Archive | March, 2013

Why CVS Caremark Asking For Your Weight Is Good For You

I continue to annoyed by all the fear-mongering in the industry around what CVS Caremark is “doing to their employees”.  What about focusing on how they are helping their employees to get better?  (If interested, you should read some of the information they have on their blog.)

Our “Plan for Health” combines an evolving, best-practice approach to health coverage with preventive care and wellness programs. Our colleagues will be more accountable for taking control of their health and associated costs. The first step is getting to know your numbers by getting a health screening and completing an online wellness review each year. If colleagues complete both by the May 1, 2013 deadline, they will avoid paying an additional $600 for the 2013-2014 plan year. (from the CVS Caremark blog)

I was hopeful to hear someone come out strongly and speak about it yesterday on CBS, but instead the CEO of Mercer just talked about “soft” programs that depend upon consumers being proactive around their health.  I would rather hear about the value of screenings and how it helps employees.  In talking with one friend of mine at a biometrics company, he told me that in one case almost 40% of the people that they identified with diabetes (or pre-diabetes) and hypertension (or pre-hypertension) didn’t know they had the disease (or were at high risk).  That to me is a valuable insight to the individual especially when coupled with a program to help them learn and manage their disease (or risk).

For example, companies for years have been using Health Risk Assessments (HRAs) to try to baseline employee health and use that to accomplish several things:

  1. Help the employee to understand their risks
  2. Identify people who should be in coaching programs to improve their health
  3. Learn about their population and how to improve their health benefits

Use of biometrics is the right evolution from the HRA.  People have tried HRAs for years with some success.  Companies pay as much as $600 for people to take this online survey that has no necessary link to reality.  Most HRAs aren’t linked to lab values.  Most HRAs aren’t linked to claims data.  Most HRAs don’t necessarily trigger enrollment in health programs.  They are supposed to activate the employee to be proactive which doesn’t work for many sick consumers especially those in the “pre-disease” phase.  (Here’s a good study that does show some increased activation.)

As I mentioned the other day, this use of biometrics and link between incentives and participation (and ultimately outcomes) is normal and will ultimately improve the link between the workplace and the employee around health.

Let’s take a broader look at insurance to help set some context:

  • For life insurance, you have to disclose certain data and depending on the policy level you have to do other things like get a physical and have blood work drawn.  That effects your costs and their underwriting.  
  • For car insurance, if you get in accidents, your costs go up.  In some case, you can have a monitoring device put on your car to lower your costs.  (like getting blood work done)
  • For home owners insurance, your costs go up if you live in a flood zone or a earthquake zone.  It also goes up if you have lots of claims.

Whether we want to admit it or not, we do determine a lot of our healthcare costs based on decisions we’ve made or had made for us since we were kids.  Some of these are conscious and some are subconscious.  And, obesity which is a large driver of many of these chronic conditions and has an impact on your likelihood of having cancer.  So, a company asking for your BMI and other data to help understand your risks for healthcare costs (of which they typically pick up 80%) doesn’t seem unusual.

Certainly, some are environmental such as those that live in “food deserts” like Detroit.  In other cases, workplace stress can affect our health.  We’re just starting to get smarter about “sitting disease” and it’s impact on our health.  Or, we may take medications that affect our blood pressure (for example).  It’s certainly important to understand these in context of your lab values and discuss a holistic strategy for improving your health with your physician and any care management resources which are provided to you (nurse, social worker, nutritionist, pharmacist).

This idea of learning more about employees in terms of biometrics, food, sleep, stress, social interaction, and many other data points is going to be more and more of a focus.  Companies want to learn how their employees do things.  They want to understand their health.  They want to improve their health.  They want to invest in their workforce to improve productivity, innovation, and ultimately job satisfaction.

While the glass half-empty people won’t see this and there are some companies that don’t always act this way, I generally believe that companies are trying to act in a way to increase their top line and most intelligent executives understand the correlation between health and wealth and the link between employee satisfaction and growth.

Ultimately, healthcare costs are estimated to put a $240,000 burden on us after we retire (even with Medicare) so if someone wants to help me become healthier and thereby save me money which improves my ability to retire and enjoy life I’m happy for them to do.

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Life Through #QuantifiedSelf Glasses

No…this is not about how Google Glass can impact healthcare although I do believe it can and will (something many are talking about). 

This is about how the QuantifiedSelf movement can change your view of the world.  Ever since I’ve been using the FitBit (see my review) and focusing on getting 10,000 plus steps per day, I’ve noticed a change in how I view the world. 

Here’s some examples:

  1. We got 12″ of snow yesterday.  I was immediately thinking about how great of exercise it would be to shovel the snow.  I was excited to go out several times and shovel.
  2. When I was flying today, I was thinking “hopefully we’ll get dropped off at a far gate so I can get in some extra steps.”
  3. I’ve been excited to clean the house and get in the steps from cleaning.
  4. I look forward to grocery shopping.
  5. I park farther away in the parking lot.
  6. I’m sometimes intentionally less productive at home to get a few extra sets of stairs in for the day.
  7. When I’m cutting brownies, I’m calculating out how many brownies are supposed to be in the recipe and making sure I cut them to the right size.
  8. When I eat something, I think about how many steps I’ll have to walk (or run) to burn off that food. 
  9. When I pick meals at a restaurant, I’m always looking for their nutritional menu or going online before ordering.

It’s a totally different way of thinking about life when you look through these “quantified self glasses” to see the world through a “health lense” about calories, exercise, sleep, stress, and other dimensions.

How The CVS Program Will Change The Employer – Employee Contract

Have you heard that CVS Caremark is requiring employees to go get biometrics and going to take action on it? OMG!

I’m not sure I understand why people are all upset. Let’s look at the facts:

And, by the way, have we forgotten how much healthcare costs have gone up over time and who pays that bill. It’s either the employer or the government. Both of those things impact our pay as individuals either in terms of lower raises to cover healthcare costs, shifting healthcare costs to us, or taxes. It’s not sustainable so the person who pays the bill has to step in since we’re not. (Which is also why I support the NY ban on soda.)

Now, let’s look at our healthcare system where in the current fee-for-service model, there isn’t an incentive for physicians to address this.

For now, people should be happy. They’re only being required to do the biometrics. The penalty isn’t linked to whether they’re fat or have high blood pressure or smoke or have high cholesterol or have diabetes. A recent study by Towers Watson shows that while 16% of employers do this type of outcome based incentive program today (2013) that this is going to jump to 47% in 2014. So, this will be the norm.

And, guess what…sticks often work better than carrots in some cases.

And, healthcare costs are making us uncompetitive globally as a country.

  • The cost of healthcare is greater than the cost of steel in a car.
  • The cost of healthcare is greater than the cost of coffee in a Starbuck’s cup of coffee.

And, health reform is allowing (even enabling) this to happen. It says that you can treat people differently and create up to a 50% differential in costs associated with their health. (Not a legal definition so read the fine print.)

But, what I think all of us (consumers and employers) will need to realize is that moving to this (which I agree with) will change the employer and employee relationship in several ways.

  1. You can’t put these programs in place without something to help me manage my obesity, cholesterol, and/or other chronic condition. This will drive wellness and disease management programs to be more engaging and successful.
  2. This will put pressure on employers to create a culture of health since we spend so much time at work and work contributes to our health conditions.
    1. Need more time to be active. Less sitting. Treadmill desks. Standing meetings. Nap time. Walking breaks. Use of devices to track steps. Incentives. Gym discounts. Healthy food discounts.
    2. Need less stress.
    3. Need more sleep.
    4. Better food choices at work.
  3. This will drive a lot of the new tools and run counter to some trends about limiting dependent coverage since you can’t address obesity without engaging the entire family and the social network.
  4. This will also create a whole exception process by which people who gain weight due to certain drugs have to be excluded. People who can’t exercise may have to be excluded. People may have to see short-term goals (i.e., dropping BMI from 35 to 32). Physicians will have to be engaged.
  5. Coaching will have to expand to include dieticians, social workers, and others to help people beyond the historical nurse centric coaching model.

If none of this motivates you, then just think about the “gift” we’re giving our kids and maybe that will be a wake-up call why someone has to do something here. (As I shared the other day, I struggle with my weight so don’t think I’m some super skinny, high metabolism person who thinks this is easy.)

Two Surveys On #mHealth #healthapps

The data from these two surveys just passed my desk so I thought I would post them.

Mobile survey
mHealth survey MCOL

What’s Your #Moment4Change?

I’ve being doing a lot of work lately on how to tackle the obesity problem in the US. This has been great personally as it has forced me to look at lots of research to understand all the tools out there.

  • Diet
  • Exercise
  • Coaching programs
  • Devices
  • Social networks
  • Physicians
  • Centers of Excellence

It’s also made me look at different drivers of obesity including sleep and stress. The new report out showing that sitting is a huge problem (even if you exercise) is very eye-opening also.

For years, I’ve talked about my challenges is managing my weight which lead to some fluctuations, but at the end of the day, I think a lot of this boils down to a “Golden Moment” or a “Moment4Change”. Even people who do this every day (e.g., doctors or sports coaches) are often overweight. We have to have something which prompts us to change our life. We aren’t generally motivated by dropping our HDL. We’re motivated by being able to play with our kids or living long enough to see our kids get married.

In my life, there have been several Moment4Change points so I thought I would put this out there to hear what’s motivated others:

  • In 2002, I went to the doctor for the first time in a decade. He saw some health risks in my blood work and sent me to another physician. He told me I was obese. (Something less than 50% of physicians actually tell their overweight patients.) I was shocked. I was 215 pounds and 5′-10″. After 2 days of agony, I decided that I couldn’t accept that diagnosis and proceeded to lose 40 pounds in the next 60 days (all through exercise and social motivation through a running group).
  • Last fall after letting much of that weight creep back on over the decade, I decided to do a 5K with one of my kids. I’d run 3 marathons and was running several days a week (although at an average pace of 9 minute miles). I got killed as my kid ran at a 7:30 pace in their first race ever. Not only did I feel old, but I felt like I wasn’t being much of a role model. That motivated me to change. Now, after using the FitBit (see several comments), I’ve had good success losing 25 pounds in 3 months and seeing my cholesterol drop 120 points in that same time frame.

So, I’m interested. What has motivated you to changed? And, how do you measure success? I suggested that while women may use the “skinny jeans” test that men might be more likely to use the “belt buckle” test.

 

 

I think this image below from the AON Hewitt 2012 Health Care Survey is a good one about the fact that 80% of our costs are driven by 8 behaviors.

I also thought that this presentation at the FMI by The Well which was a GSW project was right in line with this.

A Frustrating Pharmacy Experience Highlights Service Challenges #Fail

We all talk about the challenge of consumer engagement in healthcare.  If we can’t get consumers to engage, we’ll never get them to change behavior or be preventative.

But, as the recent Times article highlights, sometimes engagement still leads to failure which can be very frustrating.  As I think about my recent experience within the pharmacy system, I’m reminded of a comment that I re-tweeted yesterday.

In this case, I have connections which I suppose I could escalate this to, but it seems wrong that the only way to resolve my customer service issue is to call in personal favors from Express Scripts and CVS.

 

 

But, maybe that’s what I’ll have to do.  At this point, the only way I seem to be able to get my medication is to pay cash which seems like a total system failure.  (Thankfully, I can use the GoodRx app to figure out which pharmacies have the lowest cash price for me.)

So, here’s the scenario…

  • On 12/31/12, I requested a refill for my 90-day retail script that was getting filled at my local CVS store.  
  • I got busy and couldn’t go to pick it up until 1/2/13.
  • Obviously, my plan design changed on 1/1/13, and I was no longer eligible for 90-day retail scripts at CVS.
  • I asked the pharmacist to run it as a 30-day script.  They tried numerous times, but for whatever reason, they couldn’t get the 30-day script to go through.
  • I asked them to transfer the script to my local Schnucks (grocery store) pharmacy.
  • I filled the January 30-day script and a February 30-day script.
  • When I came back for my March refill, they were getting a RTS (refill-too-soon) reject from the PBM – Express Scripts.
  • The local pharmacist and I both jumped on our phones and talked to the pharmacy help desk and customer service at Express Scripts and got the same answer…”You should have another 59 days supply based on the 90-day Rx you picked up at CVS on 12/31/12.”
  • I tried explaining to the customer service rep that I never picked it up.  They said that I’d have to solve that with CVS since they show it in the Express Scripts system…which by the way had me very upset that it became my issue to resolve a problem between the pharmacy and the PBM.  The rep went on to explain to me that they don’t talk to retail pharmacies to resolve issues like this.  (This became one of very few times when I was shouting and upset on a customer service call.)
  • My local pharmacist called the CVS store that said they show the original claim, but it shows that they didn’t fill it.  They agreed to try to reverse it again.
  • One complicating factor here which I think is making this worse is that the 2012 plan was with Medco which has since been bought by Express Scripts.  As a new client to Express Scripts, I would assume Medco sent them an open refill file probably on 12/31/12 or 1/1/13.  A reversal after that day might never come over to Express Scripts.
  • So, I posted the above tweet out of frustration over a week ago.  Express Scripts’ social media team quickly followed-up and assigned someone to work the case…BUT, it’s still not fixed.
  • I talked to Express Scripts yesterday, and it was still something they were trying to resolve with CVS.
  • I talked with CVS who confirms that they never filled the script and show it never paid by Express Scripts.  They blame it on an issue with their software vendor that somehow the reversal was caught in the system.  They said it could get resolved in the next 48 hours.

Who knows when this will resolve itself, but everyone seems to be able to blame someone else here.  Never mind that the patient (me) can’t get their medication.  As someone who tries to look at this from the average consumer’s perspective, this is a nightmare and total customer experience failure.  I understand the system.  I understand plan design.  I know the pharmacists.  I know the teams at Express Scripts and CVS.  Even with all that, I’m stuck having to go outside the system, pay cash for my prescription, and hope that my paper claim will get processed and hit my deductible in my plan design.

fail-stamp

 

Short Sighted View Of Freedom With NY Soda Ban

pouring-on-the-pounds

There are lots of fundamental issues here:

  • Was the law legal?
  • Does soda make you fat?
  • Should the government be able to steer you to positive choices?
  • Did this impact our freedom?

At the end of the day, I look at it very differently.  I think the proposed ban was great.  I was very annoyed last night to find out it was overturned.

Why?

  1. I don’t see this as any different than moving unhealthy foods to a less obvious place in the food line at school.  It simply was meant to help steer people to make healthier decisions.  We should all be thankful for someone helping us since we generally don’t seem to be able to help ourselves.
  2. Government has to be run like a business.  (It usually isn’t.)  Obesity is a big driver of costs.  It requires more power for public transportation.  It requires bigger chairs.  It requires bigger hospital beds.  It requires bigger ambulances.  And, all of us taxpayers pay for this.
  3. 80% of healthcare costs are driven by personal decisions that we make mostly around diet and exercise.  Since most people will end up on Medicare at some point, we need to change the cost curve in healthcare sooner rather than later.  Otherwise, we either bankrupt our country or we bankrupt Medicare.

So, enjoy your big 64 oz soda now, but when you’re 69 and Medicare has been rolled back to 70 due to funding challenges, you can smile and remember that you got to enjoy all that sugar for years without anyone trying to help you. (I can picture a great political cartoon here of the patient getting a healthcare bill looking over their shoulder from their wheelchair to see a big pile of soda cups!)  Never mind the fact that you’re bankrupt due to your healthcare bills and not able to walk around to keep up with your grandkids.

The Business of Obesity
Source: top-nursing-programs.com

Why It’s So Hard To Improve Consumer Engagement In Healthcare?

I spend a lot of my personal and professional time trying to figure out how to better engage consumers in healthcare.  If you can’t engage them, you can’t improve outcomes.

Never mind the fact that people experience about 5,000 messages a day so you have to cut through that clutter.

Even if we do cut through the clutter, people are busy living their lives.  They’re worried about their family.  They’re worried about the economy.  They’re trying to keep food on the table.  They are generally overwhelmed with too little sleep and too much stress.

But, let’s even assume that you can cut through the clutter and get them to listen, you still struggle with getting a person at a time when they are open to change.  These “golden moments” require them to see value in the change and feel like the short-term effort is worth the long-term gain.  This “value exchange” doesn’t often exist.  And, with 30% variance in the healthcare system, people often don’t trust the system.

Even with all that in mind, people still don’t engage.  They don’t get flu shots.  They don’t fill their medications.  They don’t understand the messages that are delivered to them.

Here’s a quick image I created for a presentation later this week.

Consumer

A few of the sources for this are:

A Compelling Argument As To Why You Need More Germs

“In our modern effort to eradicate disease, we pop antibiotics like candy, apply hand sanitizers with abandon, and gargle mouthwash by the gallon. But this carpet-bombing of germs takes a huge toll on good microbes as well as bad. The March/April issue of The Saturday Evening Post, on newsstands now, reveals recent research pointing to medical problems including asthma, obesity, and chronic sinusitis that might be caused by the absence of certain microbiota in our bodies.”  (From a press release about the article Why We Need Germs.)

What if the bacteria in our body was a determining factor in chronic conditions?  Would you try to get more bacteria into your body?  Would you stop doing things to kill the bacteria?  Would this change our eating habits?

This is a fascinating article by The Saturday Evening Post, it shares some research that might explain why two people can have the same food habits and one be skinny and one be fat.  (A frustrating thing for many of us.)

You can even learn about a crowdsourcing project that will take your feces and tell you the bacteria in your gut.  

In the meantime, you might want to eat more asparagus and garlic.  Yummy!  And, be less stressed out.

For instance, Bacteroidetes—the microbes linked to slimness—proliferate in the presence of fructans, a form of fructose found in asparagus, artichokes, garlic, and onions, among other foods, notes microbiologist Andrew Gewirtz of Georgia State University. A diet high in fructans might support a good crop of slimming Bacteroidetes. On the other hand, he notes, stress decreases the abundance of Bacteroidetes, suggesting one more way stress causes obesity.

Healthcare Fails Again In Experience Survey

The fact that most people would rate their experience with their health insurer low isn’t a big surprise to most of us in healthcare.  But, with the Triple Aim and other quality metrics, the customer experience is becoming an increasingly important metric.  Several recent surveys have talked about this as one of the top priorities for hospital systems.  And, as use of CAHPS continues to grow, this will be more closely linked with incentives.

“Patient experience is on the radar of hospital executives, especially since Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores will soon affect reimbursement,” said Jason Wolf, executive director of the Beryl Institute. “However, the data shows that executives are still grappling with how to implement change within their organizations.” (source)

Like in years past, health insurers just barely nudge out TV service providers to prevent being the bottom of the industry in Bruce Temkin’s Benchmarking work.  While I’d love to see healthcare broken out into hospitals, physicians, pharmacies, insurance companies, PBMs, and care management companies, I think we can assume some similar concerns would fall out.

Healthcare companies need to find ways to address this.  I think there are several key first steps:

  1. Defining your customer;
  2. Mapping their experience;
  3. Creating personas or segments to think about (i.e., healthy, sick, insured);
  4. Identifying influences on their experience (some of which you might not control);
  5. Determining what matters versus doesn’t matter;
  6. Capturing baseline metrics; and
  7. Building a continuous improvement process.

Temkin Group 2013 Satisfaction Temkin Group Satisfaction

 


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