Marketplace: 57% of New Enrollees Were Uninsured Before Signing Up

By Cyndy Nayer, July 1, 2014

Kaiser Family Foundation--KFF-- issued a new summary on the enrollees in the insurance marketplaces, which MCOL has summarized.  In short, most of the enrollees in the #ACA were uninsured before the rollout, and most of the 57% had been without coverage for 2 years.

The chronicles of the value-based movement have shown that when costs for acquisition (copays and co-insurance, often called out-of-pocket costs) are reduced, more people become engaged and adherent in their health care.  This is important in the management of chronic disease.

But if we are determined to build a culture of health in the US, then the engagement and adherence of newly-insured to prevention strategies as well as lifestyle change will be critical. The efforts in incentive-based designs (value-based for beneficiaries and for service providers, such as physicians, health plans, care coordinators, and more) must retool to encourage 24/7 improvement.  Focusing on appropriate choices whenever possible, adding 10-minute exercise breaks, and identifying friends and relatives who encourage and join in the exercise, screenings, and healthy foods are goals that we can all achieve.

Thank you to MCOL for its continued data vigilance so that, together, we can build the healthiest US.  [image courtesy of KFF]

Breakdown of Marketplace enrollees prior to purchasing current plan;

Covered by a different non-group plan	16%
Covered by Medicaid/other public program	9%
Covered by an employer/COBRA	14%
Other/Don't Know/Refused	4%
Uninsured	57%

Source: Kaiser Family Foundation

Goldman Exec: Economy is Growing, but…

By Cyndy Nayer, CEO, Center of Health Engagement, June 18, 2014

Goldman's top economist, Jan Hatzius, believes that the US economy is now growing at an above-trend pace. This is great news regarding economics and income security. For most.

But Hatzius calls out the high student debt and overall slow pace of job creation as a hindrance to the recovery and expansion of the marketplace.  

And there is still the issue of those without health care coverage or those with income insecurity--making less than the cost of living, managing multiple jobs, or at risk of losing their pensions.  

A video was recently published on the relationship of poverty to readmissions, featuring the Detroit Henry Ford health system. When there is low income, lack of access to pharmacies and healthy food, and poor public transportation, patients discharged from hospitals are often readmitted due to poor compliance in follow-up recommendations. They skip drugs, they eat poorly and they miss regularly scheduled physician checkups. Many are readmitted to emergency rooms and inpatient stays.

This, then, becomes not only a patient risk (for both increased costs and poorer outcomes) but also a health system risk (since CMS is penalizing health systems for avoidable readmissions). Costs go up for the patient (copays, deductibles, new prescriptions, more outpatient visits). Costs go up for payers (avoidable medical and drug costs, among others; absence management if the payer is the self-insured employer). Costs go up for the community (unreimbursed medical costs go up, tax dollars are used for some of these and needed infrastructure, education, and job creation are left behind).

A new study from Mannatt and Commonwealth Fund clearly lays out the advantages of clinicians helping patients to get the community services needed to overcome these inequities.

"Before physicians can substantially cut costs and improve outcomes, they must first address patients' social needs, including whether a patient has a home or heat or access to healthy food, according to findings from a new report," says the report.

This is another opportunity for value-based reimbursements to those entities that can coordinate care beyond clinical intervention. The study calls for patient-centered medical homes (PCMH) to onboard these tasks.  

But ACOs, public health and even business entities can become allies in this effort to identify resources to improve access to healthy food, needed pharmaceuticals, expanded consumer debt counseling and educational resources.

Using value-based reimbursement strategies, payers, health systems and public entities could benefit by providing clear increases to those clinical practices that use care coordination and document better health and health cost outcomes.

Sometimes, health is achieved through non-clinical, social determinants (influences) that are improved by using the trusted resources in a patient's life. The physician, nurse, and pharmacist are 3 of the most influential.

Practice Priorities for Physicians to Thrive in ACA, Receive Higher Reimbursement

By Cyndy Nayer, February 7, 2014

The promise of value, outcomes, and payment reform are foundational within the ACA (Affordable Care Act) legislation, sometimes called Obamacare.  In order to achieve these reforms, electronic medical records, value-based designs, wellness incentives, expanded coverage through Medicaid, and new entities such as patient-centered medical homes (PCMH) and accountable care organizations (ACO) have been established. The health insurance exchanges (HIX) are now called health insurance marketplaces [and these are often confused with HIE, which are health information exchanges - basically a data repository of claims and predictive analysis]. The new HHS website is improving Healthcare.gov, and it contains with rules and financial information for physicians, employers, and individuals.

These are important changes for physicians and practice management teams to know as they will impact not only how you invoice but how your patients react to prevention, wellness, chronic care management, and more.  It will be imperative for practice managers to understand the limitations from the new insurance plans.  On the other hand, due to the previous updates in the ACA from 2010 till the present, many prevention screenings, refills on chronic care management, and educational opportunities (such as those for obesity and diabetes) are covered at lower costs to the patients or at no-cost.

The shift to accountability in care starts, first, with the provider-patient relationship. TPatients, in some of the new health plans, can receive lower costs for prevention screenings (annual exams for Medicare recipients, as an example).  New individual coverage for patients age 19-26 comes with their parents’ policies.  Others, particularly those who do not receive coverage through their current employer, began purchasing policies through the exchanges and coverage this year..   Successful practices have been asking about insurance changes and ask about the date that the new plan begins coverage.

Additional revisions in the ACA have removed limits on pre-existing conditions, leveled the premiums for women (who were previously classified as higher risk on the basis of their gender), and called for comparative effectiveness research for treatments.

Given the enormity of change, physicians and their practice members and staff may be confused about what some key concepts mean generally and how they relate to their medical practices.  Practices need to be familiar with key concepts in order to diagnose and treat people according to the new insurance plan requirements. Key to success are the changes in reimbursement that are included and what measures of quality, value and outcomes are fundamental to the success of practice management. 

A high-level overview of these concepts and their impact is included in a white paper we have developed that can help you and your practice team be better prepared for the new patients and the new reimbursement requirements. Click here to request and download the white paper.

Health Engagement and MLK

By Cyndy Nayer, January 21, 2014

It’s Martin Luther King Day 2014. The sun is shining and the quotes are flowing on the media.  Each year I seek one of his quotes to guide my efforts:

Human progress is neither automatic nor inevitable... Every step toward the goal of justice requires sacrifice, suffering, and struggle; the tireless exertions and passionate concern of dedicated individuals.[1]

I continue to seek the comfort of his timeless words because rest does not come easy to an innovator, a “change agent,” just as it does not come easy to a country in need of predictability and trust. The trial-and-error distress of health care transformation feels like a weight on the US business and health care delivery systems.  In an era of uncertainty, the goal of health improvement has been a sidebar.  The Affordable Care Act suffers from a tiresome rollout on a dysfunctional website, but the real malaise is the weariness of those who see promise in the accessibility of care by all. At these moments, Dr. King’s words inspire the courage to persevere.

In order to create predicable, sustainable business growth in the health care sector AND the general business community, we must aim for engagement of all the health care users and providers in order to achieve better health.  Better health care is a tool, just as better jobs, better education, and better roads are tools towards economic security.  These goals are not held solely in the health care delivery sector nor the US or state governments.  The power of better health lives in all of us.

We need health engagement across all of the stakeholders. Consumer-driven must not be “consumer choice” without consumer input.  Patient-centered cannot be decided around the patient without the patient and/or patient-family input.  Provider reimbursement must not fall only on the physicians and hospital networks, but to all of us to create the economic justice that will support the long-term change.

From packaging data and purchasing services, from bundling payments to building centers of excellence to increasing jobs, each strategy must address the question, “will this build better health?”  If we are to build this vision of health, which, by definition demands the alignment of goals for all of those that touch “health care,” then we must define the alignment needed and disconnects that exist.  Some of the most obvious are:

1. In an era of high-deductible health plans, asking the patient/consumer to adhere to a treatment regimen that is unaffordable;
2. Ignoring depression or anxiety in the treatment of a chronic condition, which can derail the success of a patient to get to optimal health;
3. Changes in evidence and safety recommendations that take years to get to the primary care physician and his/her staff;
4. Misaligned payments, such as fee-for-service in primary care when the goals are adherence to lifestyle and treatment regimens—this misalignment drives up total costs without regard to patient or provider commitment;
5. Purchasing health services, devices, communication, and treatments without holding the vendors accountable for outcomes, and most especially accountable for improved engagement and adherence in high-cost condition management.

These obvious disconnects are the rationale for recasting the Health Value Continuum as an engagement framework with defined goals, from waste reduction (paying for readmissions, paying for emergency care with no emergency, and paying for risk appraisals with low participation) to organizational performance, and ultimately to community sustainability (wherein there is measurable improvement in health and economic risk). 

In short, getting to health, wealth and performance demands engagement and accountability for our own health and wealth.  Our personal commitments must be mirrored in the organizational accountability from the providers, systems and payers.  These personal and system commitments should reflect in the policy improvements that will support interoperable technology, innovation, and reduction of food deserts, among other lofty goals.  Can we get there?  We can, with the faith that we are on the road to better lives, as Dr. King envisioned.  Our faith and courage will take us to the health quality and efficiencies that every community in the US needs and deserves.

---

[1] http://www.brainyquote.com/quotes/authors/m/martin_luther_king_jr.html

Study finds fewer office visits, prescriptions with CDHPs | Home Channel News

By Cyndy Nayer, July 1, 2013

There are more studies being translated for consumer sites and broader business reach.  Small and large businesses alike know that up to 20 cents of every revenue dollar goes toward health care.  Understanding what works, what appears to work, and what really isn’t hitting the mark is crucial for business success.

This article echoes the findings of studies from Employee Benefit Research Institute (EBRI),  Kaiser Family Foundation, and others.   When folks have to choose between paying out of pocket for appropriate care and paying the rent, the care falls behind.  Study after study have shown that, over the past 5 years, fewer prescriptions have been filled, more prescriptions have been subject to non-compliance (pill splitting, etc.), fewer follow up physician visits and tests/labs have been performed, all of which hinder outcomes.

AHIP recently published an infographic showing the increase in CDHP plans.  These increases appear to dovetail with the lower adherence to protocols that could prevent rescue treatments and avoidable inpatient days.  

The opportunity in value-based design is to follow the high-value protocol and treatments.  These can be place on special designs that encourage the appropriate behaviors.  Further, direct contracts with providers, urgent care centers, and pharmacist coaches can help to manage high-cost chronic care, even within account-based consumer-directed plans.

Let’s spread the word:  consumer-directed can work, but the insurance plan design and contractual arrangements for appropriate, outcomes-based quality providers, are essential.

Infographic: Chronic Care is a Team Sport

By Cyndy Nayer, June 13, 2013

Chronic care is a long-term management strategy, and it requires a focus on outcomes, especially in reimbursement for the team of providers that manage the complex conditions. Diabetes, hypertension and high cholesterol get a lot of attention, but there are more, such as depression, cancer, arthritis. While the ACA will attempt to manage the escalation of premiums, it requires a team effort to manage chronic care. Lifestyle, treatment adherence, and regular primary care visits are a must. Value-based designs will work to get better engagement from the beneficiaries, but the plan sponsors, especially the employers, must pay close attention through regular data reporting, coordinated care, and communication across all of the team members, including the patient and his/her family. Chronic care is a team effort, and to be a member of the winning team, coaches and players must be headed for the same goals!

For more blog posts by Cyndy Nayer, visit www.cyndynayer.com/category/cyndys-voice/

A response to Friedman and Obamacare Innovation Surprise

By Cyndy Nayer, June 4, 2013

Thomas Friedman posted a column in Sunday’s NYT that highlights the surprise in technology innovation as a result of Obamacare. But one example needs an update, so I, serial disrupter will now step out and argue with a journalist that I adore.  Mr. Friedman, because a system or a provider has an electronic medical record does not ipso facto mean that info can be shared and care coordinated.  If my provider is at one hospital system, but I also use another provider or system, and each use a different IT platform, they can’t talk, and I can’t get coordinated care.

This is an important fact and one that needed to be addressed before the billions of dollars were invested.   Mind you, I agree with the investments (that will anger a few of my followers), as they came exactly at the right time and place:  the intersection of health care and the economic downturn that put a lot of very smart people out of work and out of health care coverage.  We needed that influx of dollars to invigorate the geniuses to update the platform that was crushing us in health care.  You know the platform, even if you can’t name it, by the tag line:  ”our legacy systems don’t talk to each other.”  I’ve been hearing that phrase since the early 1990′s, and iPhones, iClouds, twitter, facebook and more were not even thought of at that time.  If I can get my iTunes anywhere in the world why can’t I….but I digress.

If we had required some interoperability standards BEFORE the money was awarded, we would be much further along today.  Because we supported the information expansion but didn’t consider the accountability standards for the health care delivery system nor the consumerism (read as “people must make purchasing decisions”) that would be required, people cannot get their data.  In fact, it’s been 3.5 years now since Obamacare came to be, and despite blue buttons or pink buttons, my medical record is incorrect, hasn’t been corrected in 6 weeks, and it has implications for my personal health that, if I need care soon, could have dire consequences.  Even the care provider’s information maven says my info is incorrect.  But no corrections have been made and, of course, I don’t have access to put in patient notes, either.

If we considered what would be required of folks across the country, and many of us do travel across our great land, then we would have known that our data must move with us.  We have a model like that in our country:  the veterans administration data travels with the soldier wherever he or she is stationed.  That simple process would have made accessibility so much easier without destroying “proprietary rules” of innovation companies, insurance companies, and health systems.  In other words, we did so much right from the tech and economic recovery side, but we forgot the people who will, ultimately, bear the brunt of the fallout in choices.

I chose a well-respected provider and health system.  They are part of a national leader in medical technology.  So the system did “patient-centered” without considering “patient inclusive” and that’s not ok.

It’s hard to catch the cow once she is out of the pen, I’m told (never caught a cow).  Probably applies to the innovation rocket ship we launched.  But humanity is calling to be injected into this scenario.  You can’t hold me accountable if I can’t get the data–I’m shooting blanks and so is the system without my input.  Data is just data without me and my story, or you and yours, told with accuracy.

So hurrah for the innovation injection, which, in fact, is mirroring what happened with NASA and national innovation in the 60′s and 70′s.  Now, include me.

Obamacare’s Other Surprise – NYTimes.com.

Trimtabs Applied to Health and Health Care Reform

By Cyndy Nayer, May 21, 2013

I’ve been reviewing some of my saved quotes and notes, such as the notes on trimtabs, as the airwaves heat up with IRS, AP and all things HCR (health care reform). The road to repositioning health as the goal can be a long uphill struggle, and as I continue to speak around the country and counsel employers large and small, the strain is showing. It’s time to discuss trimtabs.

It’s certainly no secret that I’ve lived most of my life in St. Louis, home to the Missouri Botanical Gardens, a world-renowned horticultural center and leader in rainforest research and environmental change.

The centerpiece and brand of the Mo. Botanical Gardens is the Climatron, a geodesic dome, the building with the smallest footprint and the largest capacity. This is the building of Buckminster Fuller, who has built many geodesign domes, which, according to his research, is the strongest building on earth, withstanding hurricanes, tornadoes, and earthquakes. You’ll note from the picture that it resembles a honeycomb curved into a shell-like structure. The intersection of the cells means that, like a honeycomb, the physical stress on the structure is equalized across all of the cells. This I learned many years ago when the Climatron was built. Bucky understood that design signals the human intention, and his intention was to live well and leave the world better when he was gone.

Buckminster Fuller was a scientist and a man who loved sailing. He understood trimtabs as the mechanism that cause rudders to move. Trimtabs are small surfaces connected to the trailing edge of a larger structure (such as a rudder) that stabilise the boat or aircraft in a particular desired attitude without the need for the operator to constantly apply a control force. This is done by adjusting the angle of the tab relative to the larger surface. In simple terms, it means that by adjusting the trimtab, or tabs, the rudder on a boat can make a series of small adjustments with less effort than trying to push the rudder against the enormous force of the water.

In Bucky’s own words:

“Something hit me very hard once, thinking about what one little man could do. Think of the Queen Mary — the whole ship goes by and then comes the rudder. And there’s a tiny thing at the edge of the rudder called a trimtab. It’s a miniature rudder. Just moving the little trim tab builds a low pressure that pulls the rudder around. Takes almost no effort at all. So I said that the little individual can be a trimtab.”

Bucky takes the concept of trimtabs further, by noting, “Society thinks it’s going right by you, that it’s left you altogether. But if you’re doing dynamic things mentally, the fact is that you can just put your foot out like that and the whole big ship of state is going to go.” He was determined to use design to improve lives; he used the familiarity of culture to make change feel familiar, less threatening, and easily adoptable. He developed solar panels to heat the geodesic domes, and even these have morphed to many more uses, including protecting turtles where they nest. In many ways, his description of the enormity of a small bit to move the Queen Mary is the embodiment of all of his work. Each of us, in our own way, has the ability to affect the course of boats, of ocean liners, of our hometowns, and of health care in America.

I’ve had the honor and good fortune to address health plans, small businesses, and large businesses over the past few weeks, literally from coast to coast. The travel is tiresome, but the amazing need for information on patient and employee engagement, health care reform, and, most importantly, WIIFM (What’sInItForMe) is never-ending. Sharing the stage or the panel with other innovators is such a pleasure. Yet, sometimes we forget in our enthusiasm to share that those who are listening need us to slow down just a bit, walk away from the acronyms, and catch them up on what we know.

It’s that rare moment when any of us can be trimtabs to the audience, to change their course and their affect from one of powerless victim (THEY are doing this, and THEY have no idea of the kinds of hassle and money this is causing me) to one of expert seafarer, with a new and clearer eye on the horizon. I love those moments.

On the road or in the air back to home base, I have the chance to review notes and consider concepts that will help attendees and readers of this blog to manage the stress that occurs with substantive change.

• Moving from a sick-care system to a true health care system is not easy. Neither is changing the course of the Queen Mary.
• Moving from incentives to intrinsic behavior change is not easy. Neither is pulling lobsters behind a trawler when the wind is in your face.
• Identifying key components of change and then enacting the changes through legislation is not easy. Neither is turning those beautiful white sails on the sailboats at the beach.
• Finding that there were items left unconsidered, or, finding them with gaping holes or costs that were unanticipated is not easy. Neither is moving great seas out of the way in order to make it home safely.

We are on a journey for better health outcomes in this country. We are creating a platform where more people can access health insurance and, in the end, health care. We trust that by creating a wider group of engaged, healthier people, our businesses and our communities can stabilize and grow to productivity and prosperity again. And our course causes some to fear, some to claim “this is mine and cannot change,” much like the wild seas attempt to claim the sailboat.

Paramount to our efforts must be engaging folks across the spectrum of health care interventions, from exercise and purchasing healthy foods to trust in a safe-care system delivered with consideration of the patient and the family. As Dr. Toby Cosgrove, CEO of Cleveland Clinic said in an IOM post recently, “We must do everything transparently and with the patient fully engaged. We must provide value and pay for outcomes.” This is a fundamental shift in how we pay for health care; it’s new and unknown, and therefore causes tension that we may not have anticipated. But it’s the course we are on so that we can get home to health and safety.

So as I have traveled these past few months, and I’ve seen the weariness and, yes, the fear, I’ve thought about Bucky and went back to my notes that I keep for inspiration. Trimtabs are a fantastic frame for the work occurring across this country, and, if we can remain committed to getting home–creating a healthier person, healthier businesses, healthier communities–then we will have succeeded. We can identify the gaps and fill them with innovation and purpose. We can take the steps, singly or in concert, and embrace the change in course so that we can achieve our goals.

The man who designed geodesic buildings to save the environment, who invented the word “synergy,” said, “Call me Trimtab.” And R. Buckminster Fuller considered the role of trimtabs and his work (you can see a video of Bucky here and here). He thought trimtabs and the efforts each of us can contribute would lead to a better course for the better lives of all. He liked the concept so much, he had it engraved on his headstone.

Boston: Coincidences, Complexity, Continuity, Care

By Cyndy Nayer, April 25, 2013

America's Freedoms Are Our Vulnerabilities

There is no doubt that the terrorism of the Boston Marathon 2013 was heart-stopping, heart-rending, and a cruel reminder that America's freedoms are also our vulnerabilities.  It's also a bit ironic that, because of a family emergency, both of my daughters had flown down to our house and were with us when the bombs went off.  Why is this important enough for me to mention here?  Because if my older daughter hadn't come down to help, she would have been exactly at the finish line where the bomb went off. Coincidence?

I don't believe in coincidences.

The week, and the socialmediasphere, have been resplendent with coincidences, the most poignant of which was the story of the couple who both were in the health care provider space, both came to cheer the runners of the marathon, both had a portion of their left legs blown off in the explosion.  They were separated by the blast, and they remain separated in different hospitals, but they are recovering and they are talking by phone to each other (see below for how you can help).

Who were the terrorists, what was their motivation, what will happen to the survivor, I have to leave to the sleuths and judicial systems to discover and decide.  My work is to uncover the learnings that we can all ingest to fortify our health promotion and business recovery.  Here are some thoughts.

1.  Boston has terrific hospitals, prepared for trauma management.  I've managed many fitness events, and, of course, a key component was the clinical staff onsite.  They volunteered their time for running injuries, dehydration, and the sort.  Some of them on April 15 had seen combat duty in Afghanistan and Iraq, and they were able to flip into mash-unit mode quickly.  All of the injured who made it to the hospitals have survived, albeit many have much rehabilitation to work through.

2.  Boston has moxie and motivation.  Bostonions have been described recently as gritty, defiant, and strong, and this makes great sense since this is the birthplace of the American Revolution--the shot heard round the world--and of the freedoms that would coalesce into the US Constitution.  When the explosions came, the runners ran INTO the crowds to help those who were hurt, ran to the hospitals to give blood (another 2.5 miles after their 26.2 mile run), and reached out to one another.  They may fight like family, but when the pressure is on, Boston is one big supportive family. For more on the grittiness of Bostonians, and a chuckle, click here to see Colbert's Report for April 16, one day after the bombs.  

3.  Boston finishes what it starts. Samuel Adams (not the beer, but the revolutionary) said, “Nil desperandum, Never Despair. That is a motto for you and me. All are not dead; and where there is a spark of patriotic fire, we will rekindle it.” There were people around the nation, and now, around the world (London) running races for Boston over the past 10 days, and there will be more.  There are calls for boosting the economy and taking Boylston Street back--it opened today--and for helping those who were locked out of their homes and businesses for these days.  This is the Boston that warned of the Red Coats, rode the Freedom Trail, waited 86 years for the Red Sox pennant.  When folks were hurt, people did what they could:  one woman baked oatmeal chocolate chip cookies for the police/troopers/FBI/ATF, etc. to eat when the 2nd suspect was arrested.  Grit and defiance demand food, too, after all.

4.  Boston wears its patriotism and small-town love proudly.    Read this excerpt from one of the London marathoners, who also ran in Boston:

“I had a hard day out here,” said Neynens, who wore a 2013 Boston Marathon hat during his London run and finished in 2:48:09. “I was hurting, but obviously I was not hurting near as much as the injuries that I saw, people who lost their legs. I finished for all those people who were hurt and those people who couldn’t finish last Monday...

There was a banner we passed around Mile 25 that said, ‘Run if you can. Walk if you must. But finish for Boston.’ That meant a lot to everybody. It was great to see the support of everybody out there for the runners and for Boston."

 There were lessons for health, healthcare, and healthcare reform, too.

1.  Interoperability of electronic medical records could have been a problem.  In the marathon were runners and family-watchers from around the world.  What if there were a diabetic runner who, because of the bombings, was delayed in his/her sugar control?  There are so many other "what ifs" that the message is clear:  we need to quickly find a way to make these EMR-EHR-PHR talk to one another for the safety and security of the providers, patients, and communities.  We cannot afford to waste time finding a knowledgeable relative when life hangs in the balance.  [I wrote about this lack of interoperability in my post "EHR Is Speechless"].  There is no magic about data, the rules engines can be preserved as proprietary to each company, but the data must be accessible.

2.  Teamwork. Who will ever forget the masses of security forces closing in on the final suspect?  Or the video of the Chief of Police of Watertown MA saying his troops were never trained on counterterrorism, so they just did what was they thought was right?    Those of us riveted to the scenes will remember the ATF, FBI, fire departments, EMT, Boston police, State Troopers, and so many more.  But how many noticed that hot food was brought by the NY-NJ Port Authorities?  How many could ever forget the cheers and singing and clapping by the Watertown citizens when the ambulances and security cars crept slowly back into the city?  Now, imagine those kinds of teamwork in communities of care, with warm "handoffs" from primary care (Watertown police) to specialists (BPD, ATF, FBI, MA troopers) to recovery and long-term care (Red Cross, Boston Globe, and so many other watch-dogs and care providers).  Everyone had their job and new exactly what they had to do.

3.  Continuity and safety.  Recently I saved an article on the rates of hospital infections in the US compared globally, sent to me from my colleagues at MCOL.com.  Because of the trauma training, the warm handoffs, and the sense of accountability, continuity is a given in Boston.  It's the accountability that will guard the injured, the fallen and the recovery.  There's a new sense of "we share in this," and it's this sense that carry Boston through.  That's the real message of accountability:  we all own at least a portion of the problem, whether it's economic recovery or health promotion, and we all have a responsibility to step up to manage our community better.

Of course, in the land of the Red Sox, with the frame of David Ortiz' opening moments in Fenway Park, and the surprise visit from Neil Diamond to lead Sweet Caroline, the poignant moments caused tears and love and hugs.  For us who weren't in Fenway, or Boston, or Watertown, I treasure the picture that went viral on twitter and other social outlets:

 I don't think there are any coincidences.  I abhor terror, bloodshed, violence.  But these moments that I've called out remind me, and I hope all of us, of the goodness of people.  Who could possibly convey it better than Fred Rogers?  We needed to hear his words, "Look for the helpers," right then, right at that moment.  It opened our hearts and made us feel safe again, and we spotted more helpers and lavished praise, because we all needed to heal.

And then Boston Daughter (who had returned to Boston) sent me an email and a picture that she took, the one that starts this blog post, the site that amazed and tore and then opened her heart.  She told me she couldn't sleep, walked to the memorial Monday morning at 5am to pay her respects, and left her pink running shoes because she wanted to be part of the healing, too.

If you want to be one of the helpers, here are two ideas for you for donations.  There are many more, I simply had intersections with each of these here:

If you, like me and my Boston daughter, are an avid fitness participant, then you may want to make a purchase at @unitedwestride UnitedWeStride will donate all the proceeds from the purchase AND AN ADDITIONAL DOLLAR

@JetBlue  I audaciously sent a tweet on 4.22 to @JetBlue asking for serious discounts to Boston so we could boost the economy--I'm betting others did, too. On 4.23 I received an email with serious discounts.  Help those most affected by the Boston tragedy through The One Fund Boston, and JetBlue will match up to $100K. http://www.jetbluegives.org

 I hope peace comes to those who mourn and to those who heal.  I hope strength comes to our leaders and our protectors.  I hope our communities come together for health.

Getting Healthy

By Cyndy Nayer, April 1, 2013

In January 2013, US News published a report on why Americans aren’t healthier and gave us the concept of a health lag.  In fact, the gap between America’s health status and that of other industrialized nations is a 30-year trajectory of lower outcomes.

Last week, Modern Healthcare published a review of Kaiser Family Foundation findings in which the highest hospital readmissions were directly correlated to the unhealthiest counties in the US.

On the same day as the MH-KFF release, I was privileged to receive a tweet on patient engagement that highlighted the blog of Gilles Frydman  on PatientDriven.org, which highlights the real engagement and outcomes of patients who seek to understand their conditions and treatment by conversing with others.  The point here is in the definition of engagement, per the blog, “An engaged patient is someone deeply involved in the scientific understanding of their disease, fully aware at all times of the entire spectrum of available therapeutic options. It requires a set of learning, cognitive and psycho-social tools that can only be acquired by conversing often with a real network of peers who are similarly involved in this complex endeavor.“ 

This, says the author, is exactly opposite of the current definition of patient engagement as used by HIT, care professionals, benefits personnel, and service providers:  “the engagement flows from the various professional stakeholders of the health care system to the patients. It is a direct extension of the concept of consumer engagement.”

It’s exactly the discussion I am most involved in, most of the time, in which the (choose one) doctor/ IT developer/ hospital administrator/ national thought leader talks about patient engagement as the patient behaving according to the “guidance” he/she is provided.  But what if the guidance reaches the patient at the same time she is dealing with her teenager who had a car accident, or her husband who may lose his job? What if the “guidance” is a follow-up visit or test, but the office isn’t open late when she is off work? What if the “guidance” is the purchase of a pharmaceutical that she either can’t afford or that may cause side effects for her?  What if she simply didn’t understand the instructions or, three months later, is feeling better and stops the medication or falls off her nutrition plan?

Unfortunately, the problem here is that the engagement and persistence (which, by definition is part of engagement) did not occur because people have other parts to their lives than the body parts with issues.  They have financial needs, emotional needs, social needs, even transportation needs that interfere with engagement. While the most-influential people in the patient’s life, according to surveys, is the clinical “face” (doctors, pharmacists, nurses, etc.), these people do not follow the patient everywhere, and others in her sphere of influence take precedence.

Emergency department visits drop when medical practices extend hours. There are examples of patient engagement strategies that work and that translate directly to saved dollars.  In surveying more than 9,500 people with steady sources of care, the Center for Studying Health System Change focused its results on 1,470 individuals who had tried to contact their primary care practices after normal business hours in the past year. The study, published online in Health Affairs on Dec. 12, found that nearly 21% had difficulties reaching their physicians after hours, and those who reported more difficulty accessing after hours had higher rates of emergency department use (37.7%  and higher rates of unmet medical needs (13.7%).

As I’m on my relentless pursuit of solutions that deliver better health outcomes, I have to  emphasize this, re-emphasize it, and then state it many times more.  Those who doubted the power of value-based benefit design or outcomes-based clauses did not fully understand the suite of services and, what I call surround-sound messaging, that is necessary for patient engagement in health.

We cannot be paternalistic, nor maternalistic, in making health the end goal.  We have to meet people where they are and stop treating body parts separately (you know, hypertension over there and depression over here and diabetes…).  We have not only organize in patient-centric efforts but, perhaps more importantly, in patient-driven circles.  This is the success of the senior-citizen breakfasts that promote Medicare health plans, of the breast-health discussions that occur in churches and hair salons, and of the Dr. Oz and Dr. Phils of the world who reach through social media (including TV) to their audiences.

Transparency will only matter if the patient is seeking healthcare.  If, instead, she is seeking a carpool for her kids or the money for rent, then transparency of treatments may not be as meaningful, if it’s on the radar at all.  ”Entitlement programs,” as Medicare and Medicaid are increasing called, cause splits in peer groups and often in the same family, pitting seniors against young working adults in the “subsidy” allotment.

These are not directly related to the delivery of treatment from the health system, but they are distractions to the patient decisions.  If the incentives to the prescriber are different than the incentives to the patient, the patient will more often seek the treatment recommended by the doctor, as this is the trusted relationship.  In survey after survey for many years, the clinician advice trumps the insurance benefit advice, yes, but it also relieves the patient of asking price or quality or convenience questions of the physician.  To this point, in my March 15 2013 I sent out the Health Affairs link to the Kaiser study showing that consumers do not want to be responsible for their healthcare costs, and they don’t want their doctors to be responsible, either.  

If we want to close the health valley that we are in, if we want to use the amazing healthcare resources in our country wisely and widely for all of us, then we have to stop this narrow focus of hospital v doctor v benefit plan v pharmaceutical manager v insurance and get back to the basics:  making healthcare understandable, actionable, and most of all, relevant WITH the patient not TO the patient.  Patient engagement IS the holy grail for healthcare and health improvement.  But it can’t be done around the patient, it must be done with the patient fully present and asking questions and envisioning the future of his or her health.  If he or she can’t see it, he or she can’t achieve it.

Who’s In: State Health Insurance Exchanges

By Cyndy Nayer, February 7, 2013

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

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

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

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

By Cyndy Nayer, January 22, 2013

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

---

Lonny Dunn (@ProNetworkBuild)

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

---

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

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

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

Sigh Heard Round the World: Accountability and the ACA

By Cyndy Nayer, June 28, 2012

The tension across the US this morning was palpable, emails quieted, phones didn't jingle, 10am ET came and went, and suddenly, there it was:  The Supreme Court Upholds the Affordable Care Act's individual mandate, which allows the changes to go forward.  Later, we heard that the Roberts Court did alter the clause on mandatory expansion of Medicaid by the states who accept Federal dollars.  To be clear, the law said that if a state accepts Federal Medicaid dollars, then it was required to accept the ACA dollars and expand Medicaid; that, the Roberts Court said, was not ok, that the Federal system could not mandate behavior at the State level, which, frankly, is alignment with the known position of Justice Roberts.

So, the kids can stay on their parents' plans till they are 26, the individual mandate means a penalty on those who don't participate (it moved from a commerce clause--you have to buy-- to a tax clause--if you don't get in, you pay a penalty, a lot like not reporting your income and paying your taxes), no one will be denied insurance after 2014, the donut hole for Medicare-covered drugs closes (a savings that seniors have felt this year), state exchanges move forward.  Or, the fight might go into November and beyond with Republicans vowing to cast this law aside.

Some of the pundits are saying the country is weary of this fight.  Others are saying it's not over.  I say it just took on a new dimension:  the actual issue is jobs, the very essence of the American dream is owning a house (NYT survey June 2011:  Which is more important your job or your house?  Majority answered "House.").  By closing, even for awhile, the arguments over the ACA, we can rise up to the real problems, of which health care is a prime cause, but jobs and house are the endposts.

This is the sigh, not one of relief, but one of checking off the box that says "ACA" and refocusing on what matters:  the economy, the jobs.  Most folks understand that taxes are paid through jobs, houses are bought with jobs, health care is delivered mostly through jobs (either at the worksite or through the money earned at the worksite).  Most folks don't want that to change.  Most folks understand that the costs of the insurance have been going up, that US businesses are buckling under the weight, and, when insurance is not in place, the whole community pays in taxes for uninsured coverage in the emergency room.  Health care derails jobs, productivity, sales, activities, and taxes, which pay for police, firemen, new roads and bridges, and so much more.  So, control the health care costs, and we can actually make a dent in this job/house situation by preserving revenues for rebuilding and purchasing, preserving jobs and communities.

Today's affirmation of the individual mandate is a subtle reminder that we all have an individual responsibility to take care of our assets, including our health.  The door has been opened wider for Americans to manage their health as they manage their wealth:  we can invest in our health checkbook with better eating habits, better activity habits, better stress management habits.  The more we do individually and with our families, the more we will save in health care costs.  As we lower our risk profiles (overweight, sedentary, smoking, no prevention screenings, no immunizations, too much alcohol or pain medication, for example), the less CARE costs us and the more HEALTH we achieve.

I've mentioned before a book I wrote years ago--Lifetips:  101 Tips for Personal Health Management (that was the name the publishing house assigned to it, I didn't get to choose)--that included the concept of health-wealth portfolio, managed by the person/CEO-of-my-health, that leads to better health and wealth and performance.  It's time we revisit the concept.

In today's lexicon, 4 years after I wrote the book, the word to use is "Accountability."  We read about Accountable Care Organizations, but I  posit an innovative thought:  The Family is the Accountable Care Organization.  Every decision we make about what to eat, stepping up our activity, cutting our risky behaviors, getting the right care at the right place at the right time, affects the health and wealth and performance of the family.  Diagnosed with an acute sickness or chronic condition?  That will cost the whole family, could cut down on vacation time, or, worse, on education savings.  Need a new car?  Might have to make-do with the clunker because the medication you need has a higher co-pay.

You understand, I don't need to belabor this discussion.  What we witnessed today is the revival of our spirits as we experienced the revival of the belief in the American system:

"The Framers created a Federal Government of limited powers, and assigned to this Court the duty of enforcing those limits. The Court does so today. But the Court does not express any opinion on the wisdom of the Affordable Care Act. Under the Constitution, that judgment is reserved to the people." John Roberts, Chief Justice of the United States Supreme Court (thank you MCOL).

Any doubt we had about partisanship on the Supreme Court has been dissolved.  Justice Roberts used the rule of law to search for solutions that upheld the Congressional will, and only in the case of the state Medicaid mandate was the revision made, still leaving the law intact but one clause modified.  The headline surprised many, but the Supreme Court did was it was supposed to do:  SCOTUS was the Accountable Organization to assure the law of the land was upheld, according to the voted representaties of our government.

Now, the collective sigh must be turned to the jobs and houses.  It starts with each of become our own CEO of our self-defined Accountable Care Organization.  Our consultants in the medical community, our beneficiaries in the neighborhoods where we live, will thank us.

We can do it.  Turn our collective will to the rebuilding of our economy and our communities.  Do the best we can at managing our everyday health and watch the wealth begin to flow again.  Make small changes, track progress and stay the course, recruit others to join.

Accountability is our action, health is our goal.  Choose wisely, my friends.  Now, inhale deeply, and sigh audibly:  it's time to make America the healthiest nation in the world.

Gabby Giffords Is the Reality Star of US Healthcare

by Cyndy Nayer (cyndyn@vbhealth.org), January 31, 2012

I’m told that one should not mix stories in a blog, but, as a serial disruptor, I’m about to do just that.  I’m inspired by Representative Giffords and see her story as a frame for some ideas that simply won’t rest in my tired brain.

You may remember that I wrote the E Pluribus Unum blog last year just after Ms. Giffords’ near-death shooting in Arizona.  Her story took the nation to a reality-check on guns and mental health, but it also broke my heart for the family of Christina, who went with her classmates to meet the local representative of the US Government (Ms. Giffords).  Christina was one of the victims that day—she died from her wounds.

Still, the sun rose the next day, and Gabby Giffords gave hope back to America.  She began her slow recovery with the amazing care she received from a health care system that was in sync to help her recover.  She was transferred, later, to a center for the intensive therapy needed to regain skills of walking, talking, and more.  She went to Cape Canaveral to watch her astronaut husband lift off on the last space shuttle trip.  She wrote a book about her journey, and we cried with joy.  

This is the promise of America:  all hands form a team that saves a life, all hands who can’t be part of the team cheer the success.  Add the glamour of space travel and romantic love, and the TV-movie industry wishes that it had dreamed up this story—yet who would have believed it, as it was so surreal?  

So where are those everyday heroes?  Because over the last 30 days, my encounters with the health system have been less than heroic, and the stop/start/stop/ halt/restart mess of interoperability-safety-communication has not only caused me anxiety and angst, but also revealed some less-than-lovely realities.

The US health system has surely been going through enormous change.  There are stellar stories of success in electronic medical records for hospitals and physicians, for empowering patients (with personal health records on my phone or iPad), for revealing transparent pricing and quality so I can choose appropriate treatments and know my out of pocket costs.   Or…?

In the last 30 days I’ve met with a new primary care physician so I could establish a medical relationship. My previous physician left her office with no notification of where she might next appear.  No problem, I have my health history, can begin anew. I sought a physician with an electronic health record that is hooked up to a health system and that will also deliver my health information to my personal health record.  I offer to pay for my initial visit because, as I tell the scheduler, I want to interview the doctor to see if our personalities and technology will jive.  When I arrive, they charge me my copay, I remind them I’d like to pay for the visit so I can discuss what I need, and they say, “No need, this is how we do it.”  Well, ok!

We meet, we greet, no ugly paper or cloth “gowns” (may I just insert that my idea of gowns are the kinds that look fabulous in public with brilliantly crafted shoes?).  He asks me some questions about my health (completely fine, thank you, here are my records).  I ask him if he can cope with a person who has a healthy scope on the health system, understands appropriate use of the system, and is the CEO of her health.  “Oh yes, “ says the kindly doctor with the white coat and stethoscope.  We schedule my physical for 6 weeks later.

I am now in the room with Mr. Hyde.  Dr. Jekyll has left the planet.  Charmingly, he begins ordering tests I don’t need (there are no guidelines suggesting the tests), “discovers” a potential “problem” in my EKG (as in “Houston we have a problem” level of problem) and immediately schedules a cardiology visit (folks, relax, there was no problem, there was a misread).  He informs me I need these new tests because just yesterday he discovered a breast cancer in a woman my age (lovely use of calming technique).  There is more, but I will spare you the rest.

Two weeks later I’m called by the nurse and told to immediately get another blood test, it absolutely can’t wait, and no we can’t tell you the lab values but they are “high.” I spend a sleepless night worried, I call back the next day and ask that the doctor please call me as I’m leaving town.  He calls mid-afternoon, says there is no urgency, but it must be done immediately upon return.  He then gives me the values, and I remind him that the numbers he is seeing, only 6 weeks after a perfectly normal blood screen and a record of good readings for 5 years, are not in crisis zone and, (I say, deferentially) that I believe the recommendation is to wait 6 months since I have no risk factors and then retest?  “No,” says the physician, “I want it done now.”

If you’ve been reading my blogs, if you know me at all, you know I tend to not react well to that order.  In fact, the Institute of Medicinejust released a white paper on the communication between patient and doctor, with principles that include supportive environment and respect.  But I do get the requisite 2^nd blood test, and once again I get a call to schedule an immediate appointment while no lab values are shared per doctor’s orders.  I respond, as kindly as my heartbeat will allow, that I don’t make appointments without doing my research so that I’m prepared, so I need the values. “Then have him call me.”  And, of course, a part of me prepares to die.

Breathe.  The labs are not life-threatening; but the doctor’s attitude was.  He told me he simply didn’t have the time to call me with lab values, I responded that I didn’t want his call, I just wanted the values and his nurse could have told me.  He told me he’d reveal the values during our face-to-face meeting, I told him I wanted to be prepared with questions so I didn’t waste his time or mine.  He told me that wasn’t how he worked.  I reminded him of our first conversation.  He said “in the office,” I said “empowered patient,” and told him I’d get back to him.  We ended the call.  Then I fired him in my mind.

But I didn’t drop my health.  Yesterday, I made an appointment with my husband’s cardiologist because of his excellent treatment of my husband.  The scheduler said, “Let’s get your records.”  “They are on your interoperable system through the nationally-recognized health information system that you have,” I say, subtly letting her know that I’m an informed patient and I speak electronicmedicalrecord-ese.  

Wait for it.  Get a cup of herbal tea.  Breathe deeply.

“But we can’t pull up records from another doctor, even if the doctor is part of our system.”

I’m speechless, no breath, no words.  This is the second time in 60 days I’ve heard this.

So we have the picture, now, of healthcare done impeccably well through a trusted relationship of patient/family and the team of clinicians, then wrapped in a love story (Gabby Giffords).  And we have a story of healthcare wanting desperately to do it well, putting systems in place that can do the job, but human rules making it so darn difficult that access and quality and that holy grail of “consumer-directed care” are unachievable.

Will reimbursement changes make this go away?  Not likely.  Will promoting primary care make this heal?  I’m skeptical of a health quarterback that can’t hear the plays because the sound is turned off.  

That wasn’t the healthcare reality that I envisioned with all the work that you and I do to improve it.  These are all good people.  In fact, WE are all good people.  We all want to do the right thing.  They are working hard to promote health.  I am working hard to promote health.  Gabby Giffords and her team are the epitome of “Hard work, well done.”  My experience, not quite.

I shared this story with good friend and VP of the Center for Health Value Innovation, Ray Zastrow MD, CMO of QuadMed. Ray paraphrased a statement from Atul Gawande MD:  Medical care should work like the pit crews of NASCAR.  The outcome is the focus—get the car and driver back on the track.  No lag time, no computer outages, or lack of transfer of knowledge.  Diagnose, triage, heal. Seamless engagement and outstanding accountability.

This is the healthcare vision of the US.  Obviously it exists, as Representative Giffords’ teams, and many other teams, including those in our Center for Health Value Innovation, show us day after day.  

So I close another chapter in the quest for US health, with a message to Representative Gabby Giffords:  Keep up the good work, Representative Giffords.  We will miss you in DC.  But you have a grander national duty now.  I know you didn’t campaign for it, but I surely hope you’ll accept it: Show us how this is done with your NASCAR team of clinicians.  Gather your pit crews around you for a stupendous recovery.  We are cheering your success!

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

By Cyndy Nayer, September 20, 2011

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

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

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

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

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

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

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

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

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

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

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

AcCOUNTable Care? Engagement Is Not Required, Just Send Dollars

By Cyndy Nayer, August 4, 2011

It's been a long few weeks, and temperatures have not subsided.  The AC needed--the cooling off that would come with accountability throughout the stakeholders of consumers, patients, physicians, health plans, health services, pharma-device-biospecialties, etc.-- is not on the horizon.    Today, the heated up consumers have shown they have lost confidence in our economy, and the stockmarket dropped 350 points already today. The Congress is worn out from its weary negotiations, and members have recessed for 5 weeks, leaving less than 90 days for negotiations by the SuperCommittee, who will, in turn, "solve" the money crisis, we hope.  But, the money counting has begun. Does this matter to health care, employee engagement, and accountable care?  It sure does, as it reflects the impact that loss of revenue and loss of taxes will have on our ability to get health care coverage for more citizens.

Then, another stunning blow:  In an overlooked clause in the PPACA legislation, Massachusetts hospitals will recoup $275M in Medicare reimbursements, and 7 other states will also be receiving new Medicare dollars, while the rest of the states get hit for these dollar transfers.  The article, in the Associated Press, explains it this way:

Hospitals in Massachusetts will reap an annual windfall of $275 million through a loophole enshrined in the new health care law. Hospitals in most other states will get less money as a result.

Hospital association executives in other states are up in arms over the news, buried in a Medicare regulation issued Monday. It comes at a time when hospitals face more cuts under the newly signed federal debt deal.

"If I could think of a better word than outrageous, I would come up with it," said Steve Brenton, president of the Wisconsin Hospital Association.

Even Medicare says it is concerned about "manipulation" of its inpatient payment rules to create big rewards for one state at the expense of others.

Hospitals in 41 states will lose money as result of the change. The biggest loser: New York, which is out $47.5 million.

Seven states come out ahead, though none do as well as Massachusetts. Runner-up New Jersey stands to gain $54 million, or about 20 percent of the Massachusetts windfall.

President Barack Obama's health care overhaul was supposed to lead to reforms in Medicare's byzantine payment system. Critics say this latest twist will encourage hospitals and other big players to game the system in a scramble for increasingly scarce taxpayer dollars.

Hospitals are paid under a complex set of formulas for their services for Medicare recipients.  When these kinds of shifts are made, the hospitals, of course, must take the hit--unless they are in the "lucky" states.  But, as you may imagine, these less-fortunate hospitals have bills to pay, too.  So, they often raise pricing on the other national payers of health care:  the employers.  This means we can expect to see the employer-provided costs of health insurance to go up, which means employers have one of 3 alternatives:

1/ pay the increase.  But their sales are down (witness the plunging consumer spends) and their insured population (workers, families) have already absorbed100%+ increases in insurance costs over the past 10 years;

2/ pass the increase to their covered lives.  See #1 above, and note that recently Kaiser Family Foundation published research that showed that 61% of the uninsured in America are part of a family with a fulltime employee who is offered affordable health care and chooses to not take it. Passing costs to employees who choose not to take it does not make a healthier employee nor a healthier corporation.

3/ do not offer insurance.  Well, it will sure save dollars for America's employers (up to $13,700 per family in 2010).  But it certainly will not increase employee engagement in their health or performance, and it will not add to the total health improvement for employers, who are experiencing the aging and sicker workforces that have been documented over and over again.

So, Turning on the AC, as noted in my previous blog, hasn't quite worked so well in the past few weeks.  Accountable Care may well have become AcCOUNTable care, emphasis on the count.  I hope that those that received the reimbursed dollars will be able to support the only reasonable outcome:  send people to those states for the coverage they will not find in their own. Another reason for Medical Travel, but, alas, it's not about improved health.  It's about improved reimbursement, just as many have feared.

Hot Temperatures, Hot Rhetoric: Turn on the AC

By Cyndy Nayer, July 18, 2011

The news shows this Sunday morning focused on the debt ceiling, a concept causing higher angst and tempers across our very hot country.  Of course, a large part of the discussion is the cost of health care in the country, and the political v clinical costs of cutting benefits and resultant strains on the health care delivery system.  So, on this sunny/rainy day in southwest Florida, typical for this time of year, I began thinking about a concept and a slide that I created about 3 years ago.  As the weather here and across the country is speeding to 100+ degrees, the body screams “cool it off,” much like the body politic is screaming about the debt ceiling.  That conflict of politics, health care, and hot temperatures was actually, was the genesis of the slide, and the concept,  that I created called Turn on the AC. 

A play on words, as noted, is often how I begin to frame the “what ifs” in my thoughts.  What if we could cool off the…..for just a bit and have a conversation to reconsider some alternatives—I remember thinking just that in late 2008, as the economy tanked and my speaking engagements picked up.  At the time, I was using the frame of “7 Wonders of Health Value Innovation,” teaching the attendees at various summits how value-based benefit designs could provide relief to a stressed corporate America.  I also remember one of my colleagues telling me, “Cyndy, a little less gloom and doom.”  But that was not really what I was proposing.  Rather, I was setting up a “what if” scenario of plummeting housing market, lower tax revenues, job cuts, hospital distress due to lower disproportionate share reimbursement (this is the Medicaid reimbursement to hospitals for providing care when there is no insurance coverage), public employees losing jobs due to lower tax revenues from lower property values, and so on.

The bad news is, 3 years later, the problem has not gone away.  Now, it’s enveloped in a bigger problem called the debt ceiling.  And this blog is NOT about the debt ceiling.  I have many things to say about debt ceiling, and none of them would I like in print, except to say this game that’s going on in Washington is not helping tax revenues, corporations, working people, unemployed people, health care access, or property valuations.  Back to the subject…

The set-up was, and still is, about the uncomfortable feeling from hot weather.  Debt ceilings contribute to the hot weather feelings, but turning on the AC can help.  We need a cool-down, one in which we remember our basic focus is a healthy, engaged, high performing America.  So, with that in mind, I update “Turn on the AC.”

1.     Accountable Consumers.  At the crux of the problem of escalating health care costs is the entitlement v accountability debate within the consumer population.  Forget, for just a moment, whether insurance is involved.  Each of us has a responsibility to care for our health as the one investment that needs to be fully-funded for our lifetime.  There are some fundamentals here that should be reiterated.

a.     Set goals and write them down.  If you’ve heard me speak, you know I am quite enthusiastic about personal health records.  As a former trainer of fitness trainers/employer health strategist/chair of the Governor’s Council on Health and Fitness, the number one behavior change strategy that I proposed then and continue to enforce is “write it down, measure it daily.”  “You can’t manage what you don’t measure,” applies to corporate strategy, so but it’s a curious item that folks don’t realize the same applies to them:  you have to set goals (small, large), then measure your success in attaining them.  No exceptions.

b.     Get the preventive care that you need.  Love it or hate it, the Accountable Care Act has ingrained this into our lives now.  In the Health Value Accelerator^TM that is being deployed in many communities now, I’m seeing just how much of an “un-engagement” this is.  In many companies, particularly larger companies (over 10,000 employees), there is less than 10% participation in primary care for prevention.  Yet, there is no cheaper investment any consumer/patient/employee/mother/father/child can make:  get your physical, your immunizations, your age-appropriate screenings.

c.      Get your family involved.  If you are the health advocate for your family, share the info you are learning.  Take the kids on a walk after dinner.  In my house, it’s about encouraging my husband to exercise, so I “coax” our fabulous dog, Phoebe, to take him for walks.  Families that eat healthy and exercise tend to forestall health issues.

d.     Spread the word at work.  Share your story of success, of challenges.  Volunteer to coordinate walking groups or healthy vending snacks.  Make your voice heard on health improvement ideas. 

e.     Reward yourself.  If you are doing well on your journey, don’t reward yourself with the hot fudge sundae, but, instead, perhaps a manicure or a movie?  New walking shoes?  Even a lovely glass of wine?  Consumer-driven rewards are completely satisfying, as no one else is dictating either your behaviors or your rewards.  Step up to identifying those rewards that will keep you motivated. 

The key message here is that YOU are responsible for your health—your doctor, your counselor, your fitness trainer, your financial advisor are your consultants, not your health-owners.  You simply must assume this responsibility or be subject to the whims of the market place and latest insurance products.  If you want some semblance of normalcy in your health, own it, track it, demand it, enjoy it. 

2.     Accountable Corporations.  Business is the backbone of America.  Business provides revenue for us to buy houses, support social causes, and even campaign for elected officials.  But business that creates barriers for its employees to get health is not a healthy business.  Wasteful spending in the health system has been calculated at up to $1.2 trillion of the $2.2 trillion spent in the United States, more than half of all health spending.  (PriceWaterhouseCooper)  Whether your position is that the ACA is going to help businesses or hurt businesses with its legislation, realize that every week there are new rulings, and American business cannot afford to waste one minute waiting for “final rulings.” 

Recently we all read that one consulting enterprise predicted what many of us saw as an abnormally high exit from corporate health benefits.  In our survey from the Center for Health Value Innovation (176 companies, 4 million lives), we saw no numbers that came close to this prediction, and, evidently, neither did many of the other large consulting companies.  But what we did hear last week was another challenge for American business:  new rules on the Health Insurance Exchanges said that states did not have to launch them by 2014—the date can be 2015, or perhaps beyond. 

What this means to American businesses is, once again, the heat is on, and the ball is back in your court.  There’s no time to waste in getting your employees healthy, re-engaging them in managing their health.  Value-based designs are one tool, and I don’t have to reinforce that message—it’s also in the ACA:  reduce beneficiary out-of-pocket costs for valuable services.  But take it a bit further:  consider those rewards, or incentives, that are outside of the insurance plan design.  How about a contest for movie tickets?  How about a healthy lunch for the business channel with the most people who get their flu shots or track 150 minutes of exercise in one week?  Think of games and challenges that cause an uptake in healthy behaviors, and applaud your champions.  Create a business expectation that people who work at your company are expected to manage their health and that the company respects all efforts for improved health.  Create a culture of engagement, in which employees bolster employees’ efforts at health promotion. Colleagues at Journal of Occupational and Environment Medicine, Pam Hymel MD and others, have written extensively about the link of health to corporate performance.  Build your culture of engagement so that you create accountability from the C-Suite to the receptionist and beyond.

3.     Accountable Care.  This, too, is part of the national and local change that is occurring with the ACA.  But in 2008, and even now (hard to believe that the measures are the same 3 years later), my focus was on the delivery system to deliver health as we want and measure it:  healing with less infections, less mistakes, less days absent, less avoidable pain and suffering, less use of unneeded diagnostics and treatments; care with more compassion, more time to listen, more care coordination so that people are not “on their own”; more interoperability so that records support efficient care. 

The 2008 AC slide was the genesis of the Outcomes-Based Contracting platform that has become the extension of everything value-based and patient-provider-engaging.  Identifying high performance providers and systems, creating benefits plans that guide consumers to competency and better health care, and linking these delivery system improvements to the shared rewards for all of the stakeholders, is true American engineering.  Removing friction and competition for dollars, installing competition for a “better outcome” is the foundation of accountable care.  Medical Homes, care coordination, benefits advocates who coach beneficiaries on improved behaviors and their link to lower premiums or expanded services—all of these are part of Accountable Care, but only if we hold our principles intact:  efficiency, effective care, and appropriate care delivered in a timely, competent fashion.  Self-insured employers understand the link and are searching for ways to direct contract with organizations so that, togetherm the accountability link is communicated. 

4.     Accountable Communities.  When the AC is going full-blast, when the accountable consumers support the efforts of the accountable corporations, who, in turn, provide healthcare coverage to the employees through identification and purchasing of outcomes-focused suppliers, the community at-large benefits.  Accountability grows in small increments, but its effect is felt throughout the families and corporations that benefit from the improved service lines and improved health status of the citizens.   When 1 or 3 or 7 corporations demand hospital-based performance metrics, everyone who uses that hospital benefits from the improved quality.  When 1 or 3 or 7 corporations demand to pay for disease management that builds engagement (instead of numbers of calls made to beneficiaries who may never engage), the systems for disease management change and the others in the community benefit.  When benefits coaches help employees and their families not only choose the right insurance plan but use it for full maximum value, they teach other families how to maximize their health benefits.  When few people use the emergency room for primary care, and instead use lower-cost onsite or offsite clinics or telehealth Emergency Room visits, more resources are saved for under-insured and uninsured folks—more accountability for choice leads to better use of existing resources.

What the AC focus does is create engagement across single, multiple, and varied participants in the health value supply chain.  AC shares the requirement of engagement and builds the outcome of accessible, affordable, actionable care.  AC rewards all of the engaged participants with lower costs and fuller wallets due to appropriate care at the right resource at the right time.  AC limits inappropriate use, instability in resource budgets, and insufficient funds for treatments that could have been managed more effectively and more efficiently “upstream,” when they didn’t cost so very much in dollars, pain, and stress.

So, on these hot days of summer, consider cooling down and challenging yourself and your constituents to a better outcome.  Turn up the AC, from the Accountable Consumer to the Accountable Corporation, to the Accountable Care and the Accountable Community.  Walk earlier, when it’s not so hard to breathe.  Consume more locally-grown fruits and vegetables to protect your heart on these hot days and protect the revenues in your community.  Create co-worker opportunities to learn and share improved health management techniques. 

And don't forget about that debt ceiling.  Be the Accountable Constituent and let your local and national representatives know how you feel.  It will reduce your body temperature and lower your stress levels.  We could all use that right now.

Five Key Trends for 2011

By Cyndy Nayer, January 3, 2011

Businesses are refocusing their efforts on the health of the workforce as new evidence shows that the right investments in the right context can drive better health and performance.  ACA, and the chaos surrounding it, had quieted down around July of 2010, but with the elections and their aftermath, the noise in the health care reform efforts became a cacophony of confusion.  And, somehow, with the approach of the holidays, the cacophony gave way to a new surround-sound system:  we have to get back to work in America.  So, while the legislators appear to be ready to fight to the knockout, America appears to be tuning out that noise.

It's imperative that the noise is muffled so that business can grow again.  Key trends that are accelerating this return-to-work philosophy can be drilled down to 5:

1.  Benefit design.  The realization is that business depends upon a healthy workforce.  Some businesses can off-shore their work to a less-expensive locale, but most cannot.  Therefore, innovation in benefit design is paramount.  And while there is some tension to leave health insurance benefit altogether, the mood appears to be softening a bit.  It's a profound realization that, with or without the health insurance benefits, business still needs a healthy and productive workforce.  So, un-managed individuals can't deliver on improved health, and insurance exchanges may offer a bit of relief to the healthcost-weary.  But the risk of the underinsured to the business is that safety incidences may rise (people engaged in their health are also engaged in their work); health costs may rise in the market, demanding higher tax revenues; and higher taxes and/or unhealthy people do not purchase products at the same rate as engaged, healthy people do.  So, benefit design, whether in-house, independent, or insurance exchange, will not go away.  And, value-based benefit designs will continue to show the improved health and reduced trends so very much needed at the business budget lines.

2.  Expansion of prevention and wellness.  As the former Chair of the Missouri Governor's Council on Health, I've never seen the rush to prevention and wellness at the speed in which it's now moving forward.  Partly it is attributable to the need to acquire healthier beneficiaries, that's true.  But it's also due to the fact that so much of the disease management efforts have delivered results only "around the edges":  rates of chronic disease continue to climb, every time one person stops smoking, another starts, and obesity is sweeping through our children like measles.  We must create a better waistlines in order to manage our business waste-lines:  obesity drives up rates of chronic disease across all populations and starts at a much younger age.  Innovation is building that will support physical activity, goal-setting and achievement, and personal health success.

3.  Acquisition of new care sources.  A quickly growing trend is the installation of onsite services and the expansion of onsite clinics into business sites in order to manage the total costs of care, reduce the barriers to early intervention, and even to treat the dependents and, sometimes, the community's health.  Using the skills of medical directors in these clinics, the rise of the medical director is reshaping the seat of power inside the business.  No longer is the medical director and his or her staff recognized only as the education director or the point person for flu shots.  Medical directors and their onsite clinics are showing phenomenal results in engagement and accountable care, and this growth will continue.  Telemedicine and medical travel will expand to competent providers with measurable outcomes.

4.  Personal Health Records will become the standard for IT.  As the use of electronic health records grows, there will be some who continue to rely on the physician and his/her office to manage "my" health.  But the real power of the first 3 trends noted here is the opportunity to create competent individuals who manage their health, health cost, and health purchases as wisely as the CEO of a business.  They record goals, strategies, measures, directional approach to targets; they use the medical system as a consult instead of the head of business at "My Health."  "My Health" becomes a tangible asset that the individual can take from employer to employer, from one physician to another.  Without it, and without putting the total information into the individual's repertoire for asset management, the rest of the IT will fail to connect all the points, because the real point of health care must be the improved health of the individual, and that only happens when the individual is engaged in the management.

5.  Outcomes-based contracting(^TM).  I'm a bit biased here, so I want to be especially transparent on this one.  The level of interest in paying for outcomes is growing rapidly.  Transparency and quality forms the comparative platform for choosing which services to buy and from whom.  Creating a contractual arrangement in which all parties share risk (usually defined through a series of desired behavior changes) and share in rewards (savings are distributed across the stakeholders, including the individual) if the best way to insure value accrues to all the participants.  OBC is growing from the focus on pharmaceutical contracting to the outcomes improvement at the health system level, the accountability for care at the clinician level, and the benefit design that most fits my family or yours. For more information on OBC, please check out: http://bit.ly/OBCtmCHVI

These are powerful trends that hold the promise of delivering more value for the money spent in health care.  But they also re-focus the conversation on units of health instead of health care.  Any business knows how to buy units of supplies to create the products they will sell.  Individuals know how to buy units of bananas, weigh them, and pay for only the weight they receive.  Purchasing health care must be the same:  we need to know the cost, agree to the terms and manage the acquisition and use.  We need to get back to business.  The ACA will continue it's march...American business needs to get back to the business of America.