Midwest Business Group on Health’s Quest to Reduce Elective Preterm Deliveries

By Clive Riddle, March 2, 2012

Last week,  Larry S. Boress, President & CEO of the Midwest Business Group on Health was one of three featured speakers in the HealthcareWebSummit event: Managing an Increasing Trend of Elective Preterm Deliveries.

MBGH has taken a keen interest in facilitating a reduction in elective preterm deliveries, and Larry shared why purchasers have gotten involved, and what they are doing about it.

Larry’s opening arguments were:

• Maternity care is the number one reason for hospitalization among employee populations
• The highest cost for maternity care is when underdeveloped infants are treated in the neonatal intensive care units of hospitals
• Preterm infants are less likely to survive to their first birthday than infants delivered at full term
• Those preterm babies who do survive are more likely to suffer long-term costly disabilities than infants born at term

He shared 2009 Data compiled by Thomson Reuters for the March of Dimes, which compared average expenditures for newborn care yielding $4,551 for uncomplicated cases vs. $49,033  for premature/ low birth weight cases.

So what exactly is an early elective delivery. Larry offered these characteristics:

• The newborns delivered with a gestational age between the 37th and 39thcompleted week, that were delivered electively
• Early elective deliveries are performed on women of all backgrounds and incomes.
• These are distinct from early deliveries performed due to clinically-appropriate reasons to avoid health problems facing the mother or the infant

And what is the scope of early elective deliveries? We learned that the national average is up to a rate of 17% of deliveries, while the Leapfrog group has set a current target at 12%. Minnesota, South Carolina, Indiana and Arizona all have rates above 25%. Virginia, Florida, and New York exceed 20%. While 53% of hospitals are at or below the Leapfrog target of 12%, 33% of hospitals have rates of 20% or higher (6% of hospitals have rates of 45% or higher.)

What are the motivations to have an elective preterm delivery, despite the dangers and costs? Larry cites these delivering physician convenience factors: (A) Guarantee attendance at birth;  (B) Avoid potential scheduling conflicts; (C)  Reduce being woken at night; and (D) the NICU can handle it. Furthermore, Larry offered these motivations for the mothers:

• Prior bad pregnancy
• Desire to deliver on special date or holiday
• Special circumstances
• Cultural factors
• Ability to  plan in advance for birth
•  Convenience
• Ability to be delivered by her doctor
• Maternal intolerance to late pregnancy
• Excess edema, backache, indigestion, insomnia

But there are serious quality implications of non-medically indicated early deliveries beyond cost that Larry cited:

• Increased NICU admissions (and separation from mother)
• Increased respiratory illness
• Increased jaundice and readmissions
• Increased suspected or proven sepsis
• Increased newborn feeding problems and other transition issues
• Under developed brain and lungs
• Potential development of cerebral palsy

The good news is this is now a national quality measure for the National Quality Forum (NQF); Leapfrog Group; The Joint Commission; and AMA Physician Performance Consortium Measure.

Larry closed by noting that in the twelve months since MBGH made its initial Call to Action to reduce elective preterm deliveries, over 70% of hospitals reduced their early elective delivery rates below previous levels, and many have set 5% as their goal.

The Business of Clinical Integration: Payment Models, Structures, Governance, Strategic Issues and More

By Claire Thayer, March 2, 2012

MCOL’s Healthcare Web Summit announces The Business of Clinical Integration: Payment Models, Structures, Governance, Strategic Issues and More, scheduled for Wednesday, April 18, 2012 at 1PM Eastern.  Join nationally renowned experts Doug Hastings, Chairman of Epstein, Becker & Green, and Dr. Mark Browne, Principal of Pershing Yoakley & Associates, as they construct the foundation of business considerations for health care organizations in pursuit of clinical integration. This session will address payment models, structures, governance, strategic issues and more, for organizations seeking: to manage populations and patients based on a culture of patient focused “Clinical Teaming”; utilizing systems and data which enable seamless coordination and continuity-of-care; and optimization of applicable incentives.

More information: http://www.healthwebsummit.com/integration041812.htm

Medicare: Predictive Analytics, MSSP & Star – Hidden Compliance & Enrollment Patterns

By  Claire Thayer, March 1, 2012

MCOL’s Healthcare Web Summit announces Medicare: Predictive Analytics, MSSP & Star – Hidden Compliance & Enrollment Patterns, scheduled for Thursday, April 5, 2012 at 1PM Eastern.  The Medicare Shared Savings Program and the Medicare Advantage Part C "Star" rating program both provide significant potential financial rewards if participating organizations meet applicable criteria. Join Milliman's Rong Yi and Bruce Pyenson as they explore how the two sets of quality measures relate to each other, and discuss what types of these Medicare members are less likely to be compliant and therefore require more targeted communication or intervention.

More information: http://www.healthwebsummit.com/milliman040512.htm

It’s the Data, Stupid

By Kim Bellard, February 21, 2012

Two announcements by payors last week caught my eye – both relating to payors and to health care data. 

Last week UnitedHealth announced that its Optum division would offer cloud services for health data, allowing health care providers and even other payors to move and access data via the cloud.  They are even extending the Apple analogy further by opening up their platform to outside developers, so that those developers can develop “apps” for the Optum platform.  They cite the example of an app that would make it easier for providers to structure payments in “bundles of care,” as are expected for ACOs. 

At the same time, three Blues plans – Horizon (NJ), Highmark (PA), and Independence (PA) – announced they had partnered with HIT company Lumeris to buy NaviNet.  NaviNet is a platform many health plans have used to facilitate real-time electronic connectivity with physicians and other health providers; NaviNet claims over 70% of US physicians use its platform.  The partnership with Lumeris is intended to improve NaviNet’s ability to communicate clinical information – in addition to eligibility, claim, and benefit information – and to facilitate ACO offerings.  Undoubtedly other Blue plans, not to mention other NaviNet customers such as Aetna, will be watching the acquisition closely.

The focus on data is by no means new to payors.  In the mid 1990’s UnitedHealth started building its data and analytics capabilities, eventually becoming Ingenix and now part of OptumInsight.  Aetna and Wellpoint also made acquisitions to beef up their data capabilities – Aetna acquiring ActiveHealth in 2005 and Wellpoint following suit in 2008 by acquiring Resolution Health.   Not to be outdone, Humana acquired Anvita Health, another health analytics company, this past December.

Equally interesting is that the payors aren’t just interested in analyzing the data; they want to help move it as well.   In 2010 UnitedHealth acquired Axolotl, one of the leading vendors that service the health information exchange (HIE) market, a market is that growing rapidly due to the influx of HITECH federal funds for HIEs and Regional Extension Centers (RECs).  Not to be outdone, a few months later Aetna acquired Medicity, another leader vendor for HIEs.  Although Axolotl and Medicity are the two largest HIE vendors, they are still estimated to account for less than 20% of the HIE market.  That would seem to leave the window open for other payors to acquire some of the remaining HIE vendors, but at least one leading firm – Chilmark Research – thinks participation in regional HIEs efforts may make more sense, given typical payor market shares and potential antipathy from providers and other payors.  

So what are the payors up to with these moves?  Some experts think they are diversifying to help offset PPACA’s limits on medical loss ratios (MLRs).  There probably is some truth to this, but we need to keep in mind that there is not as much actual insurance as most people think.  Well over half of health insurance today is self-insured, meaning the MLR rules do not apply to it and that the payors are doing the administration without the risk.  The main insured markets are individual coverage, small group (under 50 or 100 employees), and Medicare Advantage.   Historically not every payor has been in all of these markets – e.g., for decades Cigna focused primarily in large, self-funded employers – but with PPACA, the emergence of health insurance exchanges (the other HIEs), and the expected growth of Medicare Advantage, actual insurance is likely to become more important, and understanding their risk better becomes even more important to payors.  Plus, those self-funded clients are constantly demanding better and more targeted interventions to help control their costs, so the data analytics capabilities are increasingly important as part of a payor’s capabilities.  

Another hypothesis is that payors are scrambling to assert their role in an ACO world – whatever that may look like.  If providers end up as the ACOs, and they are essentially bearing the risk, the theory is that payors may find themselves antiquated.  That doesn’t seem likely to me, especially since so much of what payors do isn’t related to risk-bearing.  The exchanges and CMS are likely to still expect a (regulated) insurer to be responsible for the members, and multi-state or even multi-city employers would still need some entity to stitch the ACOs together (we saw this with HMOs in the 1980’s and 1990’s).   But by providing insight or connectivity to an ACO, payors may be able to provide value to them and to be an integral part of their solution.

Then there are the efforts by payors to buy their way into the provider world – e.g., Humana with Concentra, OptumHealth with Monarch  Healthcare, Highmark (again) with WPAHS – that will further blur the lines between payor and provider, as if the lines hadn’t already been blurred by organizations like Kaiser Permanente, Geisinger, or Intermountain Health.  Payors will have access to troves of new information through such direct involvement in the provision of patient care, but managing clinical efforts is not the same as managing network and insurance efforts (as some provider organizations have discovered in reverse!).

Data has always been one of the Achilles heels of health care.  All too often, patients’ data has been trapped in the silo in which it was delivered, with little or no ability to be shared, much less learned from or to have treatment guided by data from similar patients.  Administrative data – e.g., claims and eligibility – was able to break out of the silos to some degree, primarily because it was directly related to payment, but even with those types of data neither payors nor providers can claim to be entirely satisfied with the current state of affairs.  Health care data remains complex, minutely precise yet in many ways surprisingly useless, and generally just extremely messy -- mocking the ease and usability with which most other financial data manage to flow. 

Still, it doesn’t take much of a crystal ball to forecast that this sad state of affairs cannot last.  Data will flow.  It will be aggregated, analyzed, and applied, and it will be available -- used to guide both provider and patient treatment decisions at point of care/point of decisions.  It will acquire velocity, nearing the real-time status we’re used to seeing in most other industries.  More power will accrue to entities that can help data move and be useful, and more success will come to entities that use the data to be accountable for their efforts – whether providers, payor, or combinations thereof.  

I think it unlikely that payors will end up controlling health care data – not with the likes of Microsoft, IBM, GE Health, athenahealth, and many, many others also in the mix – but if they don’t have their oar in the data waters (and rowing hard), they’re going to get left behind. 

For centuries, medicine was the art of laying on the hands.  Some say 20^th century medicine was the era of antibiotics/prescription drugs, plus advanced imaging.  Many pundits predict that medicine in the 2st century will be all about genetic therapy.  Perhaps so, but I think it will be about the data.  Let’s hope we use it well.

Kaiser by the Numbers - 4th Qtr 2011

By Clive Riddle, February 17, 2012

Kaiser Permanente, the nation’s largest integrated health care delivery system, last week released fourth quarter and year-end 2011 financial results.  Here’s some highlights, as well as comparison to their fourth quarter and year-end 2010 and 2009 financial results:

Full Year End Results

• Combined total operating revenue:  2011 $47.9 billion  |  2010 $44.2 billion  |  2009  $42.1 billion
• Operating income:   2011 $1.6 billion  |  2010 $1.2 billion  | 2009 $1.6 billion
• Operating Income % of Operating Revenue:  2011 3.3%  | 2010 2.7%   |  2009 3.8%
• Net non-operating income:  2011  $426 million  |  2010 $789 million |  2009 $524 million
• Net income:  2011 $2.0 billion | 2010 $2.0 billion  | 2009 2.1 billion
• Capital spending :  2011 $3.2 billion  |  2010  $2.9 billion  |  2009 $2.6 billion
• Total Membership:  2011 8.9 million  |  2010 8.7 million  |  2009 8.6 million

Fourth Quarter Results

Combined total operating revenue:  2011 $12.1 billion  |  2010 $11.1 billion | 2009 $10.6 billion

Operating income:  2011 $247 million  |  2010 $42 million |  2009 $214 million

Net non-operating income:  2011 $227 million  |  2010 $205 million  | 2009 $276 million

Net income:  2011 $474 million  |  2010 $247 million  |  2009 $490 million

Capital spending:   2011 $1.0 billion  |  2010 $1.2 billion  |  2009 $900 million

More Numbers

High level browsing of KP’s financial results can be given a little more perspective by touring through some key information about the close to 9 million member not-for-profit health plan:

• Founded in 1945
• Headquarters in Oakland, Calif.
• Three main operating entities:  (1) Kaiser Foundation Hospitals and their subsidiaries;  (2) Kaiser Foundation Health Plan, Inc.; (3) The Permanente Medical Groups.
• 2010 Health Plan Membership, by Region:  Colorado: 526,258; Georgia: 222,074; Hawaii: 229,186; Mid-Atlantic States (VA, MD, DC): 488,171; Northern California: 3,263,619; Northwest (Oregon/Washington): 476,345;  Ohio: 122,342; Southern California: 3,341,646
• 2010 Medical facilities and physicians: 36 Hospitals; 533 Medical Offices; 15,853 Physicians;  167, 178 medical facility employees

MCOL.com has a new fresh look!

By Claire Thayer, February 16, 2011

Check out our new web site at mcol.com! Now it’s a whole lot easier to quickly find what you’re looking for!  Browse list of Topics and Offerings. View the What’s New section for upcoming webinar events along with e-learning and other announcements. Log-in to the MCOL member web site. Learn about advertising opportunities. And lots more! Take a peek today at www.mcol.com  and let us know what you think!!

Just Say No

By Kim Bellard, February 9, 2012

The recent flap over the recent Obama administration decision to not exempt religious organizations over rules requiring first dollar coverage of birth control leave me either bothered or bemused -- perhaps both. 

The controversy has very little to do with health policy and very much to do with the 2012 elections.  Moreover, it was entirely predictable, and it is amazing that the Administration walked right into what is becoming a big pie in its face.  However, the outrage that Catholic and some other religious leaders are expressing over being required to cover birth control in their health plans ignores one important fact.

It’s not their money.

Employers of all stripes see their health plans as a big expense and as something they have both a right and an obligation to try to manage prudently.  Acting as a prudent financial steward of the money, though, is not the same thing as imposing a particular religious belief.  In this case, the objection is, of course, that birth control is against their religious beliefs, and so should not be something they should pay for.  They’re not saying covering birth control is too expensive for their health plans or that it has adverse health consequences for people who use it.  They don’t even seem to care that the health consequences of not using it can be worse for some people.  They just don’t like it on moral grounds, and don’t want anyone using it.

The trouble is, the health plans are paid for by the employees’ money, not the employers’.  Employee benefits are part of employee compensation.  Employees have a decades-long implicit agreement with employers to receive a portion of their wages in benefits, mainly because they can receive that compensation on a tax-free basis.  But it is no more the employers’ money than, say, the money employees put into their 401k plans.

I wonder how people would be reacting if the religious organizations were saying that their employees couldn’t spend any portion of their own salaries on birth control.  I.e., they couldn’t take their wages and go off to buy birth control.  Not just that they shouldn’t, but that they couldn’t, presumably under threat of losing their job.  Would conservative politicians be rushing to support that kind of dictate?  I don’t think so, or at least I hope not.  People are pretty protective of their ability to spend their own money on the things they want.  So why should employee wages that have been retained by the employer on a pre-tax basis to finance a health plan for those employees not be able to buy medical services and supplies that employees want or need, as long as that spending was legal and medically appropriate – which birth control is.

Let’s try an equivalent thought experiment.  Let’s say the religion in question was Christian Science, and they decided that their “health plan” shouldn’t cover most hospital stays, physician visits, or prescription drugs.  Or a plan offered by an employer whose owner is a Jehovah’s Witness, and accordingly rules out covering blood transfusions in the health plan.  To make the experiment more equivalent, let’s be clear that their restrictions are not on plans offered by either church itself, but by organizations associated with those faiths and which employed many people who were of neither religion.  We probably would look askance at those faith-based exceptions, but would they actually be different in kind?

We could go a step further.  Maybe an employer isn’t satisfied just not covering abortion but also doesn’t want to include any health system or provider who provides birth control, and excludes them from their health plan network.  Maybe another employer doesn’t want any health care provider with any religious affiliation whatsoever, and excludes any such providers.  Or, to take an even more extreme example, maybe an employer doesn’t like the word “north” – for whatever reason -- and refuses to cover services by any provider with “north” in its name.   Where do we draw the line at where an employer’s idiosyncratic beliefs should be allowed to dictate its health plan rules?

One can oppose the birth control rule on other reasons more related to health policy.  You could argue, as I have and as John Cochrane did recently in the Wall Street Journal, that preventive services in general aren’t really insurance, and that covering them – particularly with no cost-sharing – is just dollar trading at best.  You could also argue – again, as I have previously done -- that the tax preference for employer-based coverage distorts the consumer market in health insurance, and inevitably invites the kind of employer tinkering with benefits that has led us to the current birth control mess.  You might also argue that birth control as preventive services stretches that term beyond its intended meaning – i.e., does it prevent disease or maintain health?  All of those are fair game for serious health policy discussions, but those are not what is driving this particular debate.

There are lots of reasons both to dislike the rule and lots of reasons to protest the protests about the rule, but it seems inevitable to me that politics will win the day and the Obama Administration will be forced to backtrack in some way.  And our crazy health system will be incrementally crazier as a result.

Managing and Increasing Trend of Elective Preterm Deliveries

By Claire Thayer, Febuary 6, 2012

MCOL’s Healthcare Web Summit announces Managing and Increasing Trend of Elective Preterm Deliveries, scheduled for Friday, February 24, 2012 at 1PM Eastern.   In the past two decades the United States has witnessed a substantial increase in the rate of elective deliveries preterm birth. Employers, health plans and Medicaid programs have become increasingly concerned, and stakeholders have created multifaceted strategies to reduce the number of early deliveries that don't have a medical justification. Join us to hear an expert panel discuss the problems surrounding elective preterm deliveries, and strategic approaches that stakeholders can consider adopting.

More information:http://www.healthwebsummit.com/pp022412.htm

Charity Care & Community Benefits: The New Paradigm

By Claire Thayer, Febuary 2, 2012

MCOL’s Healthcare Web Summit announces Charity Care & Community Benefits: The New Paradigm, scheduled for Thursday, February 16, 2012 at 1PM Eastern. Join Providence Health’s Ronald Sorensen, Huntington Memorial's Jane Haderlein and Michael Bilton from the AHA's Association for Community Health Improvement to discuss the changing environment and its long-term implications for hospital operations and healthcare delivery.

More information: http://www.healthwebsummit.com/pp021612.htm

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!

11th Annual Consumerism Web Summit 2012

By Claire Thayer, January 28, 2012

MCOL’s Healthcare Web Summit announces the 11th Annual Consumerism Web Summit 2012, scheduled for Thursday, March 15, 2012 at 1PM Eastern.  This year's event addresses consumer empowerment from multiple perspectives, and will provide attendees the intelligence to position themselves for 2012 and beyond. The event includes a featured 90 minute live webinar, three additional faculty pre-recorded sessions plus supplemental features addressing consumerism in 2012 and beyond.

More information: http://www.healthwebsummit.com/consumerism.htm

ACO Capitation 101: Understanding Medicare ACOs’ real potential to influence patterns of care

By Claire Thayer, January 26, 2012

MCOL’s Healthcare Web Summit announces ACO Capitation 101: Understanding Medicare ACOs’ real potential to influence patterns of care, scheduled for Wednesday, February 15, 2012 at 1PM Eastern.   As the pioneer ACOs gain experience with the various capitation models and if CMS incorporates capitation in the standard model, Medicare ACOs will gain a powerful tool to influence patterns of care through payment contracts and incentives. Hear from William A. MacBain, Senior Vice President of Gorman Health Group, on the steps CMS is taking to evaluate and potentially change capitation in Medicare ACOs.

More information: www.healthwebsummit.com/gorman021512.htm

Very Wired Meets Very Tired

By Laurie Gelb, January 24, 2012

We recently moved to a new city, so I set us up with docs at a Very Wired Hospital (we'll call it VWH) that boasts a fully integrated health system and enterprise EHR. My husband sees many specialists, so we've made several visits there already. I was excited that he would finally have a single record.

The yield to date on my attempt at integration: six paper vintage 1980's medical history forms and one woefully inadequate oral interview. One doc's explanation for the manilla madness was "It's for billing [so we can charge for appropriate complexity]." My contributions to these mostly took the form of "see attached" scribbles, referring to my own far superior pt summary sheet, tailored to each specialty...hm, why not specialty-specific intake forms? In the outcomes age, is that really so radical?

I did finally see a specialty-specific form from podiatry. It arrived via snail mail, barely in time-- "We can't use e-mail [to send the form] because it could be hacked." Somehow, though, sending us e-mails about billing detail is OK. It evidently hasn't occurred to VWH yet that PDF forms can be hosted on Web servers.

I could go on and on about VWH (the wall-to-wall paper at every elevator bank is staggering, the appointment and patient tracking process archaic, and yet its reputation allows stratospheric list pricing to plans), but let's focus on EMRs and payor initiatives. It's probably pretty evident that when its flagship providers lag in HIT, no network can realize optimal value from performance management.

BTW, the mail order debacle I wrote about a few months ago culminated in a pharmacy customer service e-mail asking my husband to reply to a general mailbox with his name, DOB, phone and all the incorrect rx he saw on his Web record. We politely declined, for obvious reasons. Somehow the duplication was resolved without this step.

Unfortunately, I very soon thereafter invested 2 weeks of calls in a routine refill that was repeatedly rejected [by the all-knowing, all-seeing adjudication app] for no reason that anyone at the plan, PBM, mail or retail pharmacy could pinpoint. Finally, I was put through to someone at the PBM who was able to determine that the latest PA had no refills appended instead of the 3 that it should have. Do you think that was put on anyone's future checklist? Let me know if the Easter Bunny stops by.

So how does a provider's EMR, however implemented, benefit payors? There could be lower processing costs secondary to more accessible documentation/claims denial support. The EMR should support health outcomes research, disease management, cost management, UR/QA, contracting...so many possibilities.

Many payor networks are building/upgrading their own data warehouses, and, increasingly, aggregating them with other networks.  Plans and providers are sharing via HIEs, pilot projects, academic research and more. In some geographies, public sector HIEs are being superseded by private efforts. Usability on the local level increasingly benefits from...wait for it...local oversight.

In any geography, though, we're drowning in a sea of input screens and datasets that don't reflect real people, workflow or medicine. Transaction and opportunity costs are soaring when you consider the dollars flying out the door due to long and no fixes for often undetected errors, like my husband's pharmacy döppelganger.

What can we control out of all this? Process! 2012 can be the year of common sense, when we give up tweaks to a patchwork, hands-off patient/member/customer flow in favor of [cliché alert] collaboration with those on the front lines (docs, nurses, physician extenders, call center reps, admitting reps, PBX operators and anyone with a finger on the flow) to image and set the break rather than cover it with a cast and good wishes.

Mystery-shop your PBM, clinics, DM vendors, hospitals, plans, call centers, anyone who touches those who pay your salary. Assign the same task to anyone who says, "There's just not that much we can do." If that doesn't work, a few uninterrupted call center hours just might do the trick. Rather than rearrange the deck chairs, as recent tragedy reminds us anew, some people just don't work out in their jobs.

Thought Leaders Thoughts on Readmissions

By Clive Riddle, January 20, 2012

Health Policy Publishing LLC this week launched its inaugural issue of Readmissions News, which is targeted at stakeholders interested in the management of hospital readmissions. One of the features of the new monthly newsletters is a Thought Leaders corner, and in this issue, experts were asked "Do you feel significant potential savings and improvements from further reductions in hospital readmissions can be achieved through the current set of public and private initiatives, or are expectations too high?"

Here are excerpts of what they had to say in response:

Randall Krakauer, MD, FACP, FACR; Aetna’s National Medical Director, Consumer Segment said in part “….The potential for impact has been demonstrated with several different programs under different conditions.  However, there is still a significant opportunity to broaden these efforts and create additional improvements in quality and savings.  Aetna has partnered with Dr. Mary Naylor at the University of Pennsylvania School of Nursing in developing and implementing a transitional care model that has resulted in improved quality and reduced costs for our Medicare Advantage members.  The demonstrated potential creates an imperative that public and private organizations work together to continue to expand these initiatives.  We should expect these types of programs to be as much a part of health care delivery as any other public health measure with demonstrated and accepted value.”

 Jeff Lemieux, AHIP’s Senior Vice President, Research, gave a response that included:  “The 20 percent reduction in readmission rates proposed in the Partnership for Patients Initiative sets an initial target for all stakeholders.  However, preliminary studies of variation in readmission rates across regions and plan types – and the measured success of certain transitional care programs – suggest that larger reductions may be possible.  We should aim for across-the-board improvements in all hospitals and for all patients, whether coverage is through public programs or employer sponsored insurance.  We should track progress on readmissions in the context of overall hospitalization rates….”

William J DeMarco, MA, CMC, President & CEO, Pendulum Healthcare Development Corporation, included in his response:  “…Hospitals that dropped their home health agencies need to rethink how they can realign the existing home health system or expand their own to take the pressure off of doctors by having these agencies step in with skilled nursing and custodial care.  This may include cross training people to come to the aid of those with chronic conditions early instead of having these patients filling the ER.  Several HMOs and some hospitals are building ‘navigator’ programs to attract and train people who are not professional RNs or LPNs but can be trained to watch for signs of a chronic care patient losing their way on the path to improved health status….”

Brian Jack MD, Professor and Vice Chair, Department of Family Medicine, Boston University School of Medicine / Boston Medical Center;  concluded his remarks with:  “….A variety of implementation demonstrations for hospital based transition programs such as RED, BOOST, STARR, and H2H are gaining momentum and allowing researchers to study what works and what does not.  Across the country there is now a long list ‘early adopter’ hospitals that have demonstrated remarkable reductions in readmission rates.  All this effort is forcing hospitals and communities to work together as partners, a necessary ingredient for successful ACOs.  However, safe readmission reduction can only happen if hospitals have well developed community-based partners, particularly primary care partners, willing and able to care for patients in the community.  We need to ensure that this primary care safety net is available for patients.”

Alexander Domaszewicz, Principal, Mercer, concluded  “…. real, sustainable improvements that don't require constant oversight, monitoring, and effort will likely take a shift in marketplace practices driven by payment practices. HHS not paying for readmissions caused by ‘never events’ and guarantees like Geisinger's pledge to not charge for readmissions after heart surgery within ninety days are key examples of how to get every facility and practitioner keenly focused on eliminating readmissions.”

Benjamin Isgur, Director, PricewaterhouseCoopers LLP's Health Research Institute, continued his discussion, asking  “….How responsible should hospitals be when community doctors or patients fail to follow discharge instructions?  Can hospitals realistically cut readmissions when so much is out of their control?  However, it is possible to reduce preventable readmissions if hospitals address three major issues: discharge planning, length of stay, and closer alignment to physicians.  All of these issues relate to focusing on the total health of a patient instead of performing a procedure. ….”

Peter Kongstvedt, MD, FACP, Principal, P.R. Kongstvedt Co., LLC , opened his reply with “We’re going to see modest improvements at best until we address the lack of coordination and follow up in both the transition from inpatient to outpatient and coordinated outpatient management of patients with multiple chronic diseases. Many of the approaches to managing patients with multiple complex diseases are able to demonstrate improvements in quality, but few demonstrate improvements in overall costs.  The exception is nurse-led teams involving multiple clinical disciplines and access to physician support…..”

Finally, Martin S. Kohn, MD, MS, FACEP, FACPE, Chief Medical Scientist, Care Delivery Systems

IBM Research;   concluded his remarks by saying  “….Many organizations have substantially reduced re-admissions using current technology. The greater challenge will be reducing all admissions, over longer periods for more patients.  A patient will not view a re-admission on the 31st day differently from an admission on the 29th day.   Keeping more patients safely out of the hospital will require enhanced population and predictive analytics to personalize the prevention programs to make them economically efficient with improved outcomes.”

A complimentary copy of the inaugural issue of Readmissions News can be obtained by visiting http://www.readmissionsnews.com/sample_issue.php

The Confusion in Coverage

By Kim Bellard, January 11, 2012

The more I think about our health care system, the crazier it seems. 

Let’s do a thought experiment.  You’re in an accident, and have an orthopedic surgeon fix some broken bones.  You are fortunate enough to be employed and to have health insurance from your employer, so certainly your health insurance will pay the bills, right? 

Not so fast.  Maybe the accident was work-related, in which case your workers compensation would apply.  Maybe the accident was in your car, in which case your or another driver’s auto insurance might pay.  Or maybe you fell at your neighbor’s house, in which case their homeowner’s policy might come into play.  Which type of coverage pays, how much they pay to the providers, how much you’ll have to pay, even which orthopedic surgeon you can see -- all depend on the circumstances.  One has to wonder if your eventual outcome is subject to the same lottery.

Perhaps that’s too problematic an example.  Let’s take what should be an easier example.  You get all of the recommended preventive exams.  It should be clear that those are covered by your health insurance, especially now that PPACA has specified that health plans have to cover preventive services at 100%.  Except that it doesn’t, not quite.  E.g., your preventative dental exams or vision exams aren’t covered by your health insurance.  If you are lucky, you might have dental and vision insurance that covers those exams.  Otherwise, you’re out of pocket for following the guidelines.

Adding insult to injury, if you need, say, oral surgery, you’ll probably have to figure out whether your dental or your medical insurance covers it.  Again, how much it pays, how much you pay, and which physicians you can go to depend on the answer. 

What a mess.  Then throw in the inter-insurer squabbling and coordination between the different types of insurance in situations that are overlapping or borderline.  All that adds to the costs for both payers and providers, and the frustration from consumers, providers, and payors. 

The costs of these other types of health-related insurance are not trivial.  According to the Bureau of Labor Statistics, costs for workers compensation is about 20% of health insurance costs, and about half of those workers compensation costs are for the medical component (as opposed to the disability).  The most recent National Health Expenditures (NHE) report showed “other third party payers” – which include workers compensation and a variety of other payers -- accounting for about $450 billion in 2011, almost 17% of total spending.  It’s significant.

It’s not that these other services are unimportant.  There’s a growing body of evidence linking oral health to other health conditions, highlighting the need for regular dental exams.  Vision exams are critical for spotting glaucoma or cataracts.  So why do we treat eyes and teeth differently than, say, feet or ears?  Why is periodontal disease somehow less important – often covered at only 50% in dental coverage – than diabetes, which is often correlated by gum problems?

A lot of this is due to historical accidents, if you will.  Employer-based health coverage got a big boost from the tax preference that avoided wage controls.  Medicare Parts A and B are structured to reflect then-typical Blue Cross Blue Shield plans in the 1960’s.  Medicare has struggled to evolve its design, growing ever-more complicated and adding Part D, but ending up with most recipients still adding a supplement to make coverage more comprehensive (unless the recipient chooses a more modern plan design via Medicare Advantage).  Both Medicare and employer coverage initially focused on a very medically-oriented, institutionally-based approach; both have broadened over the decades, but neither has truly revamped its approach, although the introduction of HMOs has helped force both types of coverage to include more preventive coverage. 

Medicaid does a better job than most other payers in covering a broad range of services, but actual benefits vary widely state to state and often coverage is more broad than deep (e.g., limits on hospital days or physician visits), and it requires an army of bureaucrats to determine who is eligible on any particular day.  Then we’ve got CHIP, VA, CHAMPUS, Indian Health Services and so on – each program no doubt well-intentioned but adding to the complexity of the system.  Our health system is a veritable zoo of different versions of health insurance.

The boldest thinkers at the federal level these days seem to be Senator Wyden and Representative Ryan, with their recent proposal to reform Medicare and small business coverage.  It certainly is a dramatic change from today’s programs, but I’d really like to see us take a step back and think more deeply about what “health” is, how “insurance” can support that health, and how we ensure that all Americans – regardless of age, income level, or health status have access to both health services and the redesigned health coverage. 

E.g., we certainly want employers to have safe workplace conditions, but is it necessary to have a separate medical component to incent that, or does the disability portion, along with some liability consequences, accomplish that?  I’m not talking about the so-called “24 hour” coverage that combines health coverage and workers compensation.  This has been attempted several times, none of which have, to my knowledge, been particularly successful – in no small part because each component still had to follow the specific laws and regulations that apply to the component.  That makes true integration difficult.  I’m talking about truly engineering what health insurance is, what it should cover, and how it should pay.  Rethinking what health insurance should include would be a hard task, fraught with the prospect of undue influence from various lobbying organizations, but it’s one I wish we had leaders bold enough to attempt.

I suspect few, if any, Americans fully understand the details of the various health programs they may be covered by, much less be able to have great confidence that they can truly compare choices in them.  I’m all for competition and variation, but not in the “fine print” – the definitions, exclusions, and covered benefits.  It would greatly enhance competition to truly have a uniform structure, and it would help us accomplish modern health goals if that structure was more broadly designed.  Doing so should force us to realize that some things should be paid for via insurance and others should not. 

Sadly, even the Obama Administration seems to be backing off of the PPACA requirement for common essential benefits, in their recent decision about plans offered through the forthcoming exchanges.  They are bending to calls for state flexibility by allowing state decisions on the essential benefits, within specified parameters, but the rules don’t bode well for someone who, say, lives in one state but works in another, or someone who moves between states.  They could see very different benefits based on through which exchange they get their coverage.

Some might read the above and misread me to be advocating an all-encompassing single payor system.  Nothing could be further from the truth.  I’m hard pressed to think of any monolithic program, government or otherwise, that offers the kind of innovation and choice Americans value.  I am advocating drastically new product designs that break the existing artificial barriers to protecting and enhancing good health.  If this requires changing the applicable laws and regulations – and it would – then so be it.

Winston Churchill once famous said: “Americans can always be counted on to do the right thing…after they have exhausted all the other possibilities.”  I just wish we didn’t have to go through so many other possibilities before we decide to fundamentally rearchitect not just who finances coverage but also what “coverage” should look like.

How Much is Too Much? Hospital C-Suite Compensation

By Claire Thayer, January 9, 2012

MCOL’s Healthcare Web Summit announces How Much is Too Much? Hospital C-Suite Compensation, scheduled for Friday, January 20 from 10:00AM – 11:00AM Pacific . The mission of a not-for-profit hospital or healthcare system is fairly clear: Heal the region’s patients and provide benefit to the community. Yet hospital boards find themselves under increasing pressure to offer generous compensation packages in order to attract and retain the executives who can keep their organizations out of financial distress and help them prosper in a challenging reimbursement environment. This webinar features persons knowledgeable on healthcare compensation trends.

More information: www.healthwebsummit.com/pp012012.htm

Health Care Data Predictions for 2012

By Clive Riddle, January 6, 2012

The Ponemon Institute just released this list of top 2012 predictions in healthcare data, that they edited from various health care data thought leaders:

1. Healthcare organizations will not be immune to data breach risks caused by the spread of mobile devices in the workforce, according to Dr. Larry Ponemon, chairman and founder, Ponemon Institute. In the recent benchmark study, 81 percent of healthcare providers say they use mobile devices to collect, store, and/or transmit some form of PHI. However 49 percent of those admit they are not taking steps to secure their mobile devices.
   
   
2. Class-action litigation firestorms are imminent, says Kirk Nahra, partner, Wiley Rein LLP. Class-action lawsuits will be on the rise in 2012, as patients are suing healthcare organizations for failing to protect their PHI. 2011 saw several class-action lawsuits for organizations, some of which involved business associates, due to breached patient data. Regardless of the outcomes, these lawsuits are a significant risk and tremendous expense for companies affected by them.
   
   
3. Social media risks in healthcare will grow, according to Chris Apgar, CEO and president, Apgar & Associates, LLC. As more physicians and healthcare organizations move to social media to communicate with patients and promote services, the misuse of social media will increase as will the risk of exposure of PHI. Often healthcare organizations do not develop a social media use plan and employees represent a significant risk, potentially exposing PHI through their own personal social network pages. These risks can lead to patient vulnerabilities, data breaches, civil penalties, loss of business and more.
   
   
4. Cloud computing is not a panacea; technology is outpacing security and creating unprecedented liability risks, suggests James C. Pyles, principal, Powers Pyles Sutter & Verville PC. With fewer resources, cloud computing is an attractive option for healthcare providers, especially as Health Information Exchanges (HIE) increase. However, privacy and legal issues abound, such as compliance with HIPAA privacy and security regulations and allocation of liability when a privacy breach occurs. A covered entity will need to enter into a carefully written business associate agreement with a cloud computing vendor before disclosing protected health information and should ensure that it has adequate cybersecurity insurance to cover the direct and indirect costs of a breach.
   
   
5. Growing reliance on business associates will create new risks, believes Larry Walker, president of The Walker Company. Economic realities will force healthcare providers to continue to outsource many of their functions, such as billing, to third parties or business associates (BA). However, BAs are considered the "weak link in the chain," when it comes to data privacy and security. 69 percent of organizations that participated in the Ponemon study have little or no confidence in their business associates' ability to secure patient data. Third-party mistakes account for 46 percent of data breaches reported in the study.
   
   
6. Organizations risk reputation fallout, according to Rick Kam, president and co-founder of ID Experts and chair of the American National Standard Institute's (ANSI) "PHI Project," a project to research the financial impact of a healthcare data breach. Identity theft and medical identity theft resulting from data breach exposure are causing patients financial and emotional harm, often resulting in patients seeking out different medical providers. According to the Ponemon study, the average lifetime value of one patient is more than $113,000.
   
   
7. Mobile will explode in healthcare, believes Christina Thielst, health administration consultant and blogger. The use of tablets, smartphones and tablet applications in healthcare is growing exponentially. Nearly one-third of healthcare providers use mobile devices to access Electronic Medical Records or Electronic Health Records (EMR/EHR) systems, according to a CompTIA study. Providers will need to balance usability, preferences, security and budgetary concerns, as well as adopt written terms of use with employees and contractors using personal devices at work.
   
   
8. Increased emphasis on willful neglect leads to increased enforcement of HIPAA, according to Adam Greene, partner, Davis, Wright, Tremaine LLP. The focus over the next year will be on the 150 HITECH Act audits and publication of the final rules implementing modifications to the HIPAA regulations. But the biggest changes may be at the OCR investigative level. Expect OCR to more aggressively pursue enforcement against noncompliance due to "willful neglect" starting in 2012, resulting in a sharp uptake in financial settlements and fines in the coming years. 2012 will be the year that OCR expects everyone's training wheels to have come off their privacy and security programs.
   
   
9. Privacy and security training will be an annual requirement, says Peter Cizik, co-founder and CEO, BridgeFront. Healthcare organizations have gotten better at putting procedures in place, but staff are still not following them. Because the majority of breaches are caused by human error, not technology failures, targeted training and awareness programs are one of the most effective ways to prevent data breaches.
   
   
10. Rise in fraudsters will increase fraud risk education, according to Jonnie Massey, supervisor, Special Investigations Unit, Oregon Dental Service (ODS) Companies. Pressure, opportunity and rationalization: these three dangerous elements of the triangle can lead to committing a healthcare-related crime. During hard economic times, there are more fraudsters and more opportunities for them to gain or keep a healthcare benefit they are not entitled to. Educating those at risk for fraud and communicating consequences may deter someone from stepping over the line or help those at risk to prevent them from being a victim of healthcare fraud.
    
    
11. Healthcare organizations will turn to cyber liability insurance, according to Christine Marciano, president, Cyber Data Risk Managers LLC. As healthcare organizations continue to implement their EHR systems, they will consider options to protect themselves and their patients. When a healthcare organization or other HIPAA covered entity suffers a data breach the cost can be damaging not only to an entity's bottom line, but also to the reputation of its brand. With the increased vulnerabilities and as part of a data breach response plan, healthcare organizations will increasingly turn to a cyber security/data breach insurance policy

Medicare initiatives towards accountable care: Aetna’s Provider Collaboration Programs

 By Claire Thayer, December 22, 2011

MCOL’s Healthcare Web Summit announces Moving Towards Accountable Care: Aetna’s Medicare Provider Collaboration Program, scheduled for Thursday, February 23rd from 1:00 PM to 2:00PM Eastern.  As groups throughout the health care system work to develop Accountable Care Organizations, Aetna recently announced results of collaborative relationships with several medical groups in working together to accomplish two of the main goals of ACOs through the Aetna Medicare Provider Collaboration program – improving quality of care and lowering health care costs. Join Doctor Krakauer on Thursday February 23rd, 2012 at 1PM Eastern as he reviews detailed aspects and results of Aetna's Medicare Provider Collaboration program.

More information:  http://www.healthwebsummit.com/aetna022312.htm

Good News -- Bad News

By Kim Bellard, December 19, 2011

Reading several recent news stories, I’m reminded of an old joke.  A man gets a call from his doctor, who informs him he’s got the results of some tests.  The doctor tells the man there is some good news and some bad news, and asks the man which he’d like to hear first.  The man is taken aback, but – optimist that he is – asks for the good news first.  The doctor dutifully informs the man he only has 24 hours to live.  The man is stunned.  “That’s the good news?” he asks incredulously.  “What the hell is the bad news?”   Rather sheepishly, the doctor informs him, “I was supposed to call you yesterday.” 

(Slight pause here for polite laughter).   

Let’s see how this good news/bad news works in the real world.  Take, for example, a recently released a report by Float – a mobile learning consulting company – on the increasing use of mobile technology in health care.  According to their research, 80% of U.S. physicians already use smartphones and mobile apps, and over half report either already having an iPad or planning to get one in the next six months.  They cite a number of uses for mobile technology in health care, which they expect to increase rapidly. 

That’s the good news.  I’m a huge supporter of more use of technology in health care, especially mobile.  It’s great that it is becoming more mainstream.  However, it is not an unalloyed boon.  The corresponding bad news was discussed in recent reporting by The New York Times on “distracted doctoring.”  They quote Dr. Peter Papadakos, who has published an article on “electronic distraction” in Anesthesiology News, as saying, “You walk around the hospital, and what you see is not funny…My gut feeling is that lives are in danger.”  Dr. Papadokos sees medical personnel on phones, surfing the Internet, and especially on Facebook.  The Times cites another study that indicates over half of technicians who monitor bypass machines were texting or even talking during surgery, even though most acknowledged it was unsafe behavior.  The Times even found situations where surgeons were reportedly making personal phone calls during surgery, using wireless headsets.  Scary stuff. 

It’s much like texting while driving.  We know it’s not safe, we criticize other drivers we see doing it, but we’re so used to the connectivity that the technology allows that we have a hard time drawing appropriate boundaries for ourselves.  Perhaps health care needs a NTSB to warn us when we really shouldn’t be using mobile devices.   

Another good news/bad news example is a recent study by GfK Custom Research North America about the projected impact of ACA on employer health coverage.  The news reports focused on the “good” news – that the majority (56%) of employers said they are likely to continue offering coverage.  "This survey suggests that firms aren’t considering a wholesale flight from employee health care coverage as health care reform is implemented,” said Tim Nanneman, Vice President and Director of Health Insurance Research for GfK, who also added, “However, many employers are skeptical about the potential effects of health care reform.”   

Indeed, the bad news from the study was that 12% of employers already expected to drop coverage, with another third not sure what they will do.  To make things worse, slightly more than half of employers expected their costs to rise because of ACA, with only 11% under their impression their costs would go up more slowly. 

When McKinsey estimated 30% of employers would drop their coverage once the exchanges were operational, they were excoriated by the Administration and other ACA supporters.  There were some flaws in the McKinsey methodology that left it somewhat open for the criticism, yet I’m surprised that a study showing barely half of employers expect to continue coverage hardly rates a mention, or is reported as good news.   I find GfK’s results deeply troubling – although not surprising. 

Speaking of costs increasing under ACA, the final piece of good news/bad news was the recent announcement by HHS that more young adults got coverage due to ACA provisions than expected – some 2.5 million in total.  Earlier estimates had shown one million newly covered, so the Administration took some pride in this even higher estimate.   

Everything being equal, of course, getting 2.5 million more people covered is good news.   The reality, though, is that everything else isn’t equal.  The bad news is that there is a cost to this good effect.  I read the HHS press release carefully, as well as the news accounts of it, and I didn’t see mention of the cost of those additional 2.5 covered young adults.  I previously blogged on the cost of ACA’s already implemented provisions, but the thing to remember is that this expansion is a tax on employment-based insurance.   By which, of course, I mean it is compensation taken from workers’ paychecks.  That’s the bad news.  For workers with single coverage, or who have families which do not include young adults, I might be wondering why I am paying for these young adults’ coverage.   

It never made much sense to me for this provision to be Rube Goldberg-ed onto our already jury-rigged employer-based system, making employers cover not only people who are not only not employees but who also are not even dependents of workers.  But it was politically expedient to do so and hid the costs.  The Administration is kind of in a bind: either this population doesn’t cost very much, in which case the 2.5 million perhaps isn’t worth crowing about, or the costs are substantial, in which case it should be more honest about them and who is bearing those costs.  I do think we’re talking billions of dollars annually.   When HHS starts reviewing health insurance price increases, it should remember its own complicity in at least some part of those increases.  It won’t, of course. 

There are lots of calls for transparency in health care, but we need to remember this shouldn’t just be about reporting the numbers.  The truth is rarely one-sided – something hard to remember in this hyper-partisan era – and we all should look at both sides of issues.  While I’ve been writing this blog, Reps. Wyden and Ryan have come out with their Medicare proposal, and Secretary Sebelius announced the flexibility that states will get in developing essential benefits packages…now I need to go take a look at the good and bad of each of those!

Unhappy Campers: Physicians and Health Reform

By Clive Riddle, December 15, 2011

The Deloitte Center for Health Solutions released their latest study this week: Physician perspectives about health care reform and the future of the medical profession.

Paul Keckley, Ph.D., the Center's Executive Director tells us "the data confirms that physicians are resistant to reform and are frustrated with the direction of the profession. Understanding the view of the physician is fundamental to any attempt to change the health care model – this is the person prescribing the medicine, ordering the test and performing the surgery."

While Deloitte concludes physicians are not happy campers in this respect, it should be noted their positions are not that different than many other stakeholder groups.

Their findings are based on a survey commissioned by Deloitte of 501 physicians obtained as a random sample from the AMA database, with responses weighted by years in practice according to gender, region and practice specialty to match AMA demographics.

The 40 page report paints the following picture:

• Physicians gave the U.S. health system a grade as follows: A - 8%; B 27%; C - 45%; D 15% and F - 5%. Older physicians rates the system higher (40% over age 60 gave an A or B grade compared to 29% for under age 39.) Midwestern physicians also rated the system higher (44% gave an A or B; compared to 29% in the Northeast.)

• 71% say they are somewhat informed about the Affordable care Act while 23% say they are very informed

• 44% feel the Act is a good start, 44% feel it is a step in the wrong direction; and 12% don't know

• "Consumer behavior such as unhealthy lifestyles that can lead to obesity" was the most often cited factor influencing overall health care costs (multiple answers allowed - with 94% citing this factor) followed by "defensive medicine" (91%) and "Insurance company administrative costs" (89%)

• "Increased government managed care programs for Medicare and Medicaid" was the most often cited expected result of the Act (multiple answers allowed with 85% citing this result) followed by "Increased "wait times for primary care appointments due to lack of providers" (83%) and "fewer uninsured (77%)

• 73% believe there is a high likelihood ERs could be overwhelmed if PCP visit slots are full due to changes in the health care reform law

• 13% of physicians felt very engaged in the health reform debate and 44% felt somewhat engaged

• 78% of physicians say they would be comfortable if the model for liability reform involved a separate medical court system with binding arbitration and victims’ fund

• 4% believe their income will increase next year as a result of health reform; 48% believe their income will decrease

• "An administrative role (i.e., Chief Medical Officer, Chief Executive Officer, etc.) in a large health care delivery system" was cited most often as the ideal practice setting (multiple answers allowed with 70% citing this setting) followed by "concierge medicine practice that does not take insurance" (64%) and "large integrated health system that owns its own health insurance plan, hospitals and medical practices" (60&). The settings at the bottom of the list were employer based clinics (19%) and retail clinics (21%).