Enabling Healthy Decisions

Based on the latest Milliman Medical Index data, that average costs for an American family to receive healthcare in an employee sponsored PPO plan is $20,728. In general, that’s more than 20% of the households in the US make per year. And, I believe you can buy a decent car and still attend many colleges for less than that.

Can someone say “problem”?

While companies pick up the majority of it, the average employee is paying $8,584 of that for their family. That’s a strong reinforcement for the NPR article earlier this week about how it’s hard even for the insured to afford their healthcare…much less the uninsured.

The one thing that I think many of us miss is that there are ways to fix this beyond simply waiting for the Holy Grail of health reform to transform us overnight. (I’ll let you in on a secret…even if it’s not overturned, it’s not going to fix everything.) Let’s just look at some articles about our healthcare system:

1. This story talks about the importance of communications in healthcare.
2. This story talks about non-adherence even with cancer patients and high cost medications.
3. This story talks about pharmacy waste.
4. This story is about the scary amount of wrong diagnoses.
5. And, here’s one about how infrequently evidence-based medicine is followed.

So, if you combine the systemic issues with the human behavior issues, it seems like a low likelihood of getting the best care. That’s why we all need some “big brother” who’s watching out for us. Someone monitoring our claims. Someone providing counsel to us to help us make informed decisions. Even the physicians in the ACO or PCMH concepts need that.

Unfortunately I’ve been swamped lately, but I wanted to get out the notes from the last interview I did at the World Health Care Congress (#WHCC12) in DC. I had the chance to sit down with Jeff Welch from Health Care Service Corporation (HCSC). Jeff’s the Divisional Vice President of Consumer Markets which is obviously a very hot area these days as everyone is talking about the “retailing of healthcare“.

Jeff’s focused on some of HCSC’s consumer efforts including their work with Bloom which they bought with Wellpoint and BCBSMI. As we know from lots of surveys (e.g., Medco survey, Towers Watson survey), consumerism is a hot topic with lots of recent articles about the work that companies like Change Healthcare and Castlight are doing (see Money article or Bloomberg article). From Jeff’s presentation at the conference, he pointed out that 6M Americans are in consumer driven health plans today and that $550-$600B in premium dollars are already controlled by individuals. A key driver in this area is the adoption of defined contribution plans in healthcare which like retirement plans is a model where employers set aside a fixed amount of money for employees to spend on healthcare and then give them options from which to choose.

Bloom Health, established in 2009, provides employers and employees greater flexibility, access and choice of health care services by simplifying how they select and pay for health insurance. Through its platform, Bloom Health helps employers define and better manage their health benefits spending through a defined contribution model. The employer contributes a defined amount per employee toward the cost of employee health care benefits. Employees and individuals are presented with a wide selection of benefit plans through an online “marketplace” to best fit their individual needs. (from Bloom PR link above)

Bloom is a platform for defined contribution to help consumers manage multiple choices and to facilitate them making choices. Essentially, as Jeff explained it, Bloom allows the employer to act as an automated broker. Bloom provides both technology and call center support to enable front end enrollment (not claims processing). Right now, it sounds like they are focused on small groups and national accounts, but they are adding Medicare in the future. To me, it sounds like this is the kind of front end GUI that consumers need to help them begin to understand healthcare options and make educated tradeoffs about what choices fit them best.

One of the interesting things that we talked about is the Bloom “configuration engine” (my term) which uses survey data about individual health, financial, and personality data to match you with the best health offerings for your needs. Ultimately, this makes me think about how individuals can create a personalized health insurance plan in the future rather than picking from a subset of options today. I don’t think consumers are ready to do that since we’re not good at predicting the future, but there are algorithms that could help with this especially if Bloom were to load our claims history and health risk assessment data in and use it as part of the guidance process.

Today, the basic process is:

1. Employer implements a defined contribution plan.
2. Employer defines what the consumer can see in terms of options.
3. The Bloom Health tool helps the consumer select their best option.
4. The consumer selects their plan.
5. Bloom then transfers the process to the plan for implementation and ongoing management.

So, what does this mean in the future? This will play into the Health Insurance Exchange part of the health reform. Bloom offers a private exchange platform today. I think the Kaiser Family Foundation does a good job of identifying several key components of Health Insurance Exchanges:

1. Offering consumers a choice of health plans and focusing competition on price
2. Providing information to consumers
3. Creating an administrative mechanism for enrollment
4. Moving towards portability of coverage
5. Reforming the insurance market

Perhaps not surprisingly, even with health reform’s fate still in the air, the government and health plans appear to be moving down this path based on an article yesterday.

I took a quick look at some data from the Thomson Reuters 2010 PULSE Healthcare Survey about screenings by age compared to recommendations. Here’s what it showed (in summary):

There is a lot of information in the news about obesity, metabolic syndrome, and diabetes these days. In many cases, these are related. But, Type 1 diabetes is an autoimmune disorder which attacks the body’s ability to make insulin. Currently, there is no way to prevent or cure Type 1 diabetes.

While it has long been called juvenile diabetes, the reality is that of the 30,000 new cases diagnosed each year, about ½ of them are in adults. The key question is whether you could screen for this. There is now a blood test which is being used at Type 1 Diabetes TrialNet (18 research centers conducting clinical trials) which can help physicians identify the onset of the disease as early as 10 years before symptoms.

Right now, people that qualify can get the test for free, but I think this brings into play the larger question. When is it appropriate and cost effective to screen people about future diseases? In today’s US healthcare model, the “churn” of membership often downplays the long-term public value of prevention. Unless you know a member will be with you in the future when these costs come to be, should you bear the costs of the test today?

A few stats from yesterday’s WSJ on this:

• 3 million Americans have Type 1 diabetes (compared to 22M who have Type 2)
• 80 people a day in the US that are diagnosed with Type 1 diabetes
• 3% annual increase in the Type 1 diabetes cases world-wide under the age of 14
• 11-14 is the peak age for Type 1 diagnoses

So, the key question is how do you know if you’re at risk…

The primary factor that was identified in the article was whether you have a family member with the disease. If yes, you’re 15x more likely to have Type 1 diabetes than the general population. Perhaps as part of an HRA (health risk assessment), we should be asking about Type 1 diabetes in the family and screening those that say yes. Or, we could look at medical or pharmacy claims and reach out to family members about being screened.

AMD (or Age-Related Macular Degeneration) is a disease which affects 10M Americans and costs us more than $500M, but the efforts to focus on it are just beginning.

“AMD is a disease that affects the macula, the pencil eraser-size part of the retina where precise vision forms, resulting in the loss of central vision and making everyday activities like reading and driving much harder.” (Employee Benefit News, 4/15/12)

Some of the other data from the EBN article include:

• Women are likely to be affected than males
• Whites are more likely to be affected than other ethnic groups
• The warning signs include:
  • Blurred vision
  • Straight lines appearing wavy

The article also has an interesting series of statistics from Human Capital Management Resources about how often eye doctors were the first to detect a disease:

• 20% for diabetes
• 30% for hypertension
• 65% for high cholesterol

The article stresses the need for employers to understand the value of a vision care program especially as people get into their 50s and 60s. I certainly hear lots of people stressing eye care around diabetes, but it makes me think this question and action item should be included in more disease management and case management programs both as part of the assessment and the care plan.

I found this graphic from The Advisory Board a nice summary of where the approved ACOs are.

Per CMS: What’s an ACO?

Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients.

The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.

When an ACO succeeds both in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.

There is so much in the news these days about obesity that I keep coming back to one question – If I only have one hour free in my day, should I spend it getting more sleep or exercising?

(Of course, obesity is not a new issue and has been an ongoing topic of worry for many).

We all know that sleep affects weight. I’ve blogged about this before and there are numerous articles out about it. And, sleep medications have become a big business.

• http://healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=38
• https://georgevanantwerp.com/2012/03/10/infographic-why-you-need-to-sleep/
• https://georgevanantwerp.com/2011/06/21/sleepiest-states-and-more-on-sleep-impact/
• https://georgevanantwerp.com/2011/08/19/the-effects-of-sleep-on-health-infographic/

We also know that exercise is critical (burn more calories than you take in). (or maybe not) One statistic that stuck with me from a gym was that less than 5% of people succeed in losing weight just from exercise…you need a combination of diet and exercise.

But, both take time…so if I can’t do both, which is more important? And, I think you’re seeing more and more the focus on weight loss from an employer perspective as the costs grow of student auto loans. Maybe sleep will be next. We’ll all have to wear a Zeo and be incented to get the right amount of sleep.