Remember Who the Customer Is

By Kim Bellard, October 17, 2012

An organization called OpenNotes – primarily funded by the Robert Wood Johnson Foundation – recently released a very interesting study that supports the concept that patients do want to participate in their care with their physicians.  This probably doesn’t surprise patients, but may surprise many physicians. 

In brief, the study allowed patients of three geographically disparate primary care practices to access their doctor’s notes (electronically).  The study included over 13,000 patients from 105 physicians.  The vast majority of patients did view at least one note, and survey results indicate that such viewing notes made them feel more in control of their health and improved their medication adherence.  Contrary to physicians’ concerns, such viewing did not lead to longer visits or to more questions outside of visits.  About 60% of patients wanted the ability to add their own comments to the notes, while one-third wanted to approve the notes’ content (something adamantly opposed by the physicians).

It goes back to one of what I think is one of the central problems in health care: those in the business of health care are doing things about patients, but not necessarily for patients.   

Health records are the case in point.  They are maintained about patients, but are written in a jargon that is virtually unintelligible to lay consumers (and, in the case of paper records – often illegible as well!).  The concept that they belong to the patient in any real sense would come as a surprise to the health care professionals who keep them.  Meaningful use requirements are going to quickly force providers towards more patient access to information, such as clinical summaries of visits and summary of health information.  The easiest solution to this is likely to be a patient portal with a view into an EMR, but that in itself doesn’t mean the view is useful.  Please correct me if I’m wrong, but I don’t believe any of the “meaningful use” requirements relate to how meaningful the information is to consumers.  It is telling that the requirements for how many patients actually view or download the information is very weak – only 5%.

Those in the health care business talk in a language of ICD, CPT, HCPCS, DRG, NDC, DSM, to name a few; throw in insurance terminology to complete the task of confusing consumers.  Each of those grows ever-more complex and insular, driven by needs for more detailed analysis, billing, legal protection, and other purposes.  Now we’re increasingly moving towards widespread use of various quality indicators, which are similarly very well-intentioned but may not quite be answering the questions consumers have, or should have. 

As best I can tell, no one in the health business – physicians, hospitals, payors, labs, IT vendors, etc. – really like the complicated languages that have evolved around them, and all would argue that the complexity greatly adds to the expense of running their business, but I don’t see any groundswell to simplify the situation. 

One might have thought that the movement towards consumer transparency might ignite such pressure, but that hasn’t seemed to have happened.  Transparency is one of those things that everyone is in favor of conceptually, but the details of how to do it and whether consumers will use it remain open.  UnitedHealthcare recently found that only 14% of survey respondents use the Internet to comparison shop for health care treatments and services, compared to 75% who use it to comparison shop for other goods and services, a statistic United hopes to improve through its enhanced myHealthcare Cost Estimator.  Aetna, Cigna, Wellpoint and other Blue plans have their own online cost estimator tools.  

In addition to efforts from payors to help consumers with health cost transparency, there are a number of other efforts.  I had been aware of Castlight Health and The Healthcare Blue Book, but was a little surprised to uncover a plethora of other firms, including ClearCost Health, NewChoice Health, and Change Healthcare.  Some of these are aimed at employees of certain self-insured employers, or members of specific health plans, while a few focus on the general public.  It is admittedly an uphill battle to get consumers engaged in thinking about price and quality, and these various organizations all should be lauded for their efforts to give consumers more and better options for doing so.  That being said, it’s somewhat like the talking dog: it is not that it does it well, it’s just that it does so at all.

All the efforts to make costs more transparent have to wrestle with two key problems: what is the “service” being bought, and how can that service be explained in consumer-friendly terms?  E.g., an “office visit” has numerous CPT codes that could apply, each with its own price, and many visits and procedures are accompanied with other services that have their own costs, which the consumer might rightly view as being part of the original service.  How many of us have had, say, a lab test or an X-ray and then been surprised at how many bills we end up receiving for them?  

At the risk of repeating an overused analogy, compare “buying” health care with buying a computer /tablet from the Apple Store or Amazon.  Computers have their own technical language that can be every bit as arcane as health care, but consumers are not forced to use it or fully understand it to complete their shopping experience quite satisfactorily.  When they are shopping, they get lots of options on price and features, with plenty of reviews, customer feedback, and shopping “wizards” to assist them. 

Buying health care, on the other hand, is more akin to getting your own PC back in the 1970s, which required buying a kit and/or components and then trying to assemble the whole thing yourself.  Health care transparency as we know it begins to look more like giving consumers the prices of each component in your PC and quality indicators from the chip manufacturing process.  Those do mean something, but are not really what consumers want.  The problem is that health care professionals are speaking in Greek (or perhaps Latin!) while we want to hear about our health in our own language.

People talk about “disruptive innovation” in health care, by which they often mean use of various forms of technology.  Technology is going to certainly play an even more significant role, but I have to wonder if the disruption will come instead from organizations which can make the health care experience for consumers simpler –much simpler.  I.e., radically rethink what the “products” are, what the processes should be, and how these are communicated to patients. 

Our health care system has many historical practices and preferences that muddle the roles of the various parties involved in it, but it’s helpful to remember that it all boils down to the patient as customer.  It’s their health, after all.

The Los Angeles Times Reports on The Most Litigious Doctor

Clive Riddle, August 24, 2012

The Los Angeles Times recently ran a feature story, State suing doctor over billing tactics regarding “Jeannette Martello's aggressive tactics to collect fees from emergency room patients — including lawsuits and taking out liens on their homes — prompt unprecedented court case by state officials. “

The article notes that “the state's lawsuit against Martello, however, is the first of its kind, according to Marta Green, California Department of Managed Health Care spokeswoman. State officials allege in court papers that Martello collected or attempted to collect more from patients than insurance companies paid, a practice known as balance billing.”

The story about Doctor Martello’s very unique, aggressive tactics to pursue balance bills for contracted patients first broke months ago in MCOL affiliated Payers & Providers.  The Payers & Providers weekly California Edition reported on her activities, and then released a twelve page white paper,  The Many Stories Of One Highly Litigious Physician, with the sub-heading: “Surgeon Treats Patients at Southern California ERs – Then Sues Them” that details account of her 46 small claims and 23 superior court claims filed against her ER patients during the past several years, and the impact upon a number of the patients and their families.

The Times article cites Payers & Providers Publisher Ron Shinkman: “Ron Shinkman, who wrote about Martello and her tactics in the trade publication Payers & Providers, said he had never seen a more litigious doctor in 19 years of healthcare reporting.”

Attention, Walmart Shoppers!

By Kim Bellard, August 20, 2012

I’ve been thinking about something a very smart friend of mine wrote me in response to one of my previous posts: “…I can see where technology and information-driven consumerism might work for some highly motivated and educated people ... but not the masses I see at Walmart.”  I’m sure he meant no disrespect to either Walmart or its shoppers, nor do I, but one can go to pretty much any shopping venue and understand his point. 

The grim statistics are well known -- e.g., we’re too fat, we rely too heavily on medications, incidence of lifestyle conditions like diabetes is soaring, and, of course, we spend way more on health care than any other country.  Despite all that, though, Americans remain pretty cocky about their health, with the vast majority claiming to be in “good” or “very good” health, higher than in other industrialized countries. 

We claim to exercise, with over half claiming to exercise at least 1-3 times per week, but we may be kidding ourselves, as only about 5% report exercising on any given day.  Similarly, Americans are in denial about their burgeoning weight, reporting they have actually lost weight when, in fact, they gained.  The bottom line is that most of us are not really in shape, and it is impacting our health.

One of the most telling responses to this problem appeared recently: Dr. Michael Joyner of the Mayo Clinic suggested that our lack of exercise should be considered a medical condition.  I understand his point, since we’re obviously not doing a great job of staying healthy on our own.  Certainly getting more regular exercise would help many people – and, most likely, they know it – but medicalizing lack of exercise seems to me as more of what got us into this mess.

It’s not that various parties aren’t trying to encourage us to live healthier lifestyles.  In a recent post, Clive Riddle reported on the recent Aon Hewitt 2012 Health Survey of employers, citing in particular the widespread use of financial incentives towards lifestyle changes.  That’s encouraging, and a recent survey by the National Business Group on Health echoed employers’ adoption of wellness efforts, but also reported that over twice as many employers – 43% compared to 19% -- see increase use of consumer-directed health plans (CDHPs) as their most effective strategy for controlling costs.  In other words, employers are happy to try dangling the carrot, but they still plan to use the stick.

Employers aren’t the only ones trying to lead us to improve our health; the government is trying as well.  For example, a recent study found that state laws restricting the sale of snacks and sugary drinks in schools did result in children gaining less weight.  That’s notable for at least two reasons: first, that there are a number of states already legislating such choices, and, second, that such efforts may actually work.  No wonder Mayor Bloomberg wants to ban large sizes of sugary drinks in New York City. 

In a country where, apparently, the government can require you to buy broccoli (as long as they call it a tax, not a penalty!), the prospect of it telling us how to live is a little scary.   Then, again, this is a government that can’t even ensure that its retirement payments, whether Social Security or federal employee pensions – meet their one main test, i.e., that the recipient is actually still alive.  So maybe I shouldn’t start worrying about them monitoring my ice cream consumption just yet.

How did it come to this, that we’ve delegated the responsibility of keeping ourselves healthy to third parties, including physicians, employers, or the government?  Some of the problem may come from the fact that parties in the health care system are, in fact, treating us like consumers.  Not in the respect of competing on price or quality, mind you, but in using advertising to drive consumer decisions based on image.   The saga of the impact of direct-to-consumer advertising for pharmaceuticals is widely known, with such advertising spending exploding to close to $5 billion annually after such ads were allowed in 1997.  Some are calling for an end to DTC pharmaceutical ads, as the CBO studied last year.  The hospitals are also getting into the act, pouring money into advertising, as the New York Times reported last year.  Throw in spending by various diet and alternative medicine alternatives, and it becomes clear that we face a lot of forces telling us that some other person and/or product is the key to our health.  When we don’t directly pay for some large portion of those, as health insurance can allow us to believe, the temptation to not shop prudently is almost irresistible.   We may shop for flat screen TVs at Walmart, but when it comes to health care, we think we deserve to be Neiman Marcus shoppers.

There are certainly many situations were medical advice and treatment is not only appropriate but also necessary, and thank goodness that our clinicians are always finding more ways to combat our various maladies.  We have more and better options all the time, even though often those options are more expensive and sometimes not as clearly beneficial as we should expect.  But the responsibility for our health does not lie in those clinicians’ hands, much less in the hands of our employers or government officials.  I don’t have any reason to expect that Americans will be better at managing their health than they are at managing other aspects of their lives, but we shouldn’t be worse either. 

There is a lot efforts around “patient centered medical homes,” which include many good ideas, especially better coordination among health care providers.  As long as the focus is “medical,” though, the “patient centered” part of it is going to lack important components necessary for improved health.  Health is the result of a complicated interaction of genetics, environment, lifestyle, social influences, and medical interventions, to name a few.  We need to break out of the medical model to truly get at health.

We talk about the health care system, but in truth it is still the medical care system.  If we’re serious about improving health, and impacting the quality and cost of medical care, maybe we need to step back and think about a health care system really should look like. 

I’m sure that some Walmart shoppers are spending beyond their means, buying things they don’t need and can’t afford.  Some are perhaps even in bankruptcy.  But I like to think that most of them live within their means, and have learned how to manage their financial health.  We should be thinking about what in our current system leads us to not expect them to do the same with their actual health.

The Digital Health Self-Service Counter

By Clive Riddle, June 21, 2012

So you’ve navigated the self-service checkout counter, purchasing your toilet repair kit and halogen light bulbs at your big-box hardware store; and even braved the self-service experience with your greek yogurt, arugula and asiago cheese at your grocery store. Now are you ready to do the same with your healthcare?

Accenture says you are indeed, to a point, if you can just find the checkout counter.  They have just released results of the Accenture Connected Health Pulse Survey , based on an online survey of 1,110 U.S. patients to determine the preferred channels of electronic health information and services. They found that “the vast majority of patients (90 percent) want to self-manage their healthcare leveraging technology, such as accessing medical information, refilling prescriptions and booking appointments online, but nearly half (46 percent) are unaware if their health records are available electronically.”

What’s more, as Accenture’s Kaveh Safavi, MD, JD, tells us, “patients increasingly want access to their personal medical information, anytime, anywhere. But they’re not willing to give up the option of face time with their physicians.” (85% surveyed want to be able to communicate with their doctor in person.)  So just like the grocery and hardware stores that must still provide full-service counters next to their self-checkout lines, consumers want their in-person doctors and nurses and mhealth too. Although, as an aside, who are these 15% of consumers that don’t want to be able to communicate with their doctor in person?

Here’s more consumer findings from Accenture’s survey:

• 83 % want online access to their health records
• 48 % want their doctors to manage their medical records, while 44 % prefer to manage their own
• 33 % did not know whether services such as bill pay, electronic reminders and lab results were available to them online
• 72 % want to book, change or cancel physician appointments through via  website; 68% would like to do so via a mobile device (meaning most want both)
• 88 % want to receive email reminders for preventative or follow-up care;  63% would like to receive these reminders via their mobile phone (meaning most want both)
• 76 % want the option of email consultations with doctors, 74% would like telephone consultations, including via mobile phone (meaning most want both)
• 73 % would like to use a mobile device for requesting prescription refills; 72% want to be able to use a website to do so (meaning most want both)

For more about the role of in person vs. self-service healthcare, you can check out the mHimss blog by David Lee Scher, MD in which he offers 5 reasons why mobile health apps will never replace doctors. If you just want to read the cliff notes version, we’ve summarized his list in healthsprocket.

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.

Do We Really Want Better Health?

By Kim Bellard, June 20, 2011

There are times when I despair about the prospects for improving our health care system.

To illustrate, let me give some examples – two from the physicians’ standpoint, two from the patients’ standpoint – and then see what we might conclude. 

Recently JAMA reported the results of a study by Dr. William Borden and others on the treatment of heart patients with clogged arteries, following up on their 2007 research.  That earlier research indicated that patients receiving drug therapy fared equally well as angioplasty in preventing heart attacks, and so should be tried before performing the more invasive, more costly surgical approach.  The 2007 study was widely reported on, and was expected to reduce the number of patients receiving the surgical approach.  The new research indicates that in the two years after the 2007 results were released, there was virtually no impact in the percentage of patients receiving the drug treatment approach.  Experts cite time being needed to change practice patterns as well as patient demand for the “high tech,” more immediate impact surgical approach as reasons for the modest impact.

All right, maybe that’s not the best example.  Perhaps the original study results simply hadn’t been out long enough to change practice patterns, and most likely switching to the medication approach would have significant revenue impacts on both hospitals and on vascular surgeons that might create resistance to change.  Let’s take a less controversial topic: hand washing.  This is a practice whose clinical benefits have been well known for, what, 150+ years?  Moreover, it is one whose benefits pretty much everyone -- physicians, nurses, other health care workers, and patients -- agree upon.  Despite that, the accepted wisdom is that health care professionals appropriately wash their hands less than fifty percent of the time, with some estimates as low as thirty percent.  One study indicated that the baseline rate of hand hygiene compliance was 26% in ICUs and 36% in non-ICUs…and after a year of feedback these rates increased to 37% and 51%, respectively, which is hardly cause for celebration.  Again, the problem has been well understood for years, with vigorous attempts to highlight best practices in order to improve compliance, yet the problem persists.

Patients have their own blind spots.  Take antibiotic compliance.  Antibiotics were one of the great medical advances of the 20^th century, and remain one of the leading methods of treatment for many conditions.  Unfortunately, the literature is clear that patients often are noncompliant with their prescribed programs, which can reduce their effectiveness significantly.  One study conducted a review of various other studies and found that the mean dose-taking compliance was only 71%.  Compliance was higher in once-daily regimes, falling to 51% if the dose required four daily doses.  Patients are told to take the full course, but forget to take doses or stop once their symptoms diminish.  The failure to complete a course of treatment can cause relapses and is often cited as a reason for increased antibiotic resistance.

Then there is the obesity epidemic in America.  The facts are well known: recent estimates put the incidence of obesity at a third of all adults.  That percentage is double the prevalence thirty years ago.  Obesity, of course, is associated with a number of serious health concerns, including high blood pressure, diabetes, and heart disease.  To make things worse, it is estimated that another third of adults are overweight, meaning that two-thirds of American adults have a weight problem.   The comparable figure for children is an equally startling one-third. 

Sadly, many people do not even have an accurate perception of their weight-related health risk.  A survey by Harris Interactive/HealthDay found that thirty percent of the overweight felt their weight was normal, while 70% of those considered obese thought they were merely overweight.  Interestingly, respondents to the Harris survey cited lack of exercise as the key culprit for being heavier than they should, yet pointed to surgery as the most effective weight loss method, followed by prescription drugs.  Enough said.

In previous blogs I’ve been a strong advocate of the importance of using information to help health care professionals improve their performance and to help consumers make better decisions about their choice of treatments and health care professionals.  With examples like the above, though, it seems that information is necessary but definitely not sufficient.  In each case, the “right” thing to do was fairly well established empirically, widely communicated, yet consumers and even health care professionals continued to make the “wrong” choice.  And by no means are these examples the only ones of their type in health care, or even the most egregious.  Just this week researchers reported that as many as 70,000 Americans may die of heart failure each year because they are not receiving the optimal treatments called for by accepted national guidelines. 

Between medical errors, sub-optimal care, and our own neglect of our health, it’s a wonder anyone survives the health care system.  It’s getting to the point when I’m afraid to read any more studies.

The basic problem is that behaviors are hard to change, even when given information about how that behavior should be changed.  I point to the example of car safety belts.  They were widely installed in most cars by the 1960’s, and were well understand to reduce traffic fatalities significantly, yet by the early 1980’s usage was still as low as 11%.  Today usage is up to 85% (and one could be dismayed it is “only” 85%), but it took a generation to for wearing seat belts to become the norm. 

Information is essential.  Incentives are appropriate.  Neither, even when used in combination, may be enough to change behavior until and unless the individuals in question see the need for change, and the value to themselves in making the change.  We need to do a better job of making that case.

The good news is that we can learn new behaviors when we want to – for example, almost 70% of American’s with mobile phones use them for texting (according to Comscore), a feature that barely existed ten years ago.  If we can make room in our lives for that, certainly there should be room for us to do better at improving our health and demanding better health care.  Or so I hope.

Fidelity on Retiree Future Health Care Costs and HSA Participation

By Clive Riddle, April 1, 2011

Fidelity Investments tells us that the total amount a couple just entering retirement needs to have saved for their future health care costs dropped this year from past estimates, due to one-time savings from health reform. Fidelity also tells us that HSAs are a recommended vehicle to help fund these required costs, and almost all their HSA account holders rolled over some account balance from 2010 to 2011 to save for these costs.

Fideltiy this week released their annual estimate of future health care costs for retired couples. Last week, Fidelity released findings on their study on how Fidelity HSA participants are using their accounts. The two topics overlap, as HSA participation is of course, a recommended strategy by Fidelity for persons preparing for retirement.

Fidelity cited their recent survey that indicated 68% of pre-retirees “said the cost of medical care in retirement is one of their three biggest financial concerns (outliving savings and inflation were the other worries).”

Fidelity now estimates “a 65-year-old couple retiring this year will need $230,0001  to pay for medical expenses throughout retirement, not including nursing-home care.  This represents an 8 percent decline from last year, when the estimate was $250,000” and costs increased 4.2% over 2009 costs.

Previously, the estimate has increased an average of 6 percent annually since the initial calculation of $160,000 in 2002. Fidelity indicates the “$20,000 decline in the estimate from last year was driven by Medicare changes contained in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act, both signed into law in 2010.  These changes, which reduced out-of -pocket expenses for prescription drugs for many seniors, resulted in the reduced estimate.” The health reform changes include a required 50% discount on brand name drugs that are applied to beneficiaries “donut hole” benefit level, and ultimately phases out the donut hole by 2020.

Brad Kimler, EVP of Fidelity’s Benefits Consulting business tells us “while the savings generated through the health care reform laws is a welcome relief to many seniors, it should be considered a one-time adjustment, at least for the time being. Today’s workers still face the prospect of significant medical expenses in retirement and must begin to include those costs in their retirement plan strategies. Looking forward over the next few years, Americans should expect health care expenses to continue to increase annually due to a number of factors including higher costs for medical services, the introduction of new technology and an increased utilization of health care services like diagnostic testing,”

The Fidelity Retiree Health Care Costs Estimate “assumes individuals do not have employer-provided retiree health care coverage, but do qualify for the federal government’s insurance program Medicare.  The calculation takes into account cost sharing provisions (such as deductibles and coinsurance) associated with Medicare Part A and Part B (inpatient and outpatient medical insurance).  It also considers Medicare Part D (prescription drug coverage) premiums and out-of-pocket costs, as well as certain services excluded by Medicare.  The estimate does not include other health-related expenses, such as over-the-counter medications, most dental services and long-term care.”

Fidelity, in commenting on their retiree health benefit cost estimate, hold out HSAs as a recommended savings tool. William Applegate, VP, HSA products for Fidelity Investments tells us “the continuing rise of health care costs combined with health care reform really drove the adoption of HSA-qualified health plans  by employers last year and thus the growth of HSAs. As for participants, it is clear that many are using the health-savings product to help manage not only their current medical expenses but also plan for future expenses, with nearly all participants carrying some balance over to the following year.”

Fidelity’s analysis of their 74,000 HSA participant accounts indicated the following patterns and behaviors:

• On average, HSA participants had contributions of $2,620 made to their accounts in 2010  including their own contributions and employer contributions.  
• 17% of  participants contributed, through both their own and employer contributions, more than $5,000 to their account in 2010
• 46% of participants had contributions of $2,500 or more in 2010
• 36% of participants used more than 90 percent of their annual HSA contribution on qualified medical expense reimbursements,
• 40% of participants used between 10 percent and 90 percent of their HSA contributions and carried over the rest.
• 24% of participants used less than 10 percent of their annual contributions and invested the balances for future health expenses.
• Overall, 95% of participants carried over some balance from year to year

Consumerism: 2011 Industry Insiders Perspective

by Clive Riddle, March 18, 2011

A Consumerism e-poll, involving three brief questions, was conducted in conjunction with the recently concluded 10th Annual Consumerism Web Summit. While questions in the e-poll have changed over the years, the current survey has some recent historical basis for comparison.

Survey respondents were asked the same questions from 2008 - 2011 regarding ranking typical components of consumerism, and their perspective as a respondent. Respondents were also asked in 2010 and 2011, to what degree the success of health care consumerism initiatives depend upon provisions of health care reform.

Below are summary findings from the e-poll. As you can see, overall rankings of these components of consumerism haven’t really shifted from 2008-2011. However, insiders do feel the future success of consumerism initiatives is much less dependent upon health care reform, then they felt a year ago.

1.  Please numerically rank these typical components of Consumerism according to their value from your perspective.

(Rank 1 through 5 with 1 = highest value and 5=lowest value, and only use each ranking once; i.e. only rate one item a 1, one item a 2, etc.)

	2011	2010	2009	2008
	Mean	Mean	Mean	Mean
Price and Quality Transparency	1.76	1.85	2.00	1.83
Wellness Incentive Programs	2.86	3.03	2.65	2.86
Account Based Plans (HSA/HRA/FSA)	2.90	3.06	3.08	2.97
Web Based Consumer Patient Health Records	3.53	3.35	3.70	3.63
Retail Medicine (Convenient Care, etc)	3.57	3.69	3.57	3.71

	2011	2011
	Median	Mode
Price and Quality Transparency	1	1
Wellness Incentive Programs	3	2
Account Based Plans (HSA/HRA/FSA)	3	2
Web Based Consumer Patient Health Records	4	4
Retail Medicine (Convenient Care, etc)	4	5

2. To what degree are the success of health care consumerism initiatives dependent upon provisions of the Affordable Care Act? (in 2010, the question was phrased: "…dependent upon the outcome of any impending health care reform? “)

	2011	2010
Highly dependent	21.2%	36.4%
Somewhat dependent	47.7%	41.2%
Not very dependent	31.1%	22.5%

3. My perspective is as a: 

	2011	2010	2009	2008
Purchaser (Health Plan, Employer, TPA, Agent, PBM)	37.1%	43.4%	30.6%	37.9%
Provider (Hospital, Physician, Pharmaceutical, Other Providers)	34.4%	24.0%	27.1%	36.2%
Vendor/Other  (Vendors, Consultants, Institutions, Gov., All Other)	28.5%	31.8%	42.4%	25.9%

n = 154 for 2011, 189 for 2010, 96 for 2009, 59 for 2008

What Happens to Those Unspent Dollars Inside an HSA?

By Clive Riddle, March 11, 2011

Eric Remjeske, President, and Jon Robb, Investment Associate, at Devenir gave a presentation during this week's Tenth Annual Consumerism Web Summit, in which they addressed Health Savings Account investment options and activity, based on their 2010 Devenir HSA research report.

Here’s some of the data Eric and Jon shared with the audience:

• National HSA assets in 2010 were $9.4 billion in deposits and $0.7 billion in investments
  
  
• This is projected to grow to $50.4 billion in deposits and $10.3 billion in investments in 2015. 
  
  
• 52% of HSA consumers were aware they had investment options for their HAS
  
  
• The average total balance (deposit and investment) in an HSA account was $11,635 for HSA account holders that held investment accounts
  
  
• The average yearly administration fee for HSA investment programs is $32
  
  
• In 2009 the average annual account activity broke down as follows: Personal Deposits $2,050; The average yearly administration fee for HSA investment programs is $32
  
  
• In 2009 the average annual account activity broke down as follows: Personal Deposits $2,050; Plus Employer Contributions $1,058; less Withdrawals $1,850; plus Interest Earnings $17; less Fees $33; yielding a net balance of $1,208.
  
  
• 61% of accounts in 2009 took a withdrawal of some amount
  
  

What Do We and EBRI Really Know About Consumer-Driven Health Plans?

by Clive Riddle, August 6, 2010

EBRI (Employee Benefit Research Institute) has just published a 28 page issue brief by Paul Fronstin, Director of EBRI’s Health Research and Education Program:  What Do We Really Know About Consumer-Driven Health Plans? A decade since their introduction in various forms that evolved over time, numerous studies consumer driven plans have since left a data trail that EBRI has followed and attempted to map.

The report concludes that: “the percentage of employers offering an HRA- or HSA-eligible plan increased from below 5 percent in 2005 to between 12−15 percent by 2009…. However, recently, the percentage of small firms that offered a CDHP declined while larger firms continued to add a CDHP as an option. Overall, 19.1 million, or 11 percent of people with either employment-based coverage or individually purchased insurance, were enrolled in a CDHP in 2009….Generally, premiums for CDHPs were lower than premiums for non-CDHPs….However, CDHP premiums may be lower than non-CDHP premium simply because the CDHP population is healthier, and there is some

evidence of this.…The studies agree that use of preventive services did not change (upward or downward) as a result of the CDHP…. Concerning how CDHPs affect prescription drug use, studies found that overall use of brand-name prescription drugs fell… CDHP enrollees increased their use of the mail-order pharmacy option.”

Perhaps the most meaningful analysis of other studies is saved for last: “While HRAs and HSA-eligible plans look a lot alike, the differences are significant enough to warrant separate analyses of the impact of the plans. Also, most of the research to date has focused on plan design and has ignored the impact of the consumer-driven account on use of health care services and overall spending. Individual contributions to HSAs and employer contributions to both HSAs and HRAs may affect the use of health care services. Furthermore, account balances may have an effect as well: Individuals may use health care services differently, depending on how much money is being contributed to the account, especially relative to the deductible; amounts rolled over; and portability of the account. Despite the growing body of evidence on the effect of CDHPs on cost and quality, there are many unanswered questions.”

The conclusion might de-emphasize the increase in employer popularity with the plans over time, although certainly greater with larger vs. smaller employers as the report notes. The KFF HRET annual survey cited found offer rates with large employers (1,000+) increasing from 10% to 29% from 2005 to 2009, and the Mercer annual survey cited found large employee offer rates ranging from 4% (1,000 – 4,999 employees) to 22% (20,000+)  in 2005, increasing to a range of 24%  (1,000 – 4,999 employees) to 47% (20,000+)  in 2010.

The report conclusions emphasize that offer rates may have stalled with smaller employers, evident in the KFF HRET study, but not evident in the Mercer study. The report detail does provide some meaningful disclosure regarding the oft quoted KFF HRET CDHP data: “Unlike other studies, the survey did not find growth in enrollment between 2008 and 2009. The KFF/HRET survey does not include nonworking adults or children in its estimates. It also does not include federal employees or workers in firms with fewer than three employees. The lack of growth may be due to large margins of error for data related to CDHPs in this survey. The lack of growth may also be due to the fact that, while the survey shows growth in offer rates in large firms, it shows a decline in offer rates among small firms (contrary to the Mercer findings). Because there are many more small firms than large firms, the overall offer rate declined slightly as well.”

Tracking consumer driven enrollment data can be maddening. The report cites six major sources the publish enrollment data, with somewhat materially different results. Variances are due to many factors, from differences in study methodologies as discussed above, to fundamental differences in what is defined as a consumer driven health plan. Should the numbers include all qualified high deductible health plans (HDHPs) even if they have no account based plan attached? Should they include FSAs? Should they include enrollment in other consumerism-labeled products?

Many assume numbers and studies quoted examine just HSA and HRA account based plans. This is not always the case. The EBRI report makes a great attempt as sifting through the data to examine the true HSA and HRA findings. But still, after a decade, as the report concludes, “there are many unanswered questions.”

Health Systems Organizing Themselves Around Individuals

by Clive Riddle, June 11, 2010

This week Benjamin Isgur, Director at PricewaterhouseCoopers’ Health Research Institute gave a presentation in the Healthcare Web Summit event, Healthcare in the Decade Ahead: HealthCast: The Customization of Diagnosis, Care and Cure.

In Ben’s words, what the folk at PWC’s Health Research Institute see in the decade ahead with respect to global trends for health systems, is that the “cost pressures are still there, but we’re seeing a new way forward for sustainability and systems being more efficient and effective, by organizing themselves around individuals.” The headline of his third slide said it all: “Individuals will be at the center of diagnosis, care and cure.”

Ben’s presentation was based on a paper published by their Institute, entitled HealthCast: The Customization of Diagnosis, Care and Cure. The report reflects proprietary research conducted by PwC, including more than 200 in-depth interviews in 25 countries with thought leaders and executives representing government, hospitals, pharmaceutical companies, insurance companies, clinicians, academics and the business community and a survey of 3,500 individuals in seven countries and 590 leaders of health plans, providers, government, employers, physician groups and pharmaceutical/life science firms in 20 countries.

Ben’s case for why today’s health system model must change:

1. “Both young and old consumers are developing chronic diseases in record numbers, leading to an explosive consumption of resources that is driving up spending and creating liabilities for future generations. Following a global recession, health leaders are under pressure to show more value from rising health costs.”


2. “Converging influences in health. Chronic diseases are driven by social, economic, genetic and behavioral factors that are largely unaddressed by today's medical delivery system.”


3. “Technology is leading healthcare into a new era of "mass customization," following other industries such as auto manufacturing, media, and entertainment. The use of metadata is changing the behaviors of individuals and health systems.”

Ben’s presentation used international and domestic cases to support their thesis that the trends ahead for the U.S. are really part of global overarching  developments. For example, in discussing how chronic disease now affects young and old, driving up spending, he shared this Australian experience regarding “drivers of health spending in Australia in respiratory disease (which affects the young) and neurological disease (which affects the old)”:

Respiratory cost drivers:	Neurological Cost Drivers:
Volume per case: 84%	Volume per case: 25%
Price: 9%	Price: 5%
Disease Rate: 4%	Disease Rate: 4%
Ageing: 3%	Ageing: 48%
Population: 0%	Population: 18%

Other key trends Ben addressed in the same manner:

• Health reform is moving the status quo to customized care
• Funding is being redistributed from sickness to wellness
• Incentives are being designed to encourage partnership
• Electronic medical records and IT ease collaboration, customization
• Patient communication is supporting shared decision-making
• Workforce models will be more flexible and efficient

In summary, Ben stated these are the vectors of change for customization and individual engagement:

• Regulatory reform that focuses on efficiency
• Funding that is redistributed
• Incentives that encourage partnership
• EMRs and IT that ease collaboration
• Patient communication that supports shared decision- making
• Workforce models that are flexible

The toolkit PwC prescribes to address this change includes:

1. Coordinated care teams: Consumers want coordinated care. Integrated care networks that share information, care and accountability for patient outcomes are likely to become models for the future.
   
2. Fluent navigators: Individuals lack the knowledge and skills they need to navigate the health system and understand their choices. In a patient-centered health system, there will be a growing need for consumer advocates beyond friends and family. PricewaterhouseCoopers sees the role of healthcare-fluent navigators being played by pharmacists, community workers and possibly the emergence of a new professional field much as financial planners emerged with the rise of consumer-directed investing.
   
3. Patient-experience benchmarks: In a patient-centered health system, more attention will be paid to understanding and meeting consumer expectations. Many health systems already are tracking and publicly reporting on patient-centric metrics of care, such as cleanliness, wait times and physician satisfaction, allowing patients to make more informed decisions.
   
4. Care-anywhere networks: The definition of access is being redefined by telehealth, wireless mobile devices, remote monitoring and new care delivery models that move care from hospitals, nursing homes and physicians’ offices and into patients’ homes, which increasingly are wired with networked devices.
   
5. Medical proving grounds. Through collaboration and investment, some regions and other countries are positioning themselves to be medical proving grounds, or centers of excellence in medical innovation and care as a way to attract patients, researchers and providers looking for the shortest path to access and innovation.

PwC’s Recommendations for adopting a convergence viewpoint:

• Encourage partnership
• Reward competition and innovation
• Fund wellness
• Empower shared decision-making
• Develop dynamic workforce models
• Enable IT

1.      “Both young and old consumers are developing chronic diseases in record numbers, leading to an explosive consumption of resources that is driving up spending and creating liabilities for future generations. Following a global recession, health leaders are under pressure to show more value from rising health costs.”

2.      “Converging influences in health. Chronic diseases are driven by social, economic, genetic and behavioral factors that are largely unaddressed by today's medical delivery system.”

“Technology is leading healthcare into a new era of "mass customization," following other industries such as auto manufacturing, media, and entertainment. The use of metadata is changing the behaviors of individuals and health systems.”

Hewitt Says We’re More Engaged in Selecting Our Benefits

by Clive Riddle, April 2, 2010

Hewitt Associates this week released data indicating that employees in 2009 were more engaged in selected their health benefits than in previous years. That being said, Hewitt concluded their choices weren’t all that different than before, they were just more involved in the process.

Here’s some of what Hewitt had to report on the matter: “Hewitt's analysis of 6 million U.S. workers, for whom Hewitt managed benefits enrollment in the fall of 2009, revealed the highest number of active enrollees since Hewitt began tracking the data in 2003. Nearly half (45 percent) of employees actively chose their benefits for 2010 instead of passively defaulting into the same coverage or no coverage at all. This is up significantly from the 2009 open enrollment period, where just 39 percent of employees actively enrolled. Despite employees taking a more active role in selecting their benefits, Hewitt's data shows very few workers enrolled in different health insurance plans.”

So what plans are employees enrolling in? Here’s a data table Hewitt shared indicating enrollment by plan type for the past three years (note that the survey involves large employers):

Enrollment by Plan Type

Open Enrollment Year	EPO	HMO	POS	PPO	Indemnity	HDHP
2008	1%	17%	11%	31%	15%	20%
2009	1%	17%	5%	34%	11%	18%
2010	1%	14%	8%	35%	13%	18%

So what does Hewitt make of all this? Sara Taylor, Hewitt’s Health and Welfare Strategy Leader tells us: "Employee inertia continues to play a large role in enrollment decisions—it's encouraging to see that people are more engaged in assessing their benefits, but that doesn't mean they are necessarily making different choices. If employers want workers to make different elections, they might need to adopt a more aggressive approach—whether it's changing or reducing plan options or offering plans with widely differing price points."

How do Insiders Feel About Consumerism Now?

by Clive Riddle, March 26, 2010

In conjunction with last week’s Ninth Annual Consumerism Web Summit, MCOL conducted an e-poll of professionals, asking what components of consumerism are the most important, and how linked consumerism’s fate is to the outcome of health reform.

Survey respondents for 2010 and 2009 were asked the same questions regarding ranking typical components of Consumerism, and their perspective as a respondent. 2010 respondents were also asked, to what degree are health care consumerism initiatives dependent upon the outcome of any impending health care reform.

Respondents were asked to rank the five listed components 1 through 5, with 1 being the most important, and to only use each ranking once (only one item ranks 1, one item ranks 2, etc.)

Professionals continue to feel Price and Quality Transparency is the most important component by far.  Account based plans and wellness incentive programs end up close to distant tie for second, depending on the measure you use, followed by web based consumer patient health records and retail medicine.

Interestingly, if you examine the percent of respondents ranking an item as number 1, and consider the change from 2009 to 2010: transparency, account based plans and web based records all gained ground, while wellness incentives and retail medicine lost ground.

36.3% of respondents said that  consumerism initiatives were highly dependent upon the outcome of impending health care reform, while 41.2% said they were somewhat dependent and 22.5% said they were not very dependent.

Below are details regarding how respondents ranked components of consumerism, and their perspective as a respondent, for the past two years:

(Rank 1 through 5 with 1 = highest value and 5=lowest value, and only use each ranking once; i.e. only rate one item a 1, one item a 2, etc.)

	2010	2009	2010	2010
	Mean	Mean	Median	Mode
Price and Quality Transparency	1.85	2.00	1	1
Account Based Plans (HSA/HRA/FSA)	3.06	3.08	3	2
Wellness Incentive Programs	3.03	2.65	3	4
Web Based Consumer Patient Health Records	3.35	3.70	4	4
Retail Medicine (Convenient Care, etc)	3.69	3.57	4	5

Component	Rank 1: 2010	Rank 1: 2009	Rank 5: 2010	Rank 5: 2009
Price and Quality Transparency	59.4%	55.8%	7.0%	11.9%
Account Based Plans (HSA/HRA/FSA)	17.7%	12.8%	24.9%	17.9%
Wellness Incentive Programs	7.0%	20.9%	8.7%	3.6%
Web Based Consumer Patient Health Records	11.8%	4.7%	21.6%	31.0%
Retail Medicine (Convenient Care, etc)	4.3%	5.8%	37.8%	35.7%

Perspective of Respondent:	2009	2010
Purchaser (Health Plan, Employer, TPA, Agent, PBM)	30.6%	43.4%
Provider (Hospital, Physician, Pharmaceutical, Other Providers)	27.1%	24.0%
Vendor/Other (Vendors, Consultants, Institutions, Gov., All Other)	42.4%	31.8%

n = 189 for 2010, 85 for 2009 

Rating Consumer Reports New Hospital Ratings

By Clive Riddle, August 6, 2009

Consumer Reports this week announced “for the first time, Consumer Reports will provide patient satisfaction Ratings for more than 3,400 hospitals across the U.S. Subscribers to www.ConsumerReportsHealth.org will be able to look up their local hospitals to see how they stack up and the types of challenges that patients have experienced there. CR notes several areas of concern at hospitals nationwide; the vast majority of hospitals received the worst Ratings for communication about new medications and discharge planning.”

In order to access this new tool, one must subscribe to Consumer Reports Health at a cost of $19.00 annually or $4.95 monthly. The subscription also gives you access to their rating tools for health plans, treatments, prescriptions, related products and provides various supplemental information.

Questions for those in the business of health care include, how influential will these Consumer Reports tools be? How many consumers will use them? How reliable is the information? How are providers, plans and products portrayed?

Consumer Reports touts that the hospital ratings, “are based on patient surveys collected by the federal government's Hospital Consumer Assessments of Healthcare Providers and Systems Survey, known as HCAHPS. For the first time, the HCAHPS data will be available to consumers in a user-friendly interface with CR's familiar Ratings. A team of statisticians and health experts analyzed the government data to develop the Ratings. The Health Ratings Center also integrated intensity of care rankings, revealing a link between patient satisfaction and intensity of care; the hospitals that have above average patient satisfaction Ratings provide, on average, a more conservative (and less expensive) type of medical care. The intensity of care rankings are based on data from the Dartmouth Atlas of Health Care and the Dartmouth Institute for Health Policy and Clinical Practice.”

HCAHPS and the Dartmouth Atlas of Health Care are perhaps the most mainstream established comparative data sources, so the reliability of the Consumer Reports data is not so much the issue, and hospitals are already accustomed and have access to how they are portrayed by these sources. So the remaining questions to address are how influential will the Consumer Reports tools be and how many people will use them. Should hospitals and other professionals invest energy in monitoring this?

If you’re a professional looking to research data from the Consumer Reports hospital ratings tool, you need not bother investing the $19 annually. I did, and while the Consumer Reports tool is darn easy to use and provides a choice of summary and detailed information, you can get the same data and much more for free direct from the sources. HCAHPS data in incorporated into the CMS Hospital Compare Web Site. The Consumer Reports tool lets you compare up to five hospitals at once, and Hospital Compare only lets you compare up to three. But the Consumer Reports detailed data is limited to the HCAHPS patient survey results and Dartmouth data on Chronic Care and Average Costs, while the Hospital Compare detailed information incorporates many more measures in addition to the HCAHPS survey data and provides optional graphs and tables.

As discussed in a previous blog, Checking Out CMS’ Hospital Compare, you can download the entire database from the Hospital Compare web site if you wish. There aren’t such data download capabilities from Consumer Reports. In fact, outside of providing a comparison to the top national ranked hospital in any results page (Oakleaf Surgical Hospital in Eau Claire, Wisconsin) I couldn’t find national or state average data using the Consumer Reports tool. I did find a very nice Summary of HCAHPS Survey Results indicating state and national averages for each survey indicator for free from the HCAHPS web site.  Here’s the national average of hospital satisfaction levels for their various components, which are interesting:

• Communication with Nurses: 74%
• Communication with Doctors: 80%
• Responsiveness of Staff: 62%
• Pain Management: 68%
• Communication about Medicines: 59%
• Cleanliness: 69%
• Quietness: 56%
• Discharge Information: 80%
• Overall Hospital Rating: 64%
• Recommend the Hospital: 68%

The Consumer Reports tool does include some Dartmouth data, and The Dartmouth Atlas of Health Care does cost $59 to purchase in print form. But while its not entirely simple to use, you can drill down through the site and query the databases, download applicable files and review applicable report, all for free.

So, a professional will find much more data, and free at that, going to the original sources rather than Consumer Reports. I can’t that I’d recommend the Consumer Reports tool to a consumer either for the same reasons, unless they really want and need something very simple and centralized to use, that doesn’t confuse them with too many data choices and options, and don’t mind paying for the privilege.

Of course, the Consumer Reports Health tool does offer much more than hospital comparisons, and because its offered by Consumer Reports, it will yield some influence over a number of consumers’ health decisions, and a number of consumers will undoubtedly use the service.

Insider’s View on the Direction of Consumerism and Consumer Driven Plans

By Clive Riddle, April 9, 2009

The Eighth Annual Consumer Driven Web Summit was held a few weeks ago, which included a survey of the professional attendees on a couple of key questions regarding the direction of consumerism and consumer driven plans.

What is the industry insiders’ view the main components of consumerism? Last year and this year they were asked to rank five components according to the value of the component from their perspective:

• Account Based Plans (HSA/HRA/FSA)
• Price and Quality Transparency
• Retail Medicine (Convenient Care, etc)
• Web Based Consumer Patient Health Records
• Wellness Incentive Programs

Price and Quality Transparency continues to be ranked far in front of the five components being rated, and Wellness Incentive Programs continue to be ranked second. The mean score improved for Wellness Incentive Programs and for Retail Medicine, while the mean scores declined for the other three components:

Respondents were asked to rank each component 1 through 5, with 1 = highest value and 5=lowest value, and only use each ranking once; i.e. only rate one item a 1, one item a 2, etc.

Here’s the results for the past two years:

	2009	2008	2009	2009
	Mean	Mean	Median	Mode
Price and Quality Transparency	2.00	1.83	1	1
Account Based Plans (HSA/HRA/FSA)	3.08	2.97	3	2
Wellness Incentive Programs	2.65	2.86	3	3
Web Based Consumer Patient Health Records	3.70	3.63	4	4
Retail Medicine (Convenient Care, etc)	3.57	3.71	4	5

It’s interesting to see that web based consumer patient health records aren’t prioritized a little higher, given their priority in policy circles and elsewhere. It’s also interesting to see account based plans lose ground. Many pundits have already pronounced the decline and fall of the account based plan, given the direction that the Democratic congress, Obama administration, and influential policy organizations have taken.

But not so fast. Insiders seem to feel what a number of recent surveys have shown, that employer interest in account based plans in rising as a tool to address cost related issues in this economic meltdown.

Respondents were asked to predict enrollment change for such plans. Here’s how they answered: “As a result of the Recession, will Consumer Driven Plan enrollment/ market share (compared to traditional managed care plan designs):”

· Increase significantly 26.4%

· Increase somewhat 42.5%

· Not materially change 14.9%

· Decrease somewhat 11.5%

· Decrease significantly 4.6%

Thus 66.9% felt enrollment would increase as a result of the recession, while 16.1% felt enrollment would decrease.

As health care reform takes shape over the next months (or years), the economy will undoubtedly weigh large in the discussions. The pundit’s reported death of consumer driven plans may prove to be premature.

Medical Home: Consumerism Delivered

By Lindsay Resnick, January 5, 2009

Consumer Directed Healthcare can be defined as health benefit plans that put consumers and their providers at the center of health care decision-making, giving them greater discretion and power over benefit dollars and medical care choices. These plans often include increased cost-sharing wrapped around an HSA, decision support tools to evaluate choices, “health coaches” to encourage care management, and incentives to promote healthy lifestyles. Rather than shielding consumers, CDH plans engage them directly.

CDH is based on “patient centeredness” which, as defined by the Institute of Medicine, refers to health care that establishes a partnership among practitioners, patients and their families to ensure that decisions respect patients’ wants, needs and preferences; and ensure they have access to education and support to make decisions and participate in their own care.

Consumer Directed Healthcare and patient centeredness has given rise to the next “hot trend” in healthcare - the medical home. A medical home is not a house, clinic or hospital, but rather an approach to providing comprehensive primary care. A medical home is defined as primary care that is accessible, continuous, comprehensive, family-centric, compassionate, and culturally effective.

A “whole person” orientation to healthcare delivery is at the core of the medical home. A personal physician is responsible for providing all the patient’s healthcare needs. Care is coordinated across all components of the patient’s healthcare community - hospitals, specialty physicians, pharmacists, social services, home health, nursing homes, and ancillary providers. And, it includes a vision of care for all stages of life, acute and chronic, wellness and prevention, and end-of-life. The medical home was introduced in 1967 by the American Academy of Pediatrics. Most recently, several professional medical organizations joined the AAP to redefine the basic tenets of the Patient Centered Medical Home:

Personal Relationship: Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.

Team Approach: The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing patient care.

Comprehensive: The personal physician is responsible for providing for all the patient’s health care needs at all stages of life or taking responsibility for appropriately arranging care with other qualified professionals.

Coordination: Care is coordinated and integrated across all domains of the health care system, facilitated by registries, information technology, and health information exchange to assure that patients get the indicated care when and where they want it.

Quality and Safety: This includes using electronic medical records and technology to provide decision-support for evidence-based treatments.

Expanded Access: Enhanced access to care available through systems such as open scheduling, expanded hours and new options for communication between patients and physicians.

Added Value: Payment that appropriately recognizes the added value provided to patients who have a Patient-Centered Medical Home.

The medical home is the next step toward true healthcare consumerism. With 45% of the U. S. population having a chronic medical condition accounting for $3 out of every $4 spent on healthcare, coordinated care delivery supported by a team-oriented medical management plan-of-action is a direction worth pursuing.

Personal Health Records: The Hot Consumerism Tool

By Lindsay Resnick

Consumer Directed Healthcare (CDH) is past the tipping point. Employers, employees, payers and providers have embraced these free market style health benefit plans that put consumers in the center of deciding where, when, and from whom they receive care---the customer now has more skin in the game. CDH success means changing the way people think about and deal with their healthcare choices. It takes practical decision support tools, credible information and increased connectivity throughout the healthcare system. Now, the newest consumer trend is allowing individuals and families to maintain their own online health records.
Personal Health Records (PHRs) enable consumers to have easy access to their health history and clinical make-up in order to manage benefit and medical decisions. It gives consumers more knowledge and control over their health information. In essence, it creates a smarter, better informed healthcare customer. PHRs allow an individual to enter and record personal medical information such as medical history, prescriptions, examination results, office visit tracking and, lab and diagnostic test results. Based on PHR functionality, consumers can input or scan images, charts, graphs, and print reports.
The result is a PHR that provides an accurate, up-to-date summary of a person’s health status and medical history. The information is secured online and only accessible by the individual or, medical professionals with approved authorization, at the PHR owner’s discretion. In addition to a standalone, consumer-driven PHR, other models are emerging that take a more integrated approach allowing information to be input through other, secure sources such as physicians, pharmacists, home care and even linked-in claims data.
In a predominately paper-driven medical record world, online PHRs bring the portability and connectivity that make reliable information available, quickly. The result can be lifesaving in emergency situations, help avoid harmful medication interactions, reduce unnecessary tests and properly prepare consumers with the context to ask the “right” questions. Most importantly, PHRs give consumers the control they need to make informed, confident decisions.
Internet-based Personal Health Records are rapidly emerging. In a State of the Union address, the President called for every American to have one in ten years. This year, Microsoft launched HealthVault and, Google Health is testing its own PHR. It is estimated that there are more than 200 PHR products available in the market with a wide range of functionality, level of integration and “cool” features.
With consumers well on the way to being the centerpiece in the future of healthcare benefit and medical decision-making, PHRs will continue to grow in popularity and acceptance. A recent Markle Foundation survey shows that almost 80% of the public believes PHRs would provide significant benefits to individuals in managing their health, although many (57%) express concern over privacy and security of their information. PHRs are here to stay. They represent another step in healthcare’s technological movement built around content, community, commerce and connectivity.

Easy Answers Make Poor Gifts

By Laurie Gelb

A new political era is upon us, and the red herrings that should be frolicking in the wild somehow never left the boardroom.

You’ve heard them all. Members are lazy slugs. Docs are mercenaries with stethoscopes. Pharmas suck the last dollar out of destitute Part D recipients. Often, the pharmacy chains come out best in this narrative – their low generic pricing is actually both market-driven and good for adherence. But improved outcomes are unlikely to be driven in large part by CVS or Walgreens in the current regulatory environment. So what’s next?

Recently, I’ve explored scores of managed care and health system Web sites as a strategist and competition judge. As I’ve pointed and clicked across this year’s domains of top-tier AMCs and health plans, I’ve reflected on my MCOL presentations of the last few years.

Many of us preach the need for customized decision support that validates the complexity and importance of stakeholder choices. Yet the health Web on evidence in 2008 continues to propagate the false dichotomies of idiot vs. expert, with information accessible through clunky largely static pages, with only the most rudimentary support for critical decisions like choosing a physician or evaluating the urgency [often confused with indications] for surgery.

If all you care about in selecting a doc is gender, languages spoken and hospital affiliations, you’re in the right place. If Flash first-reads displaying ethnically diverse docs and patients are your idea of immersive storyline, Google “hospital” or “health plan” and go to town. If your idea of a surgical consult on the Web is a pretty graphic and a few FAQs, welcome to the Net. But don’t we spend a lot of offline ink telling members that they need to ask much more probing questions?

Has Revolution Health and/or HealthGrades provided a quantum leap here? Hardly. Rate-a-doc portals? These probably eliminate some docs from consideration lists, but there’s scant evidence that they are helping distinguish the incompetent from the competent. The “rate a drug” racket probably does more for the raters than the readers.

Finally, hospital rankings and mortality stats, flawed in so many obvious ways, also divert attention from the notion of physician selection as a starting point, not to mention the idea of a medical home. Yes, the data quality is improving, but the support for the right ways to use it is not!

Instead of directly addressing patient and caregiver reasons for fear, loathing and denial of clinical realities (such as very few placebo-equivalent drugs or no-risk surgeries), content developers often seem to think that simply acknowledging the existence of these phenomena solves the problem. The proposition that “I’m OK, you’re OK, disease is OK” is in danger of replacing actual decision support in the health digisphere. With a President-elect who admits incomplete smoking cessation but exercises diligently, might we have a teachable moment here?

As for rational consideration of potential health decisions, the mass media’s tendency to discuss competing risks using anything but anecdotal evidence has increasingly obscured the differences between population-level statistics and individual considerations. And judging from the conflict-of-interest stories sprouting like mushrooms, no one at an academic medical center ever took money from pharma or device manufacturers till recently (NOT!) Another walk away from the real, toward the valley of oversimplification.
Disease is a real entity, with disability and death possibilities for everyone every day “We’re never promised tomorrow,” as Chief Daniels noted during one of his Polonius moments on Hill Street Blues. At the very least, addressing unpleasant facts so as to minimize risks entails the willingness to believe that decision-making can entail choosing among suboptimal choices. When members lose sight of the complexity, the effort, the costs of acquiring and acting on the best information, we’re only letting them kid themselves.

Baby talk is maybe talk. “Eat less simple sugar today! You can do it!” Passive voice is well, passive.
How honest, precise and strong are your communications?

Data from the Consumer Driven Healthcare Summit

By Clive Riddle

The Third National Consumer Driven Healthcare Summit was held earlier this week in Washington DC, addressing a wide range of current key health care consumerism issues, with leading thought leaders and industry experts from around the country. Here's some interesting data shared by speakers from four selected Track Sessions during the conference:

Individual Health Insurance

Samuel Gibbs, Senior Vice President of Sales of eHealth, Inc.(parent of eHealthInsurance) gave a presentation on "The Online Individual Insurance Market - Perspectives, Experiences and Trends." EHealth represents over 180 health insurance carriers nationwide, which are available directly to consumer via their eHealthInsurance web site. Sam shared that eHealth's individual plan profile for 2007 was as follows:

* Average Age: 36
* Percent Male: 54%
* Percent Single: 61%
* Average Annual Premium: $1,896
* Range of Average Monthly Premiums: $83 to $388
* Average Annual Deductible: $1,971

Ann Ritter from the Convenient Care Association participated in a session on "The State of Convenient Care for 2009" and shared just released RAND convenient care data including:

* Patients by age breakdown as follows: under age 2 - 0.2%; age 2-5 - 6.3%; age 6-17 - 20.3%; age 18-44 - 43.0%; age 45-64 - 22.6%; age 65+ 7.5%
* 2.3% of patients were triaged to an emergency department or physician's office
* Among patients age 65+, 73.65% of visits were for immunizations
* Ten basic treatments and services accounted for more than 90% of visits

Paul H. Rubin, PhD, Samuel Candler Dobbs Professor of Economics and Law, Department of Economics, Emory University, in a presentation on "The Cost Effectiveness of Direct to Consumer Advertising for Prescription Drugs" discussed findings from a study and paper he co-wrote with Adam Atherly of Emory University, in which they found during patient visits to their physician:

* 4% of patients schedule physician visits to ask about a drug
* 14% of patients discussed a concern because of DTC advertising
* If patients ask for a drug, 39% receive that prescription, 22% are prescribed a different drug, and 18% receive no drug
* 5.5% of physicians prescribed a requested DTC drug, but thought a different drug was better
* 88% of patients requesting a DTC drug had a relevant condition
* 75% who received the requested drug reported subsequently feeling better

Michael Vittoria, Vice President, Human Resources, Sperian Protection, in his presentation on "Integrating Wellness & Preventative Care into a CDHP" told us that Sperian, with 1,300 U.S. employees, adopted a self funded HRA in 2004, introduced HSAs in 2007 and introduced Wellness Incentives in 2008. Sperian currently has 56% of employees enrolled in PPOs, 14% in HMOs and 30% in the self funded HSA options. 34% of their 2008 HSA participants earn < $30k, 21% earn between $30k to $50k, 17% earn between $50k to $75k, 16% earn between $75k and $100k, and 12% earn more than $100k. Sperian conducted various wellness incentive programs during 2008, with their weight loss program yielding a BMI reduction in participating employees from 30.7 to 29.4. Sperian's overall medical cost trend from each previous year has been:

* 2004 - 11.7% increase
* 2005 - 4.5% increase
* 2006 - 3.6% increase
* 2007 - 2.6% increase
* 2008 - 1.8% increase

What's the current state of things in the Convenient Care Industry?

By Clive Riddle

After attending two sessions on retail medicine at the World Health Care Congress today, here's what we found out:

John Agwunobi, MD, EVP Professional Services for Wal-Mart shared the following statistics for Convenient Care visits at Wal-Mart locations, through their various contracted providers:

• adults comprise 79% of visits, 21% of visits are for children
• 55% of patients have no insurance coverage
• Patient surveys indicate, had the Wal Mart convenient care location not been available, 40-50% of patients would have seen a primary care physician; 20-35% of patients would have used an urgent care facility; 10-15% would have gone to an ER; 5-10% would have foregone treatment
• 90+% of patients indicate overall satisfaction
• 25-40% of visits are for immunizations & screenings; and 60-75% of visits are to treat common illnesses

Doctor Agwunobi also discussed the Wal-Mart $4 Generic Prescription program, which is offered to all Wal-Mart customers and is proactively promoted through the Convenient Care locations. The program involves 361 generic prescriptions covering up to 95 percent of prescriptions written in the majority of therapeutic categories. Nearly 30 percent of $4 prescriptions are filled without insurance. The $4 prescriptions now represent approximately 40 percent of all filled prescriptions at Wal-Mart.

Web Golinkin, President and CEO, of RediClinic discussed RediClinic customer experiences, noting that RediClinic is a partner of Wal-Marts. Mr. Golinkin is also President of the Convenient Care Association and shared the following insights regarding the Association and industry as a whole:

• There were 150 clinics when the Convenient Care Association founded less than two years ago to more than 950 today nationwide, with 1,500 projected by the end of 2008.
• Overall, the clinics have treated more than 2.5 million patients in 36 states
• Surveys indicate 16% of consumers have tried a clinic and between 34 to 41% say they intend to

Golinkin stated the potential obstacles or events that could slow industry growth would be if:

• The industry suffered future systemic clinical quality issues
• A shortage and/or increased cost of Nurse Practitioners (NPs) and Physician Assistants (PAs) occurred
• If various states continue with additional regulatory impediments (clinic licensure requirements, restrictions on NP/PA scope of practice and prescriptive authority, physician oversight requirements, corporate practice of medicine prohibitions, etc.)
• If increased Operator/business model failures occur. He noted that there have been some failures, commented that this should be expected with any industry having relatively lower barriers to entry but higher ongoing working capital requirements. He felt there will be a shakeout with consolidation.

Michael Howe, CEO of MinuteClinic, states their organization's strengths include:

• They are "Right Size” engineered for efficiency and high quality
• Proprietary Electronic medical record system embedded with standardized “best practice” protocols
• Facilitates measurement of results and continuous quality improvement
• Interoperability drives continuity of care back to the Medical Home
• Consumer friendly - with convenient locations in consumer pathway, and “Lifestyle conscious” hours and “walk in” scheduling
• “High touch” capability of practitioners drives compliance
• Patient Referral system facilitates the creation of “Medical Homes”when lacking

He cited an independent external research study conducted by Market Strategies in April 2007 indicating a patient satisfaction rate, as well as the percent likely to recommend, of 97%. He noted that MinuteClinic adheres to national standards of practice guidelines, (which have been adopted by their Association) but also is the first retail health care provider to be Joint Commission accredited.

Howe also cited a peer reviewed study from September 2005 through September 2006 of 57,000+ MinuteClinic evaluations of acute pharyngitis, looking for outcome measures to include adherence to best practice treatment guideline in presence of negative or positive RST, use of back up confirmatory strep culture testing in presence of negative RST, and documented rationale when antibiotic was prescribed in presence of negative RST. The study indicated an overall adherence rate of 99.15%.