NY and Physician Ranking: Let the Games Begin

October 30, 2007 at 1:50 am · Filed under Uncategorized

Given my recent post on the legal challenges that may await health plans that tie compensation to quality indicators, I forgot to mention one of the big ones as exemplified in the story summarized below. It seems that the New York Attorney General is now in the business of ranking physicians.

In the past few months, New York’s attorney general’s office has requested information from several health insurers, including Cigna, Aetna Inc. and UnitedHealth Group Inc., about how they rank doctors under their programs. Mr. Cuomo’s office has expressed concern that the programs carry “significant risk of causing consumer confusion, if not deception.” . . . His office had sent letters to Cigna, Aetna, UnitedHealth, Empire Blue Cross Blue Shield and other health plans asking them to justify their methodologies and warning some not to launch the programs in New York without approval. . .

He later announced a first-of-its-kind agreement with Cigna Corp. that he says may help to establish an industry standard for the doctor-rating systems that health insurers increasingly use to guide consumers.

Medical groups and regulators in some states say that many of these programs are confusing and may steer patients to the cheapest, rather than best, doctors. Already the practice has sparked a lawsuit by some Connecticut doctors asking a state Superior Court judge to halt UnitedHealth’s and Cigna’s rating systems, citing breach of contract and unfair trade practices, among other things.

So let the political games begin.

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Health Is a Continuous Variable

October 26, 2007 at 9:31 am · Filed under Employer CEOs, Disease Management, Business of Health, Employee Health Management, Health Management

In most cases, sickness is a discrete variable, that is, people are either sick or not sick, and the purpose of sickness care is to return patients to the non-sick state, otherwise, they are not “cured”. With chronic illness, patients are not cured at all, merely “controlled”, by some combination of their own and their providers’ efforts. In other cases, such as severe trauma and catastrophic disease, patients are not cured, but “rehabilitated” to as high a level of normal, non-sick functioning as is possible given their condition.

The point is that in most cases, patients can be described as in one of two possible discrete states: sick or cured, perhaps controlled or rehabilitated. This does not mean that no further effort is required to maintain their non-sick state, or to prevent recurrences, crises, complications or worsening of their status, but when these occur, they will again be labeled as sick, and as “patients” rather than “people”.

In health management (HM) — of individuals, populations, employees, insured plan members or government plan beneficiaries, the targets for effort and attention, as well as the source of HM’s economic benefit, relate not to moving people from sick to nonstick, but along a continuum that ranges from perfectly healthy to having some risk behaviors or conditions of concern to having a somewhat controlled chronic condition. As long as HM participants are non-sick with some acute problem, crisis or complication, they are still not patients.

Providers may deem them patients, of course, as long as they are on the books as a member of a physician’s panel, for example. But from the perspective of HM providers, including physicians, of course, and of employers, insurers, and government agencies, they are people, who may also be participants in some particular HM program or special initiative. And while they are participants, as well as because they are, such people may be moving along the continuous dimension that runs from perfect health to death, or at least to sickness. This makes their health a continuous variable.

The significance of this in HM is that people may respond to HM interventions in any way from not at all to minimally, modestly, significantly, dramatically, etc. as high as it is possible to do so. Their response, in terms of participating in coaching sessions, monitoring their conditions, changing their behaviors and lifestyles, complying with medications, etc. will also fall somewhere on a similar continuum. And as a result of their responses, their health status will usually progress in the positive direction along a wide range of continuous dimensions, such as weight, blood pressure, sugar or cholesterol levels, bone density, etc.

And as a consequence of this positive health status change, participants will deliver benefit to HM sponsors, as well as to their own health/life quality, along yet another set of continuums. The immediate consequences along the sponsor “benefit” continuum may involve reduced sickness care use and expense, for commercial and government insurers, as well as employers. For employers in particular, they may also involve reduced disability and workers compensation costs, absenteeism and presenteeism. For the least myopic employers, consequences may also include improved retention, quality, customer satisfaction, market share and revenue, as well as profits, also continuous variables.

When the effects of HM investments are continuous variables, it is usually impossible to say that any particular HM participant has “succeeded”, since this requires a discrete distinction between successful and unsuccessful participants. HM providers or sponsors may select some arbitrary (but usually not capricious) point along the continuums of response and deem that sufficient to call it a “success”, but this does not mean that participants who made progress short of success did not deliver any benefit. In fact, it will often be the case that a participant who started of at a lower level of the continuum of behaviors or conditions but makes a dramatic improvement short of success will yield far greater benefit than another who was only a bit short of the success level to begin with and improved only to that level.

So while we can talk about and measure “success rates” for purposes of counting successes, and perhaps paying success incentives, we should not ignore that there may be a continuous degree of positive change and benefit across almost all participants, perhaps even every one of them. Even participants who do nothing more than take the health risk assessment (HRA) or screenings and get action-oriented feedback, may well improve along some health dimension and as a result deliver some benefit, despite never participating in a particular HM initiative. Similarly, others may participate actively, alter their lifestyles, improve their health, etc. but not deliver any measurable benefit to the sponsor.

For these reasons, rather than concentrate on the success rate, i.e. some percentage of participants who achieve some arbitrary point on a given continuum, the most accurate way to describe the results of an HM intervention and overall program is to calculate the average benefit delivered by everyone who can be counted as having participated at all. Separate calculations can be made for those who did no more than take the HRA or screening tests vs. those who participated but did not complete the initiative vs. those who completed, etc. in order to track how much each degree of participation added to the average benefit. But the total value of the HM initiative or program should reflect the total benefit across everyone who participated in some meaningful way.

If there are no added costs for participation, per se, e.g. if the HM provider charges on a per population basis, and the sponsor does not offer incentives that have to be paid to participants, it will make no difference how many there are in terms of the costs to sponsors, though it may add to costs for providers. But when there are costs or charges incurred specifically for participants, the evaluation of results should probably differentiate degree of participation, to see if those who merely take an HRA, or participate for a few weeks deliver enough benefit to justify the costs. If not, then further investments in persuading or offering incentives for those who complete or make some defined amount of change may be needed to achieve an optimal result.

Fortunately, there is always available, though often difficult to implement, a simple “solution” that will automatically take care of most problems related to the fact that HM deals in continuous variables. If the employer adopts a pay-for-performance system for compensating employees, all those so compensated will automatically have their health and productivity/performance levels measured, and rewarded as they improve. If such improvements are due to health improvements, this should show up in the analysis of both how much participants have improved their health in order to achieve better performance. But as long as the productivity/performance dollar value of changes made by employees is measured and rewarded, the employer will be able to determine immediately whether investments have paid off.

Of course, P4P systems usually add to employers’ costs, whether or not they are tied to HM interventions. But they rarely increase costs as much as they increase the value that employers gain. For example, when a windshield repair firm switched to P4P vs. hourly wages, it found productivity increased by 44% in the first year of the new system, while overall employee compensation increased by only 10%. Employers have always known how to ensure that the firm gains an adequate if not lion’s share of any increased value that employees deliver. And employees have usually been satisfied with a fair share.

While it serves some internal measurement, planning and evaluation purposes to identify discrete points along the continuums that reflect HM results, it is the average of the continuous benefit dimension for sponsors, and the individual personal benefit for each participant that ultimately makes the most difference. Both the average sponsor benefit and the individual participant benefits should be the dominant focus of HM planning, management, and evaluation, reflecting the underlying continuous variables that represent the reality of HM effects. A few discrete “fictions” may be useful, but the continuous nature of HM’s effects should always be recognized and reflected in its use.

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Cardiology Risk Factors

October 23, 2007 at 7:45 pm · Filed under Policy Makers, Prevention and Health Promotion, Disease Management, Population health management

Let me open this blog with a disclaimer. It is not meant to be a criticism of freedom of choice or belief. It is merely an observation of a reality. What has caused this reality may in fact have been the phenomenal pressures applied across the world by the marketing machines of our internationally based tobacco and alcohol companies, or it may be that those present have determined that it is better to live life at its fullest for as long as we have, enjoy every bite of the apple, and deal with the reality of transition when the time presents itself.

My last four days were spent at a world conference on cardiology where the work done by our research institute’s cardiac team on the impact of behavioral modification on this disease was our presented topic. Our research revolves around diet, exercise, stress management and group support, and the results observed from our patients have been nothing less than remarkable.

It is fair to say, however, that, upon observing the actions and choices of those present my heart sank. The secret of life appeared to be firmly seated in the minds of at least 40 percent of those in attendance that tobacco, alcohol, heavy fats and little exercise are the keys to happiness.

Don’t get me wrong, it was a wonderful event where my international neighbors treated us with respect and courtesy throughout the four days of the conference, but getting in and out of each session without walking through a blue cloud of smoke, without ingesting blocks of high fat foods and free from huge quantities of alcohol consumption would have been only a dream for most.

The lounge areas of the conference were filled with cigarette stoking physicians, pharmaceutical and medical supply representatives and staff. The dinners all included well used ashtrays, plenty of cocktails and the X files list of banned foods. As a vegetarian, it was almost impossible to get through even the opening courses of a meal without unbelievable scrutiny as to my personal sanity.

That being said, the content of their presentations were as clear at this international conference as they are anywhere, i.e., the following things are very bad for heart disease: high fat foods, stress, cigarette smoking, lack of exercise and, of course, poor genes.

What then is the problem? Denial? The high pressure life styles of these life saving physicians, cultural considerations, a laissez faire attitude toward the Boogie Man or just another version of man’s on going stupidity and ignorance toward what appears to be very clear evidence?

Maybe cardiologist know something that the rest of us don’t know. Maybe they know that life is finite, that health is finite, that, like the saying I once saw on a tee shirt being distributed by a cemetery: Eat right, exercise, manage your stress and you’re still going to die.

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The Need for Leadership in Health Management

October 23, 2007 at 7:42 pm · Filed under Insurance, Employer CEOs, Employee Health Management, Health Management

When I began my career in teaching and writing about healthcare marketing, I confess to “borrowing” from other service marketing concepts and applications, until I had enough experience of doing it, myself, to apply personal learning to these efforts. Having been educated in a school of public health, I had no exposure to marketing in my university-based education, though I had plenty in my early career in the marketing division of Michigan Blue Cross.

By the time I got my first executive position in healthcare strategy and marketing, I was teaching and applying marketing as the alternative to management in efforts to get people to do what the organization wanted. This definition was particularly applicable to healthcare, where “patient management” was already the norm, but for physicians, who saw themselves as expert authorities on what patients should do, writing prescriptions and orders covering how patients should respond to physicians. Understandably, the idea of “marketing” to them was a startling and unwelcome suggestion.

This definition also helped with applying early healthcare marketing to healthcare organizations’ (primarily hospitals’) employees and medical staff. While management was the norm when dealing with employees, it was recognized even in the 1970s that employees had to be “acquired” and “retained”, just as customers do. And physicians were even then recognized as the key “customers” for hospitals, nursing homes, home health agencies, etc.

I recently ran across the definition of “leadership” by former US President Dwight D. Eisenhower: “The art of getting someone else to do something you want done because he wants to do it.” (“Smart Quote” AHIP Solutions SmartBrief, Oct 22, 2007] This is essentially the same definition that I had used for marketing, except that “leadership” depends on the individual or group that is the source of whatever means rely on this approach, rather than the usual techniques of marketing.

The theory of leadership that seems to govern most books and articles on the subject is that “true leaders” have to have some combination of charisma, the right mix of mission and values, a sense of the values, wants and needs of those to be led. Add to this the leader’s ability and willingness to “lead from the front” by living out those values so others will be attracted and satisfied with the idea and experience of being led, and you get the right combination of leaders and led.

Like marketers, a leader without the willing led is akin to a marketer without a customer. But clearly, there is room for both marketing and leadership when it comes to health management (HM), particularly employee health management (EHM), where employees have leaders. One of the challenges that makes commercial or government insurance plans’ HM efforts so difficult in terms of achieving demonstrable ROI is the fact that people are not quite ready to be led by their insurance plan or the federal government.

But all prospects and participants in HM are potential customers for marketing efforts aimed at engaging them in particular programs, and getting them to adopt the patterns of behavior relative to their own health that will achieve results desired by payors. The usual form of “leadership” by a recognized and respected individual or group may be absent, but the idea of participants doing something that payors want because the participants want to do it is at least as valid. And marketing, to my mind, at least, is the natural approach to achieving the “conversion” of participants — from hesitant, even unwilling to “adhere” to healthy behavior, to enthusiastic/eager/early adopters and persisters in such behavior.

All the tricks of modern marketers, from “viral” and “buzz” marketing, where peers are enlisted as volunteer or paid “ambassadors” inviting and supporting participants – to tracking and reminding HM participants of what they have accomplished for themselves and for the payor – can be useful in a combination of leadership and marketing. While the labels for HM and EHM both employ the term “management”, it is unlikely that traditional management efforts will work well in either.

While employers can offer incentives and rewards to get employees to participate, and insurers can do the same, these are of limited success and duration in achieving lasting commitments and behavior change, even though rewards and punishments are traditional tools for managers. The problems with both include the fact that they cost money, not just the costs of incentives paid, but the communications used to educate, remind, and otherwise entice people to participate, change, and succeed in improving or protecting their own health.

The art of getting others to want to do something that payors want them to do is likely to require a combination of leadership (for employees at least) and marketing, rather than relying solely on management models. While the term “management” no doubt appeals greatly to the managers who have to be sold on the idea and provide financial as well as other support to HM efforts, it does not appeal nearly as much to participants, who, if anything, would probably prefer that they be deemed the managers when their own health and behaviors are involved.

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Not all Health 2.0 sites are created equal

October 23, 2007 at 3:40 pm · Filed under Health IT

Writing on iHealthBeat, Dr. Thomas H. Lee describes the emerging world of online health care communities such as Daily Strength and Patients Like Me. He acknowledges their value but argues that just as Friendster was quickly replaced by MySpace, which is now being overtaken by Facebook, the early Health 2.0 sites may face a similar fate. Rapid technological change, shifts in platform (e.g., from desktop to mobile) and changes in social context will keep these sites in constant flux:

Someone could be defined by their friends in one year, then by their health support group in another. Context switching generates a whole different set of needs, by which some sites might become preferred over others.

This is true as far as it goes, and is particularly relevant for sites like Daily Strength that focus on Friendster/MySpace/Facebook style activities like sending hugs. That kind of thing is going to get old in a hurry. If you don’t believe me, go to the people page on Daily Strength (you’ll have to sign up) and look at the Top Huggers.

• NannaB with 2000 hugs –45 yo female with fibromyalgia
• troubled2 with 1584 hugs –27 yo female with Paranoid Personality Disorder
• missymoomoo with 1230 hugs –36 yo obese female
• man18 with 1164 hugs –18 yo male with Obsessive Compulsive Disorder and Depression

Remember folks, a small number of users generate the majority of content on sites like this. If my company’s valuation were based on the rants of these individuals I’d be worried!

Patients Like Me is really quite different than Daily Strength. Unlike Daily Strength users, who may easily “be defined by their friends in one year, then by their health support group in another,” Patients Like Me focuses on patients with life-threatening illnesses including ALS, MS, Parkinson’s and HIV/AIDS. Although it would be nice to think that an ALS patient could be defined by something other than their disease next year, it’s not really possible. The same holds true –though in some cases to a considerably lesser extent– for the other illnesses.

In the ALS forum, Patients Like Me users plot their decline in pulmonary function toward death over a period of a few years. They share all the detailed information they can to help one another reduce the slope of decline. The barrier to dropping out and abandoning their peers is a lot higher than for the OCD, paranoid, obese or merely sad patient who suddenly finds something else to do with his or her time…such as attacking me for being insensitive.

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DHHS Appeals Ruling Accessing Medicare Physician Claims Data

October 23, 2007 at 1:29 pm · Filed under Transparency/Public Disclosure, Quality Measurement

I reported previously on a landmark case where a Washington D.C. federal judge ruled in favor of a consumer group that sued the Department of Health and Human Services (DHHS)to allow disclosure of specific data about doctors from the Medicare Claims database.The non-profit Consumers Checkbook filed the suit to allow access to the database so that consumers will be able to find out how many times their physician has performed a procedure that they may be facing. Federal rules now protect the privacy of this physician information.

I asked then whether any action — such as an appeal — would be in contrast to the Administration’s current transparency and value-based initiatives. I also took the opportunity at the time to pose the question to DHHS Secretary, Mike Leavitt on his new blog. No response.

Well it is now reported that DHHS has decided to appeal the ruling. DHHS spokesperson Kevin Schweers said that the department is “fully committed to making available as much Medicare data as allowable by law.” He added, “Unfortunately, in the case at hand, two federal courts interpret the law differently, and we’re caught in the middle until that dispute is settled. When that day does come, it’ll be a day too late as far as we’re concerned.”

A cryptic yet understandable response. I hope the public interest in this case stays alive as it travels through the justice system.

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Move over RateMDs and RevolutionHealth, here comes Zagat’s

October 23, 2007 at 1:12 pm · Filed under Insurance, Consumer Engagement, Business of Health

I’m sure most of us are very familiar with Zagat, the “go-to” resource for rating restaurants all across the world. I wore out my NYC Zagat’s guide when I lived in NJ - there is a sense that you’re getting the “insider scoop” on each restaurant along with objective ratings. Their success has led them to also rate nightlife, golf courses, hotels, shopping, and other entertainment destinations.

And now, Zagat will be rating physicians, or to be more specific, WellPoint physicians. The methodology will be quite similar - they’ll use real patient comments that are representative of the larger pool of comments. And they’ll provide numerical scores (up to 30) for 4 key factors: trust, communication, availability, and office environment.

I have to say - I think this is brilliant on a few different levels. First, I can’t think of any brands more trusted than Zagat’s when it comes to peer-to-peer info sharing & rating. Second, the 4 factors are perfect. Some may say - what about clinical quality? clinical outcomes? cost? I think WellPoint purposely decided not to touch quality, cost, or other factors that would draw on claims data - this keeps them from being part of recent controversies. Plus, this is a consumer-driven tool - in the mind of consumers, quality is a subset of trust. Let other sites deal with the complexity of costs.

What do you think? Any physicians out there that care to comment on this?

UPDATE: read more conversations and reactions here.

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Healthcare Embracing Prevention Processes, But Not Outcomes

October 22, 2007 at 9:20 pm · Filed under Policy Makers, Prevention and Health Promotion

A growing number of healthcare system stakeholders and reform gurus are getting on the “prevention” bandwagon. They are recognizing that only if we reduce the incidence and prevalence of disease and injury along with the crises, complications and worsening of chronic conditions that already afflict us, can we solve the cost crisis and afford the costs of universal health insurance.

A solid illustration of the growing movement toward prevention and control of sickness, rather than simply paying for its treatment came in recent reports on the quality of healthcare in California. These reports addressed how well health plans and physician groups perform in that state, using a series of indicators that reflect both prevention and disease management, rather than sickness care. They include ratings of PPOs by NCQA, and of physician groups by county, though the one I will discuss in detail is that for HMO health plans. [“Healthcare Quality Report Card: 2007 HMO Ratings” Office of the Patient Advocate]

The HMO ratings are based on how well physicians in such organizations take care of patients over time, how well they manage risks and chronic conditions, rather than specific sickness events. They begin with ratings of the care provided for asthma, based on the percentage of adults, teenagers and children who get the “right medicine” for their condition. All HMOs rated did well on this measure, with percentages getting correct medications ranging from 87% to 98%. Ratings for cancer care were based on how many members get screened for breast, colorectal and cervical cancer, where HMOs did not nearly as well, with percentages ranging from 61% to 77% for breast, 80% to 86% for cervical, and 48% to 58% for colorectal cancer.

Diabetes care was rated on how many patients got eye exams, testing for blood sugar, cholesterol and kidney function, as well as how many had their blood sugar and cholesterol levels under control. Eye exam rates ranged from 47% to 76%; blood sugar testing from 86% to 92%; cholesterol testing from 82% to 89%, and kidney function testing from 77% to 93%. But the percentages of patients whose blood sugar was under control ranged only from 66% to 78%, and cholesterol control from 41% to 55%.

Heart care was rated on physicians’ giving heart attack patients beta blockers, and testing such patients’ as well as heart surgery patients’ cholesterol levels, along with the percentage of overall members who had their blood pressure and cholesterol under control. The right medications were given to heart attack patients from 55% to 85% of the time, while cholesterol was tested in targeted patients from 88% to 95% of the time. But cholesterol was under control in members only 57% to 66% of the time, and blood pressure from 54% to 74%. Maternity care was rated on the percentage of pregnant women who began prenatal care during the first trimester, where percentages ranged from 85% to 97%, and how many had a check-up visit within 21-56 days post delivery, where scores ranged from 79% to 89%.

Mental health care was rated on:

• the percentage of depression patients seen at least three times during initial treatment, where scores ranged from 17% to 30%
• the percentage of such patients who remained on anti-depressant medications during initial treatment, where scores ranged from 56% to 86%
• the percentage of such patients who remained on anti-depressant medications for 6months following initial treatment, where scores ranged from 40% to 67%
• the percentage of members hospitalized for a mental illness that were seen by a mental health provider within 30 days after discharge, where scores ranged from 70% to 84%

Ratings for the care of sexually transmitted disease were based solely on the percentages of patients aged 16-20, and 21-25 who were screened for Chlamydia, where scores ranged from 30% to 66% for younger patients, and 34% to 69% for older. Ratings for back pain treatment were based on the percentage of patients whose evaluation met recommendations relative to the use of high-cost x-ray services, where ratings ranged from 77% to 86%.

Treating adults was rated on how many patients prescribed long-term medications were tested for harmful side-effects, with ratings ranging from 60% to 71%; and how many rheumatoid arthritis patients got a prescription for an appropriate drug, with ratings ranging from 67% to 91%. Treating children was based on:

• how many with AHDH prescriptions had a follow-up visit within four weeks to check for side effects (20% — 36%)
• how many had, by age two, received the seven recommended vaccinations (49% — 82%)
• how many adolescents had, by age 13, received all recommended vaccinations and booster shots (38% - 74%)
• how many children ages 2-18, diagnosed with a throat infection and treated with an antibiotic were tested for strep throat (32% — 86%)
• how many ages 3 months to 18 years with a common cold had not been given an antibiotic (78% — 95%)

While included under member ratings of their HMOs, rather than based on medical records, as were all other ratings, HMOs were also rated on how helpful they had been in helping members who smoked to quit this unhealthy habit:

• whether their doctor had advised them to quit in the past year (66% to 83% across the three plans who had a large enough sample)
• had their doctor had supplied information on medications that would help in quitting (37% to 53%)
• had their doctor supplied information on how to quit (41% to 58%)

Members were also asked about their health plans’ customer service, paying claims, help in finding a doctor, getting appointments and care quickly and easily, doctor communications, and finally on their overall rating of their healthcare, where ratings ranged from 61% to 73%.

By my count, there were 25 quality ratings that solely reflected the process of care that HMO members received, whether their physicians had “done the right thing”, with widely varying percentages of their having done so. There were two ratings that reflected a combination of both physician and patient compliance, i.e. both of them doing the right thing, namely the first prescribing and the second taking the right medications. Only four of all the healthcare quality ratings related to whether the care they got worked, namely, whether diabetes and heart patients had their blood sugar, cholesterol and blood pressure under control.

Moreover, where both process and outcomes measures related to the same thing were used, namely whether physicians tested for blood sugar, pressure and cholesterol – in diabetes and heart disease patients, the outcomes scores were consistently lower than the process scores:

• blood sugar was tested in 86-92% percent of diabetes patients, but under control in only 66-78%
• cholesterol was tested in 82-89% of diabetes patients, but under control in only 40-55%
• cholesterol was tested in 88-95% of heart patients, but under control in only 57-66%
• while no rates were cited for testing it in heart patients, blood pressure was under control in only 54-74%

While there has been a long and consistent history of physicians resisting being held accountable for any kind of results, there has also been a strong demonstration of measuring such results in sickness care. Measures of patient outcomes, e.g. mortality, complications, re-admission rates for particular illnesses and treatments, are commonly used in sickness care quality report cards. Why are so few are available in health care, e.g. how many smokers quit, how many heart attack patients did not have a repeat episode, what kind of quality of life improvements were noted in patients with asthma, diabetes, mental health, heart disease, etc.?

Even how many patients were diagnosed with cancer at an early enough stage to improve their chances of survival would be a more meaningful measure than just how many were screened. How many patients have avoided sexually transmitted disease, thanks to advice and support given them regarding safe sexual practices? What are the rates of patients who don’t get diabetes or heart disease thanks to their health plan’s or physician’s preventive and proactive services? How has the quality of life among mental health patients improved thanks to the medications and support given them?

While it is good news to see health plans and physicians being rated for their preventive/proactive processes, it would be even more useful, it seems to me, if they were also rated on how well their overall efforts are working, i.e. on the outcomes they are able to achieve. True, such outcomes reflect the extent of cooperation among their members and patients as much as plans’ and physicians’ efforts. But it is how well both carry out their preventive/proactive care, not merely whether or not they did something, that makes the biggest difference, and should be of interest to plans, physicians, and certainly patients.

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A little more on Health 2.0

October 20, 2007 at 1:54 pm · Filed under Consumer Engagement, Business of Health

Our fellow healthcare blogger Matthew Holt is carving out a nice little niche as a healthcare 2.0 expert. He has some great recent posts on Sermo (sort of like the Facebook for doctors) and healthcare-specific search engines. Definitely worth a read - these emerging technology companies give us a glimpse into the very important world of consumer and physician behavior. More and more, I think we will start hearing terms like “collective intelligence” and the “wisdom of crowds” in next-generation healthcare.

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Individual vs. Employer-Sponsored Health Insurance

October 19, 2007 at 1:54 pm · Filed under Insurance, Employer CEOs, Employee Health Management

The recent report calling for “Moving Beyond the Employer-Based Health-Insurance System”, is one of many proposed solutions to the healthcare crisis that suggests employers should get away from offering health insurance benefits. [“Quality, Affordable Health Care for All” Committee for Economic Development Oct 2007]. It proposes that employees purchase their own insurance and take it with them when they change employers, equivalent to a “wealth insurance” plan like a 401(k) retirement account.

The report offers many strong arguments for such a change in its 134 pages of discussion, but the essence of the justification is that consumers, not employers, should have the “power” to decide what coverage each wants and is willing to pay for, while government and employers provide the “defined-contribution” funding needed to enable consumers to purchase coverage. The federal government would act as overseer of the market, while free competition among insurers would ensure that choices offer competitive prices and benefits to all.

Not all employers want to get out of offering health insurance benefits, of course, and a large portion of them have begun or increased their investments in employee health over recent years. Like the title of another report, many believe that “Healthy People Are the Foundation for a Productive America” [American Hospital Association Trend Watch, Oct 2007]. A growing number are offering onsite medical clinics that combine traditional sickness care with health management initiatives, and many offer onsite fitness centers to promote health and wellness among workers, knowing how much that helps promote productivity and performance, as well as saving on health insurance costs.

But the report also cites a survey that indicated roughly 2/3 of employers who responded believe that health benefits contribute to better employee health by enabling employees to afford accessing care when needed. Over half of them agreed that insurance coverage, per se, helps reduce employee absenteeism. [P. Fronstein & R. Hellman “Small Employers and Health Benefits” Employee Benefit Research Institute Issue Brief # 226 2000].

Another study found that 40% of employers agreed that health benefits were extremely or very important for improving worker productivity. Paid sick leave can also boost productivity by enabling workers to take time off to see a physician or other source of care, and to avoid coming to work sick with a condition that can infect their peers. Empowering them to get care onsite saves them the time that would be lost seeking care elsewhere, plus helps keep workers healthier and more productive at work. K. Davis, et al. “Health and Productivity Among U.S. Workers” The Commonwealth Fund 2005]

In the UK, where government health insurance already covers everyone, employers have increasingly begun offering private health insurance to improve their success in recruiting and retaining essential “talent workers”, becoming increasingly difficult to find almost everywhere. They also invest in employee health management (EHM) in order to reduce turnover, improve productivity and even add to customer satisfaction, quality, error reduction, and new business acquisition. (Check out www.vielife.com for a variety of examples.)

While solutions that rely on individuals taking responsibility for their own health and care — with guaranteed coverage for all through combinations of required employer and taxpayer contributions – may be the answer to the current crisis, it will not relieve employers of the burden of health insurance, since most will have to pay a share of the overall costs. Moreover, it will continue to make sense for most employers, particularly those relying on “talent workers” as contrasted to easy-to-find-and-replace “cannon fodder”, to invest in maintaining and improving their workers’ health.

The most important shift in health benefits will not be the shift in burden from employers to consumers. It will be the shift from sickness care to what can truly justify the name “health care”, namely prevention, preservation, and improvement of health, rather than using over 95% of the dollar on sickness care. And employers will still offer both one of the most logical contexts for health care, but the most logical partner for consumers, since they will benefit as much as workers and their families from better managed health.

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