Results from the Future Care 2010 e-poll

By Clive Riddle, President, MCOL

MCOL has just released results from our eighth annual Future Care* e-poll survey conducted this month of Future Care web summit attendees and MCOL members. Almost all responses were received after the Brown Massachusetts Senate election. Respondents represented the following perspectives:

• Payor - 30.5%
• Provider - 33.6%
• Vendor - 16.4%
• Other - 19.5%

We ask participants three questions each year. First, which of the following health care business trends do you think will have the greatest overall impact in the coming year? Respondents point to health reform and the recession as the big drivers. Its also interesting to see how cost sharing increases have significantly diminished in importance last year and this year. Here’s this year’s and historical responses:

Trend	2010	2009	2008	2007	2006	2005	2004	2003
Advances in technology	6%	3%	12%	8%	17%	14%	12%	11%
Consumer Driven plans	7%	3%	13%	18%	21%	23%	14%	15%
Compliance issues	7%	1%	1%	3%	1%	1%	6%	18%
Effects of the Recession	26%	57%	NA	NA	NA	NA	NA	NA
Health Reform Initiatives	37%	21%	24%	11%	28%	14%	4%	N/A
Increased cost sharing	5%	9%	34%	40%	26%	38%	36%	39%
Disease Management	5%	3%	13%	8%	3%	6%	24%	N/A
Other	5%	1%	4%	12%	5%	6%	4%	17%

Conversely, we asked what predicted trends do you feel is LEAST likely to occur or have an impact in the next two years? Respondents feel health plan premium increases won’t keep cooling down, and there are plenty of health care reform skeptics:

Response	Percent
Premium Increases will continue to slow down	24%
Significant National Health Care Reform Legislation will be enacted	20%
Major growth of Consumerism initiatives	19%
Health Plan cost sharing activities will level off/slow down	13%
Further growth/adoption of disease management and wellness	12%
Major advances in patient/provider/plan electronic data transfer	11%
Other	1%

Lastly, we asked respondents to rank stakeholders as winners or losers for the coming year.  Respondents feel pharmaceutical plans will by far fare the best among stakeholders, with health plans finishing a distant second, and all other stakeholders ranked way back.  Of course the great unknown is health reform, which could significantly alter the fortunes for health plans depending on the final structure.

Sector	Better Off	Same	Worse Off
Pharmaceutical	39%	40%	21%
Health Plans	29%	30%	41%
Hospitals	16%	34%	50%
Physicians	12%	33%	55%
Consumers	8%	26%	66%
Employers	7%	35%	58%

From a historical perspective, here’s how respondents see health plans future prospects from year to year. Note that despite the potential of health reform, optimism for health plans returned a little this year, after pervasive pessimism from 2007 through 2009:

Health Plans:	Better Off	Same	Worse Off
2010	29%	30%	41%
2009	12%	44%	45%
2008	14%	36%	50%
2007	12%	41%	47%
2006	54%	35%	12%
2005	43%	42%	16%
2004	36%	50%	14%
2003	36%	44%	21%

* The Future Care survey incorporates respondents from MCOL Future Care Web Summit attendees and MCOL members. n = 131 for 2010, 90 for 2009, 127 for 2008, 146 for 2007, 267 for 2006, 110 for 2005; 118 for 2004; 139 for 2003

Making Sense of What’s Next for Health Reform

by Clive Riddle, January 21, 2010

What a difference a week makes! Amidst the political chaos and confusion during the past few days on status and prospects of health care reform, some prominent pundits and lawmakers are either proclaiming health reform is absolutely dead, or that there is still a viable pathway for reform, and it will pass. Both sides of the spectrum voicing such certainty right now would seem to be ‘spinning.’ Chaos and confusion should reign as we speak, because at this point either outcome is quite possible. Thus for now, one would be wise to position for a range of possibilities.

Here are some key points to consider in this “anything’s possible” phase that will undoubtedly clear up with a little time:

• The public nationally is clearly not happy with reform as proposed. The latest Wall Street Journal / NBC poll released this week tracking this issue pegged approval ratings of Obama's handling of health care at 38% approval and 55% disapproval.

• But doing nothing, and opposing everything isn’t necessarily popular either. The same WSJ/NMC poll gave Republicans an even lower approval rating for their handling of health care: 26% approval and 64% disapproval.

• Lawmakers up for reelection this year are looking to the Massachusetts Senate election as the referendum on health reform, so some Democrats may reverse course next time around with any health reform votes. But the Washington Post today makes an interesting point: “the Republican candidate rode to victory on a message more nuanced than flat-out resistance to universal health coverage: Massachusetts residents, he said, already had insurance and should not have to pay for it elsewhere.”

• President Obama has just signaled in an ABC interview that he would like Congress to revise the reform package to include core elements that would be more publicly acceptable and potentially gain support of a few Republicans: "We know that we need insurance reform, that the health insurance companies are taking advantage of people. We know that we have to have some form of cost containment because if we don't, then our budgets are going to blow up…And we know that small businesses are going to need help so that they can provide health insurance for their families. Those are the core, some of the core elements of this bill."

• The available options for the Senate and House to proceed leave no clear path, and plenty of disagreement. The President stated he doesn’t want to Senate to “jam” something through before new Massachusetts Senator Brown arrives, and Senate Majority Leader Harry Reid agreed this approach would not be taken. The option of the House adopting the Senate version of the reform bill as-is, has been floated, but House Speaker Pelosi is signaling the votes aren’t there at this time. Instead, she is looking at getting the House to pass the Senate Bill in combination with a companion clean-up bill.  The House has a year until the Senate Bill expires. The other options include a new watered down bill as the President now advocates, or an attempt to jam various components of the bill through budget reconciliation, which just requires a simple majority to pass, but also could trigger delays,  messy procedural fights with Republicans and make Democrats up for re –election skittish about potential public wrath.

Prowling through the Census Bureau 2010 Statistical Abstract

by Clive Riddle, January 15, 2010

Okay, so sifting through The 2010 Statistical Abstract may not rank up there with bungee jumping or running with the bulls (book your trip to the Pamplona Spain San Fermin Festival this July 6^th through the 14^th) on the adrenaline rush meter, and might not be recommended to list as a favorite activity in your Facebook profile, but just the same, there’s some pretty cool, free and easy to access health care data tables available in the Abstract.

I grabbed a few of the excel files from the various categories of health care tables that I found interesting, and compiled summary information from three items I thought would be worth sharing:

From Table 160. Percent Distribution of Number of Visits to Health Care Professionals by Selected Characteristics: I wanted to see how the pie slices up by selected age group for frequency of annual visits to doctors and other health care professionals

Annual Visits by Selected Age Group	Zero	1-3	4-9	10+
Under 18 years	10.3%	57.0%	25.5%	7.2%
45 to 64 years	14.9%	45.3%	23.9%	15.9%
65 to 74 years	8.4%	35.4%	36.0%	20.3%
75 years and over	5.5%	30.6%	36.4%	27.5%

[2007 data from the U.S. National Center for Health Statistics, Health, United States, published 2009.]

From Table 158. Physicians by Sex and Specialty: I wanted to calculate the percentage that were primary care physicians (family practice, internal medicine and pediatrics- I left out Ob-Gyns), and I was surprised to see the percentage has gone up over time

	1980	1990	2000	2007
% Primary Care MDs	28.5%	31.6%	34.3%	34.7%

[Calculated from Source: American Medical Association, Chicago, IL, Physician Characteristics and Distribution in the U.S. annual]

From Table 153. Retail Prescription Drug Sales: I was interested in calculating the percentage mix of prescription sales by type of retail outlet. What you can see is the decline of independent pharmacies and the rise of mail order

Retail Outlet:	1995	2000	2005	2008
Traditional chain	38.5%	40.6%	39.6%	41.0%
Independent	30.4%	23.0%	19.2%	17.3%
Mass merchant	10.7%	9.3%	9.7%	9.8%
Supermarkets	10.2%	12.0%	11.9%	10.2%
Mail order	10.2%	15.2%	19.6%	21.7%

[Calculated from Source: National Association of Chain Drug Stores, Alexandria, VA,NACDS Foundation Chain Pharmacy Industry Profile, 2008]

What to make of the CMS National Health Expenditure Report

by Clive Riddle, January 5, 2010

CMS’ Office of the Actuary today issued their annual report on the National Health Expenditure Accounts. CMS states the report contains good and bad news. On one hand, “nominal health spending in the United States grew 4.4 percent in 2008, to $2.3 trillion or $7,681 per person.  This was the slowest rate of growth since the Centers for Medicare & Medicaid Services started officially tracking expenditures in 1960.” On the other hand, “health care spending continued to outpace overall nominal economic growth, which grew by 2.6 percent in 2008 as measured by the Gross Domestic Product (GDP).”

CMS states that “the 4.4 percent growth in 2008 was down from 6.0 percent in 2007, as spending slowed for nearly all health care goods and services, particularly for hospitals. However, health spending as a share of the nation’s GDP continued to climb, reaching 16.2 percent in 2008, up 0.3 percentage points from 2007.” Jonathan Blum, CMS Director of Center for Medicare Management tells us “this report contains some welcome news and yet another warning sign. Health care spending as a percentage of GDP is rising at an unsustainable rate.”

One of the supplemental reports: the Nation's health dollar - where it came from, where it went, provides a nice brief summary pie chart that breaks down as follows:

The Nation’s Health Dollar, Calendar Year 2008: Where it Came From:

• Private Insurance - 33%
• Medicare - 20%
• Medicaid/SCHIP – 15%
• Other Public – 13%
• Out of Pocket – 12%
• Other Private – 7%

The Nation’s Health Dollar, Calendar Year 2008: Where it Went:

• Hospital Care - 31%
• Other Spending- 25%
• Physician and Clinical Services - 21%
• Prescription Drugs - 10%
•  Nursing Home Care - 6%
• Program Administration and Net Cost - 7%

Digging into other supplemental files provided with the report, it’s interesting to examine trends in the portion of public vs. private funding of spending, and the subset of private spending from consumer out of pocket payments, which we compiled as follows:

% of Total National Expenditure	2008	2005	2000	1995	1990	1980	1970	1960
Total Public Payments	47.3%	45.4%	44.1%	45.8%	40.2%	42.0%	37.5%	24.5%
Total Private Payments	52.7%	54.6%	55.9%	54.2%	59.8%	58.0%	62.5%	75.5%
Consumer Out-of-pocket	11.9%	12.5%	14.2%	14.4%	19.1%	22.9%	33.3%	46.9%

The continual shift between public and private funding is certainly apparent, as is the decline in the portion accounted by consumer out of pocket payments. While much has been made over ever increasing consumer cost sharing, that concern has been expressed in absolute, as opposed to relative terms. Relative to total national health expenditures, consumer out of pocket costs continue to decline as a percentage. Of course the shift towards private funding is the cause- as more consumers are covered by public vs private programs over time and public cost sharing requirements are generally much less than private cost sharing.

Here’s some other highlights CMS noted in regard to the actual numbers comprising where these dollars went or came from:

• Hospital spending in 2008 grew 4.5 % to $718.4 billion, compared to 5.9 % in 2007, the slowest rate of increase since 1998.
• Physician and clinical services’ spending increased 5.0 % in 2008, a deceleration from 5.8 % in 2007.
• Retail prescription drug spending growth also decelerated to 3.2 % in 2008 as per capita use of prescription medications declined slightly, mainly due to impacts of the recession, a low number of new product introductions, and safety and efficacy concerns.
• Spending growth for both nursing home and home health services decelerated in 2008.   For nursing homes, spending grew 4.6 % in 2008 compared to 5.8 % in 2007.
• Total health care spending by public programs, such as Medicare and Medicaid, grew 6.5 % in 2008, the same rate as in 2007.
• Health care spending by private sources of funds grew only 2.6 % in 2008 compared to 5.6 % in 2007.
• Private health insurance premiums grew 3.1 % in 2008, a deceleration from 4.4 % in 2007.

The Reimbursement and Value Based Purchasing Revolution

By William DeMarco, December 21, 2009

MCOL asked me to respond to the following question for their current issue of “Thought Leaders”: Outside of pending national health care reform legislation, what trend(s) or issue(s) do you think will have the greatest impact on health care for 2010?" My abbreviated summary response is included in the newsletter, but what follows is my detailed response.

I think the entire revolution of reimbursement and value based purchasing is changing health care with or without reform.

First, consider the shift to for profit for so many organizations: Blue Cross plans that are consolidating under Well Point; not for profit hospitals that are aligning with or being bought by for profit hospitals;  and finally physicians who came out of the Physician Practice Management ( PPM) environment only to find they did need to invest in other for profit businesses or sell out to the hospital. Ambulatory care centers or buying a bone density scan to make revenue to keep ahead of the rising cost of managing the practice is new for most doctors. These were unheard of a decade ago.

All of these enterprises are having difficulty getting the asset valued that would permit them in some way to get some meaningful equity out of their hard work. That equity could be turned into cash or at least a cushion for future transactions. The new reality is bond houses are just as stingy as traditional investors and financing cost centers like facilities is increasingly difficult

At the same time reimbursement is shifting to a more sophisticated level with ICD 10 and MS DRGS and additional changes that will reveal just where the care and dollars are going. New innovations for treatment at less cost is a hoped for outcome but the ability to police more services and eventually go to a bundled payment system will put both doctors and hospital at risk for living on a budget for each episode.

This new integration is more cohesive than before and as more consolidation occurs collaboration not competition will be a key to survival. How the detail in each of these new expanded payment codes must be reported and tracked. This will be impossible with our current machines that barely report receivable and payables even for the most sophisticated practice. Collecting for managed care, now the majority payer has spawned a new business of revenue cycle management but now a new dimension of reporting utilization is also a requirement under pay for performance.

This disremediation of the old payment and billing systems physicians’ practices and hospitals used is making many rethink their “falling apart” systems.

The “new integration” brings this billing and payment all together again but not through a centralized structure. “Meaningful use” has arrived and that means web based connections to physicians hospitals employers insurance companies and even patients  is a requirement to get at bundled payment, report episodes of care and invoke some accountability into the definitions of necessary and unnecessary care.

Our point is that without the data, the payment will be reduced and where insurance companies had all the data for years its now time for providers to also invest in data driven strategies to better their reimbursements but , more importantly , begin to innovate and test methods to improve quality without increasing costs. This means permanently removing wasted effort and procedures that are inconsistent in their outcomes from the practice, but also, and this is what physicians and hospitals are most afraid of, changing behavior to make a living through more precise and frugal use of insurance and consumer dollars.

This underlying structure is shifting all at the same time reform is being discussed. Like two tectonic plates that shift causing an earthquake and then settle until the next large change. The results are unstable sections of land, tsunamis and new opportunities for growth What we see is slowly the components of value based purchasing are becoming a clear and present danger to the provider that waits too long to take action.

The providers waiting out the rules of reform right now are behind. That means for them 2010 will be remedial instruction on integration. Organizations that have the discipline to prepare the plan A and plan B of strategy are already ahead.

They are not waiting for rules to develop strategies to get around rules they are already making their own rules and slowly and consistently changing all their substructures to accommodate change with intelligent human capital, strong organizational culture and the confidence that their growth plans will eventually succeed.

Others are still cost cutting to make money. They are waiting for a bail out and telling their boards they will respond to the market AFTER an event has occurred. Henry Kissinger would often say that a crisis is a group of untreated issues that people knew they needed to change but did not change and now the cumulative effect is a crisis.

The reason we did not change them is often times because if fear or denial. We kept saying the health care delivery system is falling apart, the Institute of Medicine gave us evidence as to what was falling apart and then offered us a solution to bring these parts back together. But the understanding of what integration was supposed to look like was not clear and many organizations failed in an attempt to use it as a strategy to control doctors and or control managed care.

We now have a second chance with or without reform to re engineer our business process, right size our medical staff organizations and join together reimbursement and quality initiatives to get to the point of being able to reward superior performance with better payments and differentiate ourselves in the marketplace as providers and health plans with distinction. This may be a long road back for some which is why getting started now is the best strategy for 2010.

Five Trends to watch for with 2010

by Clive Riddle, December 17, 2009

As the first decade of the millennium closes, and the new year is just  a limited number of sunrises and sunsets away, the time has come to consider some major health care business trends that should deliver an increased impact for 2010 and beyond.

The big “duh” of course is the health care reform package still being tossed around in Congress, but in fact, much of the anticipated legislation won’t kick in until after 2010 anyway. So, what else is there to consider?

1. Regulation for starters. As the focus shifts from legislation, assuming the reform package finally passes in early 2010, implementing regulations will take center stage. But increased regulation won’t stop with the health benefit coverage-dominated reform package. The Obama Administration has signaled an objective to enhance oversight of health plans, particularly with programs such as Medicare Advantage, and to further crack down on fraud and abuse. And assuming a reform package that improves coverage is adopted, there will be increased pressure from most vantage points to start addressing costs via regulations. So expanded regulation should be a big trend emerging in 2010.

2. Expanding Primary Care Access will gain considerable attention. While coverage from Health Care Reform won’t fully kick in until well after 2010, the debate and discussion about who is going to treat all these people with new or enhanced coverage, and where are they going to treat them? Medical Home Development should gain ground, with altered and enhanced primary care reimbursement mechanisms that help motivate practitioners to stay or train for primary care practices and incorporate information technology and infrastructure that can handle increased patient loads. Retail clinics, while continuing to fluctuate in growth and contraction spurts, will likely serve as an increased marketplace response in urban areas. Programs to develop, train or import more primary care physicians into the pipeline will increase.

3. Provider Information Technology Readiness will grow as a concern during the year, and other stakeholders will be squeezed to help get lagging physicians to where they need to be. While vendors and health plans appear reasonably ready for ICD-10 conversion, providers in general, and medical groups in particular appear to be well behind where they need to be. While hospital and health plan EHR initiatives progress at a reasonable rate, large segments of physicians continue to lag. For health plans, hospitals, vendors and government, their own respective positions will suffer due to the state of readiness of a significant segment of physicians, particularly small practices, and these other stakeholders will undoubtedly have to commit and contribute increased resources in 2010 to help move things along.

4. Integrated Health Care Delivery will continue to expand and evolve with a greater number of regional health systems, as a strategic response to the above issue. A greater focus from all stakeholders on costs will move more systems in this direction, new health reform coverage provisions may motive them in this direction, the need to expand primary care access may force them in this direction, and the infrastructure needs of medical groups may necessitate the move in this direction.

5. Developing and Monitoring Pilot Programs will command significant attention as 2010 progresses. Reform legislation, and Obama Administration initiatives will stimulate numerous pilot programs, and various organizations and stakeholders will scramble to get in on the action. But everyone will have their eyes on the status and progress of these projects, given the implications their success or failure may bring.

Oh, and here’s wishing all of you, a happy new year, and a more prosperous decade ahead.

HealthChangeBulletin

by Claire Thayer, December 11, 2009

Health Change Bulletin is the free twice weekly e-newsletter for health care professionals following health care change and reform initiatives, developments, discussion, and implications, from a variety of perspectives. Each issue of Health Change Bulletin provides a quotable quote and selected headline links from the news, blogs, tweets and video.

Check it out at: http://www.healthchangebulletin.com/

Survey on Plan, Provider and Vendor ICD10 Transition

By Clive Riddle, December 10, 2009

MCOL this week released results from an exclusive survey of HealthcareWebSummit participants in the ICD-10 web summit and other interested parties. Participants were asked to respond to four items:

1. Please categorize your organization.
2. When do your project your organization will complete transition to ICD-10?
3. How prepared is your organization at this point for transition to ICD-10?
4. Is your organization undertaking other IT or Administrative initiatives to leverage use of the ICD-10 codes?

Here’s what the survey found:

• Overall, only 3.1% of respondents indicated that their organization had completed the transition to ICD-10 while a plurality of respondents, 26.15% projected their organizations would complete the transition in 2013.  A majority (55.3%) of respondents projected their organization to complete transition sometime between 2010 and 2012 (21.5% in 2010; 20.0% in 2011; 13.8% in 2012.)

• A majority (58.7%) of respondents considered their organization to be prepared for transition to ICD-10, with 14.3% indicating being very prepared and 44.4% being somewhat prepared. (17.5% stated unprepared, 14.3% very unprepared and 9.5% were unsure or not applicable.)

• 62.5% respondents indicated that their organization were either undertaking other IT or administrative initiatives to leverage use of the ICD-10 codes (34.4%) or at least considering doing so (28.1%.)

• Responses, in some instances, varied materially by category of respondent.  Those respondents who listed their organization as vendor were not only more prepared for transition than providers or payers, but also projected that they would complete transition sooner and were more likely to be undertaking other IT or administrative initiatives. 

• While payors were more likely than providers to be very prepared for transition, providers were more likely to be some degree of prepared with 55% listing their organization as somewhat prepared.

• General category of respondents (N = 66):
  • Payor              33.3%
  • Provider          31.8%
  • Vendor/Other   34.9%

Simpson’s Paradox and U.S. Infant Mortality

by Clive Riddle, December 3, 2009

There’s a little tingle you feel when you encounter a term for a phenomenon you’ve previously observed. Maybe not Spiderman’s “spider-sense” tingle, but a tingle none the less. So, a tingling I did detect when reading yesterday’s  Wall Street Journal article, “When Combined Data Reveal the Flaw of Averages.” There I learned about Simpson’s Paradox. Surely I came across it countless times in statistics classes and conferences, but my eyes must have been glazed over.

In non-technical terms, as the WSJ article puts it, “Simpson's Paradox reveals that aggregated data can appear to reverse important trends in the numbers being combined….’It's the magic of weighted averages,"’ says Princeton University economics professor Henry Farber.”

The WSJ article cites Simpson’s Paradox impacting current unemployment figures, baseball comparisons between Derek Jeter and David Justice, UC Berkeley admission rates and a study of Kidney Stone treatments.

For me, it brought déjà vu regarding a report CDC's National Center for Health Statistics released last month: "Behind international rankings of infant mortality: How the United States compares with Europe."

Consistent with numerous studies indicating the U.S. compares unfavorably with Europe regarding various key health outcomes, this report indicates the U.S. infant mortality rate lags behind our European counterparts, and in fact ranks 30^th in the world. As indicated in the table below compiled from the study, the U.S. incurs 6.9 infant deaths per 1,000 live births, worse than all but one country cited below and far off the mark from a rate of 2.4 in Sweden.

So what’s really going on behind the numbers? If one digs one level deeper, one would attribute the higher overall U.S. numbers to a much higher preterm birth rate, given that pre-term births globally experience a higher mortality rate. Stopping there, the conclusion would be to focus solely on reducing the preterm birth rate (an admirable goal.)

Fair enough, the U.S overall infant mortality rate would decline if the preterm birth rate declined. But dig another level deeper, into morality rates by gestation, and one will see that the U.S. mortality rate is highest for full term births, but compares much more favorably with premature births. Thus if the U.S. lowers its preterm birth rate, it won’t improve in overall comparisons, because of unfavorable experience with full term births, which comprise close to 88% of all U.S. births. Thus focus needs to be given on the mortality for our full term cases.

	Infant Mortality Rates (Deaths/1,000 Live Births)
Country	%Preterm	Overall	22 wks+	24-27 wks	28-31 wks	32-36 wks	37 wks+
U.S.	12.4%	6.9	5.8	236.9	45.0	8.6	2.4
Austria	11.4%	4.2	4.1	319.6	43.8	5.8	1.5
Czech Republic	7.0%	3.4	3.7
Denmark	6.9%	4.4	4.4	301.2	42.2	10.3	2.3
England	7.5%	5.0	4.9	298.2	52.2	10.6	1.8
Finland	5.6%	3.0	3.4	315.8	58.5	9.7	1.4
France	6.3%	3.6	3.9
Germany	8.9%	3.9	4.1
Greece	6.0%	3.8	4.0
Hungary	8.6%	6.2	6.6
Ireland	5.5%	4.0	4.6
Italy	6.8%	4.7	4.0
N. Ireland	6.6%	6.3	4.0	268.3	54.5	13.1	1.6
Netherland	7.4%	4.9	4.6
Norway	7.1%	3.1	3.0	220.2	56.4	7.2	1.5
Poland	6.8%	6.4	6.8	530.6	147.7	23.1	2.3
Portugal	6.8%	3.5	3.9
Scotland	7.6%	5.2	4.9	377.0	60.8	8.8	1.7
Slovakia	6.3%	7.2	6.7
Spain	8.0%	4.1	4.0
Sweden	6.3%	2.4	3.0	197.7	41.3	12.8	1.5

The Disparity between State Health Rankings

By Clive Riddle, November 19, 2009

How much difference is there between overall health care performance rankings of states, conducted by major organizations? I thought I’d peek into two recent studies and compare them. Interestingly, the two studies both agreed on who was first (Vermont), who was last (Mississippi), generally agreed on this highest and lowest ranking states, but agreed on little in-between.

This week, United Health Foundation, the American Public Health Association and Partnership for Prevention released the 20^th Anniversary Edition of America’s Health Rankings. The full report can be downloaded, or drop-down queries can be made from www.americashealthrankings.org. 

Their press release states that the rankings “provide an analysis of national health on a state-by-state basis by evaluating a historical and comprehensive set of health, environmental and socio-economic data to determine national health benchmarks and state rankings. The Rankings employs a unique methodology, developed and annually reviewed by a Scientific Advisory Committee of leading public health scholars.” 21 core measures and 15 supplemental measures were used, categorized into determinants including Behaviors, Community Environment, Public and Health Policies, Clinical Care, and Outcomes.

Last month, The Commonwealth Fund released their report "Aiming Higher: Results from the 2009 State Scorecard on Health System Performance." This is a comparative follow up to their 2007 state scorecard report. The report has been released in the context of health reform, with the finding that there continues to be significant disparities between states regarding a wide number of health care measures. The Commonwealth Fund states their report "includes 38 indicators grouped into five dimensions of performance—access, prevention/treatment quality, avoidable hospital use and costs, equity, and healthy lives. The analysis ranks states on each indicator and then averages the indicator ranks to determine the dimension rank. Dimension scores determine the overall rank. Equity measures the gaps in performance between vulnerable groups and the national average."

So I compiled the overall state rankings for both reports (but I encourage you to review the individual measures in both reports- it gets more meaningful when you examine the specifics.) I indicated the absolute difference in rankings between the reports for each state (factoring out DC which was included in the Commonwealth report but not America’s Health Rankings- also it should be noted there are duplicate rankings in both reports when states tied.)

The exercise kind of reminded me of the college football ranking comparisons displayed this time of year with the BCS, AP and Harris polls.

State	Commonwealth	America's	Difference
Alabama	39	48	9
Alaska	33	34	1
Arizona	35	27	8
Arkansas	47	40	7
California	30	23	7
Colorado	24	8	16
Connecticut	8	7	1
Delaware	14	32	18
Florida	42	36	6
Georgia	36	43	7
Hawaii	2	4	2
Idaho	28	14	14
Illinois	41	29	12
Indiana	27	35	8
Iowa	2	15	13
Kansas	23	24	1
Kentucky	44	41	3
Louisiana	48	47	1
Maine	5	9	4
Maryland	17	21	4
Massachusetts	7	2	5
Michigan	20	30	10
Minnesota	4	5	1
Mississippi	50	50	0
Missouri	36	38	2
Montana	18	26	8
Nebraska	13	16	3
Nevada	46	45	1
New Hampshire	5	5	0
New Jersey	29	18	11
New Mexico	42	31	11
New York	21	25	4
North Carolina	40	37	3
North Dakota	9	17	8
Ohio	26	33	7
Oklahoma	49	49	0
Oregon	31	13	18
Pennsylvania	15	28	13
Rhode Island	11	10	1
South Carolina	32	46	14
South Dakota	12	20	8
Tennessee	38	44	6
Texas	45	39	6
Utah	19	2	17
Vermont	1	1	0
Virginia	22	22	0
Washington	16	11	5
West Virginia	34	42	8
Wisconsin	10	12	2
Wyoming	25	19	6

Medicare Advantage Survival Guide: Value Chain Analysis

By Lindsay R. Resnick, November 13, 2009

Many moons ago (1985 to be exact) Michael Porter’s bestselling book, Competitive Advantage: Creating and Sustaining Superior Performance, introduced the concept of value chain analysis - the chain of activities within an organization that each adds value to the final product or service. Companies were taking an introspective look at their strategic vision and tactical approach to their value chain components and markets they serve.

Fast-forward to 2009. Never has the value chain been more important to a Medicare plan than today. Regulatory pressure, competitive positioning, shifting consumer priorities, and sustainable profitable growth make a successful Medicare Advantage plan a dicey venture these days. As these plans plot a course for the future a “self assessment” may be appropriate.

Six areas of focus deserve attention —

1. Regulatory Compliance – Tracking, managing and reporting on the never-ending stream of CMS rules and regulations has never been easy for Medicare contractors. Costs associated with a Corrective Action Plan or marketing suspension are extensive in terms of financial penalties, brand deterioration, and staff distraction. Most recently, CMS has raised the bar with a set of reporting requirements for Parts C and D that incorporates hundreds of new, complex data points.

• Does your plan have a real-time mechanism able to provide managers a “dashboard” view of critical compliance reporting across key operations or, does your compliance officer have to go “hunting and gathering” each month like a blind squirrel hunting for nuts?
• Is your plan able to withstand the scrutiny of a CMS audit (or even a mock CMS audit) in areas such as routine documentation, policies & procedures, appeals & grievances, and fraud/waste/abuse?

2. Revenue Management – Medicare Advantage payment rates are dead center in the Obama administration’s target for cost reduction—within the next five years MA and FFS will be on a level playing field. With the pressure of shrinking payment rates survival depends on aggressive revenue management and flawless enrollment operations.

• Does your plan have expert tools in-place to make sure you’re maximizing reimbursement through Hierarchical Condition Category (HCC) and Part C/D reconciliations on a timely and up-to-date basis?
• What metrics are used to manage and measure your Plan’s enrollment operations to make them an integrated member management function (vs. fragmented collection of data entry staff)?

3. Medical Management – With 80% of seniors having at least one chronic health condition, the knock on Medicare Advantage has been an inability to demonstrate value of care management and improved beneficiary health outcomes. And now, with reduced reimbursement rates, there is renewed demand on plans to improve medical loss ratios to maintain profitability.

• Is your plan linking its complex and chronic care management efforts to its HCC management?
• Are care management tactics such as personal health assessments, medical home, and evidence-based practice guidelines part of your 2010 medical management plan?

 4. Customer Service – Competitive rivalry means your customers are another MA plan’s prospects. Customer retention now takes a mindset that combines proactive customer service with continuous “after-sale sale” tactics.

• Is there a formal member retention program to protect your customers from competitor “switcher” campaigns, build long-term, and track retention costs…as carefully as you track acquisition costs?
• Are operations and marketing working together to communicate with customers in a way that blends benefit education with ongoing selling of your plan’s value (i.e., an after-sale sale)?

5. Marketing Mix – Data, Data, Data…it’s at the core of every successful MA plan’s marketing mix. Customer and prospect data mining, modeling and profiling deliver tremendous competitive advantages to MA plans, from diversifying product portfolios to customer segmented messaging to new media strategies. 

• Does your plan have ready access to accurate intelligence on your competitors’ MA, MA-PD and PDP plans, including detailed plan-by-plan benefit and enrollment information in your service areas?
• Have you segmented your existing customers and prospects using demographic indicators combined with psychographic profiles such as lifestyle priorities, buying habits, and advertising preferences (including Internet usage)?

6. Distribution Capacity – Inappropriate marketing and sales practices are by far the biggest problem for MA plans. And, CMS is taking a hard-line approach – secret shoppers, onerous penalties for non-compliance, shutting down sales, and issuance of a glut of new rules. At the same time, organic membership growth gets tougher and tougher. The ability for a plan to deploy multiple distribution channels is separating winners from losers.

• Are your field sales agents (in-house and outside brokers) fully trained, credentialed, certified, and monitored to make absolutely certain you’re limiting exposure to CMS marketing and sales rule violations?
• Have you moved away from a single source distribution strategy to maximize a multi-outlet sales approach: complementary field agent channels, telesales and Web?

This self review is a quick start to figuring out if your plan is where it needs to be in today’s tumultuous Medicare marketplace. If answers are hard to come by or, if there’s little internal agreement, it’s an important sign—don’t wait. Your plan needs a deeper dive into those areas that are coming up short. Organize a dedicated effort to attack problem areas, utilize outside experts well-versed in the “ins & outs” of Medicare Advantage, and take corrective action. Most importantly, do it sooner rather than later.

Commonwealth Fund International Survey of Primary Care Physicians

by Clive Riddle, November 6, 2009

The Commonwealth Fund this week released their report: A Survey of Primary Care Physicians in 11 Countries, 2009: Perspectives on Care, Costs, and Experiences which compares U.S. primary care physician attributes to those in Europe, Australia, New Zealand and Canada.

Harris Interactive and subcontractors conducted the surveys via mail, phone and internet earlier this year, with results reported from over 10,000  primary care doctors, including 1,016 in in Australia, 1,401 in Canada, 502 in France, 715 in Germany, 844 in Italy, 614 in Netherlands, 500 in New Zealand, 774 in Norway, 1,450 in Sweden, 1,062 in the U.K., and 1,442 in the U.S.

The Commonwealth Fund press release on the report shaped their study in the context of health reform. Cathy Schoen, Commonwealth Fund Senior Vice President and lead author tells us "we spend far more than any of the other countries in the survey, yet a majority of U.S. primary care doctors say their patients often can’t afford care, and a wide majority of primary care physicians don’t have advanced computer systems to access patient test results, anticipate and avoid medication errors, or support care for chronically ill patients. The patient-centered chronic care model originated in the U.S., yet other countries are moving forward faster to support care teams including nurses, spending time with patients, and assuring access to after-hours. The study underscores the pressing need for national reforms to close the performance gap to improve outcomes and reduce costs." Commonwealth Fund President Karen Davis adds “access barriers, lack of information, and inadequate financial support for preventive and chronic care undermine primary care doctors' efforts to provide timely, high quality care and put the U.S. far behind what many other countries are able to achieve. Our weak primary care system puts patients at risk, and results in poorer health outcomes, and higher costs. The survey provides yet another reminder of the urgent need for reforms that make accessible, high-quality primary care a national priority."

Here’s a few highlights the Commonwealth Fund pointed out from their report:

• More than half of U.S. physicians (58%) report their patients often have difficulty paying for medications or other out-of-pocket costs, compared to between 5 percent and 37 percent in the other countries.

• Twenty-eight percent of U.S. doctors report their patients often face long waits to see a specialist—a rate similar to that reported by Australian (35%) and U.K. (22%) physicians, the lowest rates in the survey

• Just 29 percent of U.S. doctors report any arrangement for patients to see a doctor or nurse after hours, a drop from 40 percent in the 2006 Commonwealth Fund International Health Policy Survey. In contrast, nearly all doctors in the Netherlands (97%), and large majorities in New Zealand (89%) and the U.K (89%) report after-hour provision.

• While nearly half (46%) of U.S. primary care doctors report using electronic medical records (EMRs)—up from 28 percent in 2006—U.S. primary care practices, along with Canadian doctors, continue to lag well behind other leading countries.

• Primary care physicians in the U.S., are among the least likely to report that they receive financial incentives for quality improvement, such as bonuses for achieving high patient satisfaction ratings, increasing preventive care, use of teams, or managing patients with chronic disease or complex needs.

• Teams that include health professionals such as nurses serve an important role in managing care, especially for chronic conditions. The survey results indicate that use of teams including nurses and other health professionals to manage care, especially for chronic conditions,  is widespread in Sweden (98%), the U.K, (98%) and many other countries but was far less frequent in the United States (59%), Canada (52%), and France (11%)

• Asked about comparative information systems, doctors in the U.K. are most likely to routinely receive and review data on clinical outcomes (89%), followed by Sweden (71%), New Zealand (68%), and the Netherlands (65%). Less than half of doctors in other surveyed countries—including the U.S. at 43 percent—report such reviews.

• U.K physicians (65%) were by far the most likely to report they receive data on how they compare to other practices and, along with Sweden and New Zealand doctors, the most likely to have information on patient experiences. Notably, U.S. doctors lagged well behind these leading countries on feedback on both clinical quality and patient experiences.

I compiled some selected key issues addressed in the survey into a table, to make it easier to compare various primary care responses by country. While the Commonwealth Fund does go out of their way to paint the U.S, “system” in a bad light as fodder for reform, and perhaps glosses over that U.S. Access to Care isn’t comparatively that bad (refer to specialist wait times below) it is hard to argue we don’t have a lot of room for improvement across the board.

Country	(1) EHRs	(2) Patient Reminders	(3) Rx Costs	(4) Long Specialist Waits	(5) Patient Rx List	(6) Outcome Data	(7) Financial Incentives
Australia	95%	89%	23%	34%	12%	24%	65%
Canada	37%	31%	27%	75%	16%	17%	62%
France	68%	60%	17%	53%	43%	12%	50%
Germany	72%	32%	28%	66%	66%	41%	58%
Italy	94%	33%	37%	75%	59%	40%	70%
Netherlands	99%	80%	33%	36%	4%	65%	81%
New Zealand	97%	97%	25%	45%	5%	68%	80%
Norway	97%	15%	5%	55%	20%	25%	35%
Sweden	94%	51%	6%	63%	29%	71%	10%
United Kingdom	96%	97%	14%	22%	83%	89%	89%
United States	46%	47%	58%	28%	30%	43%	36%

(1) MDs using EHRs

(2) Send Patient Reminders for Preventive/Follow Up Care

(3) Patients have difficulty paying for medications

(4) Patients have long wait times to see specialists

(5) Routinely provide patients list of all medications

(6) Routinely receives/reviews patient outcome data

(7) Can receive various Financial incentives

ICD-10 Web Summit: Issues for 2010

by Claire Thayer, October 30, 2009

MCOL’s Healthcare Web Summit has announced a new event that will look at the key strategic, resource, compliance and operational issues pertaining to ICD-10 implementation in 2010.  The web summit event, scheduled for Tuesday, December 1st, 2009 at 1PM Eastern, will feature Gena Misouria and Jerry D. Kneller, Health Care Services Corporation, George Mansour and Katie Kuesters Huyck, PricewaterhouseCoopers, and David MacLeod, Ph.D.,  The Trizetto Group.  The event will also feature faculty podcast recordings on: “Potentials for Loss of Data Integrity with Crosswalks,” “Case Experience from ICD-10 Conversion,” “Predictive Modeling Implications for ICD-10 Conversion,” and “The benefit of ICD-10 increased claims specificity with targeting population-based programs.” In addition, other Web Summit features will include an ICD-10 Article Library and an exclusive ICD-10 Conversion e-poll for attendees.
Detailed information is available at: http://www.healthwebsummit.com/icd10.htm

What Changes To Health Care During The Past Ten Years Have Had The Most Profound Impact

by William DeMarco, October 28, 2009

MCOL asked me to answer the following question for their current issue of their Thought Leaders e-newsletter: "As this first decade of the new millennium draws to a close, what change(s) to health care delivery, financing or structure that have occurred during the past ten years have had the most profound impact, and why?"

My abbreviated response appears in the newsletter, but what follows if my expanded thoughts on this matter.

To review the entire decade I think would fill a library of changes but to get it down to a few changes I would have to say first that moving physicians groups from the small cottage industry of one and two man practices into multi-specialty groups that share a model of care would be something few would have thought necessary or even possible.

In the days of early medicine many physicians worried more about the patients and the noble calling of medicine. There was an entrepreneurial spirit that led many practioners to brave the lack of equipment and resources using their diagnostic skills accumulated over a life time.

Teaching medicine still focuses on watch one, do one, teach one but now we have a narrower funnel of certainty we deal with trying to use diagnostic tests, many of which we are finding have a high false/ positive outcome, and relying on larger complex hospital, clinic and university centers that in the words of medical students “made medicine into a business”.

Driving much of this was a change in reimbursement when insurers and the government stepped in between the patient and the physician offering to handle the payment and coding review and many doctors thought this was great as patients often time did not pay on time if at all and now we can bill these service bureaus claims processors for more and more volume.

That allowed practices to purchase equipment that here to fore was a hospital revenue stream. When Medicare A and B separated the fight between hospitals and doctors turned into a turf war ending with hospitals buying doctors as a bonding strategy. Integration disintegrated except for many providers who owned their own health plan and therefore could control with some precision the model of care and the type of care provided.

Our physician friends and advisors often comment on their observation of new graduates being technically savvy but unwilling to be that entrepreneur to start a practice or work 7 days a week to build a following. Instead working three days a week and having family time is a priority and it often takes 2 doctors to make up one FTE.

This same outline applies for hospitals getting bigger. Hospital systems offering tertiary care even in smaller hospitals is driven to a great extent by reimbursement where more income per patient and high volumes of complex patients are the keys to success according to many managers.

Hospital networks formed to squeeze even more reimbursement out of HMOs and Insurance companies and have succeeded in many markets to chase insurers away or demand 250% above Medicare fees for specialty care as the sole commodity in a given geographic area. This morning I heard the argument that many of these community based not for profit hospitals would eventually have to become for profit in order to survive the health reform legislation. Right now 70% of our nations hospitals are not for profit and although there is a solid economic argument to take equity out of the hospitals to refinance growth and sustainability the opposing argument is that will a for profit hospital focus on the needs of the patients or the needs of the financial enterprise that the hospital would be based upon.

Many not for profit hospitals already act like for profit hospitals forcing projects to have a economic ROI but not really be able to measure their investments in Human return on investment. Do we need tertiary care in every community? Can we even staff these needs with newly minted doctors? Are we driving our own costs up by looking at revenue gain instead of expense of this care? Will our community trust us as the local hospital? Will our physician see us as part of the noble mission or just a workshop and bank?

One only needs to look at the transition of the trusted HMO movement of the early 70s when most plans were built around a community need to inject competition and offer better benefits at traditional major medical insurance plans. Then the government allowed insurers to become HMOs and also the government stopped funding HMOs so many went to the for profit side of the equation. We see more and more consolidation of Blues plans and provider based plans as premium income and utilization go opposite directions. Over time the physician and many consumers lost faith and trust for these plans as money people took the reins of these health plans and the social entrepreneurs left to build medical management and disease management companies.

Consider then the largest single issue that has followed this evolution is the trust of the patient, well or ill, the trust of the community that helped fund and support the not for profit an the fact that as insurance executives bonuses could fund the deficits of a small country that this lifecycle in medicine of moving towards a for profit mindset has eroded peoples respect for insurers perhaps the continuous move by hospitals and even for profit physician structures is not , in itself, a solution but could be the biggest change in a decade that will erode confidence in the healing profession, reduce mutual respect for the leaders of hospitals and insurance companies and stifle the very innovation we now need to carry out the re engineering of our health system to emerge as the admired system of the future.

So loss of some levels of trust is the trade off for moving to an exclusively for profit model too quickly. I fear this more than government run insurance because it is the worst form of rationing that will eventually discriminate between profitable patients and those who restrict earnings per share.

Accelerated and Deferred Strategic Maintenance

By Clive Riddle, October 22, 2009

As the Great Recession kicked in, two phenomena were documented in a number of studies: 1) accelerated utilization of services from employees and dependents with their existing health plan coverage, due to impending loss of coverage from layoffs or fear of potential loss; and 2) deferred maintenance with health care services by the uninsured, underinsured and those with broader coverage that sill involved material cost sharing.

Now impending national health care reform may be bringing about similar polar trends regarding strategic actions and resources deployed by all types of health care organizations: A) Accelerated steps taken by those organizations concerned that their applicable activities might be curtailed or inhibited post-reform; and B) Deferred activity by health care organizations that have adopted a “wait and see” philosophy until specifics of reform become tangible and apparent.

As opposed to consumer health care behavior derived from the Great Recession, which can by more readily quantified through survey and other research findings, such organizational behavior is evidenced only anecdotally.

But start networking with those involved in the business of health care, and it is difficult to escape a mounting sense of such anecdotes, particularly regarding deferred strategic maintenance. Now everyone loves a good reason to procrastinate, and “waiting until we see the specifics of what reform shakes out” has become a great reason de jour for executives to say no to requests for everything from planning meetings, conference attendance, capital purchases, programming changes, product development, and promotional campaigns.

Of course there are those who aren’t afraid of possibly spinning some wheels and take some risks in order to “hit the ground running.” But a combination of recession driven economic pressures that inhibit strategic initiatives, combined with the temptation to avoid the risks and unrewarded costs of spinning wheels, seem to motivate a growing number of health care organizations to defer their Strategic Maintenance for another day. So the question is, how soon is that Day going to be?

Comparing HDHP, HMO and PPO Value based on Employer Benefit Survey Data

By Clive Riddle, October 7, 2009

The Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2009 was released a couple of weeks ago.  The annual survey is a must read for any professional interested in employer health benefit issues and is packed with data.

I thought it would be interesting to use the data to compare the value of HDHPs to HMOs and PPOs, realizing of course for any individual’s actual situation, you’d need to compare specific benefit and premium parameters of specific plans. Also, this doesn’t take into consideration if there were any employer contribution to an HRA or HSA account in conjunction with the HDHP, or tax advantaged employee contributions were made to the account. But the survey data can still provide an overall sense of the industry-wide value of each plan type on the basis of premium and deductible comparisons.

Here’s ratios of single premium by plan type, compiled from the survey data.

HMO Premiums 1.011
PPO Premiums   1.020
POS Premiums   1.002
HDHP Premium 0.826
Overall Average 1.000 ($402 per month)

So based on the survey data does the HDHP premium, at 82.6% of the overall average premium, justify itself when the deductible cost sharing is taken into account? Let’s compare, based on single premium and deductible data.

HMOs: The survey data indicates that 84% of HMOs have no deductible requirement, and that those who do have an average of a $699 annual deductible. This yields a weighted average (16% * $699) of a $111.84 deductible for all HMOs. The survey data indicates that the average HDHP deductible is $1,838. Thus the net annual difference in deductibles is $1,726.16.

For simplicity, assuming that the HMO and HDHP copay/coinsurance requirements, benefit limitations and maximums after the deductible is met are in the same ballpark (which of course often isn’t the case) we’ll compare the value of an HMO to HDHPs solely on premium versus deductible differential.

The total annual difference in premiums based on the survey data is $892 ($4,878 annual HMO premium versus $3,986 HDHP premium). If you were to consume the entire HDHP deductible amount, the HMO would save you $834 (the deductible difference of $1,726 less the premium difference of $892.

But another way of looking at it is the HDHP would save you $892 if your total annual health expenditures for the year were less than $111.84 (the average HMO deductible amount.) Assuming an equivalent coinsurance rate of 18% after the deductible is met, meaning that 82 cents of each dollar consumed after $111.84 (the HMO avg deductible) would be reduced from the $892 savings for the HDHP. This means that once you spent an additional $1,087.80 ($892 divided by 82%) the savings stop. This equates to total annual health claims of $1,199.64 ($1,087.80 + the $111.84 avg HMO deductible.)

So you’d have to gamble that your annual health claims would costs less $1,200, or 65% of the HDHP deductible requirement in order for the HDHP to save you any money compared to an HMO.

Traditional PPOs: Using the same methodology, the survey data indicates that 26% of PPOs have no deductible requirement, and those who do have an average $634 deductible, yielding a weighted average $469 deductible for all PPOs, and an annual net difference of $1,368.84 compared to the HDHP deductible. The total annual difference is premiums based on the survey data is $936 (the PPO annual premium is $4,922).

So if you were to consume the entire HDHP premium, the PPO would save you $432.84  ($1,368.84 less $936). The HDHP would save you $936 if your total annual health expenditures for the year were less than $469 (the average PPO deductible amount.) Assuming an equivalent coinsurance rate of 18% after the deductible is met, meaning that 82 cents of each dollar consumed after $469 (the PPO avg deductible) would be reduced from the $936 savings for the HDHP. This means that once you spent an additional $1,141.46 ($936 divided by 82%) the savings stop. This equates to total annual health claims of $1,610.46 ($1141.46 + the $469 avg HMO deductible.)

So you’d have to gamble that your annual health claims would costs less $1,610, or 87.5% of the HDHP deductible requirement in order for the HDHP to save you any money compared to a traditional PPO.

Health Care Crisis and Reform: Everything Old is New Again

By Clive Riddle, October 1, 2009

As the Summer Town Hall agitation of health care reform has now wound its way into autumn, it seems darn perplexing trying to prognosticate what exactly will happen next with health reform and what exactly is the national mood at this moment.

So I thought it might be instructive to listen to the ghosts of health reform and health crisis past. I took a stroll down memory lane, sifting through Time Magazine’s archives for the past 70+ years. Along the way I found many a headline that surely must have surfaced from discussion from this summer’s town hall meetings. But it seems, both health care and Yogi Berra are experiencing déjà vu all over again.

Here’s a timeline of recycled topics from the 30’s through the 60’s:

Presidential Commission Recommends Complete Reorganization of American Medicine

December 5, 1932: “The Committee on the Costs of Medical Care finally published its recommendations for the re-organization of the practice of medicine in the U. S.” The Committee report notes that a massive number of Americans have no access to care (“38.2% of the population were getting no medical care whatsoever”) and that if the “U. S. annual sick bill were equitably spent, every inhabitant of the nation would get adequate medical attention, every person connected with the practice of medicine would earn an adequate living.” The Committee advocates large group practices, based around hospitals.

A Book on What is Wrong With Health Care and a Call for National Health Insurance

May 15, 1939: Professor Bertram Bernheim, MD of Johns Hopkins pens “a startling book, Medicine At the Crossroads.” He “sees national health insurance coming” and says that eventually “all doctors will band together and practice in clinics, and this streamlined system of medical care will in itself bring greater specialization and raise the quality of service. Once this great step is taken, he believes it will make little difference in a doctor's professional life whether the patient or the government pays the doctor's bill.”

Study on Nation’s Health Finds U.S Plagued by High Rate of Chronic Disease

January 15, 1945:  the Senate subcommittee on Wartime Health and Education after a two-year study of the state of the nation's health found that “about one U.S. citizen in six has a chronic disease or physical impairment.”

Physician’s Rebel Against Discounted Insurance Payments and Second Guessing Over Tests Ordered

December 1, 1947:” San Francisco rumbled last week with a battle over compulsory health insurance. Under fire was a medical system covering San Francisco's 12,000 municipal employees. The only governmental compulsory health insurance system in the U.S., it provides medical care in return for a small monthly fee deducted from members' pay….Because members' payments were set too low, doctors have often been paid less than the scheduled fees. Last fortnight, aroused by rebuffs of their demands for a 15% raise in fees, and by Medical Director Alexander S. Keenan's suggestion that they had needlessly pyramided costs by calling for too many laboratory tests and X rays, the doctors finally rebelled.”

Heated Debate Over Competing Proposals of Public Option vs. Private System

December 29, 1952:  “Attention has been concentrated on two rival methods…compulsory national health insurance (favored by President Truman and Federal Security Administrator Oscar Ewing, "socialized medicine," to its opponents) and the present system of private payment…..ast week the U.S. was offered a middle way. The President's Commission on the Health Needs of the Nation recommended that the U.S.: 1) put the Truman-Ewing plan on ice, 2) go all out to extend voluntary insurance plans to tens of millions not now covered, 3) let federal and state governments pay the premiums for those who cannot afford to pay them, 4) dot the nation with up-to-date medical centers where doctors would practice in groups.”

U.S. Health Care is Touted as Best in the World, But Really Isn’t

November 16, 1953: A noted physician, Boston's Dr. James Howard Means, pens a book, Doctors, People, and Government in which he states "The impulse to reform in medical public affairs comes usually from without, and resistance to it from within the majority fold of organized medicine ... It is only under the lash of public opinion that organized medicine makes any social progress” The article notes “though U.S. medicine is often touted as the best in the world, he asks, ‘Best for whom? Doctors, patients, or everybody? Certainly it is not best for everybody, else the public affairs of medicine would not have been in turmoil for the past two decades.’”

Medical Costs Rising Much Faster Then Any Other Segment of the Economy

August 27, 1956: “Medical costs have been rising faster than any other item on the cost-of-living index, according to the Bureau of Labor Statistics. A patient must now pay 25% more for treatment than in 1950, as compared to an 8% rise in the overall price index. At the same time, benefit payments from health-insurance programs are running a fifth higher this year than last.”

Physicians Having to Hire Staff Just to Deal With Insurance Paperwork and Hassles

September 8, 1957: “Health insurance, a boon to no million people in the U.S., is regarded by more and more doctors as a paper-spewing ogre. Reason: the torrent of technical information requested by insurance forms is cutting into doctors' valuable time for treating patients, leading directly to higher costs for medical care. With even minor treatment requiring detailed reports, many busy doctors find they can no longer get along with just a receptionist or nurse, are hiring a new kind of medical officeworker—the ‘insurance secretary.’”

Covering Millions of More American Will Cause a Log Jam Trying to Access Health Care

October 22, 1965: In the Article Medicare: Will It Work? fears are cited that “no one in the Administration or in the American Medical Association can be really certain as to how many aged eligibles will jam into hospitals for long-delayed, noncritical "elective" operations or other "nonessential" treatment.”

Health Insurance Industry Fights Government Insurance Proposals Only To Embrace Them After Passage

October 22, 1965: Before the health insurance lobby opposed today’s Public Option, they opposed the HMO Act of 1973, only to embrace them later. Before that, “the insurance industry was second only to the medical profession in battling the advent of medicare. For years, insurance lobbyists in Washington opposed any Government-sponsored health-insurance program. Last week the insurance industry's representatives were still active, but this time it was at the huge social-security complex on the outskirts of Baltimore, where they are negotiating with the Government to get their share of medicare. Most insurance companies now realize that medicare, far from being the disaster they once predicted, may prove to be a welcome pep pill for their industry.”

American Health Care Is Un-Organized, Inefficient, Costly and Not Always High Quality

December 1, 1967: The article Crisis of Organization states “costs for its services are rising twice as fast as the general cost of living, and are expected to keep on soaring, hospital costs to the tune of 250% by 1975, physicians' services by 160% and dental care by 100%. Yet the industry is ill-organized and inefficient, and much of the care given in hospitals is of poor quality. That is what the National Advisory Commission on Health Manpower reported to President Johnson last week.”

Medical Home Web Summit – Plan, Hospital and Payment Initiatives

by Claire Thayer, September 23, 2009

MCOL’s Healthcare Web Summit has announced a new event that will examine recent Patient Centered Medical Home initiatives undergone by health plans, hospital systems and payment systems.  The web summit event, scheduled for October 29, 2009 at 1PM Eastern, will feature Dr. Kenneth Phenow, Senior Medical Director, North Texas, CIGNA, Mark Barnes, Director, Richland Care, Palmetto Health, and Guy D'Andrea, President and Founder, Discern Consulting.  The event will also feature medical home podcast recordings on: Children's Mental Health, Medical-Dental Homes, and PCMH Future Direction, as well as a medical home article library and an exclusive e-poll for attendees.
Detailed information is available at: http://www.healthwebsummit.com/medicalhome.htm

Health Plan Coverage of H1N1 Virus Administration Varies

by Clive Riddle, September 17, 2009

Earlier this week, the FDA announced approval of four vaccines against the H1N1 virus. As we await the expected spread of the H1N1 virus this fall, health plans around the country are announcing their policy regarding coverage. Of course, the H1N1 vaccine itself is being covered by the government, once it becomes available. So the coverage issue is with respect to payment to providers for their administration of the shot.

Is it a no-brainer that health plans will provide coverage for administration of the H1N1 virus? It is as long as their specific plan of benefits cover immunizations. But typically, health plans offer a wide menu of benefit plans, including some that do not provide immunization coverage.

However, some health plans have announced they will take the extra step to provide administration coverage for all their members, even those whose benefit plans do not offer immunization coverage. Such health plans are taking the public health policy approach that by removing barriers to the vaccine, they are doing their part to reduce the potential spread of the virus, which should provide the indirect benefit of reduced overall incidence and corresponding cost of treatment for their member population as well.

A survey of recent health plan coverage announcements indicates health plans uniformly will cover H1N1 administration costs for member benefit plans that cover immunizations, but are split on providing H1N1 administration coverage when their benefit plans do not cover vaccines.

Those who will provide administration coverage to all members include:

• CIGNA has just stated they will provide coverage of H1N1 vaccine administration for all insured members without application of any deductible or copay requirement.

• United Health Group has announced they will on a corporate-wide basis provide coverage of H1N1 vaccine administration even for members whose benefit plans exclude immunization coverage.    

• Likewise, Independence Blue Cross in Pennsylvania issued a release that they will provide coverage of H1N1 vaccine administration including for members whose benefit plans exclude immunization coverage

•  Blue Cross Blue Shield of Arizona issued a statement that they will provide coverage of H1N1 vaccine administration including for all members

• Blue Cross and Blue Shield of Florida also will provide coverage of H1N1 vaccine administration including for members whose benefit plans exclude immunization coverage. BCBS Florida also announced its operational continuity preparedness plans in case of a significant disruption due to pandemic influenza.

Those who will limit administration coverage to members with vaccine coverage benefits include:

• WellPoint some time ago announced they will provide H1N1 vaccine administration coverage only for members with benefit plans covering vaccines.

• Aetna sent notices to providers that they will provide H1N1 vaccine administration coverage only for members with benefit plans covering vaccines.

•  Wellmark Blue Cross and Blue Shield in Iowa and South Dakota issued a statement they provide H1N1 vaccine administration coverage only for members with benefit plans covering vaccines.

• Blue Cross and Blue Shield of Nebraska also announced they will provide H1N1 vaccine administration coverage only for members with benefit plans covering vaccines.

The AAFP news yesterday published a story providing details on how physicians should code and bill major health plans and Medicare  for H1N1 administration fees. Interestingly, there is not a standard approach for coding by the health plans. The administration fee cannot exceed the regional Medicare vaccine administration fee.

Using Social Media to Model H1N1

By Clive Riddle, September 10, 2009

In the September 2009 issue of Predictive Modeling News, Russell A. Jackson reports on the use  of Twitter, Facebook, blogs, search engines and more in modeling the spread of the H1N1 influenza virus, in his article “Social Media, Traditional Data Sources Fuel Swine Flu Models” Both social media updates and comments, and keywords from online searches, can provide data useful for such analytics.

Russell writes “One example of the cutting-edge marriage of predictive modeling and social media is the Social Web Information Monitoring for Health – or ‘SWIM for Health’ -- project operating out of the University of Iowa. Researchers there have embarked on a major study that tracks public perception of the swine flu outbreak and other infectious diseases, utilizing technology from OneRiot that indexes the social web in real time. The project, its participants say, ‘has the potential to enhance disease tracking and forecasting by harnessing the power of the social web.’ By monitoring updates from Twitter and Facebook, recent blog posts, current popular search queries and other web usage activity, public health officials can potentially locate an influenza outbreak or simply indicate an elevated perception of disease risk. Such information might help public health authorities better address public concerns. The first step in the research includes an interactive, real-time map of the United States that monitors swine-flu-related Twitter updates. It’s available at http://compepi.cs.uiowa.edu/swim/.

Who is OneRiot you ask? Jackson tells us “launched in November 2008, OneRiot “finds news, stories and videos people are talking about right now across the social web.” Unlike any other search engine, it ranks a web page’s relevance based on its current popularity with real people. OneRiot is a privately held company headquartered in Boulder, CO, with offices in San Francisco.”

Another initiative Russell cites is a project in which “researchers with the National Institutes of Health’s Models of Infectious Disease Agent Study, or ‘MIDAS,’ recently posted these questions on Facebook: [1} “When did you first learn about the swine flu outbreak?”  2} “Have you searched the internet for additional information on the swine flu outbreak?” {3} “If a vaccine for swine flu became available, would you want to be vaccinated?” …. The researchers will use the Facebook responses to build a dynamic model that simulates how changes in decision-making influence patterns of disease spread. The model will help them and others identify the strategies that improve adherence to interventions and reduce the spread of disease. “

So perhaps not only can you reduce your chance of contract with H1N1 by socializing online instead of in person, but you might help measure and combat its spread at thie same.