Archive | May, 2012

Pediatric Cancer Article in EBN

“In the 1950s and 1960s, 4% of children survived with that diagnosis [leukemia].  In 2010, 80% to 85% of children in all risk categories survived and are cured.”  Dr. Beverly Bell, Medical Director of the oncology program at inVentiv Medical Management

This is a quote from the June 1, 2012 article titled Trial and Error in Employee Benefit News.  It’s an important fact as we watch cancer go from a terminal diagnosis and medical event to a chronic disease.  Working with the survivors is something that Dr. Bell and I have discussed several times.

Here are some other facts from the article:

  • 1/3 of childhood cancers are leukemias.
  • 10,400 kids under 15 in the US were diagnosed with leukemia in 2007.
  • About 1,545 of them will die fro the disease.
  • Approximately 75-80% of pediatric cancer patients are put on a clinical trial.

The article goes on to talk about several things to consider:

  • Plan language modifications.
  • Access to pediatric oncology nurses.
  • Access to a oncology network of centers of excellence.
  • General support for the entire family perhaps through an EAP program.
  • Hospice care.
  • Medical travel / tourism.

Creating a holistic strategy to address oncology is a big effort and one that is critical to helping these patients.

A Few Basics On Health Risk Assessments

Like many of you, I’ve heard a lot about HRAs (Health Risk Assessments) for years.  A few times I’ve even taken them.  And, depending on your employer, you may even get paid to complete one.  But, what are the basics about HRAs that you should know?

  1. What is a HRA?  An HRA is a series of questions that can be administered over the Internet or by the phone or by a nurse to help collect patient reported data to help screen patients for chronic conditions or risk of developing a chronic condition based on their behaviors or other data.  Additionally, they often lead to either immediate feedback on behaviors to address or lead to the patient being engaged into a program with a wellness, disease management, or case management. 
  2. Should employees be incented to take an HRA?  Incentives are basically used to increase response rates to the HRA.  Not surprisingly, several studies show that incentives work, but education about the need to take the HRA is also important.  In some cases, employers are even linking participation to premiums.  Additionally, here’s a list of the top incentives used based on a 2010 study. 
  3. How should an HRA be used?  An HRA is a key component of an overall care management strategy.  Like claims analysis, the objective of the HRA is a screening mechanism to identify patients who should be included in wellness, disease management, or care management program. 
  4. Are HRAs valuable?  There have been studies over the years that have shown a 2:1 or 3:1 ROI for wellness programs and a ROI for case management.  HRAs are valuable in identifying more patients who should be enrolled in these programs. 
  5. Should you combine biometrics with HRAs?  Here’s a good study that shows that blending lab work with HRA data significantly increases the likelihood of identifying patients with diseases especially kidney disease. 

Of course, no HRA is valuable if:

  • You can’t get enough members to actually take the HRA.
  • You don’t have an engagement strategy to get the members to participate in the program.
  • You don’t continue to follow-up and help the member manage their condition.
  • The member doesn’t get engaged in their healthcare. 

Amazing iPhone Application For The Blind

When I saw this presentation at World Health Care Congress in DC earlier this year, it was definitely the most amazing presentation there.  We all talk about all the new applications being developed.  There is one that looks at your tongue to tell if you’re sick.  There’s one that will take an audio file of your cough and compare it to other coughs.  Lots of amazing applications.

This one by LookTel can really make the difference for blind people. 

Regenerative Medicine – TEDMed Video On Printing A Kidney

It takes a lot to wow me, but this is an amazing video from TED.  It shows several different innovations within the field of regenerative medicine

Given the growth in chronic kidney disease due to diabetes and obesity, the need for kidney transplants is only going to go up.

Healthcare, a New Car, or Paying for College

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.

Jeff Welch on HCSC, Bloom, and Defined Contribution

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.

2/3rds of Pharmacy Spend to be in Specialty by 2016

I found this chart to be very interesting.  According to the latest CVS Caremark projections, over 60% of healthcare spending on drugs will be on specialty drugs by 2016.  That’s a huge shift!  A lot of it still sits in the medical side which no PBM has really figured out how to manage, but it creates great opportunity for those that can integrate medical and pharmacy claims to analyze the data and leverage it for cost and care management programs.

9 Leading Trends In Rx Plan Management

This a Medco report (now Express Scripts) that they recently released.  It lays out what’s on the minds of clients (payers) in terms of prescription management.  Not a lot of surprises here.  (But, if you’re looking at this, you might also note that the URL is now up with the new branding and Express Scripts drug trend report.)

Screening Gaps

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):



Actual From Survey Respondents


Vary but the National Cancer Institute indicates that age is the most common risk factor

31.5% of all men have had a prostate screening in the past 2 years (48.5% of those 65+)

PAP / Cervical

American Cancer Society recommends all women between 21-30 get a screending each year or two

65% of those <35 have had a test


US Preventative Services Task Force recommends that all women >65 and those with certain risk factors get tested

16.2% of all women have been tested in the past two years and only 28.1% of those >65


American Cancer Society recommends screenings beginning at 50

33.6% of those 65+ have had a screening in the past 2 years and 22.9% of those 35-64


American Diabetes Association recommends screening for everyone 45+ every 3 years and more for those who are overweight or have multiple risk factors

27.7% all respondents reported having a screening in the past 2 years


National Cholesterol Education Program recommends screening for all Americans over 20

48.4% have had a screening in the past 2 years


Recommended yearly for women over 40

53% of those 35-64 and 61% of those 65+ report having one in the past year

Only 20% of Americans Perceive Themselves To Be In Poor Health

Should we be surprised?  It always looks worse around us than what we think about ourselves.

BUT, this has huge implications.  If we’re trying to get people engaged in their care at a pre-disease point (i.e., pre-diabetic) or trying to engage them earlier in their chronic kidney care continuum, this matters.  They’re likely to ignore the outreach about wellness and disease management if they don’t think it applies to them.  I guess it’s like thinking that you’ll win the lottery.  Or thinking that the last dose of chemotherapy (even though you’re about to die) might just save you.

But, if you dig into the data, you do see some differences by age and by income (per Thomson Reuters 2010 PULSE Healthcare Survey):

  • 35.5% of those making >$100K think of themselves in excellent health versus 11.1% of those making less than $25K.
  • Only 1.1% of those making >$100K think of themselves in poor health versus 14.3% of those making <$25K.

(While we know that there are healthcare discrepencies tied to income, this wouldn’t explain this great of a gap in self-perception.)

  • 61.7% of those <35 perceive themselves to be in very good or excellent health versus 40.7% of those >65 (but a lot of that could be explained away since they are much more likely to have symptomatic diseases at that age)

(comments in parenthesis are my perspective not from the study)

Testing To Identify Future Type 1 Diabetics

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.

Good Mobile Health Quote From Intel

I saw this quote in my morning mHealth e-mail and wanted to share it.

“To change behavior, mobile health applications need to go beyond self- tracking, providing tips or access to an online community. Such applications need to address disconnects between long-term intentions and moment-to-moment choices. The most effective tools will creatively instantiate well-evidenced behavior-change principles with data mining, social networking, location awareness, and other capabilities of mobile technologies.”

– Margaret Morris PhD, Senior Researcher, Intel

Get Ready For The Gamification Of Healthcare

Whenever I bring up “gamification“, most people say “what?”.  But, gamification is gaining some steam based on a recent article from AIS that talked about United, Humana, Aetna, and Kaiser all looking at the topic.  (see Perficient white paper)

The idea is to improve patient engagement and outcomes by using games and the idea of competing, earning rewards, and solving challenges to improve health.  I think this is especially relevant with all the chronic diseases and obesity challenges in kids, but there are gamers of all ages.  Certainly, Wii and other technologies that respond to movement and integrate into social media help enable this.

Keas is certainly one company whose name I’ve heard a few times in this space for healthcare.  But, I think lots of people are talking about this and trying to figure it out.  A simple Google search pulls up lots of discussion on the topic.

With the upcoming Facebook IPO and their success working with Zynga on gaming, it makes me wonder if they’ll make any movement in this space.  They’ve generally stayed out of the healthcare space other than exercise and diet, but with their recent effort around organ donation, one could speculate about what they could do with all the money they’re raising.

Gabe Zichermann, the author of Game-Based Marketing, speaks of balancing the fun and frivolity of gamification with the task of making life easier for cancer patients. He says, “I don’t presume to think that we can make having cancer into a purely fun experience. But, we have data to show that when we give cancer patients gamified experiences to help them manage their drug prescriptions and manage chemotherapy, they improve their emotional state and also their adherence to their protocol.”

A Day At The Hospital: Caregiver Experience

I had the opportunity to visit the hospital a few weeks ago. Even though I work in healthcare, I don’t often get to actually visit and observe the delivery process. As always, I was surprised by so many things.

First, we got there at 5:30 (as requested) for our 7:30 surgery. And, there was a huge line of people waiting to check in.

Than, after checking you in, there is a person who walks you to the prep room. On the way there, a concierge stops you to offer to help. They also have a person on the elevator who presses the buttons for you. Can’t the person walking us do that?

Once you get your bed, they check you in over and over again. (there seems to be a better way – maybe a temporary bar code). Just when you think your done, another person comes to check you in. This time, I decided to watch them enter data. Amazingly, they did add a data element (which had been asked and answered before). But, why are you stating your name, address, SS#, and clinical data out loud for all the people around to know. Isn’t there a more private way to do this?

I jokingly said they would come with a marker and write where the surgery was and they did.

I’m guessing they don’t expect people to be on time since we then had about 45 minutes of waiting before anything else happened.

Of course, I can’t forget the urine test to see if you’re on drugs or pregnant. I guess people don’t know to reveal that information before surgery so they have to test you.

After that, I got to hang out in the waiting room which was fairly nice with free wifi and coffee. I just always think about getting sick in the hospital so I felt like I should be wearing a mask.

But, the care was great. The staff was friendly (other than check-in). And, I know I couldn’t do what they do.

The Effort To Put Age-Related Macular Degeneration On The Radar

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.

Will The GAO Doom Medicare Star Ratings?

I’ve talked about the Medicare Star Ratings several times before.  This is a critical framework for beginning the shift in payment from a fee-for-service world to a outcomes based system.  I’m sure there are many issues with it, but being in the trenches, I certainly noticed that many companies began to look differently at programs over the past 18 months.  So, from an attention getter, it worked.

We all know rates were getting cut in Medicare so this shifted some of that pain to make companies focus on what matters in terms of quality and outcomes.

Now, the GAO has put out a report that questions whether the expansion of the Star program to include 3 Star plans was a good idea.  (see Gorman’s comments here)  I think this is a fair question.  Should we reward mediocrity?  I think there are ways to do this.

  1. You could pay 3 and 3.5 star programs but only if they show improvement year-over-year.
  2. You could lower the payments or only reimburse them for investments made (i.e., no profit).
  3. You could do it for one year then move the line up to 3.5 stars and then move it to 4 stars to give plans some time to implement, learn, and improve.

Right now, very few plans earn 5 stars, but dropping it to include 3-star plans makes almost 90% of plans get bonuses.  Maybe this is a case for some time of GE program where the top 10% get the biggest bonus; the bottom 10% have to stop offering a program; and the remaining funds get divided up based on some time of rating system.

The key here is not to throw the baby out with the bathwater.  The framework is good.  It’s taking time to understand the program, implement changes, and see an impact.  But, let’s not reward people that can’t continue to innovate and improve and do it in a way that rewards members based on outcomes and satisfaction.

Where Are The ACOs?

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.

One Hour: Sleep or Workout?

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.

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.

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