Archive for Retail healthcare
by Scott MacStravic
April 4, 2008 at 1:21 pm · Filed under Health Plan/Payer CEOs, Business of Health, Retail healthcare, Health Management
Just last week, I described the many developments that, together, may comprise a “tipping point” in the movement toward proactive health management (PHM) as a complement to and means of reducing the need, demand, and expenditures for sickness care. Today, two news stories have described further developments in the same direction.
In the U.K., employers are already ahead of their U.S. counterparts in the use of health management for their employees. Since the government covers employee health care costs through the National Health Service, employers are focusing on even broader ranges of financial advantages from improving employee health. These include: reduced turnover from family or employee health causes as well as improved morale and satisfaction; often dramatically reduced absences; improved customer satisfaction and loyalty; and even new business that results from retained employees and improved service.
And now, the range of providers being enlisted to support the U.K.’s overall health management is being greatly expanded by including pharmacists in such efforts. The Health Minister there is pushing for the inclusion of pharmacists as providers of screening tests and vaccinations, even prescribing some drugs in particular cases. [J. Goldstein “In the U.K., a Push for Primary Care from Pharmacists” Wall Street Journal Health Blog Apr 4, 2008 (blogs.wsj.com/health)] In this, they would be emulating the many examples of pharmacist-based PHM for chronic disease patients, such as the Asheville, North Carolina project that has been successfully doing so for diabetics for years.
Meanwhile, there is another story about the development, in the U.S., of a retail clinic specifically and uniquely for healthy people, where most are intended for those with minor sickness problems. The clinic, called WellnessMart and based in California, describes itself as “The New Way to Healthcare”, and offers health services, health education, and health insurance, as well as health products onsite.
It is owned by physicians, including Richard McCauley, MD, and recently moved from the hallway of a health club to a strip mall in Thousand Oaks, according to this article from the Wall Street Journal Blog: “A Retail Clinic for Healthy People”. It claims to be “…revolutionizing the way America accesses care by making preventive services available through convenient retail stores. These stores are designed to provide healthy people the quick, easy, understandable tools and information they can use to make sure they avoid disease.”
This is in contrast to reliance on physicians’ offices. “Until now, the basic tools that healthy people need to prevent disease have been confined to the doctor’s office, a place designed for sick people.” The “mart” offers free workshops throughout the day to help people understand their body and how it works, to ensure people know not merely what to do in order to be healthy, but why. It offers clients a $100 “Wellness Bucks” reward for every year they renew their health insurance through WellnessMart.
Of course, all retail clinics offer some preventive services, such as brief physical exams for school, common immunizations for flu and pneumonia, for example. The RediClinic chain offers a wide range of “Stay Well” services to complement its “Get Well” services. But the Wellness Mart seems to be the first to focus entirely and exclusively on promoting health and preventing sickness.
It will be interesting to watch the Wellness Mart to learn if this business model works, at least in the California locations where it is offered. The idea of offering a different place for wellness vs. sickness care may be appealing to consumers, or physicians and retail clinics may be able to combine them in a logical and complementary way that works even better. But clearly, the movement toward wellness is growing.
by Scott MacStravic
April 2, 2008 at 3:11 pm · Filed under Chief Medical Officers, Business of Health, Hospital Administration, Retail healthcare
The impending shortage of physicians, particularly primary care specialists such as family practitioners, internists, pediatricians and geriatricians, has been shouted about by medical professionals as well as health care gurus of many stripes. It has been used as a reason to criticize concierge practices, despite their affecting only about 1/1000th of all physicians so far. It has also been used as an argument for rescinding Medicare cuts to primary physician payment schedules, and for adding new payments for their “medical home” and “proactive health management” services.
More recently, the medical profession has taken on developments such as retail clinics which use nurses or physicians’ assistants, rather than physicians, on grounds of quality concerns. The fact that these clinic offer more convenient care at lower prices, hence take away lucrative patients and visits from physicians is by no means ignored, though never mentioned by physicians, themselves, as a reason for their objections.
Meanwhile, the vast majority of proposed solutions to the impending if not already arrived “health care cost crisis” and even the promotion of health insurance for all, depend to a great extent on the mis-labeled health care system actually moving more to health vs. sickness care. This would normally be the logical jurisdiction of primary physicians, except that there are nowhere near enough of them, and they are not particularly adept at it, plus being the most expensive source of health management care available. Though some have proven their abilities in disease management, only those functioning in concierge practices, which many physicians also object to, seem to be making a go of health management.
While they may argue as much as they wish about nurses and other non-physicians being involved in sickness care, there are few and far weaker grounds for objecting to nurses, physicians’ assistants, pharmacists, etc. from being primary sources of health management services. Nurse coaches already function as the main sources of coaching for people participating in health risk and chronic disease management programs offered by insurers, specialized suppliers, and healthcare organizations who provide such services.
Pharmacists have been demonstrating for years their high level of cost-effectiveness in managing the conditions of chronic disease patients, such as diabetics, whose care is largely dependent on medications and adherence to their prescribed use. The Asheville, NC example of diabetes management using pharmacists has been delivering amazing results for a decade. The Diabetes Ten City Challenge combines pharmacist diabetes management with value-based insurance operates in ten cities for 29 self-funded employers. [L. Masterson “A Prescription for What Ails Us?” HealthLeadersMedia News: Health Plans, Apr 2, 2008 (healthplans.hcpro.com)]
The use of non-physician health professionals to deliver the vast majority of the kinds of services that will be needed to achieve the kind of reduced incidence of disease and injury on which the survival of our health care system depends is not merely a desirable, but an essential reality. Perhaps it is time for physicians to work on how to engage and coordinate their special expertise with the rest of the wide range of health professionals out there, rather than devote so much energy to protecting their own jurisdictions.
by Scott MacStravic
March 26, 2008 at 1:27 am · Filed under Business of Health, Retail healthcare
In a story appearing Mar 3, it was reported that an idea that is roughly thirty years old in the US has reached Europe, at least to the extent that the UK is recognized as part of Europe despite its maintaining its own currency. This idea is that of the kind of retail medical clinic called “urgent” or “convenience” care when it began in the 1970s here. I remember when one of my students at the University of Washington initiated the first one in the Seattle area after graduation, and later sold out to a large firm for a handsome profit.
The kind of clinic that recently opened in the Manchester, England area, in a Sainsbury supermarket is unlike the ones that have opened in drugstores, supermarkets and superstores such as Wal-Mart here. It is staffed by physicians, and is strictly an “after-hours” option, open only on Tuesday and Thursday evenings 6:30 to 9:30 PM, and Saturday 11:00 AM to 3:00 PM. Here, they are usually staffed by nurse practitioners rather than physicians, and are open during the day as well as after hours. [J. Werdigier “Combining Grocery Shopping with Doctors’ Appointments” New York Times, Mar 3, 2008]
It works by appointment, and will serve only patients who are already registered with local general practitioners, otherwise could not be paid by the National Health Service. It will function as a “covering” service for these GPs, as well as a convenience for those who have trouble getting away for an appointment during working hours. It is called “Doctors in Store”, and was created by Dr. Mohammed Jiva, after finding that his patients were often requesting evening appointments.
Like patients in superstores in the US, patients at Sainsbury’s will get pagers so they can shop rather than wait for the physician if running late, and can get their prescriptions filled in the store immediately after their visit. The location also makes it safer for physicians than if they had to lock up their own offices at night in what are sometimes rough neighborhoods. And it will certainly be convenient for patients as well. [J. Reid “Shoppers to Be Seen In-Store by GPs” Sky News, Mar 3, 2008]
The story in Sky News noted that this is not the first clinic where GPs make their services available in a store, since there are already two examples in Boots drug store chain stores, but these are only open during normal office hours. And a reader commenting to the story reported that there is already an after-hours example in Dublin, though Ireland is no longer part of the UK, of course. The need to be pre-registered with a local GP and the in-store clinic, and to make appointments, as well as the fact that they are staffed by GPs rather than NPs, makes their operation quite different from the US examples, though the idea of adding an option for convenience reasons is the same.
Another reader commented that if the GP in Sainsbury’s recommends a healthier diet to any patients, they will have to skip right by the many unhealthy food and drink options filling the shelves in the store, from sugary drinks to pork pies to alcohol. Though a similar challenge faces all patients served in supermarkets and superstores in the US, it is not nearly as big a challenge as the general one facing the shopper population at large. Judging by the growing rates of obesity in both the UK and the US, it has been a challenge not won by healthy over “comfort food”.
If the first example in Manchester proves successful, it is expected to be repeated in other Sainsbury stores later this year. And if the US example is a good predictor, it might also be repeated in other supermarket chains such as Tesco, which has an ever larger share of the market than does Sainsbury’s. These clinics normally provide classic symbiotic benefits to their host stores, by driving added general traffic shoppers, as well as promoting use of their pharmacy in particular.
In an effort to improve the overall availability and convenience of GPs, the British NHS had already opened a few walk-in centers in railroad stations around London, though these have been weakly promoted, and suffer from lack of continuity of care and patient records with such “drop-in” patients’ GPs. A proposal to extend the hours of GPs, generally, has been rejected by the British Medical Association, making the after-hours model that much more competitive in the UK.
While this development is thirty years late, compared to the US, it does suggest that British patients have similar kinds of concerns over the inconveniences of traditional medicine. The retail clinics in the UK are thoroughly within the realm of traditional physician practices, with added convenience of place and time, and it should be interesting to watch what happens there.
by Fred Fortin
January 18, 2008 at 12:31 pm · Filed under Uncategorized, Insurance, Industry Sector, Public Purchasers, Health Plan/Payer CEOs, Policy Makers, Business of Health, Medical Tourism, Retail healthcare, Electronic Medical Records, Research, Alternative Medicine
I don’t know if you’ve noticed but as we move into 2008 there’s a glut of papers, reports and predictions about what is going to happen in health care. Some have such a definitive tone, it makes you wonder if any have read Nassim Nicholas Taleb’s, The Black Swan, which engenders in the reader a humble appreciation and respect for role of high impact, improbable events in social affairs.
Anyway, I’ve taken the time to look through some of these pronouncements. Many are rehashes of the what I would call “more of the same” prognostications, others find us at various tipping points — unsustainability being a key concept here — in health care and forecast some, often vague, deep changes to come. Below are some of the bits and pieces of these various offerings of the future that caught my eye.
- Expect large institutions to make significant IT investments; RHIOs will still struggle with architecture and governance models; EMRs creep closer to reality, and health plans will continue to implement consumer-directed vendor partnerships. (Forrester)
- Doctors are using the Internet far more than their national averages, using email, obtaining professional information from online journals, attending courses and conferences, receiving professional updates and performing professional, administrative functions. . . In essence, in the short space of time that the Internet has been easily accessible through the Web, doctors have harnessed its power in both their personal and professional lives. All indications are that they will continue to do so. ( Masters)
- Two areas that are going to get a lot of play in the next year or two. There are a number of products in the telemedicine space that use IT not as a database or workflow tool, but as a telecommunication and management system, teleradiology is one prime example. The other is interoperable home-monitoring devices. There’s good value with keeping people out of nursing homes, and it’s getting a lot of attention right now from doctors, hospitals and health plans. (Brailer)
- Don’t see much of a business case for health 2.0 technologies, although personal health records as a concept has some validity, particularly as a service provided by health plans and employers. Still in a wait-and-see mode on PHRs. (Brailer)
- Medicare’s Hospital Insurance (HI) Trust Fund is already expected to pay out more in hospital benefits this year than it receives in taxes and other dedicated revenues. The growing annual deficit is projected to exhaust HI reserves in 2019. (Friedman)
- For the first time, a safe, effective and reversible hormonal male contraceptive appears to be within reach. Several formulations are expected to become commercially available within the near future. Men may soon have the options of a daily pill to be taken orally, a patch or gel to be applied to the skin, an injection given every three months or an implant placed under the skin every 12 months. (Schieszer)
- U.S. health care costs are growing at 8 percent per year, an unsustainable rate that will be forcing every employer to make a crossroads decision in the next 12 to 36 months: either continue to provide health care benefits to employees and become very aggressive about controlling expenses or exit the insurance market completely and let employees fend for themselves. (Deloite)
- Physician-hospital tensions will increase. Employer-health plan tensions will increase. The non-conventional provider movement (complementary and alternative medicine) will be pitted against the conventional. Off-shore resources will compete against high-cost domestics. The under-insureds will compete with employers for funding and services. Biologics developers will attempt to fend off traditional pharma to capture the high ground in diagnostics and therapeutics. Tension, anxiety, and turf battles for success will heat up, but so, too, will opportunities. (Deloite)
- In an environment where employers and consumers are demanding more for less, medical tourism, telemedicine, and other innovative disruptions offer attractive options for people who require expensive surgery and procedures but do not want to be limited by their health care insurance policies. (Deloite)
- Significant change is unlikely prior to 2010 and is apt to be gradual thereafter. Although urgency is still the operative word, the players involved have a healthy respect for the complexity of the problem and the runaway costs that will result if they get it wrong. Even if some changes emerge in the first year of the new administration, implementation would take at least a year. Bigger changes would probably follow, being phased in starting in 2011. (Booz Allen)
- A surge in the number of retail clinics will force states, payers, and policy makers to think about the right model for the delivery of primary care. (PWC)
- The market for individual health insurance could take off. (PWC)
- We envision the proliferation of “health infomediaries” (HIs) who help consumers navigate the insurance, channel and service options in care delivery. HIs will become a fixture in the landscape for both the well and the chronically ill, and for a much broader socioeconomic segment of the population. (IBM)
- The combination of the push for universal coverage, the erosion of employer-based insurance and the aging population is expected to drive this continued shift to individual and government-based coverage. (IBM)
by Scott MacStravic
January 15, 2008 at 12:50 pm · Filed under Hospital and Health System CEOs, Retail healthcare, Population health management, Alternative Medicine
The concept of having a “chief experience officer” is starting to catch on in healthcare organizations (HCOs), witness the organizations such as the Cleveland Clinic that have adopted the idea. These “CEOs” do not usually sit at the same table or work in the same “C-Suite” as the chief executive officer, chief financial officer, etc. but the notion of having a person at a high level in the organization responsible for customer experiences has at least some champions. [A. Cirillo “Embracing the Philosophy of the Chief Experience Officer (Even If Your Organization Won’t” HealthLeadersMedia.com Jan 8, 2008]
The idea of having a single person “in charge” of customers’ experiences is founded on the reality that customer experience is becoming the major, often the sole competitive distinction available to many HCOs, where consumers tend to think all are of equal quality in terms of health services. The recognition is also growing that the “patient experience” includes more than what happens inside the walls between admission and discharge in a hospital, or arrival and departure from an ambulatory care facility.
Recognition that “customers” include more than patients, such as family members, especially physicians who refer or admit patients to the hospital or ambulatory facility, and payers peaked long ago, while focus on consumers is growing. And no one in most HCOs is in a position to manage the entire customer experience for any of these customers, though programs for physicians and payers are often more formally organized, with clear accountability held by somebody. [In my last position as Chief Marketing/Strategy Officer, I shared responsibility for payer relations with the CFO.]
But does having a chief experience officer make sense for HCOs that are engaged in the population health management (PHM) business? Clearly, it makes sense for such organizations to have someone accountable for relations with the employers, commercial insurers or government agencies the PHM HCO deals with, both winning new customers and keeping current ones. But does it make sense for the other “customers”, namely the individual participants in the PHM interventions that are the main source of benefit to employer, insurer, or government clients?
To answer such a question requires first a definition and description of what the “experience” is for participants, as does the same question with respect to clients. In most cases, the experience that champions of the chief experience officer are dealing with involves the processes of interaction and transactions between the seller and the buyer. But in PHM, a far more important consideration for clients will be the outcomes of such interactions and transactions, not so much the process that is involved. And even with participants, the outcomes to individuals may play a major role in determining how many participate in the first place, and how many remain participating as long as they yield benefit for themselves and the payer that is footing the bill.
This does not mean that the process elements in interactions and transactions are ignored. Any inconvenient, upsetting, disrespectful, or otherwise unpleasant interactions or transactions between the PHM HCO and its clients or participants would seriously jeopardize the relationship. But it is more often the question of what clients and participants get out of this relationship, versus the characteristics and process elements of the relationship, that make the biggest difference.
For these “new” CEOs to be successful in PHM HCOs, they will primarily have to become fully familiar with what kinds of outcomes both categories of customers expect and would welcome from their process experiences. Not only must these process experiences be satisfying in their own right, they must lead to early indications of progress, if nor success in PHM initiatives and investments. How much clients and participants have to invest, for example, in money, time, and effort, compared to how much benefit they perceive themselves as gaining, will greatly determine what they think of the experience.
PHM HCOs would be wise to initiate their own “early warning” systems to monitor what is happening as a result of their PHM efforts – how many participants show changes in: 1) knowledge/attitudes toward the health challenge each is working on; 2) behaviors that will lead the kinds of health status changes desired, or avoid the changes feared; 3) health status indicators and biometrics that reflect progress and success; and 4) what kinds of reduced use/expense for sickness care (insurers) plus workers compensation and disability expense, worker productivity and performance (employers) has been noted.
The early warning indicators can not only give clients and participants confidence that positive changes are happening, or negative ones not happening, but serve to clearly show the connection between the PHM tactics and activities and the intermediate as well as final results and economic benefit that results. It will enable PHM providers to not only describe what benefits have arisen for both types of customers, but to make a strong case that they arose specifically in response to the PHM intervention or strategy involved, rather than by chance or due to some other cause.
The new CEO in PHM will have to become or already be expert in measuring in addition to achieving the results that clients and participants are looking for. With participants, this will usually involve some objective biometrics, and some subjective perceptions, with both playing a major role in affecting satisfaction and perseverance. With clients, it will usually involve a combination of “hard” objective data from the client’s own operational databases or records, as well as new measures or estimates of productivity/performance impact on employees.
These estimates may become increasingly difficult to tie to PHM elements and measured progress, but when they occur at the same time as, and in a way that is closely correlated with early indicators, the estimates will likely be more readily accepted and deemed credible by clients. Letting any supplier measure the success of its own efforts will always generate some skepticism, but if there is clear evidence for the connection between the process experiences of participants, and their estimated as well as measured results, and a strong link between both hard and soft results, the measurement experience itself is likely to be more satisfying to clients and participants alike.
In the long run, this new CEO must also include the “E” of evidence, since unlike sickness care where recovery and rehabilitation have well-established measurement techniques, the process of tracking outcomes in PHM is in its early development phase, as far as soft data on workforce productivity and performance. Fortunately, this soft data is not only easily translatable into financial benefit measures for clients, but into personal health/life benefits for participants, through well-tested health/life quality metrics. And if chief evidence officer as well as experience, these new CEOs may easily prove their worth to their own organizations, and end up joining their peers in the “C-Suite” based on their proven importance and value.
by Scott MacStravic
January 4, 2008 at 5:27 pm · Filed under Hospital and Health System CEOs, Retail healthcare, Population health management
I just read what, if I recall correctly, is at least the third article on the subject of whether retail clinics are good or bad for hospitals published in the past year. (M.K. Scott “Retail Clinics – Friend or Foe of the Hospital? Part 1: The Opportunity for Hospitals to Win with a Retail Clinic Model” HealthLeadersMedia.com Jan 4, 2007] It brought to mind almost identically titled discussions of population health management (PHM) relative to hospitals, of which there have been at least an equal number, some written by myself.
The article, which is certainly worth reading, cited six positive impacts that retail clinics could have for hospitals, if they exploit the opportunity well:
* Diverting patients that would otherwise overcrowd the hospital’s emergency room (example: Aurora Health Care System in Wisconsin)
* Preventing rival hospitals from “capturing” patients for their own “networks” by offering their own clinics (example: AtlantiCare in New Jersey)
* Capturing new patients to the hospital’s own network, including outlying areas from which it may not be getting many patients at present (examples: Geisinger in Pennsylvania and Allegent Health of Omaha)
* Creating significantly more opportunities to interact with potential and current consumers/patients than is likely with just current hospital in- and out-patient services
* Improving the public’s health through health and wellness services
* Creating a new channel for other “business lines” (example: durable medical equipment sales and distribution for Atlanticare, and pharmacy business for Aurora)
The article also mentioned two indirect challenges/opportunities that accompany developing retail clinics: 1) piloting a “skunkworks” approach to innovation that can serve other opportunities for serving and capturing patients; and 2) gaining a greater understanding of the “generation X” patient segment, whose members (aged 28-42) are far more likely to use retail clinics than hospitals. The second article in this series will discuss specific tools that hospitals can use to assess the retail clinic opportunity.
Since the author is in the business of consulting with hospitals, as a “nationally recognized authority on retail clinics” (author’s bio at end of article), it makes sense that this analysis reaches a completely “friend” vs. “foe” conclusion to the question it begins with. But from a strategic perspective, the picture is not quite as clear, as is the case for hospitals’ engaging in PHM. [S. MacStravic “Alternative Ways to Gain Revenue from Employers” HFMA’s Managing the Margin Oct 2007]
Retail clinics’ primary business is “sick care”, i.e. the reactive treatment of patients who have symptoms of routine, non-emergent illness or injury, and hospitals depend on physicians for referrals and admissions that fill their beds. But physicians may not like retail clinics, may feel they deliver inferior quality of care, or simply compete with physician practices, particularly the clinics that are staffed by nurse practitioners or physicians assistants. Many physician organizations have publicly and vigorously opposed such retail clinics, for example.
And having such clinics (then usually labeled as “urgent care” clinics) staffed by physicians doesn’t calm other physicians’ objections. I still recall the case, now two decades old or sol, when a San Francisco hospital operated and heavily as well as effectively advertised its own retail/physician-staffed clinic. While it had created no great fuss when it started, the advertising and subsequent dramatic increase in patient volume greatly angered physicians who deemed this competing with their practices.
At the next board of trustee meeting, the angry physicians managed to capture the majority of seats, and both the administrator and the director of marketing, deemed responsible for such an unfriendly act, were tossed out peremptorily. Such a risk surely remains today, even though primary physicians are not as involved in hospital affairs nor as powerful on their boards as was once the case. There remains the potential that all physicians might be greatly exercised by the very idea of retail clinics.
An even greater objection among physicians may arise if the retail clinics that hospitals invest in or simply work with happen to be engaged in proactive health management (PHM) services, in addition to the sick care services that compete with physicians. In the “medical home” model that primary physicians are embracing, such clinics would be competing with those physicians in a wide range of PHM services, from immunizations to screenings, to coaching.
The RediClinic chain of retail clinics, for example, offers both “Get Well” sick care services and “Stay Well” PHM services, and promotes both to the public and existing patients. The new Convenience Care Clinics chain will do much the same. Hospital-sponsored might be less likely to offer, or at least advertise PHM services, since they operate against all physicians’ interests in the sense that they aim to reduce the incidence and prevalence of disease and injury, which form the foundation of the vast majority of specialists’ as well as hospitals’ revenue and profits.
Many hospitals already offer PHM services to some degree, though often limited to selected diseases or populations. Some offer just PHM disease management (DM) services, though most who offer seem to lose money at it. Some offer broader health/risk management to frail elderly population segments, to keep them from needing what often turns out to be unprofitable episodes of hospital care, which is in both the patients’ and the hospitals’ best interests.
PHM for employee populations has been strongly recommended by consultants who help hospitals develop programs that do so. The rationale is that hospitals should be able to capture enough added sick care business from employers who establish working relationships with the hospitals offering such services, to offset the loss of sick care business, though I know of no study that has compared such gains to losses.
Another argument may be that employers who save considerable money through improving their employees’ health are likely to be more generous when PHM is a “cost-savings/profit enhancement center” for them than they will ever be with sick care, which will always be thought of as an expense, and one which is already annoying employees severely. The trouble is that PHM is already replete with specialty suppliers offering already proven strategies and initiatives, so hospitals may prove to be weak competitors, or may not make as much profit as predicted in such a competitive market.
In any case, there have certainly been no studies thus far as to the extent to which retail clinics, including those operated or paid for by employers at their worksites, which deliver far more PHM services than do the usual retail clinics, and have reported significant reductions in sick care use and expense. Moreover, the MDVIP concierge practices have already shown reductions in hospital and ER use that range from 30 to 90% among the populations they serve.
When primary care practices — whether offered by nurse practitioners, physicians’ assistants, or primary physicians – offer PHM services to any significant degree, they will automatically be operating against the financial interests of procedure-based physician specialists and the hospitals they use as their “workshops”. If hospitals engage in or otherwise support any form of primary care that includes, and particularly those that emphasize PHM vs. sick care, those specialists upon which their sick care revenue may be even more likely to compete with the hospital by creating and operating their own specialty hospitals and free-standing ambulatory care centers.
In any case, while it may be possible for hospitals and retail clinics to be “friends”, it will be a major undertaking to achieve all the market responses and successes that such clinics offer, while maintaining success in hospitals’ current dominant sources of services demand, revenue and profits. There may be some way to get the level of enthusiasm among specialists all the way up from antipathy to apathy, but winning their enthusiastic support seems a bit unlikely.
by Scott MacStravic
October 5, 2007 at 2:47 pm · Filed under Chief Medical Officers, Hospital and Health System CEOs, Business of Health, Retail healthcare
Solutions have frequently been cited as a major part of the healthcare cost crisis. Their wide variation in how aggressively and expensively they treat sick patients is one example often cited. Their modest adherence to best practices in such treatment, barely over 50%, is another. Physicians have been criticized for not providing enough prevention, wellness, and risk reduction, as well as not managing chronic disease cost-effectively, though since they are rarely paid for such services, this can hardly be surprising.
But there are exceptions, and there have been significant recent moves toward creating practice models that balance sick care with true health care, protecting and improving patients’ health, managing their chronic conditions, and as a result, actually saving money for patients and payors. One example is the “concierge medicine” development, where physicians collect an annual retainer from patients, to cover the added costs of delivering health as well as sickness care.
The MDVIP organization of primary retainer practices has about 175 physicians practicing in 16 states the last time I checked. For an annual retainer of $1500-1800, they offer a comprehensive program of health protection and improvement to each patient, and with no more than 600 patients per physician, they have the time as well as money to do so. As a result, they have reported dramatic reductions in the average hospital and ER costs per patient, compared to patients in traditional practices in the same states. (www.mdvip.com)
An even more radical and recent example is the practice of Dr. Jay Parkinson, in New York City. He opened this practice on Sep 24, so it could hardly be more recent. It combines a “prepaid” visit program, where patients get up to two visits a year, the first to obtain basic information on each patients’ health history, current medications, etc., as a foundation for subsequent care. These visits are made at patients’ homes or work sites, since Dr. Parkinson does not operate an office practice, thereby keeping overhead minimal. In addition to these prepaid visits, patients get e-mail or phone consultations, referrals to specialized care when needed, prescriptions and advice for routine problems, and ongoing health or disease management support.
Dr. Parkinson intends this practice for adults aged 18-40, without traditional health insurance. It fits well with CDHP insurance, since the deductible may be satisfied, or at least largely satisfied by the prepaid payment, while the practices services will tend to keep patients from incurring the total deductible unless they are really sick. And the “catastrophic” insurance of CDHP, or any major medical insurance plan, would fill in for specialist physician, hospital, and other costs that exceed the deductible.
He also intends to help patients save money by having information about the prices charged by specialists, lab tests and diagnostic scans, prescription vs. generic drugs, etc. so that patients may choose the “best deal” available as they see it. And by promoting healthier lifestyles, risk behavior and condition reversal, and disease management, he will save them money on sickness care, if they cooperate in such efforts.
Unlike the MDVIP retainers of $1500-1800 per year, Dr. Parkinson charges $500, with additional house calls when needed at $200 each.
With unlimited access to phone, online ,video chats, instant messaging or wireless communication, patients may aim to lose weight, quit smoking, manage diabetes, reduce cholesterol, handle chronic migraines, improve fitness, diet, or any similar proactive health goal.
This practice is specifically designed to serve employers well, in addition to patients. The age group of 18-40 is most likely to be employed, compared to seniors, for example. By making worksite “house calls”, he saves employees the need to seek care elsewhere and lose travel and waiting time away from work. By making lower-cost CDHP insurance work better for employees, it helps employers save money on health insurance, while still offering it in order to recruit and retain employees.
Moreover, since protecting and improving employees’ health saves employers, the practice is one both could love for that reason alone. With proven savings from employee health management in terms of health, disability and workers compensation costs – absenteeism, presenteeism and turnover costs – and even improved quality, customer satisfaction and new business and their related revenue increases – employers could gain far more than just saved physician visit time.
Physicians who are aware of the potential savings from practices that focus on both sickness care and proactive health management may find an interested audience among employers. After all, a large number of employers, mainly larger ones, pay for onsite medical clinics to provide precisely this mix of services for their employees. Physicians in practices such as the MDVIP organization, and Dr. Parkinson’s “placeless” care, should represent a significant source of support for this model, to say nothing of their employees.
by Scott MacStravic
September 14, 2007 at 8:02 am · Filed under Insurance, Hospital and Health System CEOs, Consumer Engagement, Disease Management, Retail healthcare, Health Management
The major emphasis in “consumer-directed healthcare” proposals for reforming consumers’ healthcare behavior – turning them into prudent and well-informed purchasers of sickness care when needed. This would be in sharp contrast to the pattern of purchase behaviors where someone else is responsible for paying, and consumers feel entitled to as much care as they feel like getting, at least if they are insured well enough to cover the costs.
But there is an equal and potentially more valuable effect that may arise from shifting more costs, responsibility and information to consumers with respect to sickness care costs. They may begin to seek, on their own, ways to manage their own health so as to reduce their risk of and thereby expenses for sickness care. Already, employers, commercial insurers and government insurance programs have enrolled millions of people in free-to-participants health management (HM) programs, in any one or a mix of: general health and wellness promotion, risk behavior or condition prevention and correction, and chronic disease management.
While the costs of payor-sponsored HM programs tend to be lower than what consumers could purchase as individuals, this is not always the case, particularly when payors don’t get involved until consumers are patients with complex and expensive chronic diseases or multiple co-morbidities, where costs of disease management can run to over $5,000 a year per participant. Consumers have access to a wide range of differently-priced options if they wish to take charge themselves, and are willing to pay out-of-pocket for that right.
Concierge Physician Practices
“Boutique”, “concierge”, “retainer”, “membership” or “patient-paid” practices were started primarily to offer premium access, availability, amenities, and advocacy relative to sickness care when they were introduced just over a decade ago. But most of the later-introduced examples were started, or have chosen to include major proactive HM services along with sickness care, and a few specialize entirely in HM, offering no sickness care.
These practices charge as little as $50 a month, and as much as $100,000 a year, though most are in the $1,000-2,000 range. The MDVIP practices, numbering over 150 in 16 states cite the fact that “VIP” means “value in prevention”, not merely “very important patient”. And they have proven the value to payors, as well as patients, in their services, with dramatic reductions in hospital inpatient care utilization and expense among their patients, compared to average Medicare patients, and members in the best managed care plans. (www.mdvip.com)
Cash-Only Practices
Some physicians have offered health management services on a patient-paid fee for service basis, rather than annual retainers. These are typically “opt–out” practices where physicians chose to reduce their overhead to a minimum by not dealing with insurance, though they normally provide the paperwork necessary for their patients to seek reimbursement for their payments from insurers. I recall an early adopter of this approach was a practice called “HMNo” in Denver, though it has since changed its name and become a retainer practice.
At the “Beyond Care” practice in Branford, Connecticut, the physician offers packaged HM programs related to wellness, fitness, stress management, nutrition, diabetes/metabolic syndrome, etc. and lasting from three to six months. These programs were offered at prices between $1800 and $2800 when I first encountered them, though a recent visit to the practices website found no prices mentioned. (www.beyondcare.net) The Tempus Clinic in Los Gatos, California offers a wide range of HM programs, including its health club memberships, that were once priced at between $10,000 and $30,000, though a recent visit to its website also found no prices mentioned. (www.tempusclinic.com)
Retail Medical Clinics
The majority of these convenient, low-cost, nurse-practitioner-staffed clinics focus almost exclusively on routine sickness care, at convenient locations, affordable prices, and easily accessible hours. But at least some have added significant proactive HM services to their offerings, in addition to the usual array of physicals and immunizations. These are the RediClinic locations, of which there are seven in five states in the South. These offer a “StayWell” set of services to complement their “GetWell” treatments.
These include extensive health risk screening packages, ranging in price from $39 to $89, as well as traditional physicals. And the clinics also offer a four-visit “Stop Smoking for GoodSM” program priced at $128. And they have recently added a variety of “Cholesterol Challenge” programs at some locations, ranging from $49 to $89 in price. They also offer a “Heart Health” program at prices of $79 or $129. (www.rediclinic.com)
Low-End Options
HM programs that rely mainly on automated analysis of health risks and automated online communications, or website self-service can afford to charge highly affordable prices per participant for payor-sponsored population-focused HM programs. The same options are available for individual consumers, as well. Three physician practices in Colorado offer a fitness/weight management program called Physicians Fitness Coach, through incentaHEALTH, in Denver. It includes physicians, along with e-mail communications, and is priced at only $19.95 per month.
Another Colorado practice, Family Physicians of Western Colorado was able to apply the Chronic Care Model of disease management for its diabetes patients at an additional cost to the practice of only $104 per patient per year. It lost money in this effort, because it could only get one health plan to pay for this program, and that plan covered only a minority of its patients. [P. Mohler & N. Mohler “Improving Chronic Illness Care in a Private Practice” Family Practice Management 12:10 Nov/Dec 2005 50-56] But had it chosen to offer it to self-paying patients, this would easily have represented an affordable option for most patients.
With growing numbers of consumers choosing, or being offered no other choice but high-deductible health plans, these self-paid options are becoming increasingly attractive to many of them. Even the higher-end practices such as the MDVIP examples are attracting middle-income patients, some of whom find their annual retainer is a bargain compared to the deductibles and co-payment costs of their insurance plan. And many such plans permit employees to use their health spending accounts to pay for the retainer.
With other options available at prices as low as $20 per month, the number of consumers who could afford to pay for their own, particularly if they lack insurance coverage, is sure to increase. Whether the number who choose such programs will also increase is another question, however. Many will no doubt prefer to try personal HM on their own, without help. But most such efforts have failed, and in the long run, affordable self-paid options may become widely popular.
by Scott MacStravic
September 14, 2007 at 8:00 am · Filed under Employer CEOs, Health Plan/Payer CEOs, Hospital and Health System CEOs, Business of Health, Retail healthcare
While numerous and varied healthcare reform gurus have suggested numerous and varied solutions to the healthcare crisis, physicians, employers, and other stakeholders in the “system” have already initiated their own. There are four specific medical care innovations, for example, that have created a mixed “sickness and health” model for delivering real healthcare, with increasing focus on health, as well as sickness.
Concierge Medicine
This innovation is not the oldest, but is certainly one of the more successful, both in growth and in health results. I have a list of over 200 organizations engaged in “patient-paid medicine”, and know of over 700 physicians involved in either these organizations or private practice examples thereof. The vast majority of these mix health management with sickness care, often in a close to 50/50 mix overall, though the mix for individual patients can vary widely.
While the MDVIP organization of over 150 physicians is the only one that I know of that has reported results of its model of health and sickness care, it has described dramatic reductions in the use of expensive sickness care, such as hospital inpatient care, among both commercially and Medicare insured patients served by its practices. These reductions range from 30% to 90% across the states where comparisons have been done with patients served by traditional primary care. (www.mdvip.com)
Worksite Medical Clinics
Employer-sponsored medical clinics have been offered by large businesses for decades, though most used to be limited to occupational medicine and work-related injuries. Many of those limited to sickness care closed as employers found them an insufficient and expensive solution to rising healthcare costs. But there has been a resurgence in this innovation, mainly including health along with sickness care, and promoting risk reduction along with general wellness, to reduce the incidence and prevalence of sickness, along with eliminating the need for employees to go elsewhere for sickness care.
Employers have frequently developed their own clinics, though firms specializing in operating such programs, such as Concentra (www.concentra.com) which operates in over 200 locations across the US, can bring in “outsourced” programs. Quad/Med is the medical care division of Quad/Graphics, a major printing firm in Wisconsin, and uses its experience as an employer to help other employers set up and operate onsite medical clinics of their own. Whole Health Management in Cleveland is another example of outsource clinic managers.
It is the emphasis on health and wellness, along with risk reduction that makes these onsite clinics different from former occupational health programs aimed mainly at reducing employee time away from work getting sickness care. These new clinics enable employers to reduce healthcare, workers compensation and disability costs, but also worker absences and impaired productivity/performance at work, greatly multiplying the benefits of a healthy workforce, to the employees as well as the employer.
Retail Clinics
These rapidly increasing innovations fill a niche as convenient, low-cost alternatives to physician practices and hospital ERs. While most are staffed by nurse practitioners, whose limitations rather than advantages seem to get most of the attention from physicians, there are many “urgent care” clinics staffed by physicians as well. Their location and hours-of-availability convenience are widely popular among consumers, though controversial among physicians.
While the major emphasis of these clinics is on routine sickness care, along with immunizations and school physicals, their potential value as sources of inexpensive and convenient health management services has also been recognized. A reader’s comment to a bog story (“Some Health Systems Out to Beat Retailers at the Clinic Game” Wall Street Journal Health Blog May 16, 2007] suggested that Wal-Mart-based clinics would be great places for checking blood pressure, blood sugar, weight, etc. in conjunction with primary-physician-based health management. But most physicians do not really manage health, and most insurers have no codes for billing such services.
At least one retail clinic chain, RediClinics, has a “Stay Well” as well as a “Get Well” program, with health management services at affordable prices, just like its sickness care services (www.rediclinics,com). It offers preventive services such as risk condition and chronic disease screening, smoking cessation, etc. for as little as $19, more complex screening men’s, women’s and heart health packages for $59+, and cholesterol challenge packages starting at $5. The full potential for retail clinics to become major sources of ongoing health management support for consumers is only beginning to be recognized.
As primary physicians continue to be in short supply, and this form of sickness care practice loses even more of its luster for medical school graduates, the health management side of healthcare may offer new reasons for physicians to choose one of these innovative options. Physicians may be the sole or major health manager for patients, the leader of a more cost-effective team approach, or merely stay informed about services provided by nurse practitioners through close communications therewith. All three at least have the advantage of working toward what virtually all healthcare stakeholders are hoping for – reduced incidence, prevalence, and financial as well as life quality costs of sickness.
by Nick Jacobs
September 4, 2007 at 11:21 am · Filed under Health Plan/Payer CEOs, Hospital and Health System CEOs, Retail healthcare, Population health management
The very first time I ever visited a nursing home, a high end nursing home, I vowed that, regardless of my infirmity, I could find someone to help me get to the Netherlands to avoid the experience. One of the elements that contributed to this conclusion was my observation of the help. They were generally overworked, underpaid and angry. Clearly, minimum wage or near minimum wage was difficult enough, but the responsibilities of a nursing home aid are as difficult as imaginable.
Imagine that this is the best scenario possible, a supervised, controlled environment. Now, take these employees from the structure of a nursing home, put them into private homes, pray that they get at least 75 hours of instruction to become a home nursing aid and hope for the best.
As additional baby boomers need help in their final years, it is a ticking time bomb that will become more of a problem for this country. There are few controls in place in many states to ensure proper training, to monitor certification granting centers or to observe the capabilities of these employees.
New York State Attorney General, Andrew Cuomo, has begun an investigation of home health aides in New York. One of the issues being investigated is the fact that no one has accurate figures as to how many home health aides work in the State. According to the New York Times, Cuomo is “in the middle of a two-year investigation into fraud into the home health industry.” Included in the investigation are schools that have issued inappropriate certifications and agencies that have billed Medicaid for labor that was never performed.
The Times reported that an estimated 131,000 aides are working in New York, and they are generally working long hours for low wages. Cuomo went on to identify various scams currently being pursued in the state not the least of which involves completely fraudulent billing.
Bottom line? Although it is a very small percentage of the overall Medicaid budget, it represents millions currently being diverted away from those with medical needs, and, unless or until every state looks into this, the problem will only grow.
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