National Healthcare Measures: A lot of Improvement Overshadowed By Obesity and Diabetes

By Clive Riddle, March 16, 2017 On this Ides of March the CDC National Center for Health Statistics released Selected Estimates Based on Data From the January-September 2017 National Health Interview Survey with great data covering measures fifteen different selected topics. We selected a key statistic from ten of the topics to share below. What’s striking is that despite our marked improvement in most topics during the past two decades, the percentage of persons reporting they had excellent health didn’t improve (although half a percentage point better than ten years ago, it is two percentage points lower than twenty years ago.) The culprits in the case must be due in a large part to the fact we living large(er). Two topics below in which increasing percentages aren’t a good thing are obesity and diabetes, but increase we did. We can make policy and administrative changes that impact the percentage of people with insurance, access  care, receive vaccinations, promote exercise and promote smoking cessation. Obesity and Diabetes seem  tougher to tackle. ·         Percentage of persons without health insurance coverage: 2017  9.0% | 2007 14.5% | 1997 15.4% ·         Percentage of Persons With a Usual Place to go for Medical Care (Age adjusted):  2017  88.1% | 2007 86.5% | 1997 86.3% ·         Percentage of persons of all ages who failed to obtain needed medical care due to cost at some time during the past 12 months (Age Adjusted): 2017 4.4% | 2007 5.8% | 1997 4.5% ·         Percentage of adults aged 65+ who received an influenza vaccination during the past 12 months (Age Adjusted):  2017 70.6% | 2007 66.8% | 1997 63.1% ·         Percentage of adults aged 65 and over who had ever received a pneumococcal vaccination (Age Adjusted):  2017 69.9% | 2007 57.8% | 1997 42.6% ·         Prevalence of obesity among adults aged 20 and over (Age Adjusted):  2017 31.4% | 2007 26.6% | 1997 19.5% ·         Percentage of adults aged 18 and over who met 2008 federal physical activity guidelines for aerobic activity through leisure-time aerobic activity (Age Adjusted):  2017 54.8% | 2007 42.0% | 1997 43.3% ·         Prevalence of current cigarette smoking among adults aged 18 and over (Age Adjusted):  2017 14.3% | 2007 19.7% | 1997 24.6% ·         Percentage of persons of all ages who had excellent or very good health:  2017 66.5% | 2007 66.0% | 1997 68.5% ·         Prevalence of diagnosed diabetes among adults aged 18 and over: (Age Adjusted):  2017 8.4% | 2007 7.5% | 1997 5.3%

Perhaps Accenture’s Surveyed Consumers So Willing To Share Healthcare Data Should Read Accenture’s CyberSecurity Survey Report

By Clive Riddle, March 9, 2018 Accenture has just released a 12-page report with findings from their 2018 Consumer Survey on Digital Health in which they conclude that “Growing consumer demand for digital-based health services is ushering in a new model for care in which patients and machines are joining doctors as part of the healthcare delivery team, and that  “consumers are becoming more accepting of machines — ranging from artificial intelligence (AI), to virtual clinicians and home-based diagnostics — having a significantly greater role in their overall medical care. “ Here’s some survey response highlights shared in the report: ·         19% have already used AI-powered healthcare services, with 66% of these consumers likely to use AI-enabled clinical services ·         Consumer use of mobile and tablet health apps has increased from 16% in 2014 to 48% currently. ·         44% have accessed their electronic health records in patient portals over the past year, with 67% of these consumers seeking information on lab and blood-test results; 55% viewing physician notes regarding medical visits, and 41% looking up their prescription history ·         The use of wearable devices by consumers has increased from 9% in 2014 to 33%t currently. ·         75% view wearables  as beneficial to understanding their health condition; while 73% cite them helping engage with their health, and 73% also cite monitoring the health of a loved one ·         90% are willing to share personal data with their doctor, and 88% are willing to share personal data with a nurse or other healthcare professional. ·         72% are willing today to share with their insurance carrier personal data collected from their wearable devices has increased over the past year, compared to from 63% in 2016. ·         47% are willing so share such data and with online communities or other app users today, compared with 38% in 2016. ·         38% are willing to share data with their employer  and 41% with a government agency Interestingly while consumers seem to trust sharing their data most with their doctor and clinical professionals much more than their health plan, another Accenture survey recently released on healthcare cybersecurity found that while overall 18% of healthcare organization employees were willing to sell confidential data to unauthorized parties for as little as between $500 and $1,000; there was considerable disparity between plans and provider offices: 21% from provider organizations would sell confidential data compared to 12% from payer organizations.

Peter Kongstvedt on the Amazon Healthmarket, Coming Soon to an Alexa Near You

By Clive Riddle, March 2, 2018

Lendedu released survey results this week on consumer acceptance if Amazon ventured into several financial related markets including virtual currency, banking, lending, investment and insurance. Their survey involved polling 1,000 consumers who purchased something from Amazon within that past 30 days.

In the insurance arena, consumers were asked about Life, auto and health insurance: “If offered, would you be open to the idea of using the listed insurance product created by Amazon?” For health insurance, 35.8% said yes, 31.3% said no and 32.9% were unsure. 41.6% of the consumers who were Amazon Prime users said yes. Acceptance for auto insurance was nine percentage points higher and life insurance was two percentage points higher.

Just over a month ago, most everyone in the healthcare universe got excited or at least paid notice when AmazonBershireJPMorgan healthcare was announced. Of course some such as Sam Baker cautioned in Axios that “We don't know what they're even trying to do” and that “other big companies have tried something similar.”

A month later AmazonBershireJPMorgan healthcareis still a blank canvas that we’re allowed to paint our own perceptions into. Healthcare media reported on the Lendedu survey results with headlines such as 35.8% of Americans would use an Amazon health insurance plan.

The national treasure of healthcare wit and expertise that is Peter Kongstvedt, MD FACP had this to say in response (including footnotes) to these headlines:

“Who wouldn’t be eager to sign up for an undescribed health plan, for which we can imagine it to be low-cost, super-convenient, available through Alexa, delivered in your home by the same day, and come with unlimited music and video streaming?* Few if any barriers to achieving this. Merely need to tell hospitals, physicians, and drug manufacturers what they will accept as payment in full and their obligation to meet Just-in-Time delivery, and they will all fall all over themselves to be in the Amazon HealthMarket.® ”

* PrimeHealth® 12-month subscription required, renewable at PrimeHealth’s sole discretion. Treatment options and bandwidth limitations may apply. Offer only available in U.S. states and territories. Acceptance denotes consent with all EULA Terms and Conditions including your Blood oath to forever abandon WalMart® and Apple® iTunes®.

The State of the Uninsured and Health Insurance Coverage

by Clive Riddle, February 23, 2018 The National Center for Health Statistics has just released updated health insurance coverage estimates from selected states using 2017 National Health Interview Survey data.  Here are seven things to know about their findings for the first 9 months of 2017: 1.     28.9 million (9.0%) persons of all ages were uninsured, not significantly different from 2016, but 19.7 million fewer persons than in 2010. 2.     12.7% of adults aged 18–64, were uninsured, 19.5% had public coverage, and 69.3% had private health insurance coverage. 3.     4.4%  of adults aged 18–64 (8.6 million) covered by private health insurance plans obtained their coverage through the federal or state-based exchanges. 4.     Adults aged 25–34 were almost twice as likely as adults aged 45–64 to lack health insurance coverage (17.3% compared with 9.2%) 5.     4.9%  of children aged 0–17 years, were uninsured, 41.9% had public coverage, and 54.6% had private health insurance coverage. 6.     The percentage uninsured decreased significantly for all age groups from 2013 through the first 9 months of 2017, ranging from –6.2 percentage points for ages 45–64 to –10.7 percentage points for ages 18–24. 7.     43.2% of persons under age 65 with private health insurance were enrolled in a high-deductible health plan (HDHP) compared to 39.4% in 2016 However, as a warning sign that 2018 may see slippage in these insurance coverage, the Minnesota Department of Health just issued an ominous press release, indicating that “last year Minnesota saw one of its largest, one-time increases in the rate of people without health insurance since 2001. The uninsured rate rose from 4.3 percent in 2015 to 6.3 percent, leaving approximately 349,000 Minnesotans without coverage.”

Employees Feel Their Own Health Plan is Better Than Most Others

By Clive Riddle, February 9, 2018 Surveys have consistently shown over the years that the public generally ranks Congress low in esteem, but their personal Congressman is held in higher regard. Health Plans, like Congress, have been a favorite target as well, but similarly – people tend to like their personal coverage more than how they view health plans overall. AHIP has just released a 42-page report of findings from their national survey “The Value of Employer Provided Coverage” that not only reinforces this phenomenon – in which respondents rank their own plan higher than their overall view how health care is covered, but also makes the case that consumers place employer provided coverage in higher regard than the nation’s health coverage system as a whole. On top of that, there is perhaps less angst about the nation’s health insurance system overall than one might have thought. 63% were satisfied with the nation's current health insurance system, and 31% were dissatisfied. 71% were satisfied with their own health plan, and 19% were dissatisfied. 60% felt their personal cost was reasonable and 29% felt the cost was unreasonable, while 66% felt the cost was unreasonable for Americans as a whole. 52% described their deductible as reasonable, while 36% said it was unreasonable. However, for those dissatisfied with their plans, 82% cited costs as the main reason. 72% say they are adequately informed about health insurance benefits under their plan, yet only 20% understand that employers average paying above 75% of the total costs. In other findings from the survey: ·         71% remain concerned the cost of health care will continue to rise ·         56% prioritize comprehensive benefits while 41% prioritize affordability of plans. ·         46%said health insurance was a deciding factor in choosing their current job ·         56% support keeping employer provided coverage tax free, and 13% oppose ·         58% prefer increased market competition while 42% support increased government involvement to address costs ·         Prescription drug coverage (51%), preventive care (47%), and emergency care (47%) rank among the benefits that matter most.

Accenture’s Advice to Pharma: It’s The Evidence, Stupid.

By Clive Riddle, January 12, 2018 Remember when Bill Clinton’s first presidential campaign mantra was “it’s the economy, stupid”?  Accenture advises the pharmaceutical industry to substitute evidence for economy in that equation and focus more on evidence-based solutions than products or brand. Accenture has just released 16-page report: Product Launch: The Patient Has Spoken in which they conclude “brands are not major influencing factors when patients consider new pharmaceutical products. More than two-thirds (69 percent) of patients surveyed said the product’s benefits – i.e., treatment outcomes – are more important than the brand itself, with less than one-third (31 percent) citing a strong affinity to brands in a healthcare setting.” Accenture tells us that for the report, they commissioned a survey of 8,000 patients in France, Germany, the U.K. and the U.S across eight therapeutic areas – immunology, cardiology, pulmonology, neurology, oncology, rheumatology, endocrinology and eye disease. Respondents represented three main age demographics: baby boomers, Gen Xers and millennials. Accenture shared the following findings: When patients were asked which factors influence their healthcare product and treatment decisions: ·         66% cited the doctor/physician relationship ·         55% indicated the ability to maintain their current lifestyle ·         53% said ease of access to the care they’ll need ·         But just 31% listed brand loyalty or popularity, and this ranked twelfth out of 14 influencing factors The report notes that patient perspectives include: ·         38 % said they feel very knowledgeable about new or existing products coming to market for their condition ·         25 % reported having either very limited or no knowledge of new products that might be suitable for them ·         48 % believe that their doctors discuss the full range of product options with them ·         44 % feel that they have significant input into their treatment selection ·         63 % said they want to be involved in such decisions ·         47% said they’ve thought about switching their treatment at some point ·         62%of those who think about switching end up doing so So if it isn’t product and brand, what does drive patient treatment choice decisions? Accenture says “despite survey results showing that many patients look online for information about new treatments, physicians remain the primary influencer of their treatment choices. In fact, the reason patients cited most often for switching treatments was a recommendation from their physician (cited by 81 percent of patients who switched treatments), followed by proven benefits compared to current treatment (79 percent) and fewer side-effects than their current treatment (78 percent).” Regarding demographics, the survey “findings also identified differences in attitude and behavior by age group, with younger patients more likely than older ones to understand which treatments are available—and switch treatments when they believe there’s something better. For instance, while physician recommendation was the most-cited reason across all age groups for switching treatment, Millennials are almost twice as likely as Baby Boomers to be influenced by people posting alternative treatment options on social media.” Of course what the report doesn’t focus on regarding treatment decisions is the role of insurance coverage, cost-sharing and formularies. But Accenture’s message in this value based era should still resonate. Accenture’s Jim Cleffi, a co-author of the report, tells us “given the significant budgets pharmaceutical companies devote to driving brand equity in the marketplace, our report findings should be a strong signal to the industry that launch strategies need to change. Patients in our study made it clear that outcomes matter most which means that pharma companies should focus their launch strategies and communications more on patient value and impact versus the brand—and do so in a much more precise and personalized way. Reallocating parts of launch budgets to programs that resonate the most with different patient segments would not only better meet patients’ needs and deliver better outcomes, but likely provide the companies with better ROI.” Accenture provides pharma two recommendations in the report: 1)    Bring an outcome – not just a product – to market. Patients value outcomes over brands, so instead of launching just products, pharmaceutical companies should start launching evidence-based solutions, or products with services as a secondary offering. This will require collaborative data-sharing – between patients, providers and payers – along with advanced analytics to generate robust insights and delivery via digital channels. This mindset should begin at the clinical trial-stage so it informs new launch strategies and full commercialization. 2)    Make it personal and precise. One size no longer fits all; pharmaceutical companies need to understand patient sub-segments and develop value-driven launch strategies tailored to each segment. Harnessing advanced analytics and other new technologies that leverage the proliferation of health data will help enable companies to modify launch strategies that make new treatments more relevant to patients while also driving better-informed resource and investment allocations.

Looking A Little Deeper into CMS National Health Expenditure Report

By Clive Riddle, December 20, 2017 The CMS Office of the Actuary recently released their annual National Health Expenditure Data, current and historical through 2016. We thought we’d take a slightly deeper look at data released to expand upon the publicized highlights. CMS found that ”in 2016, overall national health spending increased 4.3 percent following 5.8 percent growth in 2015.” For comparison PwC in their annual Behind The Numbers medical cost trend report pegged the number at 6.8% in 2015; 6.2% in 2016; 6.0% in 2017 and project 6.5% for 2018. Of course overall national health expenditures measured by CMS are not an identical universe to how PwC measures medical cost trend. The portion of national GDP that healthcare consumes has been one of the most used comparative measures of healthcare to the overall economy. CMS found that “During 2014 and 2015, the health spending share of the economy increased 0.5 percentage point from 17.2 percent in 2013 to 17.7 percent in 2015. Health care spending grew 1.5 percentage points faster than the overall economy in 2016, resulting in a 0.2 percentage-point increase in the health spending share of the economy – from 17.7 percent in 2015 to 17.9 percent in 2016.” Looking back into CMS historical files, in 1966 healthcare consumed 5.7% of the national GDP. In 1976 it was 8.1%. In 1986: 10.3; 1996: 13.3%; 2006: 15.5%; and last year to 17.9%. CMS reports that “private health insurance spending increased 5.1 percent to $1.1 trillion in 2016, which was slower than the 6.9 percent growth in 2015.” Private insurance comprised 22% of national health expenditures in 1966, 25% in 1976, 29% in 1986, 32% in 1996, and 34% in 2006 as well as 2016.   Regarding Medicare, CMS states “spending grew 3.6 percent to $672.1 billion in 2016, which was slower growth than the previous two years when spending grew 4.8 percent in 2015 and 4.9 percent in 2014.  Medicare comprised 4% of national health expenditures in 1966, 13% in 1976, 16% in 1986, 18% in 1996, 19% in 2006 and 20% in 2016 For Medicaid, CMS says “expenditures grew 3.2 percent in 2016, while federal Medicaid expenditures increased 4.4 percent in 2016. The slower overall growth in Medicaid spending was much lower than in the previous two years, when Medicaid spending grew 11.5 percent in 2014 and 9.5 percent in 2015.” Medicaid comprised 3% of national health expenditures in 1966, 10% in 1976, 9% in 1986, 14% in 1996 and 2006, and 17% in 2016. CMS tells us that overall “out-of-pocket spending grew 3.9 percent to $352.5 billion in 2016, faster than the 2.8 percent growth in 2015.  Additionally, 2016 was the fastest rate of growth since 2007 and was higher than the average annual growth of 2.0 percent during 2008-15.”Examining out of pocket expenses as a percent of overall health expenditures, we found the percentage has decreased from to 48% in 1960; 33% in 1970; 22% in 1985; 15% in 2000 and 11% in 2016. CMS reported that “retail prescription drug spending slowed in 2016, increasing 1.3 percent to $328.6 billion. The slower growth in 2016 follows two years of significant growth in 2014 and 2015, 12.4 percent and 8.9 percent, respectively” Looking back at historical files for Rx total spending, percentage of overall healthcare spending and the percentage paid out of pocket for the past six decades, we found: 1966: Total $4.0 Billion | 8.6% of Total Health Expenditures | 90.2% paid out of pocket 1976: Total $8.7 Billion | 5.7% of Total Health Expenditures | 74.7% paid out of pocket 1986: Total $24.3 Billion | 5.1% of Total Health Expenditures | 64.8% paid out of pocket 1996: Total $68.1 Billion | 6.3% of Total Health Expenditures | 35.6% paid out of pocket 2006: Total $224.1 Billion | 10.4% of Total Health Expenditures | 22.9% paid out of pocket 2016: Total $328.6 Billion | 9.8% of Total Health Expenditures | 13.7% paid out of pocket.

Three Recent Studies and Three Different Perceptions of Value Based Payments

by Clive Riddle, November 3, 2017 Three different recently released studies addressing value based payments fuel three different perceptions: (1) value based payments have solid momentum; (2) that hospitals view value based care is growing more slowly than anticipated; and (3) physicians prefer FFS systems to value based care. The Health Care Payment Learning & Action Network has just released a report with survey results indicating “29% of total U.S. health care payments were tied to alternative payment models (APMs) in 2016 compared to 23% in 2015, an increase of six percentage points.” The Network states that “the survey collected data from over 80 participants, accounting for nearly 245.4 million people, or 84%, of the covered U.S. population.”   While 29% of payments were value based and totaling “approximately $354.5 billion dollars nationally” in 2016, the Network determined that 43% of payments were “traditional FFS or other legacy payments not linked to quality” and 28% was “pay-for-performance or care coordination fees.” Deloitte recently released results from their 2017 Survey of US Health System CEOs which includes are chapter on Population health and value-based care that provides these insights: ·         “Survey participants say the transition to value-based care is happening, but at a slower rate than initially anticipated. Still, many of the CEOs report that they are developing and expanding innovative delivery and payment models, and are focusing on MACRA and physician activation. ·         “Many CEOs also are looking into strategies to generate physician buy-in and encourage behavioral change, which will help them be better prepared for the transition to population health and value-based care.” ·         “Many of the surveyed CEOs express concern about operating under two different payment systems—FFS and value-based care—and having misaligned incentives. Moreover, moving towards population health and bearing financial risk likely will require a large patient population.” ·         “Many CEOs who previously had acquired and invested in physician practices report being more engaged and prepared for MACRA implementation than other survey respondents. “ ·         “In our survey, some respondents indicate they are using tools including clinical integration, employment contracts with incentives, ACOs and risk-sharing agreements, among others to better activate physicians in care delivery transformation.” Meanwhile, Bain & Company recently released their Front Line of Healthcare Report 2017, in which they surveyed 980 physicians and concluded that “more than 60% of the physicians we surveyed believe it will become more difficult to deliver high-quality care in the next two years as they struggle to cope with a complex regulatory environment, increasing administrative burdens and a more difficult reimbursement landscape. After years of experimentation, physicians now want evidence that new models for care management, reimbursement, policy and patient engagement will actually improve clinical outcomes. Without it, they see little reason to alter the status quo and move toward widespread adoption.” Specific to physician receptivity toward value based care, Bain found that physicians very much prefer FFS if they had their druthers: “More than 70% of physicians prefer to use a fee-for-service model, citing concerns about the complexity and quality of care associated with value-based payment models. Fifty-three percent of physicians say that capitation reduces the quality of care, and most see little advantage from pay-for-performance models either. Further, many believe their organizations are not sufficiently prepared for the shift to value-based care.”

The Impact of Time and Money on The Physician – Patient Relationship

by Clive Riddle, October 6, 2017 The “physician-patient relationship remains strong but cost may challenge its future,” is the headline takeaway offered by The Physicians Foundation, who just released findings from their second biennial patient survey. Their 45-report discuss analyzes survey responses from a nationally representative sample of 1,747 adults, ages 27-75, who had two visits with the same doctor in the past year. We are told “89 percent of consumers are fearful that the rising cost of healthcare will adversely impact them in the future. In particular, over half (56 percent) of patients say the cost of prescription drugs and pharmaceuticals directly contributes to rising healthcare costs. In fact, because of cost, 25 percent of patients surveyed said they did not fill a prescription and 19 percent have skipped doses of their medicine…..Fifty seven percent of healthcare consumers feel they are one sickness away from being in serious financial trouble. And 75 percent of consumers are concerned with their ability to pay for medical treatment if they were to get sick or injured, an increase from the first survey issued in 2016 when 62 percent were concerned.” What do consumers think is driving increased costs? The Foundation says “eighty-eight percent of consumers look to pharma companies and the way they price drugs as the main reason for rising healthcare costs. Other factors that consumers feel contribute to rising healthcare costs include absence of free markets (24 percent) and fraud (23 percent).” 33% of consumers say they have debt because of medical costs, with 30% of those with debt owing $5,000 or more. Time is the other major concern. The Foundation states that “only 11 percent of patients and 14 percent of physicians report that they have all the time they need together. This signals a significant challenge to providing high quality care, especially when 90 percent of patients feel the most essential element of a quality healthcare system is a solid physician-patient relationship.” The Foundation goes on to report that “65 percent of patients feel that time is always or often limited with the physician, however only half of physicians feel similarly. Yet the same number of patients (53 percent) and physicians (52 percent) are of a common mindset in terms of workload – believing physicians to be at full capacity.”  But despite the pressures from time and money, 95% of patients said they were satisfied with their overall primary doctor relationship, including 64% who said they were very satisfied. 5% said they think about changing their primary doctor all the time, and 15% said they thought about that often.

Studies on Prescription Drugs and Social Media

By Clive Riddle, September 29, 2017

Given that prescription drugs are perhaps the most direct-to-consumer marketed U.S. healthcare service, and pharmacies perhaps the most retail oriented distribution of health care services, social media would seem to have the greatest influence on pharmaceuticals than other healthcare sectors. PrescribeWellness this week released results of its 2017 Pharmacy Social Media Survey, which "looked at how Americans choose their pharmacy, what pharmacy services they most value, and their interest in interacting with their neighborhood pharmacists online and through social media."

Here’s what the shared from their findings:

• 37% look to Google when looking for a pharmacy, versus 34% relying on word of mouth
• Another 18% look to Facebook to choose a pharmacy
• 32% look for a pharmacy with a useful website
• 78% would consider following their pharmacist on social media— and 48% already do
• 42% percent wish their pharmacist were more active on social media.
• 47% say their preferred social network for interacting with their pharmacist is Facebook
• 15% prefer Twitter in this regard and 12% prefer Instagram (12 percent)
• 34% are interested in their pharmacist’s website
• 25% would be interested in a pharmacy email newsletter.
• 54% would be more inclined to use a product that their pharmacist recommended on social media

Respondents say the top benefits of following their pharmacist on social media include:

• Deals and promotions – 58 percent
• New offerings or services – 39 percent
• Healthcare news – 37 percent
• Relevant news and tips about health and wellness – 37 percent
• Seasonal vaccine reminders – 31 percent

62% use their pharmacy’s website, with 61% using the site for refill requests; 47% for online orders; 29% for medication reminders; 29% for a medication list; 20% for online appointments; and 19% to access messages from their pharmacists, 40% say their pharmacy has a mobile app, which they use to place refill requests (48%), receive refill reminders (38%) and place orders (38%).

Moving on from pharmacies to pharmaceutical companies, earlier this year, the Journal of Medical Internet Research published to paper: Direct-to-Consumer Promotion of Prescription Drugs on Mobile Devices: Content Analysis, which sought to “investigate how prescription drugs are being promoted to consumers using mobile technologies. We were particularly interested in the presentation of drug benefits and risks, with regard to presence, placement, and prominence.”

Of the mobile communications they examined, 41% were product claim communications, 22%) were reminder communications, and 37were help-seeking communications (includes information about the medical condition but not the drug name. 69% linked to branded drug websites indicating both benefits and risks, 25% linked to a landing page listing benefits but no visible risks, and 6% linked to a landing page listing risks but no visible benefits.

The Frontiers in Pharmacology journal last December published the article Perspectives for the Use of Social Media in e-Pharmamarketing which among other things concluded that "in November 2015, American Food and Drug Administration (FDA) has encouraged the use of social media to improve communication and information exchange in health promotion and public health (U.S. Food and Drug Administration Social Media Policy, 2015). Foreign studies show that one in four interactions with doctor, patient, and healthcare providers in the United States is a digital contact. Patient education through social media is therefore an opportunity for the pharmaceutical industry to gain confidence in the company and increase the awareness of consumer when choosing a product. In this way, customer acquires knowledge about health, diseases, and treatment. In various social media channels it is possible to find information on any drug. This information is available on: websites of a manufacturer, social network brand fanpages, portals for white staff specialists. According to a study, conducted by Comscore, patients who are familiar with drug brand website often followed the recommendations for its use (20% of patients). Internet advertising also influenced the use of a drug (13.5% of patients; ROI Media, 2016). E-pharmamarketing activities in social media and in the network tend to increase. It is estimated that in the year 2016 the US pharmaceutical companies allocate for this purpose 2.48 billion dollars.”

Nine Things to Know About Current Opioid Misuse from a New SAMHSA Report

By Clive Riddle, September 15, 2017

The HHS agency  SAMHSA (Substance Abuse and Mental Health Services Administration) has released a new 86-page report: Key Substance Use and Mental Health Indicators in the United States: Results from the 2016 National Survey on Drug Use and Health, which among other things provides an updated peek at opioid misuse during the past year.

 

Here’s nine things to know from the report:

1. In 2016, approximately 11.8 million people aged 12 or older misused opioids in the past year,         representing 4.4 percent of this population.

2. About 891,000 adolescents aged 12 to 17 misused opioids in the past year, representing 3.6 percent of adolescents.

3. About 2.5 million young adults aged 18 to 25 misused opioids in the past year, representing 7.3 percent of young adults.

4. 8.4 million adults aged 26 or older misused opioids in the past year, representing 4.0 percent of this age group.

5. In 2016, approximately 11.5 million people misused prescription pain relievers in the past year, making it the predominant means of opioid misuse.

6. Among people aged 12 or older in 2016 who misused prescription pain relievers in the past year, the most commonly reported reason for their last misuse of a pain reliever was to relieve physical pain (62.3 percent.)

7. 53.0 percent of people who misused pain relievers in the past year reported that they obtained the pain relievers the last time from a friend or relative.

8. Another 36.8 percent of people who misused pain relievers in the past year indicated that they obtained pain relievers the last time through prescription

9. Another 6.0%  people who misused pain relievers in the past year bought the last pain reliever they misused from a drug dealer or stranger.

Fighting Over Who The Healthcare Punching Bag Should Be: Health Plans vs. Pharma

By Clive Riddle, August 25, 2017

Earlier this month the Doctor-Patient Rights Project released Not What the Doctor Ordered: Barriers to Healthcare Access for Patients an eighteen page report presenting consumer survey results regarding health insurance coverage denials. The Project issued statements in conjunction with the report including from Stacey Worthy, Executive Director of Aimed Alliance and one of the Project’s founding members, who said “our research reveals a hidden healthcare crisis. The current debate about healthcare reform has focused on getting more Americans covered. Yet, the real crisis is among patients with chronic illnesses who tell us that insurance is worthless when their insurance providers withhold coverage of essential treatments prescribed by a doctor.”

The Project highlighted that the survey found:

• Insurance plans denied treatment coverage 24% of patients with a chronic or persistent illness or condition
• 41% of these patients denied coverage were denied once, while 59% were denied multiple times.
• 55% of those denied treatment said they were denied a prescription medication
• 41% of those denied treatment said they were denied a diagnostic or screening test
• 24% of those denied treatment said they were denied a medical procedure
• 53% of those denied coverage for a treatment of a chronic or persistent illness appealed the denial
• 49% of those appeals were ultimately successful
• 70% of the denied treatments for chronic or persistent illnesses were for conditions described as “serious
• 43% were for treatment of patients described as “in poor health”
• 29% of patients initially denied coverage reported that their condition worsened
• 34% denied coverage had to put off or forego treatment altogether

What isn’t clear at all in the report, is what the overall denial rate was for the 1,500 consumers surveyed. One wonders why that information wasn’t shared. The report focuses on denials for those responding that they had a chronic or persistent medical illness or condition, or on types of denials for the overall population surveyed.

The report tells us that 55% of the denials were for prescriptions, with 37% of these for formulary exclusions, while 12% required prior authorization, 9% required step therapy and 5% involved therapeutic substitutions. It becomes less clear from the report what portion of these denials still resulted in an alternative covered prescription, or ultimate coverage of the requested prescription after qualifying conditions were met.

The health insurance industry counters that runaway prescription costs are what we should be focusing on. The Blue Cross Blue Shield Association, AHIP and others have regularly produced reports highlighting the prescription cost problem. AHIP, for example one month ago posted Myth vs. Fact: What’s Behind Drug Prices on their website, in which AHIP goes about “fact-checking some of the pharmaceutical industry’s main arguments for why they have to charge hundreds of thousands of dollars for a course of treatment.” They cite reports and articles to support statements including: “High prices have little or nothing to do with drugs’ innovation or efficacy for patients”; “Pricing is based on what already exists, and competitors use shadow pricing to drive each other’s prices higher”; and “Instead of promoting true medical advances, a common business strategy in the pharmaceutical sector is to buy the rights to older drugs and then immediately jack up the prices.”

Morning Consult wrote about the dustup between the two sides this week, stating that health insurers are “alleging it [the Project Report] is part of a campaign by the pharmaceutical industry to distract the public from rising drug prices,” and that “Insurers say the coalition [Project] is tied to pharmaceutical companies.” The article quotes AHIP: “Big Pharma initiated another long-rumored political ad campaign in its attempts to distract from skyrocketing drug pricing, AHIP spokeswoman Cathryn Donaldson said in an email Monday, adding that instead of spending money on advertising campaigns, pharmaceutical companies should address high prescription drug prices.”

The article also quotes the other side punching back: “PhRMA spokeswoman Holly Campbell said pharma companies spend 20 percent of their revenue on research and development, fueling economic growth and bringing patients new treatments. In contrast, the insurance industry invested $0 in R&D and instead spend nearly 20 percent of premium dollars on administrative costs, she said in a Monday statement.”

Employer Surveys Project 2018 Cost Increases in the Five Percent Range

by Clive Riddle, August 11, 2017 The National Business Group on Health has released results from their Large Employers’ 2018 Health Care Strategy and Plan Design Survey, which projects the total employer cost of providing medical and pharmacy benefits to rise 5% for the fifth consecutive year in 2018. The total cost of health care is estimated to be $13,482 per employee in 2017, and is projected to increase to $14,156 in 2018, with employers funding 70% of these costs. What is driving cost increases? The most often listed top driver was specialty pharmacy (26%) and 80% of employers ranked this among the top three cost drivers. Similarly, last week Willis Towers Watson released preliminary findings from their 22nd annual Best Practices in Health Care Employer Survey, which found that "Employers expect health care costs to increase by 5.5%* in 2018, up from a 4.6% increase in 2017." The NBGH 2018 survey also produced this grab-bag of interesting employer survey responses regarding health benefit strategies, regarding telehealth, onsite care, value based care, and CDHP: ·         96% will make telehealth services available in states where it is allowed next year ·         56% plan to offer telehealth for behavioral health services ·         20% of employers are experiencing employee telehealth utilization rates of 8% or higher ·         21%s plan to promote ACOs in 2018, and another 26% are considering offering them        ·         54% will offer onsite or near site health centers in 2018         ·         88% expect to use Centers of Excellence in 2018 for certain procedures         ·         40% of employers have incorporated some type of value-based benefit design ·         18% will use value-based benefit design to steer employees toward telehealth in 2018 (16% in 2017) ·         66% of companies will offer medical decision support and second opinion services in 2018 ·         90% will offer at least one Consumer Directed Health Plan (CDHP) in 2018. ·         40% of employers will offer a CDHP as the only plan option in 2018, compared with 35% this year ·         28% pair a HDHP with a Health Reimbursement Arrangement

More on Medicaid Satisfaction: J.D. Power finds Medicaid Members More Satisfied Than Commercial Plan Members

by Clive Riddle, August 4, 2017 Recently, we  posted about The July 10 , 2017 Research Letter published in JAMA, A National Survey of Medicaid Beneficiaries’ Expenses and Satisfaction With Health Care, which found that “Medicaid enrollees gave their overall health care an average rating of 7.9 on a 0 to 10 scale. Forty-six percent gave their Medicaid coverage a score of 9 or 10, while only 7.6% gave scores under 5.” We noted these relatively high satisfaction levels occur despite a study published in the May 2017 Health Affairs: Outpatient Office Wait Times And Quality Of Care For Medicaid Patients which found Medicaid patients were 20 percent more likely than others to wait 20 minutes or longer. We also noted Medicaid managed care satisfaction rates were also measured last summer, under a survey commissioned by AHIP, which found 87 percent were satisfied with their Medicaid coverage and benefits. This week J.D. Power published a 2017 Managed Medicaid Special Report, which concludes that “Medicaid recipients are more satisfied with their coverage than traditional, commercial health plan members.” Their study measured “overall satisfaction with managed Medicaid organizations based on six factors (in order of importance): provider choice; coverage and benefits; customer service; cost; information and communication; and claims processing. Satisfaction is calculated on a 1,000-point scale.” The study found that: ·           Overall managed Medicaid satisfaction averaged a 784 score ·           The Medicaid average score was 78 points higher than the commercial health plan score for 2017 ·           Medicaid enrollees indicate provider choice as the most important factor of overall member experience ·           In contrast, commercial members list coverage and benefits as the key driver of satisfaction ·           42% of Medicaid managed care members deferred medical treatments due to cost ·           40% of Medicaid managed care members avoided buying prescription medications due to cost Given that Medicaid is administered and differs at the state level, the study addressed state differences, and reports that “Medicaid recipients in states where a dominant regional plan or a plan that owns a health system have the easiest access to doctors and hospitals, underscoring the importance of building robust networks and focusing on coordination of care between providers. Iowa, Tennessee, Arizona and Indiana have the easiest access to doctors and hospitals, compared with the other states included in the study.” The report also share that “the states with the highest levels of satisfaction among Medicaid recipients are Utah (885), Iowa (859), Colorado (854), Arizona (840) and Virginia (840). The lowest-performing states in terms of overall recipient satisfaction are Kansas (683), Mississippi (686), Delaware (716), New Jersey (728) and California (731).”

State Employee Benefit Plans Provide Insight Into Overall Group Benefit Trends

By Clive Riddle, July 20, 2017 The Summer 2017 edition of Data, Segal Consulting’s publication providing research findings on public sector employee benefits, presents findings from their 2017 State Employee Health Benefits Study. As states are one of the largest employers, and their benefit decision making is directly impacted by policy makers, monitoring the pulse of state employee benefit plans provides insight into benefit trends for group coverage as a whole. Andrew Sherman, Segal’s National Director of Public Sector Consulting, tells us “health benefits have become more important to state leaders as the cost of coverage outpaces overall inflation, placing budget pressure on health plan funding and underscoring the need for ongoing cost-management efforts. Examining what other states offer can be helpful for these leaders when they make difficult decisions about potential changes in coverage.” The 23-page issue exclusively presents their study which involved a review of the websites for all 50 states and the District of Columbia in the fourth quarter of 2016, capturing medical, prescription drug, vision and dental plan information, as well as wellness and tobacco-cessation programs, including 105 PPOs/POS plans, 83 HDHPs/CDHPs, 149 HMOs/EPOs and five indemnity plans. One insight from the study was “there are stark geographic discrepancies to where it is offered. According to the study, 13 Southern States offer HDHP/CDHPs, compared to just two in the Northeast. They are offered in eight states in the Midwest and seven in the West.” This equates to 22% of the states in the Northeast, 76% in the South, 67% in the Midwest and 54% in the West offering consumer driven plans. Single premium increases averaged 8% for HMO/EPO plans, 10% for PPO/POS plans and 14% for HDHP/CDHP plans. The average single monthly premium was $780 for HMO/EPO plans, $713 for PPO/POS plans and $563 for HDHP/CDHP plans. Single deductibles averaged $194 for HMO/EPO plans, $483 for PPO/POS plans and $1,997 for HDHP/CDHP plans. For the prescription benefit, single copayments averaged $9 for generic, $29 for brand formulary, $53 for brand non-formulary, and $101 for specialty drugs.

Medicaid Patient Satisfaction: High Despite Naysayers and Longer Wait Times

By Clive Riddle, July 13, 2017 The July 10 , 2017 Research Letter published in JAMA, A National Survey of Medicaid Beneficiaries’ Expenses and Satisfaction With Health Care, and authored by researchers at the Harvard T.H. Chan School of Public Health frames the issue like this”: “some policymakers have argued that Medicaid is a broken program that provides enrollees with inadequate access to physicians. While numerous studies demonstrate that Medicaid increases access to care, the literature has less frequently focused on patient satisfaction among Medicaid enrollees themselves. We analyzed a newly released government survey examining Medicaid beneficiaries’ experiences in the program.” Co-author Michael Barnett, assistant professor of health policy and management at Harvard Chan School, tells us “the debate on the future of Medicaid has largely marginalized a crucial voice: the perspective of enrollees. Our findings confirm that Medicaid programs are fulfilling their mission to provide access to necessary medical care.” The authors used the Medicaid Consumer Assessment of Healthcare Providers and System (CAHPS) survey administered by CMS. Here’s their summary of results: “Medicaid enrollees gave their overall health care an average rating of 7.9 on a 0 to 10 scale. Forty-six percent gave their Medicaid coverage a score of 9 or 10, while only 7.6% gave scores under 5. Ratings were similar in Medicaid expansion and nonexpansion states (7.8 vs 7.9; P = .54). Ratings were slightly higher for older adults and dual-eligible beneficiaries, but similar in the fee-for-service and managed-care groups. Overall, ratings ranged from 7.6 to 8.3 across all demographic groups.” Access was also addressed:  physician access, 84% of enrollees reported that they had been able to get all the care that they or their physician believed was necessary in the past 6 months, and 83% reported having a usual source of care. The mean percentage of beneficiaries able to get all needed care was significantly higher in Medicaid expansion states than in nonexpansion states (85.2% vs 81.5%; P < .001). Overall, only 3% of enrollees reported not being able to get care because of waiting times or physicians not accepting their insurance. Two percent reported lacking a usual source of care because 'no doctors take my insurance.' This level of patient satisfaction comes despite a study published in the May 2017 Health Affairs: Outpatient Office Wait Times And Quality Of Care For Medicaid Patients which found Medicaid patients were 20 percent more likely than others to wait 20 minutes or longer, with the median Medicaid wait time for Medicaid patients 4.6 minutes past their scheduled appointment time, compared to 4,1 minutes for the privately insured. 18 percent of visits for Medicaid patients has a wait time of more than 20 minutes, compared to 16.3 percent for privately insured patients. The concern stated with the study is the wait time would impact the Medicaid satisfaction rates measured in the CMS Consumer Assessment of Healthcare Providers and System (CAHPS). Yet the new survey findings would indicate otherwise. Medicaid satisfaction rates were also measured last summer, under a survey commissioned by AHIP, which found: ·         87 percent were satisfied with their Medicaid coverage and benefits ·         Medicaid managed care plan member had higher satisfaction with their benefits (85 percent) in comparison to those enrolled in traditional Medicaid fee-for-service programs (81 percent); ·         9 percent) said they are dissatisfied with their coverage; and ·         83 percent were highly satisfied with their level of access to doctors when needed.

Healthcare 2017 Viewed Through Brokers’ Lens

by Clive Riddle, July 7, 2017

With the onset of the ACA at the start of this decade, if one asked how brokers would view the world of healthcare seven years later, some would have answered “who cares – they will become irrelevant.” But flash forward to 2017 and here they are, continuing to play the role they have always played, even though the landscape has certainly shifted. Despite disintermediation, public exchanges, technology and a host of other challenges, brokers remain at bat, swinging away.

BenefitsPRO has just released they annual broker survey, with responses from 350 brokers representing the spectrum of industry sectors. One might have thought brokers of all people, would firmly be in the camp of ACA repeal, 50% “would like to see the ACA retained and repaired, while 28 percent prefer a gradual repeal and replace, and 22 percent want it repealed and replaced immediately.”

One insight is that brokers business has evolved so that the public exchange market isn’t a material part of their business. When asked, “how have state exchanges’ struggles impacted your business,” 48% said there was no effect, 35% replied it hurt a little or significantly, and 17% said it helped a little or significantly.” The individual market has gravitated away from brokers, with 34% not involved, 37% reporting minimal demand, and less than ten percent stating “enrolling individuals on the public exchange is worth the effort.” Private exchanges aren’t a dominant force at this point, as “nearly 6 in 10 of those responding say they do not have a private exchange partner for enrollment and benefits administration.”

While technology has facilitated some disintermediation, brokers continue to attempt to enhance their value offering a personal touch that online tools can’t offer. The survey report noted that 53 “percent of respondents say meeting in a group setting at the worksite is the primary enrollment technique, while 36 percent cited one-on-one meetings in the workplace. However, 39 percent say their top method is using an electronic enrollment tool independently.”

But losses of individual and other health insurance market share have been offset by growth in the voluntary benefit sector, with 57% identifying with the statement that “they will use voluntary benefits to offset anticipated commission losses from health insurance this year.”

Looking toward the future, consolidation looms large, just as in all other healthcare sectors, as “27% expect their organization to acquire or merge with another broker/agent organization,” while 14% “ look for another broker/agent to acquire their organization” and “14% also say their company will leave the health insurance brokerage business.”

Brokers focus for the future includes 84% “promoting ancillary insurance coverage,” 58% “promoting health plan consumer engagement and health and wellness programs,” 43% “promoting third-party consumer engagement and health and wellness programs, while 53% will be concerned about the threat of “the new wave of disruptive companies entering the industry.” A particular innovation they are concerned with is payroll companies with direct benefits distribution, with 57% viewing this a concerning.

Top Challenges Facing Healthcare Executives

By Claire Thayer, June 29, 2017

Complying with government requirements and mandates continues to be one of the top challenges healthcare executives face along with health insurance affordability. Healthcare providers rank quality and patient safety outcomes, electronic health records,  privacy and cybersecurity as top priorities for their organizations.

This weeks’ edition of the MCOL Infographic, co-sponsored by LexisNexis, offers highlights of these and other pressing concerns for healthcare executives today:

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

A virtual tour of new studies on virtual visits

By Clive Riddle, June 23, 2017 The Advisory Board reports that “up to 77% of consumers would consider seeing a provider virtually—and 19% already have,” according to just published results from their Virtual Visits Consumer Choice Survey of 4,879 U.S. consumers, “designed to better understand the tradeoffs that consumers make when they need different types of care.” The survey found consumers “would be willing to consider a virtual visit in each of the 21 primary and specialty care scenarios tested,” with over 70% of respondents interested in “a prescription question or refill, pre-surgery and select post-operation appointments, receiving ongoing results from an oncologist, and ongoing care for chronic condition management. Select pregnancy checkups, weight loss or smoking cessation coaching, dermatology consults, and psychologist consults also ranked among top offerings.” The survey also addressed consumer telehealth concerns, with 21% citing care quality as their top concern, “followed by the provider not being able to diagnose or treat them virtually (19%), meaning they would have to go to the physical clinic anyway. Only 9% of respondents said they had no concerns about virtual visits.” The current issue of Annals of Family Medicine includes the article “Patient Perceptions of Telehealth Primary Care Video Visits, in which co-authors from the National Academic Center for Telehealth, Thomas Jefferson University conducted “in-depth qualitative interviews with adult patients following video visits with their primary care clinicians at a single academic medical center.” They found that “all patients reported overall satisfaction with video visits, with the majority interested in continuing to use video visits as an alternative to in-person visits. The primary benefits cited were convenience and decreased costs. Some patients felt more comfortable with video visits than office visits and expressed a preference for receiving future serious news via video visit, because they could be in their own supportive environment. Primary concerns with video visits were privacy, including the potential for work colleagues to overhear conversations, and questions about the ability of the clinician to perform an adequate physical exam.“ The May 1, 2017 North Carolina Medical Journal includes the article A Clinical Pharmacist in Telehealth Team Care for Rural Patients with Diabetes which describes a study of the “diabetes telemedicine program funded by the Health Resources & Services Administration and Kate B. Reynolds Charitable Trust was offered in 13 sites in eastern North Carolina, including federally funded Community Health Clinics. A telemedicine team offered interdisciplinary care in the primary care provider's (PCP's) office without the patient needing to travel. The interdisciplinary team included a clinical pharmacist, dietician, behavioral therapist, and physician specializing in diabetes. The PCP referred the patient to 1 or more disciplines depending on the patient's needs. The program targeted underserved rural adults with uncontrolled type 2 diabetes.” The study found that “92% of telehealth patients were ‘very satisfied’ with their care and 83% agreed that telemedicine made it easier to get care.” Referring physicians (vs direct consumer demand) may indeed be the potential driving force for telehealth, at least in rural settings. The current issue of the Journal of the American Board of Family Medicine includes the article Family Physicians Report Considerable Interest in, but Limited Use of, Telehealth Services. A survey of 1,557 Family Practitioners found "15% reported using telehealth services during 2014, and that FPs using telehealth were:  26% more likely to be located in a rural setting; 40% more likely to work in a practice with <6 FPs; 22% less likely to work in a privately-owned practice; and 76% less likely to provide general primary care to patients. Of the FPs using telehealth: 22% used it 1-2 times, and and 26% using it 3-5 times; 55% used telehealth for diagnosis and/or treatment; 68% used telehealth to refer patients to specialists; and 28% used telehealth to refer patients to mental health providers. Still, a rosy future telehealth market is projected according to Hospital & Health Systems 2016 Consumer Telehealth Benchmark Survey results released this month, with health systems cited as a primary driver. They report that “seventy-six percent of U.S. hospitals and health systems either have in place or expect to implement a consumer telehealth program by 2018. Drivers for the rapid adoption growth include the desire to improve access to care, improve care coordination, increase efficiency, prevent readmissions and expand population health programs. In addition, 69 percent of organizations that currently have consumer telehealth programs are planning to expand their offerings, and 76 percent of organizations without consumer telehealth indicate it is a high strategic priority for their organizations.”

A Dozen Takeaways From PwC’s Medical Cost Trend: Behind the Numbers 2018 Report

By Clive Riddle, June 16, 2017 PwC’s Health Research Institute has released Medical Cost Trend: Behind the Numbers 2018, their twelfth annual report projecting the growth of private sector medical costs in the coming year and identifying the leading trend drivers. The findings are largely based upon PwC’s annual Health & Well-being Touchstone Survey results, which draws from responses of 780 employers from 37 industries, and have also just been released. Here’s a dozen takeaways from this year’s 32 page Behind the Numbers report, and 114 page Touchstone Survey report: 1.       PwC’s HRI projects a 6.5 percent growth rate for next year, a half percentage point increase from the estimated 2017 rate.   2.       This growth rates steadily decreased from 11.9% in 2007 to 6.5% in 2014, and has fluctuated slighly above or below that figure since then   3.       PwCs provides this definition of their projected medical cost trend: the “increase in per capita costs of medical services that affect commercial insurers and large, self-insured businesses. Insurance companies use the projection to calculate health plan premiums for the coming year.”   4.       PwC's HRI has identified three major inflators expected to impact medical cost trend in the coming year: (A) Rising general inflation impacts healthcare. As the U.S. economy heats up, a rise in general inflation during 2016 and 2017 will likely put upward pressure on wages, medical prices and overall cost trend in 2018; (B) Movement to high-deductible health plans is losing steam. The wave of growth in high-deductible health plans, employers' go-to strategy in recent years to curb health spending, may be plateauing; and  (C) Fewer branded drugs are coming off patent. Employers may have less opportunity to encourage employees to buy cost-saving generics in 2018.   5.       PwC's HRI has identified two major deflators expected to impact medical cost trend in the coming year: (A) Political and public scrutiny puts pressure on drug companies. Heightened political and public attention could encourage drug companies to moderate price increases; and (B) Employers are targeting the right people with the right treatments to minimize waste. They are doubling down on tactics such as prescription quantity limits and exploring new technologies such as artificial intelligence to match people with the best treatment.   6.       The report also cites these healthcare drivers affecting the 2018 cost trend:  Technology and treatment innovation: Provider and Plan Consolidation; Government regulation; and Evolving Payment models.   7.       The report allocated these proportions of costs by component for 2018: Pharmacy 18%; Inpatient 30%; Outpatient 19%; Physician 29%; Other 4%   8.       The Touchstone Survey cites that “Medical plan costs have continued to increase, but employers expect that the rate of increase will start to slow. Plan design changes contributed towards slightly lower-than-expected increases in 2016;” and that “the average increase in 2016 was 6.8% before plan design changes and 3.6% after plan design changes. In 2017, participants expect to see a 6.0% increase before plan design changes and a 3.2% increase after plan design changes.”   9.       The Touchstone Survey notes that “participants appear to be in a "wait and see" mode – rather than considering broader and more transformational changes, they continue to use traditional cost-shifting approaches to control health spend;” and that “57% of participants expect to continue to increase employee contributions in the next three years, while 38% (29% for Rx) plan to increase employee cost-sharing through plan design changes.”   10.   The Touchstone Survey finds that “participants are increasing contributions in the form of surcharges for spouse, domestic partner and dependent coverage. This may be contributing towards a decrease in enrolled family size and slowing the rise in net employer spend.”   11.   The Touchstone Survey also finds that “participants are utilizing High Deductible Health Plans (HDHPs) more and Preferred Provider Organizations (PPOs) less, although PPOs remain more popular among employees. PPOs are the highest-enrolled plan 44% of the time, compared to 46% in 2016 and 60% in 2009. HDHPs are the highest-enrolled plan 34% of the time, up from 32% in 2016 and 8% in 2009.”   12.   The Touchtone Survey found that employer interest in population health is strong but private exchange interest is waning. They report that “79% offer wellness programs compared to 76% in 2016, and 63% offer DM programs compared to 56% in 2016;” while  “8% of participants are considering moving their active employees to a private exchange; 2% have already done so. Interest seems to have dropped off as the discussions on public exchanges and ACA have increased. However, 36% of participants who offer retiree medical coverage are considering moving pre-65 retirees to a private or public exchange.”