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 AcceleratorTM 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.
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