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A New C-Suite Member – the Chief Wellness Officer ?

by Scott MacStravic

In their insightful books, “Discover Wellness: How Staying Healthy Can Make You Rich” and “Discover Wellness at Work: The Ultimate Solution to the Health Care Crisis”, the authors make the case for adding yet another member to the “C-suite” = a Chief Wellness Officer.  They also make the case for each individual becoming a “CWO” for each’s own health and care use.

In addition to making a strong case for focusing on wellness, in order to reduce the “drag” of the $2 Trillion-a-year sickness care system on our economy, global competitiveness, and health (given the horrifying numbers of medical errors, adverse drug events, nosocomial infections, and other negative impacts of sickness treatment).  But in addition to other arguments for individuals becoming wealthy and employers helping them to do so, they cite the many ways in which this can make both employees and employers rich!

Well, “rich” may be too strong a word, but they make some pretty good economic arguments, citing the many ways in which people can gain by being or becoming healthier, in addition to the ways that employers can do the same for their firms.  While we have had relatively modest success at best in persuading or educating individuals and populations toward better health, perhaps making them rich, or at least considerably better off financially, will make the idea as popular among employees as it is becoming among employers.

There are clear connections between health and wealth, though these are rarely covered in full by most who have described them.  The more obvious ones arise from avoiding direct out-of-pocket costs due to being sick.  These include not only the lost time/pay from work that many suffer if they have no disability or sick leave, but the increasing portion of sickness care costs workers are being asked to pay, from higher premiums to deductibles, co-insurance and co-pays.   Even if they get disability pay, it is normally only a portion of what they would be making if working.

To these must be added the indirect costs of “unhealth” on what employees earn in the first place.  If they are paid on a productivity or performance basis, sick employees naturally produce less or perform worse than they would if healthy.  With chronic conditions, as well as risks such as obesity, they lose productivity/performance-based compensation, to say nothing of promotions and raises that would likely have been offered to them had they been healthy.

Moreover, pursuing unhealthy lifestyles often costs a lot of what would otherwise be “discretionary income”.  Cigarettes can easily impose an “addiction burden” of thousands of dollars each year.  Alcohol and drug use adds widely-ranging amounts as well.  Eating unhealthy fast food compared to healthy home-cooked or employer-subsidized meals can add thousands of dollars to the annual food bill.  Of course, mitigating these costs may be the out-of-pocket costs that individuals incur in joining fitness clubs, buying exercise equipment, wearing out walking shoes, etc.  Fortunately, employers often subsidize or obtain discounts from sellers on such items, thereby reducing costs to employers.

Moreover, employers are increasingly offering employees bonuses for participating in wellness programs, with amounts often in the $1000-2000 range each year.  Or they may impose similar-sized penalties, in the form of premium share, or other increases in sickness care costs.  Healthy employees can far better afford to take the risks involved in Consumer-Directed Health Plans, and if they keep their sickness care costs low, they can save on insurance premiums, as well as build up hundreds of thousands in tax-free HSA accounts in preparation for their retirement.

It has already been shown that giving people a “scorecard” to use in keeping track of how much better off they are for engaging in EHM efforts is a good way to keep them interested and participating.  Making that scorecard a financial one is almost sure to be more powerful than scorecards based on “health age”, “health-wellbeing scores”, etc. and similar direct health measures.  It can also represent a continuous threat, since money gained and likely to be gained in future can easily become lost if employees or their family members “relapse” into unhealthy habits and sickness costs.

The idea of a CWO for individuals, with a helpful partner chosen from among a wide range of health professionals to help, is matched by the idea for a CWO in business and other organizations.  Such an “officer” would at least be useful for keeping track of the full scope and amount of economic value that employers tend to gain through EHM.  Since the vast majority of employers count less than half of the economic benefit they are already gaining, and that among those who count it at all, this could make both a challenging and worthwhile career in business.

Understandably, given their training in chiropractic medicine, the authors make pretty good arguments for looking past physicians as prospects for the CWO position in business, or the preferred partner for individuals who act as their own CWO.  Given the growing shortage of primary physicians in this country, it is unlikely that we can afford to spare any more to become CWOs or even partners for individuals, though hundreds are already doing so in “concierge medicine”.  Of course, how employers and the insurers that serve them decide who would make the best CWO is up to them, as is true for consumers as well.

On the other hand, the authors are not promoters of chiropractic alone as an appropriate background for CWOs.  They note that other Complementary and Alternative Medicine (CAM) providers, as well as physicians, may be well qualified.  Physicians, of course, when they are paid by insurers, rarely can afford to take the time for “cognitive therapy” related to wellness, while consumer-paid CAM providers can afford as much time as consumers are willing and able to pay for.  And physicians in the concierge model of medical practice have proven how well they can promote patient health and reduce sickness care. (e.g. www.mdvip.com)

Doctors of naturopathy are another logical option, since they take a holisitic and proactive approach to patient care, much more so than most medical doctors.  The combination of holistic health vs. solely disease focus, and proactive vs. reactive approaches to health, is what is needed for a CWO or personal health management partner.  There is probably too little evidence yet to identity which background is likely to produce the best CWOs, since the idea is so new, but we can hope that science will come to our aid there, as it has tried to do in sickness care, and help employers and consumers choose the best qualified and most successful providers.

Predictive Analytics in Population Health Management

by Scott MacStravic

Predictive analytics (PA), the science of collecting, analyzing, and applying information about customers to promote the success of firms that use the information successfully, is a rapidly growing element in marketing and sales, as well as customer service efforts.  It includes two main aims:

  1. to identify the potential worth of different customers in order to tailor the level and costs of effort to the relative value of each, and thereby improve the ROI from investments in customer acquisition and retention; and
  2. to tailor the kinds of communications and experiences delivered to customers to optimize the ROI from acquisition, “development” (usually means up- and cross-selling/marketing), and retention investments

[J. Tsai “Predictive Analytics Foresees Change in the Future” DestinationCRM.com, Oct 30, 2007]

While these applications have had a long history in marketing applications, they are only recently being used in population health management (PHM), of commercially or governmentally insured, and particularly employee populations.  The application of the concept of predictive analysis in PHM has been slow to develop, and its applications still fall far short of those in customer marketing, sales, and service, though it is moving in the direction of more sophisticated and comprehensive efforts.

Initially, PA focused primarily, if not solely, on identifying those members of a given population who had the highest level of current or past expenditures, and perhaps the greatest risk of future expenditures.  This usually meant identifying people with expensive chronic diseases, whose conditions had recently been diagnosed, involved a significant crisis or complication.  Because they had already generated high expenditures, this often meant closing the barn door well after the horse had departed.  It also added to the widespread early tendency for PHM results to be exaggerated by ignoring the tendency for high-cost individuals to “regress to the mean” in the following year, whether or not any PHM intervention had been applied to them.

Gradually, PA has grown to identify those at risk for high expenditures in future, including those at risk of contracting new diseases, both acute and chronic.  By adding those at risk, a far larger population of potential PHM participants can be included in PHM efforts, and a far broader range of expenditures can be avoided or reduced.  Where chronic disease management may target 5-30% of the population, increasing with the average age thereof, it usually engages only a minority of those targeted, meaning that only tiny minority of the total population is involved, and many long after they have generated their highest levels of costs.

By adding in not only disease risks, in employee populations, but productivity/performance impairment factors, PHM can also greatly expand the measured costs and benefits of PHM investments.  Typically, the costs and savings related to improving health and thereby reducing absenteeism, presenteeism, and performance impairment, as well as creating positive impacts on both, is from two to five times as great as are “direct” healthcare, workers compensation and disability expenses alone.  And these are usually improved far more through addressing impairment factors such as general emotional problems, lack of sleep, stress, poor nutrition and hydration, etc. than through disease risk factors, alone.

PA really adds value when it is also applied to identifying which members of a given population are not only most expensive, at risk or impaired, but also most likely to respond to PHM interventions.  Analysis of individuals’ “stages of change”, “internal vs. external locus of control”, self-efficacy, motivation, perceived personal benefit, etc. can differentiate those who are likely to make the necessary behavior changes to succeed vs. not can make PHM interventions more effective and efficient.

For example, HealthMedia, Inc. Ann Arbor, Michigan employs an online health risk assessment (HRA) that includes not only questions used to estimate productivity impairment, but to identify which individuals are the best prospects and what kinds of support will have the best impact on them.  American Healthways, Nashville, Tennessee rely on their personal nurse coaches to learn about and incorporate individual characteristics, attitudes and barriers — not merely in general, but at each coaching session – to customize their coaching accordingly, in addition to using HRA analysis upfront.

Healthcare organizations are already using simple tools to identify individual characteristics and facts that enable them to customize sickness care experiences.  St. Jude Medical Center in Fullerton, California, for example, uses a set of 10-12 questions that patients are asked to answer, so that physicians, nurses, and other staff serving them can identify interests or experiences they have in common with patients, adding to the personalization of interactions, particularly about reasons that will motivate patients strive to get better. [N. Vssell “Simple Tool Helps Personalize Health Care” Strategic Health Care Marketing, 24:11 Nov 2007 5-7]

Duke University Health System can customize its support to eligible participants in its Duke Prospective Health Program based on the individual health vision and mission statements each participant is asked and helped to complete at the beginning of PHM efforts.  By understanding the personal motivations different employees and dependents bring to PHM participation, personal coaches can more explicitly tie their efforts to the reasons that drive participants, not merely the cost-saving reasons that drive the system. (www.dukeprpospectivehealth.org)

By combining a broader focus for interventions and measurement of their impacts with more predictive understanding of which prospective participants have the best prospects, and what kinds of interventions will work best with each, PHM can multiply its probability and value of success many times.  As predictive modeling technology improves the accuracy and precision of its analytics, PHM figures to deliver increasing probability and value of results, along with greater efficiency, effectiveness and ROI for its investors.

Choosing the Best EHM Investments

by Scott MacStravic

Perhaps the biggest impact of looking at employee health management (EHM) rather than general population health management (PHM) is the difference it makes in what make the best investments.  When the sole concern is reducing sickness care costs in an insured population, it makes pretty obvious sense to look at sickness risk factors and chronic diseases.  But when the concern expands to include reducing all factors that impair or impede productivity and performance among employees, the scope of investments can expand dramatically.

For example, while chronic conditions such as diabetes, asthma, coronary heart disease, congestive heart failure, and chronic obstructive pulmonary disease may be the biggest causes of preventable sickness care costs in a population, they are likely not to be the best investments for employers.  Other factors, such as depressed feelings, stress, smoking and alcohol addictions may be far greater impairment factors because of their higher frequency than chronic diseases in employees.

While it is possible to separate the impact of diseases on sickness care costs, merely by analyzing the diagnostic codes involved, it is anything but easy to identify the impact of individual impairment factors.  When such factors are identified, they almost never occur alone, but are part of a set of factors that vary widely across individuals in their mix and severity of impact.  Depression is a common co-morbidity for diabetes and heart disease, but stress is a common “co-impairment factor” for a wide range of others, including overweight/obesity, poor sleep, nutrition and fitness levels, as well as depressed and anxious feelings.

When productivity/performance impairment is found through objective measurement, or self-reported by employees, it usually comes in people who have multiple factors at the same time.  Their overall impairment normally gets counted as linked to every factor reported, and counted multiple times.  This multiple counting can be overcome by either dividing the total amount of impairment by the total of all prevalence figures for all the factors, or by separating out the individual factors in some way.

Dow Chemical Company, for example, asked each employee to identify which was the primary impairment factor affecting each, so as to count the effect of each factor only once.  But this under-counts the overall impact of each factor, by not recognizing the potential that some add to the effects of others, even if not primary, while over-counting the effects of some which are most often labeled primary, but whose impact is exaggerated by what may be many secondary accompanying factors.

If the true effect of individual factors can be identified, along with the true effects of EHM programs targeting each such factor, employers would have a far better chance of selecting the most promising target factors and individuals for EHM investments.  Moreover, EHM vendors could use the identification of the factor that has the greatest impact on individuals’ impairment in recruiting employees for participation in the program that will affect it the most.

As long as individual employees see themselves as benefiting predictably and significantly if they improve their productivity/performance, they should be as motivated to devote their efforts to the program that will achieve such an improvement.  Particularly for employees who are paid, either wholly or in part, on the basis of their productivity/performance, it would make explicit economic sense for them to enroll in the EHM program that will simultaneously do them and their employer the most good.

Employers must always be kept from knowing which employees are impaired by which factors to what degree.  They always have access to whatever productivity/performance data is already available through their ongoing employee reviews or data, but are prohibited from identifying confidential health information about their employees that may be responsible for lower than desired performance.  But as long as employees give permission to EHM vendors, with the understanding that identifying the most powerful impairment factors affecting each and the most promising EHM programs for each, the employees stand to benefit as much as the employer.

Employers can use what they learn about the effects of particular factor-specific EHM interventions and the effects they have on overall employee productivity/performance to graduate the incentives they offer to employees that achieve specific health goals, such as quitting smoking, or reducing their blood pressure, sugar, and cholesterol, for example, or improving their nutrition, fitness and sleeping habits, controlling their stress or managing their chronic disease.  As long as employees’ achievements can be verified, employers should be confident that they, too, are benefiting.

Difficulties will arise with respect to self-reported impairment and recovery, whenever there are incentives to be gained.  It would be a simple matter for employees to report that they are sleeping better, exercising more, have their stress under control, eating better, have reduced their alcohol intake to no more than some set limit per day.  But employers may prefer verification to paying off for good reports, alone.

Some verification is relatively simple: weight loss can be checked by a scale, smoking cessation by testing for nicotine, fitness by a test, etc.  But many are not easily verified, while productivity/performance improvement, per se, should be verifiable at least to some degree.  And as long as employees figure out a way to produce more and perform better, they should be eligible for rewards.  The EHM provider need only make sure that enough employees improve enough through participation in the best interventions to make such improvement possible.

If employees learn that improving their stress management can increase their productivity by 10%, for illustration, and employers learn that stress is a major impairment factor for the entire workforce, employers can work on reducing stress levels they impose on workers, while helping workers cope with stress.  This may involve a combination of an EHM provider’s stress management program, employer-sponsored training in time management, and improved scheduling of efforts so that demands and deadlines are reasonable rather than oppressive.

It is clear that predictive modeling is approaching the point where the most promising individual impairment factors will soon be able to be identified as directly and simply as can the most expensive sickness.  Once this is achieved, the potential for enabling both employers and employees to make the best possible decisions about where to focus their investments of money and effort will be greatly improved, and thereby, the success of EHM investments in general.

Not The Same Old Trizetto

by GVanAntwerp

Before a whole week passes, I need to capture my interview with Gene Drabinski from Trizetto.  Gene is the President of Cost and Quality of Care.  This was a fun interview where we just kicked back at the end of day two at the World Healthcare Congress and talked.

I haven’t spent much time around the Trizetto people recently and still thought of them as Facets which was the software that I remember from my payor days at Ernst & Young LLP.

Of course, I had done some homework prior to the meeting and began by asking some questions about being acquired by Apax who is taking them private.  We talked about the advantages of being private versus public.  The big one being the ability to plan long-term and make investments rather than try to make each quarter’s number.

He was then kind enough to walk me through some of the history of Trizetto.  If you go to their news page off their website, I had realized before I talked to them that I was outdated in my frame of reference.  They are talking about social networking and consumerism and decisioning not about claims processing and efficiencies.

We talked a lot about the CareKey application which they acquired.  CareKey (now CareAdvance) is a PHR (personal health record) which sits on top of a member database.  He described several key features of the application:

  • Good metadata (i.e., data about data)
  • Ability to reach out and capture new data systemically
  • Custom rules environment
  • Able to be integrated with workflow and used in disease management, case management, and utilization management

CareAdvance Enterprise - Enterprise software that allows health plans to automate utilization, case, disease and population management, and to extend a personal health record and personal health management tools to their members. The system includes two modules: Personal CareAdvance and Clinical CareAdvance, which integrate with the health plan’s core information systems, aggregating the member’s personal claims and diagnosis history, current prescriptions, and laboratory data into a single data repository.

We talked about transfering the information from one PHR to another.  He clarified that the transaction data was transferable but not the context.  We then spoke about their vision for Integrated Healthcare Management as an out-of-the-box solution to make the patient “be the best I can be”.  From what he said, the physician is the final constituent that they need to get integrated.

“Integrated Healthcare Management is the systematic application of processes and shared information to optimize the coordination of benefits and care for the healthcare consumer,” said TriZetto Chairman and CEO, Jeff Margolis.

From Gene’s session at the conference, he facilitated a panel that included Vicky Gregg who is the President and CEO of BlueCross BlueShield of TN.  One of her slides which captures the Trizetto IHM vision is here:

My takeaways were (a) Gene’s would be an enjoyable person to work with and (b) Trizetto is doing a bunch of interesting stuff and focused on how to use technology to transform the industry.

It’s also worth reading through Jeff Margolis’ document called The Health Plan of Tomorrow.

(This is probably my last post here for now, but I encourage you to look at my personal blog Patient Centric Healthcare.)

OptumHealth Interviews From WHCC

by GVanAntwerp

Both Rob Webb (CEO of OptumHealth Care Solutions) and Chad Wilkins (CEO of OptumHealth Financial Services) were presenting at the WHCC in DC and were able to sit down with me for an hour to talk about their business.

Let’s start with some of the basics:

  • OptumHealth is part of United Health Group.
  • OptumHealth Care Solutions provides consumer advocacy, wellness, health care decision support, disease management, case management, health information portals, and specialized networks.
  • OptumHealth Financial Solutions is a health care financial services provider which provides consumer health accounts (HSAs, FSAs, HRAs), benefits administration, and debit cards (among other things).

In preparing to write up my notes from the interview, I retrospectively read the press packet. My one takeaway is that most of the programs here (e.g., dental or incentives) are not what you typically think of when you think of UHG. They second caveat I will add is that we jumped around a bit as I was interested in learning about lots of little things versus creating one big story.

I began by asking them what they thought about using flat dollar copays on drugs versus percentage dollar copays. [Dr. Gupta from CNN had done a report that morning around how patients should look for health plans with flat dollar copays. And, the WSJ had earlier in the week had a story about how percentage copays on specialty drugs disadvantage the sick.] I think their response (rather than no comment) was appropriate in saying that:

  • In general, simpler plan design eases adoption which I take to mean drives the intended behaviors. (and I know it reduces calls)
  • Using a percentage copayment brings the condition into play. (I completely agree)

We moved on to my favorite topic – communicating with patients. We talked about how socio-economic conditions play into prevalence of conditions and phases of change in terms of messaging. Rather than being big believers in the Pro-Change model, they talked about focusing on “how compelling is the case for change”. They focus on delivering a message that says something like “we have something for you to consider” and including some data to reinforce that suggestion. I will have to follow-up with them to get the data, but we then spent some time talking about using inductive call logic versus deductive call logic.

I can’t talk about communications without talking about messaging channels so we addressed that next. I specifically asked them what if anything they had done on the SMS / text messaging front. Although I am generally a skeptic about text messaging in healthcare for things that require lots of PHI (protected healthcare information), I do think there is a role for some wellness type activities like smoking cessation and weight loss. There has also been a study done over in Scandinavia that had positive results (although the cell phone culture there is more like Japan than the US). They mentioned two things:

  • They added a second phone option for cell phones several years ago.
  • They recently added an “opt-in” type of field for patients to say they were willing to accept text messages. (Since some people still get charged per message, this is important.)

After that, we spent a few minutes talking specifically about each of their businesses. First, Chad talked about the Financial Services business giving me some of the history. We then talked about their scope of services. A couple of interesting takeaways were:

  • They are able to take the card data and integrate it into their PHR. (Which I think every PHR should do.)
  • 27% of the people with HSA plans used to be uninsured. This is a very interesting fact.
  • Since it was Earth Day, their PR person pointed out the amount of paper they save per year by moving all these things to electronic.
  • He talked about linking accounts, cards, and incentives.
  • We also spoke about the impact that the economy would have on the business. He pointed out that at $1 to print a check, $30 to talk with a provider, and $5 to re-process a check that the current downward trend in the economy would likely drive cost-focused programs.

Next, I talked with Rob specifically around Care Solutions. A few of my takeaways here were:

  • They focus on trying to identify why a patient has (or could have) a gap in care and solve the problem systemically (what I would call quality at the source) versus how he positions their competitors as focusing on the gap in care.
  • Since United Health Group is the biggest buyer of their services, he believes they bring a healthy skepticism to the table in terms of evaluating program outcomes and ROI.
  • I asked him about their predictive engine which I know companies like ActiveHealth have. He talked about the fact that they have a similar model, but that ActiveHealth has done a great job of bringing back the appeal of the predictive engine. And, he talked about their interest in pursuing a low-cost model for intervention using letters at $1.50 per intervention. [It was hard for me not to point out here that for similar or less cost we could probably get them a much higher response rate and ROI using our personalization engine and automated outbound call technology at Silverlink.]

Overall, I found it a very interesting conversation about two areas of United Health Group that aren’t always the first thing consumers think of. I am sure our interactions with them are more that each of us think given their market prevalence.

What’s Next for PHRs: Interview with Debbie McKeever, EHE International

by JMcCabeGorman

It happens all the time at packed conferences like WHCC; your days are full of appointments, lectures, and meetings, but you seldom get the chance to talk to everyone you’re scheduled to see in person.

Luckily, Debbie McKeever, President of EHE International, was kind enough to stay in touch after the show.

Debbie’s firm, EHE International,  provides a nice contrast to newer employer-provided wellness programs. Founded in 1913, the company has been around for more than 9 decades - how’s that for longevity in the space?

In true Health 2.0 fashion, Debbie provided answers to some pressing questions via email, including why EMRs/PHRs are not universally embraced (consumers not taking ‘personal responsibility’ ring any bells?).

 Here’s her take on what’s next for the healthcare/wellness industry.

EHE has separate individual and corporate offerings, which line is stronger?

EHE International’s services are available in both the corporate and individual market segments; however, our book of business is mostly comprised of corporate employers who offer our preventive care and wellness program as a benefit to employees at all levels.

EHE offers a personal health record – can you give me an idea of adoption numbers?

Every patient (employee and individual) has access to EHE International’s proprietary PHR as part of the program offering.  Within this group, approximately 85% of patients elect to have their EHE medical information populated to their PHR; a PHR that provides for management of data, forms, and records from a multitude of providers/sources.  While that number may be impressive, not nearly enough of this patient base utilizes the EHE PHR for non-EHE medical record information.

What do you feel are difficulties in systemic PHR implementation/barriers to use?

Barriers to use are not systemic of implementation or technology, but rather to the fundamental principle that far too many healthcare consumers have not accepted “personal” responsibility for management of their medical records—electronic, paper, or other types of storage/management—and continue to view this as their healthcare providers’ responsibility.  Collectively, healthcare providers need to promote the value and benefit of personal record management, namely that a fragmented system of medical record management can impede optimal care. 

You rang the bell on the NYSE for Diabetes Alert Day this year – how did that feel? Why are you so invested in the cause?

Ringing the NYSE is both an honor and a thrill, especially as chairperson of the Greater New York American Diabetes Association Board as it gave national recognition to “Diabetes Alert Day.” 

My interest (passion) about type 2 diabetes is driven from an employer perspective vs. a healthcare provider prospective.  Type 2 diabetes is at epidemic proportions in the U.S.  Today in the U.S., 21 million have diabetes, 90% of which is type 2, and another 54 million are pre-diabetes.  Type 2 diabetes can be avoided and or the onset of the disease prolonged with two simple lifestyle interventions—eats better; move more.  The impact of type 2 diabetes not only affects employers’ healthcare costs, but it also impacts the talent pool.  Because of their disease, persons afflicted with type 2 diabetes are unable to a) perform their jobs at optimal levels; and b) unfit to perform specific jobs, period.  The burden of healthcare costs associated with type 2 diabetes and its affect on talent resources will (some will argue has) make the U.S. less competitive.

What are you doing to forestall future competitors like Healthwise, Limeade, etc. from taking a piece of EHEs more established market share?

Truthfully, I’m not too concerned about “forestalling future competitors” given the depth and breadth of opportunity in this business segment due to the health of (or lack of) employees.  As the health of corporate America improves, this position will change.  Our nearly 100 years of experience in preventive healthcare gives us a clear advantage that we will continue to capitalize on (and improve) as the market changes—hopefully, changing due to improved health.

What features/benefits do you have that distinguish EHE from the next generation of HRAs/Web MDs etc?

The EHE International model is distinguished from other models as it delivers both preventive care (the evidence-based approach to health assessment, “knowledge”) and wellness (the education, tools, and resources, “access”) for personal proactive health management.  Our approach to health has changed little since the company’s founding in 1913.   We view HRAs and website portals as instrumental “wellness” or “access” modalities; from that perspective, we will continue to strive to be a trendsetter. 

Are employers asking for new/additional features to be bundled with current models for PHP plans?

Yes, as they should.  This year, as example, three new components were added the EHE International program—cognitive behavioral stress management, sexual health management, and pre-diabetes management.  In any business, your customer can make you better and stronger through identification of their specific needs/desires

How do you market EHEs individual offering - directly to the healthcare/wellness consumer? What channels are you currently using? Are you exploring new channels? If so, what prompted the expansion?

1.            We do not market on the individual side.  As previously stated, this is a small segment of our business that typically results in new private patients finding us through word-of-mouth.

2.            For corporate sales/marketing, we use typical channels of print advertising, conference sponsorship, and a team of national sales executives.

3.            We are not looking for new channels, although we being more active/engaged with thought-leader organizations, e.g., National Business Group on Health, National Coalition of Business Group on Health, the Institute for Health and Productivity, to name a few.  This helps promote EHE International as a recognized leader in preventive health and wellness, and keeps us close to ever-changing perspectives in employee health management.

What are your top 3 takeaways from WHCC this year?

1.            Healthcare cost containment remains a paramount concern among senior corporate executives.

2.            The lines between employee privacy and employer responsibility for employee health are challenging for most employers.

3.            Employers’ interest in prevention and wellness programs is stronger than ever. 

Where is the industry going?

While most understand that preventive care and wellness are promising solutions to healthcare cost containment, proven evidence that these investments will yield results is needed.  The industry is exploding, but without standards.  I believe there is still much more growth coming, but among a fewer number of players—players that have a proven track record and a willingness to integrate services/programs for the benefit of employers and employees.  

Thanks again Debbie for your time and insight.



Interview with Evan Falchuk of Best Doctors: Giving consumers the opportunity to double check diagnosis and treatment decisions

by Vijay Goel

Interviewed Evan Falchuk, President of Best Doctors, on their product allowing consumers to get additional information and options regarding diagnosis and treatment options.

The interview took place at the World Health Care Congress and the podcast is below.

This post is crossposted at Consumerfocusedcare with a full transcript of the conversation

icon for podpress  Interview with Evan Falchuk: Download

Honesty in Advertising of Health Products and Services

by Scott MacStravic

Honesty is required by law in advertising of medical treatments and pharmaceuticals, though both are subject to some “overenthusiastic” promotion by physicians and drug companies, alike.  On the other hand, there have been even more cases of overenthusiastic promotion by manufacturers of vitamins and food supplements, as well as providers of “alternative medicine” services whose methods have not been subject to scientific proof of safety and effectiveness before being advertised.

The regulation of treatments and products used in sickness care has long been a major effort in the interest of protecting patients from unscrupulous manufacturers, retailers, and providers who can easily take advantage of patients desperate for something that works, or those who rely too much on emotional vs. rational bases for making decisions about the care and providers they seek.  There are certainly a large number of complementary and alternative medicine treatments that have solid evidence behind them.  But in some ways, this makes it easier for unscrupulous sellers to make the case that their offering will work, by citing other examples where medicine has been wrong in concluding that previous CAM therapies were worthless.

The growing popularity of health management, of persons and populations (both deserving to be labeled “PHM”) has opened up a large new market for CAM therapies.   Where CAM providers have achieved greater credibility among their patients for their approaches, and even greater success in terms of bang for the buck, thanks to their holistic approach to patient care, or their ability to enlist more enthusiastic collaboration among patients, they may be significantly more successful than are traditional physicians, at least in terms of benefits vs. costs.

Achieving a greater benefit/cost ratio is sure to make CAM providers more popular among payers, whether governments, commercial insurers, or employers.  A growing number of insurers, for example, are offering, and employers as well as consumers selecting, lower-priced coverage plans that involve more use of CAM providers for health management of sickness care services.  The generally lower prices they charge for their services, and lower overhead/operating costs for their practices, make CAM providers more likely to be able to compete on costs, at least.

The challenge in PHM is to promote honesty in advertising by its providers, whoever they are – specialty organizations that focus on PHM, traditional providers, or CAM alternatives – about what kind of results they are getting for what kinds of costs.  If honesty in advertising were enforced in PHM, then unscrupulous or simply ineffective providers would be severely limited in their ability to attract payer clients, or even consumers, whether they pay out of their own pocket, or have a third party doing so.

There would be a significant number of current PHM providers who would probably be forced out of business if there were forced honesty in advertising, or even if there were the kind of comparative testing and reporting of outcomes and providers as is increasingly true with sickness care.  Commercial insurance plans are already talking about developing and rating the performance of physician practices in terms of managing the health and costs of patients with chronic diseases.  It would be relatively simple to do the same for practices engaged in protecting and improving their patients’ health, such as the MDVIP retainer medicine practices, now numbering over 200 in the US.

If honesty in advertising were required across the board in PHM as well as in sickness care, there would naturally be the same two effects as already noted with publication of comparative quality in sickness care.  The lower-performing providers would strive and many succeed in improving their performance to make themselves more competitive with their higher-performing rivals.  Or they would be forced out of business, as more consumers and payers would be able to “Buy Right” in PHM, as well as sickness care.

It will take a major improvement in the numbers of payer clients forcing and financing rigorous evaluation of the actual performance that PHM providers achieve.  This will have to be done on a set of comparable outcome dimensions, rather than only those that individual PHM providers choose to measure or report.  And there would have to be the kinds of rigorous analysis of the different results that different PHM providers get as has already been done in sickness care, and even in disease management D(M), though for the wrong reason.

Instead of rigorous scientific analysis of a number of different PHM providers and methods, there should be equally rigorous analysis of individual PHM providers’ results across their entire book of business.  And instead of pursuing a ludicrous and futile answer to the general question of whether PHM works, as has characterized reviews in DM, these analyses should aim to develop comparable performance data on competing PHM providers to identify which do the job best.

This will speed up the ability of PHM sponsors and buyers to identify and selectively prefer those PHM providers who have been shown, in objective, accurate, and rigorous ways, to deliver the best outcomes.  Ideally, these “best outcomes” should include both economic effects on payers, and personal health/life quality for those persons and populations that participate and invest their own time and effort, as well as their money in many cases, to achieve these outcomes.

The same amount of money already wasted on answering the unanswerable general question of whether it works could go a long way toward identifying which PHM methods work best.  The general question is unanswerable because PHM, as is true for DM, is simply not one “treatment” that can be examined across different populations and problems to find out if it works.  PHM and DM are a wide range of significantly different approaches, with highly varying costs and intensity, being applied to highly variable sets of problems and populations.  The individual programs that do work should be the focus of analysis, not the collection of diverse programs, where some do and some don’t, virtually guaranteeing the almost always equivocal and uncertain results of studies addressing the general question.

Armed with comparative, rigorous, reliable and valid data on the performance of competing PHM methods and providers, the entire discipline and market of PHM could become dramatically more effective and efficient, and in a far faster time than is possible without such an effort.  When the results of publishing such data are combined with regulated, honest advertising, PHM would have its best chance of succeeding, for its providers, its payers, and the populations that should be benefiting from such success.

In PHM or EHM, Shoot for High Customer Advocacy Score

by Scott MacStravic

The “Customer Advocacy Score” is becoming common as part of marketing and business intelligence for a wide range of firms.  It is particularly useful for firms which rely on a large portion of repeat, even continuing customers, in industries where customers are ‘highly involved” in their supplier relationships because of the importance of the products or services provided.  Banks and other financial service firms, and healthcare providers fall easily into this category.

In population or employee health management (PHM or EHM), insurer and employer clients are sure to be highly involved in their supplier relationships, because of both the amount of economic impact available through these strategies, and the amount of trust that and cooperation that is essential between them and their supplier.  Clients share all kinds of sensitive information with such suppliers, to say nothing of the even more personally sensitive information shared by their employees, where health-plan member or employee trust is essential to gaining adequate participation in PHM or EHM.

A 2007 survey by Forrester Research, Inc. involving more than 10,000 Europeans in seven countries found that only 27% of respondents rated their own banks high in terms of “customer advocacy”, the same percentage as in 2006.  Customers that rate banks’ customer advocacy high are far more likely to turn to that bank for other products and services, while banks with high scores outgrow their lower-scoring rivals significantly, without having to rely on mergers and acquisitions.  [J. Compton “Advocacy Strengthens European Banking Relationships” 1to1 Weekly, Dec 17, 2007]

The score is based on where customers place their bank on a continuum from “Does what is best for its bottom line, regardless of its impact on customers” to “Does what is best for customers, regardless of its effect on its bottom line”.  Firms whose customers’ score them toward the latter pole are considered to have far better scores than those whose customers score them toward the former. [B. Doyle “Customer Advocacy 2006: How Consumers Rate Their Banks, Brokerages, and Insurers” Forrester Research Business View Trends, May 22, 2006]

For healthcare organizations (HCOs)considering entry into the PHM/EHM market, learning how prospective clients, i.e. insurance plans or employers, rate them on customer advocacy, particularly in comparison to other suppliers already active in the market, may help in deciding whether to make the entry, and which prospects to try first.  Learning how consumers rate the organization may also prove helpful, since if they don’t rate the HCO well on this dimension, it is unlikely it will be able to enroll many targeted plan members or employees in an intervention program, even if the client is won over.  And without high participation, success is both less likely and sure to be less delightful for clients.

Since HCOs have been sources of double-digit inflation in sickcare costs for a long time, both employers’ and insurers’ views of them may be somewhat jaundiced.  Employers may be a far better prospect, in any case, since they can gain far more in economic benefits – through improved productivity and performance, turnover reductions, and even increased customer satisfaction and loyalty – while insurers are focused on reducing healthcare expenditures.  Moreover, since reducing insurers’ expenditures tends to cost dollar for dollar in HCOs’ revenue, this class of payer is nowhere near as attractive.  By contrast, employers gain more by reducing productivity and performance impairment than by cutting healthcare costs, so need not affect HCO’s sickcare revenue nearly as much.

Where HCOs are successful in gaining employer clients, checking their perceptions of the HCO’s commitment to their interests vs. the HCO’s own should be a good predictor for retention vs. defection of these clients.  Learning why consumers as well as clients rate the HCO high or low will also help in either maintaining good ratings or improving poor ratings, and thereby gaining an improvement in future attraction of new or retention of current customers. Learning why they rate rival suppliers good or bad on the scale will also provide useful “competitive intelligence” about the market.

In any case, learning how the HCO is rated by prospective clients as well as consumers, will greatly assist in making decisions about the PHM/EHM market.  Learning how its own employees rate it on “employee advocacy” can also help in deciding whether to invest in internal EHM, or even in an outsourced program, since trust in the HCO as an employer will be key in achieving high participation in either case.  Helping employer clients to check their scores on this same dimension will also help in their decisions, and perhaps justify the high level of employer support required when HCOs are suppliers and the employers the clients.

Health Care “Places” Are Multiplying

by Scott MacStravic

Almost 25 years ago, I recall reading an article with the title “The Hospital: Is it a Place or a Thing?”.  The author argued that hospitals and health care in general had espoused the “place” option, concentrating in urban “pill hills” and focusing their investments on building facilities of eminence and technology.  This was fine, but it ignored opportunities to think of themselves more as “things” that could develop ways to deliver health care in far more ways and settings.

Since then, hospital places have persisted, though many have moved from urban centers to the suburbs, chasing affluent patients in hopes of competing with physician-owned specialty hospitals, ambulatory surgery and diagnostic imaging centers.  But most of the new places where health care is available have been developed by non-hospital organizations, even non-physician organizations in many cases.

Closest to hospitals in concept, free-standing emergency rooms have appeared, the one example of new places usually owned and operated by hospitals.  As traditional ERs have become overcrowded with poorly paying patients, hospitals have opened free-standing alternatives in shopping centers and similar convenient locations to both attract better-paying patients, and relieve the hospital-based ERs. [J. Appleby “More Emergency Rooms Open Away from Hospitals” USA Today, Apr 24, 2008]

Next in terms of similarity to ERs are physician-staffed “urgent care centers”, which have also been growing of late.  These were being developed as early as the 1970s, though many fell out of favor, but they have enjoyed a recent resurgence.  The “new consumerism” that is demanding greater convenience of care is finding waiting for appointments with traditional physician practices onerous, and has created a new wave of demand for these “walk-in clinics”.  M.J. Feldstein “Time-Strapped Patients Feeding Growth of Urgent Care Centers” STLToday.com, Jan 9, 2008]

Many of these centers are owned and operated by hospitals, such as St. Anthony’s Medical Center and St. Luke’s Hospital in St. Louis, cited in the above story.  But more often, they are developed by physicians or physician-owned (at least partially) companies.  Their resurgence came after roughly 15 years of decline following their initial emergence, and there are reportedly 12-20,000 such centers in operation according to a report by the California Health Care Foundation.

Competing with the physician-staffed urgent care model are nurse-practitioner-staffed “retail clinics”, typically small “kiosk” or minimal-space operations inside pharmacies and retail stores or superstores.  These also number in the thousands, though not yet as many as those reported for urgent care models.  They are growing faster, however, as major chains such as Minute Clinic and RediClinic link up with pharmacy and superstore chains throughout the US.  These are rarely linked to hospitals or physicians, except as sources of oversight and support, though many create working relationships with physicians their patients report using.

An old style place option is the worksite medical clinic.  Originally, and these go back many decades, they were simply places where workers who were otherwise far from medical care could get it without having to travel far, such as the medical facilities that Kaiser Permanente created for workers during WWII.  Most provided routine primary care, though many included immunizations and physical exams related to work.  But their resurgence has gone well beyond “occupational health and safety” to include proactive health management aimed at reducing risks plus preventing disease and injury, as well as treating people for them.

The most recent development moving away from traditional healthcare places is e-health, where online and phone communications with nurses and physicians take the place of visits in many cases, include advice on the type of care needed including self-care options, and may include health coaching as well.  What has made this development possible has been the growth of new methods by which healthcare providers can generate revenue thereby, including, but not limited to, consumers’ out-of-pocket payments.

Initially, physician practices charged patients a little extra, perhaps $25 per month or so, to cover any and all online communications, or phone for patients without Internet access.  Concierge physicians have routinely included such communications under their annual retainers, usually one or two thousand dollars.  But increasingly, third-party payers are catching on to the advantages for them in paying for such contacts, and covering selected types of “placeless” visits.

While payers are split on covering retail clinic services, many have realized they cost less than traditional sources, particularly ERs.  Payers are generally opposed to concierge practices that include placeless visits in their extra services, but generally support the idea of patients being able to avoid visits by accessing online consultations.  Many have begun paying a pre-determined fee for online visits, for example.

As the “medical home” idea catches on, one element common to the model amounts to turning patients’ homes and workplaces into places where people can get medical advice, plus screening and coaching, from physicians or health management suppliers.  People can already get home, worksite or hotel visits from physicians who specialize in such services on a fee-for service basis, or from their concierge physician, covered by the annual fee.  At least one physician, Jay Parkinson, MD in New York City, offers an entirely online plus home visit practice, where there is no physician practice location other than where patients live.

Physicians in traditional practices have been slow and remain somewhat reluctant to offer e-mail or phone consultations to their patients.  Hospitals have moved only a modest amount toward expanding the places where they offer care to patients.  But at least a few thousand physicians and many entrepreneurs have ensured that health care, though not usually hospitals, is definitely not a place but a thing

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