012 is in commercial health plan partnerships, which continue to spring up. An increased number of commercial ventures will appear in 2012, and results (good and bad) from early adopters will become more apparent.


7. Accelerated demise of the small physician practice
   
   The list of woes for a small physician practice is long, growing, and facing a number of impending deadlines and other “shoes” to drop. Pick your poison: Meaningful Use compliance; ICD-10 conversion;  increased overhead costs in an economic downturn; the specter of Medicare and other program payment cuts (see above); increased difficulties in recruiting junior partners to a small practice; increased patient expectations for ehr, patient portal and other technological capabilities; increased purchaser compliance requirements; value based provider payment arrangements that require greater infrastructure to succeed; and purchaser initiatives and market forces to drive patient populations into more integrated networks.


8. “Retailization” of health care will advance more than ever
   
   There are so many marketplace, health reform and other forces converging to fuel the” retailization” of  health care beyond its current orbit. Medicare, and increasingly – Medicaid, offer selection choices at the individual level. Public and numerous private health insurance exchange initiatives are in full swing (with private initiatives immune from any Supreme Court or election-day mood swings) that offer significant potential to drive a material portion of commercial health plan offerings into a full retail venue. Consumer driven plans still continue to grow, which nudge the health care consumer into more of a retail mode. Generic drugs (see below) are now often priced below health plan copayment levels, meaning consumer can shop on a retail basis for applicable generics regardless of health insurance restrictions. Employer and health plan continue to expand initiatives to further empower consumers, such as with wellness initiatives, or to offer new direct access choices such as on-site clinics. Furthermore, technology enhancements and expansion, via web portals, mobile pda apps, consumer ehr interfaces, and much more, continue to facilitate this retail environment.


9. Implications of Consumers’ further embrace of generics will be far reaching
   
   What was innovative several years ago when Walmart introduced national flat copayment-0like retail pricing for their generics, is now mainstream with major pharmacies. Generics accounted for 78 percent of retail prescriptions in 2010, up from 63 percent in 2006. Health plan and employer initiatives to drive consumers further towards generics were taken up a number of notches by these pharmacies’ retail pricing programs. Beyond increased use of generics, there are a number of implications for 2012 and beyond. Pharmacies will continue to enhance and shift  their retail marketing efforts and channels for these package priced generics. Consumers are now increasingly purchasing their generic drugs outside of their health insurance because the price is below the cost sharing requirement (see above). This could ultimately drive even more health plan prescription benefit designs into deductibles (to pull these outside prescriptions back into the fold – as the consumer would need to meet the deductible requirement.) In the short term, the situation will cause an increasing vexing problem for providers and health plans trying to maintain a complete ehr for a patient, and prevent data loss for analytics staff trying to manage these patient populations



10. Health Plan M&A Activities will continue to concentrate in government sector
    
    Many health plans are strategically trying to increase their member mix with program patients (vs commercial.) 2011 witnessed a number of such national health plan acquisitions of companies serving these populations: Cigna acquiring Healthspring; AmeriGroup acquiring Health Plus (Medicaid); WellPoint acquiring CareMore; and UnitedHealthGroup acquiring XLHealth.  2012 should witness additional acquisitions, including more Medicaid in addition to Medicare. As Medicaid has a large presence of non-profit and publicly owned plans, such ventures may also be in the form of management contracts and other structures.

Managing Patient Security and Privacy on a New Data-Sharing Playground

By Claire Thayer, November 24, 2011

MCOL’s HealthcareWeb Summit announces the Managing Patient Security and Privacy on a New Data-Sharing Playground, scheduled for Wednesday, January 25th at 1PM.  Join PwC's Sarah Haflett, as she presents findings and insights from 2011 HRI research encompassing a survey of more than 600 provider, health insurer, and pharmaceutical/life sciences professionals on the privacy and security implications of the explosion of new data sources and uses in the healthcare industry; and interviews of 25 chief privacy officers (CPOs), chief information security officers (CISOs), chief information officers (CIOs), and other executives of healthcare organizations. 

More information: http://www.healthwebsummit.com/data012512.htm

Transparent Cost Networks: A Consumer Driven Solution

By Claire Thayer, November 22, 2011

MCOL’s HealthcareWeb Summit announces the Transparent Cost Networks: A Consumer Driven Solution, scheduled for Thursday, February 9^th at 1PM.  Milliman's Will Fox discusses the issues, implications and components of a transparent cost network, and the specific approach and steps involved in implementing the network.

More information: http://www.healthwebsummit.com/milliman020912.htm

A Health Care “Moon Shot”

By Kim Bellard, November 15, 2011

There was a great op-ed in the New York Times a few days ago, in which Frank Moss – a former Director at M.I.T.’s Media Lab – called for a radically different approach to health care, a technology-driven approach he calls “consumer health.”  It would use technology to monitor and advise consumers about their health, with technology-based consultation with physicians or other health care professionals as appropriate.  Moss argues that not only might this approach improve health and reduce costs, but also would create significant export opportunities.  I like many of the ideas, but what I especially love is the call to be truly bold, like President Kennedy’s call to put a man on the moon in the 1960’s.  You don’t see much boldness in health care reform these days.  

There are things about Moss’s future that trouble me – it can seem a little Big Brother-ish – but the technology is, in many ways, the easy part of reforming the health care system; it is the rest of the infrastructure that stands in our way.

To that end, and on the advice of Daniel Burnham (“Make no little plans; they have no magic to stir men’s blood…”), here are sacred cows I’ll take on:

• More consumer responsibility: for all the complaints about how expensive health care is, most consumers have been spoiled.   I.e., only 31% of covered workers have a deductible of $1,000 or more, their average copayment for a primary care physician is still only $22, and their portion of premium contributions was only 18% for single coverage/28% for family coverage (Kaiser Family Foundation).   Certainly some individuals and families are devastated by health care costs – and this is unacceptable – but the frustrating part is that the system, by and large, doesn’t reward consumers for managing their health effectively. 
  
  We don’t want to punish people who have high health costs simply because of what is, essentially, an accident – whether that be genetic, physical calamity, or unexpected exposure to infections, to name a few.  Regardless of what their health status is or how it got that way, we do want to reward people who actively take efforts to maintain and improve their health.  Various wellness programs – typically employer-based – attempt to do this, but their ability to monitor, intervene, and reward has historically been fairly limited.  With the new technological tools that are or soon will be available, we will be in a much better position to actually observe desired behaviors – and we should use those to strongly reward individuals who actively exhibit those behaviors.  If auto insurance companies can base rates on monitored safe driving patterns (see, for example, this), why wouldn’t we want the same kind of rewards in health insurance?  Lower premiums, real-time lower cost-sharing, and/or actual monetary rewards are all be options that should be used.  Consumers who do not take appropriate actions, or who do not choose to be monitored, need to be willing to bear the financial consequences of those decisions.
  
  
• End employer-based coverage: Employer-based coverage has been the dominant form of health coverage in the U.S. since the 1940’s.  Employers have pushed insurance companies into many of the innovations of the past thirty years, such as care management, more aggressive provider contracting, an emphasis on quality and outcomes, and more focus on wellness.  In many ways, it has been the employers – particularly large, self-funded employers -- who have been the leaders in innovation.  That being said, employers can also be blamed for ending community-based premiums, for “job lock,” and for creating such a myriad of distinct benefit plans that few consumers or providers can understand them, much less compare.   
  
  There are a few reasons why ending employer-based coverage will or should happen.  One is the money.  The tax preference for employer contributions to health coverage remains one of the largest federal tax preferences.  With our soaring budget deficits, it is only a matter of time before this preference is eliminated or sharply reduced – the so-called “Cadillac-plan” tax in ACA is just the start.  The second is the existence of a viable alternative.  Currently, there are many barriers to widespread adoption of individual health insurance, but once ACA’s exchanges and prohibition of medical underwriting go into effect in 2014 (unless the law is repealed or does not survive its various legal challenges), obtaining individual coverage will become much more attractive.  Indeed, McKinsey estimated 30% of employers would drop their coverage once the exchanges become operational (although this estimate was not without skeptics).   Personally, I wonder why the number is as low as 30%.  Third and finally, in the kind of monitored world that Moss calls for – which is already starting to happen – there will be increasing privacy concerns about what information one’s employer has access to.  We’ve already seen employers making employees pay more in premiums based on participation in various screenings or wellness programs, and even prohibitions against certain types of non-job behaviors (e.g., smoking).  With the kind of monitoring Moss discusses, the type and amount of potential data becomes much more personal.  At some point, consumers are going to rebel about their employer’s oversight of their lives.
  
  
• Reform medical education & licensure:  With the much lamented trend towards specialty and sub-specialty, by the time a physician gets into practice much of his initial training may be out-of-date, not to mention his/her having spent a small fortune.   Victor Fucks has eloquently argued for more distinct yet faster approaches to training, and that is the kind of fresh approach we should be considering.  I would go even further.  As a layman, the distinction between allopathic and osteopathic medicine has always been murky to me.  Throw in chiropractic, podiatric, acupuncture, nurse practitioners, and the array of health care practitioners begins to look like something from the 19^th century medicine.  One is surprised that phrenology is no longer on the list of extant medical professions.  We need a Flexner Report for the 21^st century, not focused just on allopathic training but on medical education period.  Blow it up and start fresh, with a comprehensive, empirically based approach, based on validated medical practices rather than on historical professional silos, and with different end points based on type of practitioner.
  
  As for licensure, I’ve previous blogged about the seeming ineffectiveness of state medical boards and on issues relating to licensure’s impact on telehealth.  Public Citizen’s analysis indicates fewer than half of physicians who suffered clinical practice actions also had state licensing actions.   It leads one to wonder: whose interest is the current system serving?  If we can monitor individuals in real time and advise them on better health behavior, certainly we should be able to do the same for physicians, and to use data to make better decisions about which health care professionals are practicing appropriately.  Licensure shouldn’t be based on reputation, state of residency, old boy networks, fear of impact on malpractice suits, or other constraints that aren’t keenly focused on better patient care.  It should be based on ongoing, proven performance.  We can do better. 
  
  

I could go on with this list of reforms – and I may in future blogs – but I’ll stop for now.  Each of the above changes would be a monumental task in itself, with many interest groups heavily entrenched in the status quo.  Still, to use another oft-quoted line – if not us, who?  If not now, when?

Webinar Event: Midwest: Healthcare Environment in 2012

By Claire Thayer, November 10, 2011

This event is Co-sponsored by Payers & Providers.  The year 2011 seems to be accelerating to its conclusion, but before it ends we want to contemplate what is coming over the horizon for 2012.  Join us on Dec. 9 as we convene a forecasting session with several of the Midwest’s foremost experts on how the private healthcare marketplace will be developing in the near future. It promises to be a lively hour!

More info: http://www.healthwebsummit.com/ppmidwest120911.htm<

Thoughts on the Medicare Shared Savings Program Final Rule

By Bill DeMarco, October 31, 2011

The dynamics of the new final Medicare Shared Savings regulations are re-igniting interest by many who had passed this by because the proposed regulations were overwhelming.

Several associations including AHA, AMA and AGPA who were skeptics in reviewing the proposed regulations have come out publically and see some potential here. We see the upside opportunity being improved putting more on the physician plate to better plan for startup costs and see the reduction on the number of indicators to be reported making the medical management requirement a bit more realistic. Dropping EMR requirement has been a good decision by CMS as this was a burden for many physician networks.

Finally, the concern over attribution looks like it has been replaced with a more solid assignment process of patients so physicians know who they are accountable for. Several points that are missed in these comments are:

1) Value based purchasing and all that it has become is the over arching goral of this shared savings process and we see that for private or public payers that this is a good framework to start with.

2) This is truly a BIG opportunity for Primary care to band together and manage at a higher level both clinical care improvements and financial integration of their practices in a manner that makes care delivery scalable.

3  This ACO evolution gives health plans and physician something positive to discuss with the knowledge by most plans that if the providers should become dissatisfied they, the physicians, may start their own plan.

Calling Mr. Watson

By Kim Bellard, October 24, 2011

I was going to write something about the recent controversies about the PSA test or Pap test, but the effort by the U.S. Preventive Service Task Force to use documented evidence in determining the value of periodic testing seems almost certain to be overcome by the combination of tradition, emotional responses, and self-interest by impacted parties, so I’ll let that go for another day. 

Instead I’ll turn my attention to one of my favorite topics, the use of technology to improve the delivery of health care services. 

I’m enough of a science-fiction fan to believe that I should be able to get medical advice and consultation whenever and wherever I am, from an appropriate expert (or at least a qualified person with real-time access to any necessary expertise), using real-time biomedical and other readings.  I’m glad to say that this is rapidly moving from science fiction to reality.

Earlier this month, California passed AB 415, the Telehealth Advancement Act.  The bill updates California’s prior telemedicine law, and makes various improvements to allow wider use of telehealth in California.  It allows broader use by more types of providers, removes rules requiring documentation of barriers to in-person visits, and eliminates restrictions on reimbursement for services provided by email or telephone, among other things.  The bill’s proponents claim it should save up to $1.3 billion per year to the state’s Medi-Cal program, much of which comes from electronic home monitoring programs for patients with diabetes or potential heart failure. 

Several studies (e.g., University of Texas Medical Branch and UnitedHealth Group) argue for telehealth’s particular value in care delivery for rural populations, where access to in-person services may be especially problematic.  Again, closer monitoring of patients with chronic conditions is cited as an opportunity for improved care and lower costs. 

Meanwhile, the Mercy health system has announced plans for what it calls the nation’s first “virtual care center”.  It will bring together a variety of existing and planned telehealth programs, such as the Mercy SafeWatch program.  This program is an electronic ICU, monitoring 400 beds in 10 Mercy hospitals to provide around the clock support from specialists and ICU nurses to the bedside practitioners.  Mercy plans to spend $90 million on building the center and another $590 million in technology to support their multiple initiatives. 

Similarly, Washington Health Center, in Washington D.C., announced CodeHeart, a mobile application it developed in conjunction with AT&T.  It allows cardiologists to view video and test results while a critical care patient is in transit, allowing them to better prepare for the patient’s arrival in the emergency room, where time is usually of the essence.

It’s no surprise that telehealth is a hot topic.  Manhattan Research claims that 75% of physicians own an Apple mobile device – iPhone, iPad, or iPod – and 26% of U.S. adults have used their mobile phones for health information and tools.  Mobile is rapidly becoming crucial to telehealth, supplementing prior video-conferencing capabilities.

The barriers to telehealth are no longer technological, since the increased availability of broadband connections and more robust mobile platforms have made possible a wide variety of options.  The real barriers are artifacts of historic practices, especially related to reimbursement and licensing.

Reimbursement for telehealth remains uneven.  Medicare, for example, covers some telehealth services, and is expanding its rules for 2012, but still does not do so uniformly.  For example, it is more favorable to beneficiaries in rural areas than in urban areas, and only covers live interactions, not so-called “store-and-forward” methods used for images and certain other patient information.  Fourteen states require private payors to cover telemedicine, but the rules are not consistent across states, nor do they necessarily speak to reimbursement equivalence. 

Licensing is an issue because health care practitioners are licensed by the state in which they practice.  Telehealth, of course, is not bound by geographic location, but under current laws providers in one state cannot treat patients in another state unless they are licensed in that state.  Practicing in multiple states thus is onerous. 

Both of these issues can be overcome, but it will not be easy.  Most private payors follow Medicare’s lead in reimbursement policies, so if and when Medicare makes progress in how aggressively it wants to use telehealth, the private sector should follow.  The reluctance of payors is understandable; the practice of telehealth is still in a relatively early stage, and many payors are concerned that paying for telehealth could lead to an explosion in costs.  In an ACO world, where ACOs have strong incentives to live within a global budget or budget target, employing the use of cost-effective telehealth services should seem entirely logical.  In a predominantly fee-for-service world, perhaps not, or at least not necessarily. 

As for licensing, state licensing agencies are not surprisingly reluctant to cede oversight.  They can justifiably claim that patients could be at risk by treatment from practitioners over whom they have no control and no assurance of competence.  While valid, we seem to be able to conduct inter-state commerce in other fields without abandoning consumer protection.  It argues for more uniform licensing practices and reporting across the states, lessening any particular state’s concerns.  Indeed, the American Telemedicine Association has launched an initiative – FixLicensure.org – to make licensure more appropriate for 21^st century capabilities and practices, including telemedicine.  E.g., why should my access to the best doctors be subject to my physical location?

Licensure will become even more problematic with the evolution of expert systems or artificial intelligence.  This is starting to become real; take, for example, the recent collaboration between Wellpoint and IBM’s Watson technology.  For readers not familiar with Watson, it is the system that beat the Jeopardy champions of champions.  Wellpoint plans to use Watson to help suggest treatment options and diagnoses to doctors.  With so much medical knowledge, and with that knowledge increasing exponentially, such assistance seems inevitable, not to mention highly desirable.  Still, at what point will that kind of assistance be considered practicing medicine?

History buff may recall the apocryphal story that Alexander Graham Bell uttered, “Mr. Watson, come here – I need you” into the first working proto-telephone, launching the era of electronic voice transmission.  It seems ironic, yet somehow fitting, that Watson may again be critical to launching of another technological revolution.

I = Innovation

By Laurie Gelb, October 17, 2011

If you thought the 80's were "the Me Decade," consider these the "Me, Myself & I" years. Introspection is in, singly or in groups (witness the Occupy Wall St. Movement).

What does this have to do with managed care? Depends on who's doing the managing (or thinks they are).

A top tier disease management vendor's intake form currently includes the following question:

Do you currently have any of the following conditions:

[list of 12]

where the list includes cancer, pregnancy, poor circulation, heart attack and stroke, among others, in seemingly random order.

So just as they're signing up for a program that invites unknown strangers into their care, the first thing that [mostly seriously ill, some terminal] patients learn about their disease manager-to-be is that it's insensitive to the distinctions between acute and chronic, and between clinical and colloquial dx. There is no clue as to what, if anything, a given patient should write in the "other specify" field.

What exactly would "currently having" a heart attack or stroke mean? That you should call 911, of course. So the first thing you've learned is not to take DM communication literally. It's only a short step to take it for a joke, like most of your mail.

Nor does this invitation reminder letter explicitly mention that program signup is optional, not mandatory. In fact, it finesses the difference "introducing the program...part of your health benefits coverage..." If I were the plan sponsor's risk manager, I'd feel a bit squishy.

So the promise on the accompanying letter that "Your health is important to us" (appearing once on each side of the paper) is ringing a bit hollow, no? And our introspective, seeking-the-good member is blatantly being treated like a number, a bundle of [poorly] specified conditions, from intervention day one.

There isn't a simple declarative, personal, conversational sentence in this enrollment package. The signature is in cursive typewriter font, in the proudest tradition of 1970. I've signed thousands of letters to document I cared enough about someone's behavior to wield a pen my own self.  (And yes, there are scanners, too.)

So as you expend your resources and your members' time, goodwill and wellbeing on DM, consider that for every condition listed in a vendor's portfolio, there is a SNF, a clinic, a university program, an industry pilot, a health system, a single clinician whose DM is state-of-the-art. I'm not talking about 7-8 figure CER, AHRQ style, but the one-patient-at-a-time evidence base that can blossom into something new and improved.

For example, one psychologist (whom I'm proud to say taught me Psych101 eons ago) directs translational research into innovative Alzheimer's care that has been successful in several facilities. To what extent would moving the needle on AD progression and sequelae in any setting benefit your organization and/or anyone you care about?

The corollary question is whether you have appropriate resources allocated to find and leverage this essential intellectual capital. You know that incents -- from money to recognition -- can move the needle when little else can (and let's not pretend the wormy apples of P4P or buy-me pharma grants are the same thing).  If and when you spark something real, that helps create competitive advantage that in turn adds to brand and ally equity.

Did you notice Wendy Schmidt's contest to find better tech to clean up oil spills? The winning team tripled the "industry standard." When they asked the contestants why they hadn't tried these new approaches before, the responses boiled down to, "No one else [e.g. oil company clients] cared. Everyone felt they were doing OK."

What's in your MCO's wallet? Maybe the down payment on improved outcomes for millions.  All it takes is an I for innovation.

Top 5 reasons that members ignore disease management messaging

By Laurie Gelb, October 10, 2011

1.  It's inaccurate and/or inapplicable. "Our records indicate that you have not filled a prescription for ... [recently sent to pt continuously on drug for 8Y w/ no sampling] Reverse-gender content is common. 

Variable data printing is a wonderful thing! Information can be stratified by database variables such as gender, age, zip, fills, dx and more. And it's much better to present the information standing free than the usually-unnecessary but still Orwellian "our records [about you]."

If VDP won't work, segregate stratified info and ID it with a revealing heading, so members can skip past it easily. A general newsletter directed toward all household members can do this, although it's time to question the ROI of this approach. PR, podcasts, videos, etc. should be target-specific and clearly titled, for the same reason. 

2.  It's wordy. Most Americans do not read a daily newspaper, nor read extensively in their daily activities. Data suggest the reading ability and habits of even college grads have declined. A full-page, single-spaced letter is seldom digested in full, let alone acted on. 

Use active verbs and state the facts, using gradual reveals even in print.  "For recipes and tips, call 800 VEG 4NOW or go to veg4now.com." Footnote or link the legalities rather than filling the page body.

3.  It's condescending. "You may feel that eating five servings of vegetables is too difficult, but did you know that a 6 oz glass of tomato juice is one full serving?"

Best practice: a sidebar or callout with examples of popular, little-known or tasty veg choices, without airing your assumptions about people you've never met. 

Stock photos of happy, multiracial people clusters, whether in print or on line, are a similar turnoff. Perfect people can't get sick. Picture something from real life that matters (examples in our next installment). 

4.  It's impersonal. "Some patients may..." 

Best practice: Use "you" if/when it makes sense. "You may feel dizzy, nauseated and even vomit after your first dose of an x drug."

5.  It's contradictory. Messaging about the high sodium in tomato juice has appeared adjacent to praise for vegetables and their juices. Fruit juice often suffers from the same fate. 

Choose your core objectives based on member and epi data and follow through. One well-supported message makes more impact than four throwdowns. And "lower-sodium" can modify every mention of tomato juice. As for fruit juices, recent evidence is more positive, apart from drug interactions to avoid, so why not give them their due?

-------

Each of these reasons is a way to ice the dialogue before it begins. Does the car salesman approach you and say "You look like a luxury buyer" or "I'll bet you can barely afford a beater"? No, she generally asks what you have in mind, because that's her quickest path to a sale. The more interaction, the more specific the stimuli you can present. Content that's personalized, urgent, relevant and engaging (PURE) drives behavioral change.

More, Please

By Kim Bellard, October 2, 2011

Private health plans – everyone’s favorite scapegoat – are getting rolled.  They might as well get used to it.

Kaiser Family Foundation released its annual Kaiser/HRET Health Benefits Survey, which showed that health insurance costs increased 9% for family coverage – over $15,000 per family annually.  This compares to last year’s more promising 3%.  Single coverage was up by an equally daunting 8%.

What struck me was Kaiser’s estimate that health care reform accounted for 1-2 percentage points of the increase.  It’s a good thing for the Administration, then, that the overall increase was as large as it was, so that the effects of health reform couldn’t be blamed for a larger share of the private sector health spending increases.  Whether that proportion is one-ninth or one-third of the total, though, it’s still a lot of money.  Private health insurance expenditures are on the order of $850 billion, so that 1-2% increase is a cool $8.5 - $17 billion hidden tax increase annually.  And it’s only starting. 

Just a few days ago, there were various news reports trumpeting the success of Affordable Care Act (ACA) in getting more young adults coverage, via the requirement to cover dependent children up to age 26.  Both the CDC and Gallop released findings validating the increase in coverage, estimated at some 900,000 more young people with health insurance.  But insuring these young adults has a cost.  The Kaiser study reported 20% of firms have covered young adults due to the law, an estimated 2.3 million adult children.  The difference between the 900,000 and the 2.3 million suggests a majority of those adult children might have obtained coverage on their own rather than through their parent’s insurance.  If I were an employer trying to cover my health insurance costs, I might be kind of mad about that.

Kaiser also reports that the ACA impacts are just starting to be felt.  Seventy-two percent of employers still had “grandfathered” plans, which have not yet been fully subject to ACA requirements.  Among those requirements are coverage for specified preventive care services without deductibles or cost-sharing.  Last month we saw one shoe drop in this regard, when HHS announced the list of services considered preventive for women’s health.  The services include not just birth control, but also, among others, HIV screening and counseling, breastfeeding support and supplies, and domestic violence screening and counseling – all very worthwhile services, but not all ones traditionally seen as either preventive in nature or covered by health insurance.  Then again, the federal government is requiring the private sector to pick up the costs, so serving political or social justice goals becomes part of the equation.  The Wall Street Journal reports that Catholic organizations are, not surprisingly, already upset with the requirements about contraception, and it will be interesting to see how special interests play out against other special interests in achieving ACA’s goals.

It’s going to be very tempting – too tempting – as ACA moves forward, for more special interest groups to lobby to get their services covered at no cost-sharing to the consumers.  No cost-sharing to consumers, of course, doesn’t mean no cost; it all has to get paid for somehow, and it all adds up.  We’ve been down that road with state mandates for health insurance, except that under ACA there are no jurisdictional escape routes for employers or health plans. 

Critics of health insurers, of whom there is no shortage, blame the 9% increase on health insurers trying to make their money before they are required to hit the loss ratio and disclosure requirements of AAPCA.  Those critics might want to note that Kaiser also reports that 60% of covered workers are in self-insured plans, so their argument loses much of its force, as these firms have no incentive to raise their costs any higher than necessary.  Self-insured or not, employers provide the vast majority of private health insurance, and they are struggling to afford it.  They are not an endless piggybank to be used for political purposes. 

The only “good” news about ACA I’ve seen lately is that the Administration is finally being forced to be more honest about the CLASS long term care program.  Skeptics of this program, including me, argued that the program was not structured to be sustainable. It was included as a tribute to Senator Ted Kennedy and as a way to count the program’s initial years’ premiums as revenue in the bill’s cost – rather than reserving them to pay for promised benefits.  Now it appears that HHS may try to not implement the program, having gotten rid of the actuary assigned to work on it and reportedly planning to close down the CLASS Office.   I feel bad for the people who might have benefited from CLASS, but as a taxpayer I’m relieved that we might not have jumped off this particular cliff yet.  

It remains to be seen if the 9% increase in costs is an aberration or the start of an ominous trend.  As the various ACA changes more fully impose direct costs on private health plans, and as providers continue to cost-shift to private payors due to worsening Medicare and Medicaid payment shortfalls, the prospects for holding costs down are grim.

Bad as they are, the cost increases could be worse.  Consumer Reports found that 48% of consumers are skimping on prescription drugs or other forms of medical care, up from 39% last year.  Presumably costs might be higher if patients didn’t “skimp” on health care, which included delaying a doctor’s visit or declining a test.  Of course, this concern about “skimping” on health care should be counterbalanced by questioning whether all of the recommended care was needed.  A recent study found that 42% of primary care physicians think their patients get too much medical care, driven in part by malpractice concerns and ordering tests rather than spending more time with patients (see my previous blog on addressing this).  They thought sub-specialists were even worse in this regard; 61% thought sub-specialists provided too much care.

The fact of the matter is that we still don’t know how to tell what care is needed and what isn’t, and ACA hasn’t helped accomplish that.  Yet.

Perhaps HHS will get the ACO regs right, and ACOs will flourish.  Perhaps EMRs and meaningful use will quickly yield the desired paybacks.  Perhaps the exchanges will be a boon for consumers and health plans alike.  Perhaps, perhaps, perhaps; the big problem with ACA was that it focused primarily on how health insurance is financed, not on making structural changes to how we deliver and pay for health care.  Until we do the latter – health plans, better open your wallets (and by “your wallets,” I mean “spend our money…”)!

Medicare Marketing’s Top Ten

By Lindsay Resnick, September 26, 2011

With compliance scrutiny at an all-time high, a selling-season that has been dramatically shortened, and bonus payments and year-round marketing directly tied to the CMS Star Rating system—managing Medicare Advantage aren’t getting any easier. Add to the mix a surge of baby boomers entering the Medicare marketplace at a rate of almost 10,000 every day and one thing is for sure…you better have your Medicare marketing house in order.

Below are our Medicare Marketing’s Top Ten success factors to help sharpen your approach and meet or exceed stakeholder expectations. 

1. Understand the impact of CMS COMPLIANCE – Today’s Medicare marketers must understand and respect the important role CMS compliance plays in the member acquisition process. This means making sure the link between marketing, sales and compliance is as strong as possible, always supporting the spirit of CMS consumer protections.
2. Be DATA DRIVEN to ensure a strong foundation – Always start with data. It needs to be sorted, cleaned, refined, and turned into actionable marketing intelligence. From building predictive models for most likely responders to variable direct response call-outs to optimize media buys, the goal is to bring a grow while continually lowering your cost per lead and cost per sale. 
3. Modernize your AGE-IN process – With thousands aging into Medicare every day, new approaches are needed to attract today’s boomer-seniors. “It’s not your Daddy’s Medicare.” It takes a combination of meaningful education, sequenced messaging, and innovative approaches to outreach to connect with newly eligible beneficiaries. 
4. RETAIN MEMBERS to increase ROI  – In a fiercely competitive Medicare market, aggressive “switcher” campaigns have become routine. The cost of acquiring a new member is 5X the cost of retaining an existing one. Loyalty-based member engagement plays a big role in a health plan’s long-term profitability under the label of member LifeTime Value. 
5. STAR RATINGS impact the bottom line – As CMS deploys its 5-Star Rating across Medicare plans, marketing’s role is critical to ensure member communications reinforce customer satisfaction. Engagement marketing goes a long way in a plan’s ability to achieve the highest possible Star Rating and the bonus payments that go with it.
6. CUSTOMER INTERACTION makes a key difference – Give beneficiaries a reason to engage and connect with a Medicare plan they trust. It’s all about them. It takes tested, personalized direct response marketing that create opportunities for one-on-one interaction to communicate value and answer a Medicare beneficiary’s most important question, “What’s in it for me?” 
7. Don’t ignore DIGITAL MEDICARE – As more and more Medicare shoppers use the Web as their primary research tool, it’s essential to have a Medicare online experience that’s user tested, compelling, and built for seniors. From ease-of-navigation to the images and words on your website, it needs to be tailored to your Medicare audience.
8. Consider MULTI-CHANNEL SALES that match customer preferences – Different Medicare customers require different doors of entry….some will call on the phone; others come in through a website; some prefer to respond via mail;  many like a discussion across their kitchen table; and, others may even desire a retail experience. A multi-channel sales distribution strategy is critical to success. 
9. Understand your DIFFERENTIATED VALUE – Being the health plan of choice for Medicare beneficiaries is achieved by building trust, credibility and relevancy around your value proposition. This means understanding drivers that motivate prospects to select your plan, and an ability to get the most differentiated and preferred product offerings in front of them. 
10. Measure MARKETING ROI to determine actual results – You can’t manage what you can’t measure! Combining sophisticated upfront data analytics, direct response discipline and flawless campaign execution can significantly lower member acquisition costs and increase retention. Tracking, analyzing and measuring results throughout the marketing cycle is a Medicare marketing must. 

Successful Medicare marketing hinges on educating seniors, defining value and creating motivated buyers. It takes learning as much as you can about your target market so you understand what’s important to them, what concerns them, and what they want from their Medicare plan. It will go a long way toward answering Medicare beneficiaries’ number one question—what’s in it for me?

Look Up! The Stars Are Aligning for Prevention and Wellness!

By Cyndy Nayer, September 20, 2011

I’m thinking this evening of the amazing journey we’ve begun together, and I’m thinking about the conversation I had with Dr. Joycelyn Elders, former US Surgeon General, who will open our Annual Meeting and Innovation Summit on Nov 14.  Each of our phone calls is such a delight.  Imagine being able to call the woman who “explained” to Congress how teenagers need more guidance, and to ask her some of the hard questions on national health policy!

I’ve been very lucky in this career of mine.  I’ve been blessed to work with some of the most amazing folks at every turn.  What’s remarkable is that so many of us know the real gold in health care is not the care itself, but in making HEALTH the goal of our endeavors.  What’s exciting now is that many of us “passionate idealists” are working hard to make sure that the improvement in health is the #1 priority, and that health care becomes one of the tools to get there.

Each of us approaches this in different ways.  For instance, Brian Klepper, whom you often read about when you read my writings, is passionately moving the needle on Primary Care Providers, blogging on Health Affairs and causing a ruckus with the RUC (the panel that sets clinician reimbursement rates, the panel that is so very much under-represented by primary care physicians).  Brian’s efforts are getting bolder and growing stronger, and I am an ardent supporter of the efforts to be sure that Primary Care gets equivalent pay that shows their importance in the health engagement and promotion that keeps people well, working, and building healthier, prosperous communities.

Another good friend is Ron Loeppke, MD MPH, whom I’ve know for far too many years to remember.  Ron’s passion is now directed to his new job, as Vice Chairman of the Board, U.S. Preventive Medicine, Inc. (traansparency: I have the honor of serving on the board with Ron and so many of our mutual friends).  Ron is also the past Chair of the American College of Occupational and Environmental Medicine (ACOEM), and has chaired the Health and Productivity section for as long as I can remember.  Recently, Ron wrote an op-ed piece on the need for preventionists, and it’s posted on the ACOEM site.  Ron has been a driving force for linking worksite health to worksite performance, and we’ve had the joy of sharing many conferences, slides and ideas together.  As he says in the article:

The clinical science of preventive medicine focuses on wellness and health promotion and health risk assessment to keep people healthy (primary prevention); and early identification/diagnosis of illness through age/gender/risk appropriate screening and biometric testing (secondary prevention); as well as earlier evidence-based intervention/treatment to deter complications and the disabling impact of conditions (tertiary prevention). The preventive health care movement reaches well beyond the four walls of medical facilities to include workplace health and community health initiatives. 

I quote this as others in the space of value-based designs do not see the ROI of prevention and wellness.  But think about it:  if we can prevent the high cost interventions, if we can build intrinsic desire for health and accountability to save our health, the saved dollars will go far to build healthier communities.  The companies that tell me that they cannot focus on health, that they only want to get the costs down, are doing themselves, their families, and their communities a disservice.  Simply stated, if the company gets 80% or more of its workforce from the geographic community, then there is an 80% chance that the next person coming to get a job will have the same risk factors as the person who just left.  Want more proof?  Google Ron and start reading.

And on the topic of value-based designs, another friend I’ve been very much in contact with lately is Mike Critelli, the former CEO of Pitney Bowes who is now the Chair and CEO of Dossia, which is so very much more than a Personal Health Record.  Under Mike’s direction, Dossia is quickly growing into the family and community health management tool that I have been hoping for, building the capacity of families to “gather” into one record that the head of the family health improvement plan (usually the mom, folks, that’s been my story all along!), can manage.  With the strong support of a very talented group of programmers, community health improvement experts, international IT experts, and more that are too many to name, the group at Dossia is getting grand traction around the country, and I am, of course, delighted to have them on the CHVI board.  We share many strong ideas of accessibility and accountability, and then we work with our different constituencies to influence change as far and as fast as possible.

It’s stunning, isn’t it, that we expect an “engaged, accountable patient,” yet the patient gets no records, has virtually no decision-making authority except how much he/she is willing to spend out of his/her own pocket for care.  Yet, that’s not the accountable consumer we want.  We want a consumer who protects the health of herself, her family, her community.  We know, from research published by another renowned colleague, Dee Edington (of Univ of Michigan fame), that an engaged consumer of health has costs 30% lower than one who is unengaged.  We know that reducing risks from hi to moderate lowers costs 33%–that’s what happens when people are engaged, not entitled and waiting for the system to cure them.

Yes, I’m quite lucky, indeed.  Yes, I’ve used this opportunity to highlight the amazing work of my friends and colleagues AND to link to our upcoming summit, because I’m excited about our mission, and I’m excited that they will all be there with us.

Maybe, too,  as I watch the sun set over the beautiful SW Florida sky this evening, the stars really are aligning.  Perhaps we’ve squeezed as much value out of the delivery system as we can–and remember, most of the dollars, all $2.6 Trillion of them, are focused on the 10-20% of folks who are not so committed to health promotion or prevention.  Maybe now that the economics of health is so very important to understand, the stars are ready to assist.  Perhaps the stars, whose light has to travel so very far to be seen, have finally arrived in sight–and those of us who have spent so very many years promoting health, are finally being seen as well.  Perhaps the focus on outcomes allows all of us to ask the question, “How do we short-circuit the path to achieving these outcomes?”  and we can, finally, all get quiet while the stars’ universe responds, “It’s in the path to health promotion.”

It’s a wonderful night to dream of what could be, to imagine that there is a growing focus on health, outcomes, and healthy communities.  Tonight I’m not going to focus on this paradise’s need for jobs, affordable care, and primary care clinicians.  Tonight I’m going to hope and pray and dream of the US as healthy, prosperous, and job-wealthy.  I believe that’s what the stars are showing us.  If we’ll only look up, they will tell us that nothing is impossible.

A Penny (Or More) For Your Thoughts

By Kim Bellard, September 13, 2011

Let’s start with the non-news: a primary care physician association – in this case, the American Academy of Family Physicians – thinks primary care physicians aren’t being paid enough fairly and wants CMS to change the Medicare payment system.   It would be a surprise if any primary care physician organization argued any other position, and there is a lot of sympathy for the argument that primary care physicians are undervalued compared to specialists.   I’m sympathetic myself.

On the other hand, a new study in Health Affairs asserts that primary care physicians in the U.S. both are paid higher fees than primary care physicians in several other countries and also have higher incomes as a result.  The study, by Laugesen and Glied, further asserts that the higher incomes are simply the function of the higher fees, not due to higher practice costs, higher volumes, or medical school tuitions, as some have theorized.  The study also notes that the same type of gap exists for orthopedists in the U.S. versus in other countries, and that the income gap between U.S. primary care physicians and orthopedists is wider than in other countries. 

The fact of higher physician fees and physician incomes for U.S. physicians compared to their international peers is nothing new, and I’ve blogged about this previously.   With the ongoing and increasing pressures on Medicare and Medicaid spending, we can expect even more pressure on how we pay which physicians.  No one seems to be stepping up to say that they are overpaid.

A few other recent studies give me pause about this topic.  On of the most interesting was a study from Israel that concluded medical history and examination were more important than extra tests, particularly CT scans, in making a diagnosis.  The authors found that added tests only helped in about one-third of the cases, while adding significant costs and exposing patients to additional radiation and its attendant risks (see, for example, this nice summary).  This was in Israel, mind you, and one can only imagine how many more “extra” tests are performed in the U.S., given our culture to always do more and patients’ demand that everything possible be done, regardless of cost-benefit.  It’s nice to have it confirmed empirically that cognitive skills still trump technology most of the time. 

An example that dramatically illustrates this is a recent study about the effectiveness of “brain stents” to prevent strokes.  The study not only found the costly procedure was not more effective, but actually was worse for patients than those treated conservatively with drugs and advice.  Patients with the stents had more strokes and more deaths, to the extent that the study was halted prematurely once the results became clear.  Interestingly, this study is on the heels of another recent study indicating that heart stents were not more effective than medication, yet the number of such stents being performed hadn’t gone down once those results had become widely known.  The U.S. health system just seems to be in love with procedures and testing, not always to be benefit of its patients.

Now, some observers might view the results from Israel and claim that, well, if it was your mother/spouse/child, surely you would want those extra tests as well, just to make sure, since in one of three times they did prove to be useful.  It isn’t easy, after all, to tell which of the three will benefit before the fact.  It’s a valid argument, and this attitude is typical of our health care system, where doing more is usually seen as better.  We don’t seem to have this attitude in all aspects of our life.  If, say, it turned out that police routinely arrested three people to find the one person who was guilty, there would be cries of outrage across the board.  We’d argue indignantly that the police need to take a little more time to be sure they had the right person before making arrests.  We seem to hold our policemen to higher standards than we do our health care practitioners, and I’m not quite sure why.

I enjoy watching the television show House, in which it’s grumpy, damaged lead physician plays Sherlock Holmes with baffling diseases, eventually putting together all the clues to (usually) save the patients’ lives.  Every time I watch it, though, I have two reactions – first, those poor patients, who are put through a bewildering and often painful array of tests and procedures before the Dr. House reaches his miraculous conclusion, and, second, who is paying for all this?  There’s never any real sense that Dr. House and his team ever worry about how much their efforts are costing, and there seems scant concern for what they put the patients through.  All House cares about is getting to the right diagnosis.  It’s great TV but a horrible patient experience.

So here’s my thought.  Let’s pay physicians more for the cognitive work, the so-called Evaluation and Management codes (“E&M”).  All doctors, any doctors, plus nurse practitioners and other physician extenders.  It’s less important which doctors get it than what we incent them to do, and what we should want them to do first and foremost is to use their intellect, training and experience to figure out what is or might be wrong with us.  “First do no harm” and all that.

We should give them not just a token increase but a major one – double, triple, pick a number, but make it a very noticeable one.  I would assert that the health care system won’t go bankrupt – well, more bankrupt – because of too many office visits, even if we start paying for e-visits and telemedicine visits, as we should.  It’s what happens from those office visits that we have to worry about – the prescriptions, the tests, the procedures and treatments that result.  Of course, we’d need to find a way to ensure that those added payments for E&M visits aren’t just additive, but actually help deter other inventions that are not truly necessary.

The pot of money available in health care is, for practical purposes, a zero-sum game.  Pretty soon employees are going to realize that their “employer contributions” for health care is their own money, and pretty soon the federal government is going to have a harder time paying for its health programs using deficit financing.  So whatever we increase in E&M payments will need to come from elsewhere in the existing spending.  For example, could we use “thinking time” as the unit of measure, so that a procedure which takes an hour to perform should get paid the same as seeing patients for an hour?  Alternatively, perhaps many tests and procedures should end up getting paid more like a commodity – more expensive initially as people learn how to do them and as the initial development costs get paid for, then rapidly dropping the price as volume increases and people get used to doing them.  We have a tendency to start out high and never drop payment levels.   Smarter people than me can figure out exactly how to make the offset, although the lobbying opposition will be very intense as every specialty fights to protect its turf.

We all like to think that the patient-physician relationship is sacrosanct.  So why not pay for it like we actually believed that?

Health Net Said: ACEP Said – A Dustup Over Emergency Room Use

By Clive Riddle, September 9, 2011

Yesterday Health Net released what they thought was a benign media statement on Emergency Room use, entitled “Know When the ER is the Right Choice for Care.” The health plan opened by stating “with flu season waiting in the wings, emergency rooms nationwide will likely soon be crowded with those who’ve been bit by the annual bug and who are mistakenly seeking treatment in the ER instead of in their primary care physician’s office or in an urgent care setting. In advance of these yearly throngs, Health Net, Inc. (NYSE:HNT) is working to increase awareness regarding when it’s appropriate to visit an emergency room.”

Jonathan Scheff, MD, Health Net’s Chief Medical Officer tells us “while emergency rooms play a vital role in our communities by providing lifesaving services, many ER visits are unnecessary” and goes on to say   “because the most serious cases are treated first in emergency rooms, those with non-emergency needs can expect extended waits.”

This wouldn’t seem like controversial stuff to most, but Health Net then goes on to state “the American College of Emergency Physicians (ACEP) points out that it’s in everyone’s best interest to reserve emergency rooms for those who are seriously ill or injured” and cites the ACEP’s list of warning signs for adults and for children a medical emergency that should demand immediate attention.

And it would seem Health Net might not have consulted and collaborated with the ACEP on their release.

ACEP fired back a media release the same day:  “ACEP Takes Issue with Statements Made Today by Insurance Giant Health Net, Inc. Regarding Emergency Visits.”  Dr. Sandra Schneider, President of ACEP tells us “the nation’s emergency physicians take issue with the efforts of health insurance companies to prevent emergency visits. It may save some money for them, but it’s bad for patient health and potentially life threatening. It also violates the spirit of the prudent lawperson law, which requires insurance plans to pay for emergency care based on whether an average person would believe they have the symptoms of a medical emergency.  In addition, emergency care represents less than 2 percent of the nation’s health care dollar, so preventing emergency visits will never put a significant dent in the nation’s soaring health care costs.”

The two organizations have different takes on using National Center for Health Statistics data. Health Net states  “according to the National Center for Health Statistics, of the more than 300,000 Americans who are treated in our nation’s ERs each day, the majority don’t require emergency care.”  ACEP cites “less than 8 percent of emergency visits are classified as nonurgent by the National Center for Health Statistics, which also says “nonurgent” does not mean unnecessary. Nonurgent visits can include broken bones and kidney infections that require treatment within two to 24 hours.”

Doctor Schneider closes with “these health plan tactics are dangerous because it puts people in situations of having to self-diagnose their medical conditions — out of fear the plans won’t pay, for example, when their chest pain turns out to be heart burn. Health plans send messages to their beneficiaries not to make any “unnecessary” emergency visits. But it’s not that simple — I’ve seen people with mild symptoms turn out to have life-threatening emergencies. ….This is a very simple message we want to share with all Americans — if you think you’re having a medical emergency, go to an ER immediately. Leave the diagnosis to the experts: emergency physicians.’”

Health Net, in its defense, closes with the tip: “for more information about when emergency care is needed, as well as about injury prevention, visit http://www.emergencycareforyou.org .” This web site, by the way, is operated by the ACEP Foundation.

The Health Care Employment Situation

Clive Riddle, September 2, 2011

With Labor Day upon us, I decided to click on over to the Department of Labor and see what was going on. As luck would have it, the DOL agency, the Bureau of Labor Statistics, was issuing their monthly report: the Employment Situation, today, so I decided to check out The Situation myself.

Interestingly, health care was mentioned in the opening paragraph of the BLS Employment Situation news release: “Nonfarm payroll employment was unchanged (0) in August, and the unemployment rate held at 9.1 percent, the U.S. Bureau of Labor Statistics reported today. Employment in most major industries changed little over the month. Health care continued to add jobs, and a decline in information employment reflected a strike. Government employment continued to trend down, despite the return of workers from a partial government shutdown in Minnesota.”

A couple of paragraphs down, I learned “Health care employment rose by 30,000 in August. Ambulatory health care services and hospitals added 18,000 and 8,000 jobs, respectively. Over the past 12 months, health care employment has grown by 306,000.”

So this month, while overall national employment was flat, health care added 30,000 jobs, and for the past year, health care has accounting for 24% of employment growth overall (1,259,000 jobs were added overall nationally during the past twelve months.)

Digging down into the detailed tables of the report, I compiled some numbers and learned that health care currently employs 14,127,500 and comprises 10.8% of total non-farm employment overall. Here’s how health care employment breaks down by their sub-categories:

• Offices of physicians: 19.6%
• Outpatient care centers: 5.1%
• Home health care services: 9.4%
• Hospitals: 39.4%
• Nursing and residential care facilities: 26.5%
• Offices of physicians: 19.6%Outpatient care centers: 5.1%Home health care services: 9.4%Hospitals: 39.4%Nursing and residential care facilities: 26.5%

These employment figures don’t account for health care’s overall employment impact, once you factor in vendors to the health care industry, health care insurance, medical schools, etc. For example, the report indicates Insurance Carriers employ 2,207,900 as of August, although health insurance is just a part of that.

Of course, while many of these health care employees will be working this weekend, here’s wishing a happy and safe labor day weekend for all.

Fewer Access Problems, More Uninsured

by Clive Riddle, August 26, 2011

That is the title to the opening section of a new study released from the Center for Studying Health System Change:  Mixed Signals: Trends in Americans' Access to Medical Care, 2007-2010, Tracking Report No. 25, August 2011 by Ellyn R. Boukus and Peter J. Cunningham.

In a statement, the Center commented on this paradox by noting “about 9 million fewer people had health insurance in 2010 compared with 2007, and logically such a large increase in the uninsured population would be accompanied by an increase in access problems. However, approximately 17 percent of the U.S. population in 2010—about one in six people—reported not getting or delaying needed medical in the previous 12 months, down from 20 percent—one in five—in 2007, the study found.”

So how can that be? The statement goes on to answer this question: “the decline in access problems was driven primarily by fewer problems for insured people, likely reflecting recession-related decreases in the demand for medical care and subsequent easing of health system capacity constraints.”

The study authors also say that access for the insured improved much more than for the uninsured.  Ellyn R. Boukus, M.A., health research analyst with the Center, and coauthor of the study tells us “while overall access problems declined, the access gap between insured and uninsured people widened in 2010, especially for lower-income people and those with health problems.”

Here’s some key findings from the study:

• The proportion of insured people reporting an unmet medical need declined from 6.2% to 4.5% between 2007 and 2010.
• 17.5% of the uninsured reported an unmet need in 2010 compared to 16.6% in 2007
• 75.2% of the 52 million people reporting access problems identified cost as an obstacle to needed care in 2010 compared with 69.0% percent in 2007.
• 95.3% of the uninsured cite cost as a barrier compared to 65.9% of the insured in 2010
• In 2010, 9.3% of people with incomes below 200 percent of poverty ($44,100 for a family of four) reported an unmet need compared to 3.0% for those with incomes at or above 400 percent of poverty
• This 2010 ratio of 3.1 (9.3%/3.0%) for low incomes peoples unmet needs/higher income unmet needs compares to a ration of 2.2 in 2007
• 16.9% of those in fair or poor health reported forgoing needed medical care in 2010 compared with 4.6% of those in good, very good or excellent health (16.9% vs. 4.6%)
• 30% of uninsured people in poor or fair health reported they went without needed care in 2010
• Among all people citing a health-system obstacle, the biggest declines were associated with the following reasons: inability to get an appointment soon enough (10.2 percentage point decrease); takes too long to get to the provider (6 percentage point decrease); inability to get to provider when the office was open (5.7 percentage point decrease); and inability to get through on the telephone (5.5 percentage point decrease)

Kaiser Permanente by the Numbers -2nd Qtr 2011

By Clive Riddle, August 19, 2011

Kaiser Permanente earlier this month released highlights from their quarterly financial operating results.  Not being a for-profit publicly held plan, Kaiser’s numbers don’t always get the same level of attention as their national counterparts. Here’s some selected figures worth reviewing. Please note as an integrated system, they are combined results for Kaiser Foundation Hospitals, the Health Plan, and various subsidiaries.

• Combined operating revenue was $11.9 billion for the second quarter 2011, compared to $11.0 billion in 2Q 2010. For the six months ending June 30, 2011, total operating revenue was $23.9 billion, compared to $22.0 billion for the six months in 2010.
• Operating income was $390 million in the second quarter of 2011, compared to $313 million in the same quarter last year.  Year-to-date (thru June) operating income was $1.0 billion, compared to $794 million for the same period in 2010.
• Net non-operating income was $273 million in the second quarter of 2011, compared to $91 million in the same quarter last year.  Net non-operating income was $564 million in the first six months of the year, compared to $316 million in the same period last year.
• Net income for the second quarter was $663 million versus net income of $404 million in the same period last year.  Year-to-date net income (thru June) was approximately $1.6 billion, compared to $1.1 billion for the same period in 2010.
• Capital spending in the second quarter of 2011 was $735 million, versus $576 million in the same quarter of last year. Capital spending for the first six months of 2011 was approximately $1.4 billion, compared to $1.0 billion in the same period last year.  Kaiser notes they have opened 13 new and replacement hospitals and 86 medical office buildings in California over the last five years.
• Kaiser Permanente membership increased 208,000 members during the first six months of 2011, now totaling more than 8.8 million overall.
• Currently, kp.org serves over 100 million visitors each year. Year-to-date in 2011, members have securely viewed 34.8 million laboratory results, exchanged 6.2 million emails with their Kaiser Permanente caregivers and refilled 4.6 million prescriptions online.

Not a bad showing. Operating revenue for the first half year is $1.9 billion more than the first half of 2010;  net income is $0.5 billion more over last year for the first six month, and membership went up, not down.

 Executive Vice President and Chief Financial Officer Kathy Lancaster shared in a statement that “our year-to-date operating margin of 4.3 percent was in line with our financial plan. Our operating results, coupled with a sound investment strategy, enable us to reinvest in health care facilities, technology and programs that are essential in continuing to meet the needs of our members, patients and the communities we serve.” 

Should you want to check out how the major publicly held health plans performed in the second quarter of 2011, listen to the MCOL Quarterly Reports Podcast (August 2011) featuring Doug Sherlock, of Sherlock Company.

Big Bump in Emergency Department Use of CT Scans

By Clive Riddle, August 11, 2011

Keith Kocher, M.D., M.P.H., a clinical lecturer in U-M Department of Emergency Medicine, was lead author for a 14 page paper just published in the August issue of Annals of Emergency Medicine:  “National Trends in Use of Computed Tomography in the Emergency Department” [doi:10.1016/j.annemergmed.2011.05.020]. They examined national data for CT Scan use in EDs from 1996 to 2007, using CDC’s National Hospital Ambulatory Medical Care Survey, that involved 1.29 billion weighted records of emergency visits , 97.1 million of which included patients who received a CT scan.

Kocher’s team found that the “rate of CT use grew 11 times faster than the rate of ED visits during the study period. The study also showed that the use of CT scans was less common early in the study period, but rose significantly over time. Just 3.2 percent of emergency patients received CT scans in 1996, while 13.9 percent of emergency patients seen in 2007 received them.”

Doctor Kocher tells us "this means that by 2007, 1 in 7 ED patients got a CT scan. It also means that about 25 percent of all the CT scans done in the United States are performed in the ED. There are risks to overuse of CT scans, because each scan involves radiation -- so if they’re done for marginal reasons you have to question why. For example, patients who complained of flank pain [pain in the side] had an almost 1 in 2 chance of getting a CT scan by the end of the study period. Usually most physicians are doing that to look for a kidney stone, but it’s not clear if it’s necessary to use a CT scan for that purpose. I think a lot of the increase is related to changes in how doctors practice medicine and the availability of CT scanners. They provide lots of information quickly and so doctors and patients see CTs as a means of arriving at diagnoses efficiently and conveniently. Couple that with the fact that CT scanners are commonly housed in or near the ED itself, and the barriers to getting the test done are lower than in the past."

On the other hand, they note that “patients who received a CT scan in the beginning of the study had a 25 percent chance of being admitted to the hospital directly from the ED, while by 2007, this rate had been cut in half…[and that] this difference suggests that CT use may also prevent ICU admissions, perhaps shifting these hospitalizations toward a non-ICU bed. In general, however, the effect of CT use in the ED and hospitalization or transfer appeared to diminish after 2003 when the adjusted rate flattened and stabilized between 10.8% and 12.8% despite a continuing increase in overall CT use.”

They also note that “for all of the 20 most common reasons patients came to the ER for treatment, the study found that CT use increased during the study period. However, CT use was particularly high for the following complaints” [% of visits with CT scans indicated] impairments of nerve, spinal cord or brain function (50.7%); flank pain (43.3%); convulsions (38.9%); vertigo, dizziness or light-headedness (36.3%); headache (32.5%); abdominal pain (31.7%); and general weakness (25.6%).