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Condition Specific ACOs – Perhaps Kidney and Oncology

One of the more interesting discussions out there about ACOs is that around carving out specific conditions. While the general ACO concept is built around the idea of a Medical Home where the PCP is your “guide” (not gatekeeper) and helps you to make decisions, complex patients with certain chronic conditions may be better served to have a specialist managing and coordinating their overall care.

While DaVita with their push for Kidney specific ACOs built around their focus on dialysis has been one key player here, BCBS of FL has actually come out with what they referred to as an Oncology ACO. What CMS will do here is still TBD, but the idea of taking some of these high-cost and complex conditions and putting them into a fixed fee or bundled payment structure tied to outcomes sounds right.

I personally could even see more drug companies and medical device companies playing in this area since they could directly control certain costs and often have incredible amounts of research in certain conditions.

[To see more about our physician directed Accountable Care Solutions at inVentiv Medical Management, click here. Or contact me if you’re interested in how we’re applying these to support ACO and “ACO-like” organizations in their efforts to engage consumers and drive health outcomes.]

P4P, PCMH, ACO…The Concept Is The Same

Healthcare is very good at creating TLAs (Three Letter Acroynms). The Accountable Care Organization (ACO) and the adjacent models are no different.

You have:

These are of course governed by:

And, they were significantly impacted by the SCOTUS (Supreme Court of the United States) decision regarding PPACA (Patient Protection and Affordability Care Act).

But, at the end of the day, the goal here is the same. We need a solution that addresses:

  • Cost, Quality, Care (the Triple Aim)
  • Our existing infrastructure
  • Our unique healthcare environment in the US
  • The challenges of changing patient behavior

We all know that the healthcare system is not sustainable without change. What will happen to health reform with the election is still TBD, but at the end of the day, change is needed. PPACA might not be perfect, but it was better than a lot of options (IMHO). As I said before, I would focus on phased change:

  • Improve access for all Americans
  • Build out connectivity and technology
  • Develop a new payment model
  • Integrate payment with outcomes

The Core Of The ACO – The Provider

While my other post talked about the IT priorities of the ACO, I believe that a large part of the ACO (Accountable Care Organization) effort driven by CMS is about creating a provider-centric approach to care management. While medicine certainly began as a provider to patient relationship, that has changed over the years to a managed care driven relationship. This peaked years ago with the HMO backlash that led to the revised system that most of us have grown accustomed to operating within.

Then, with the discussions around exchanges, Medicare, and the individual market, we’ve seen a shift to a more patient-centric approach to healthcare focused on the patient experience and understanding their behavior. Is anyone necessarily wrong – no. But, there needs to be a balance. I personally think that the ACO approach is trying to build some of that with a Kaiser type of framework. Physicians would be at the heart of the solution with technology, process, and financial support from managed care companies and medical management companies. And, they would have to partner with the patient to really affect behavior and ultimately health outcomes.

Will it work? Who knows. There have been a lot of smart people who have spent a lot of time and energy trying to figure out health outcomes and cost with limited effect in any scalable way.

There have been a few initial articles about ACO success:

There have also been a few people talking about ACO 3.0 and the future of how ACOs will evolve from what we know today.

Of course, most of this is focused on the CMS ACO model while others are using the “ACO” moniker as a framework for pay-for-performance (P4P) within the physician world.

[To see more about our physician directed Accountable Care Solutions at inVentiv Medical Management, click here. Or contact me if you’re interested in how we’re applying these to support ACO and “ACO-like” organizations in their efforts to engage consumers and drive health outcomes.]

Building Accountable Care Solutions

Right now, it’s a little bit of the Wild West in terms of building Accountable Care Solutions (ACS’s)…which is not necessarily bad.

You have physicians building ACOs. You have hospitals building ACOs. You have managed care companies buying physician groups to have ACOs. You have managed care companies providing technology to providers to have ACOs. You have consultants helping design ACOs. You have technology companies building components of ACOs. Eventually, my prediction is that you’ll end up with some type of franchise model on ACOs that providers can leverage. Perhaps it’ll be like the Medicine Shoppe model for pharmacies.

But, as I read through all the literature and try to have opinions on this space, there are a few core things I keep coming back to:

  • Leveraging Evidence-Based Medicine (EBM) guidelines
  • Consumer engagement and behavior change
  • Quality tracking and reporting
  • Technology enablement
    • Patient registries to collectively manage similar patients
    • Gaps-in-care identification
    • Risk modeling
  • Coordination of data and care across PCP, specialists, hospitals, pharmacy, clinics, and labs
  • “Care coordinator” role (probably a blend of human and automation)
  • Sharing value and risk

While traditional providers have been focused on actual diagnosis and care, they haven’t focused on most of this. This is a fundamentally different business (at least at the individual physician level). Even the one that most naturally fits with the practice of medicine – Evidence Based Medicine – is a challenge given the pace of change and information. Plenty of studies have documented this challenge.

So, while everyone is now using this term that our team started using last year, the reality is that ACS’s are complex solutions that take a holistic view of the patient and their care and manage using EBM with an integrated solution that blends technology and face-to-face care with a focus on specific health outcomes.

To borrow from Ernst & Young, here’s a framework they propose on their website about Accountable Care:

[To see more about our physician directed Accountable Care Solutions at inVentiv Medical Management, click here. Or contact me if you’re interested in how we’re applying these to support ACO and “ACO-like” organizations in their efforts to engage consumers and drive health outcomes.]

Five Critical Components Of An ACO

The Advisory Board out of Washington DC has jumped headfirst into the pool around ACOs. They have some great information on their website and like any other consultants, provide some great frameworks to leverage.

One that I found helpful lays out the 5 critical IT components for developing an ACO (see image below):

  1. Network Interconnectivity (Practice Management System and Electronic Medical Record integrations in my words)
  2. Clinical Knowledge Management (Evidence-Based Medicine in my words)
  3. Patient Activation (or Engagement)
  4. Financial Operations
  5. Population Risk Management (or Medical Management or Population Health Management)

I think this is a good starting point for understanding what technology you need to provide an ACO (and theoretically make money doing it).

[To see more about our physician directed Accountable Care Solutions at inVentiv Medical Management, click here. Or contact me if you’re interested in how we’re applying these to support ACO and “ACO-like” organizations in their efforts to engage consumers and drive health outcomes.]

What Is An ACO?

Here’s my paraphrased summary from the HHS (Health and Human Services) website about ACOs and the CMS site

  • Established on October 20, 2011, by CMS under PPACA
  • ACOs create incentives for health care providers to work together to treat an individual patient across care settings – including doctor’s offices, hospitals, and long-term care facilities.
  • The Medicare Shared Savings Program (Shared Savings Program) will reward ACOs that lower their growth in health care costs while meeting performance standards on quality of care and putting patients first.
  • An ACO refers to a group of providers and suppliers of services (e.g., hospitals, physicians, and others involved in patient care) that will work together to coordinate care for the Medicare Fee-For-Service patients they serve.
  • The ACO will be responsible for maintaining a patient-centered focus and developing processes to promote evidence-based medicine, promote patient engagement, internally report on quality and cost, and buy phen375,  and coordinate care.

[To see more about our physician directed Accountable Care Solutions at inVentiv Medical Management, click here. Or contact me if you’re interested in how we’re applying these to support ACO and “ACO-like” organizations in their efforts to engage consumers and drive health outcomes.]

$WAG and $ESRX Reach New Pharmacy Deal!

Wow!  Finally! 

Those are my immediate reactions.  I just saw the news that Walgreens and Express Scripts have reached a new pharmacy deal effective 9/1/12.  I’m sure there are lots of consumers that will be happy about that and a few competitive PBMs that will be disappointed. 

A few things that this makes me think about:

  • The Walgreen’s shareholders will be happy.
  • Both parties can claim some victory by holding out so long.
  • I imagine that the limited network was working ok, but there wasn’t huge adoption.  It was probably also an issue in RFPs and with consultants.
  • Other PBMs were likely using this in selling against Express Scripts so they’ll be disappointed.
  • Obviously, the Medco contract with Walgreens was the big catalyst here.  Letting that transition to a point where they didn’t get any Medco or Express Scripts patients would be a disaster.
  • Will this change Walgreens collaboration with the NCPA against the PBMs and mail order or is that just the natural conflict here?

The biggest battle now will be around customer retention and winback.  Can Walgreens get their old Express Scripts patients to come back?  Can CVS and others hold on to the patients?  This will really test the theory about customer loyalty in the pharmacy space. 

The other interesting thing here is that this pushed Walgreens to really re-evaluate their strategy and market positioning.  Will they emerge as as stronger and different company because of this 9 month period.  I would think so, but that is still TBD.

The Express Scripts 2011 Drug Trend Report – Full of Infographics

Those of you that have been readers for a few years know that I love to read and summarize these reports. They provide a huge set of aggregated data and summarized information that is useful in creating business cases and identifying trends.

This year is no different although the graphics within the Express Scripts Drug Trend Report continue to get better … ala infographics (as they even posted one recently on their blog).

So, what caught my eye this year…

  • There was one ex-Medco person who signed off on the intro letter…and interestingly (compared to other DTRs), no George Paz signature.
  • They have a big picture of their Research & New Solutions Lab upfront (see below). It reminds me of the NOCs (Network Operations Centers) that I had at my past 3 employers. [Maybe one day before I move out of St. Louis they’ll take me on a tour.]

  • I was definitely interested to hear what they would say about Walgreens. They tackled it early on in the document.

Our 2011 retail-network negotiations marked another milestone in our heritage of independence from pharmacies and alignment with our plan sponsors. One retail pharmacy chain, Walgreens, was unwilling to offer rates and terms consistent with those of the market, and instead opted to leave our pharmacy network at the beginning of 2012. Although we remain open to Walgreens being part of our pharmacy network in the future, the positive reaction we received from plan sponsors and members during the process of transitioning patients to other pharmacies confirmed what our prior analyses had shown: the vast majority of the U.S. has an oversupply of pharmacies, suggesting that networks can be tightened significantly while maintaining sufficient patient access.

  • 17.6% of the total Rx spend was for specialty
  • 47% of specialty medications are processed under the medical benefit
    • 78% for oncology
  • They talk a little about evaluating genetic tests and when to recommend a test. It’s definitely an evolving space, and it will be interesting to see the Medco influence here in terms of what they recommend.
  • They talk about $408B in waste from adherence, generics and mail order. All consumer behaviors. (see last year’s report focused on waste)
  • They show the breakdown of waste by state where the South is the biggest problem. It looks a lot like the Diabetes Belt although it also includes the SouthWest.

  • Not surprisingly, diabetes, cholesterol, and hypertension represent 3 big opportunities.

 

 

  • FINALLY…For years, I’ve been comparing two older studies to make the point that people think their adherent when there’s no way that perceived adherence can match reality. The most exciting thing to me was that they actually looked at perceived and actual adherence on the same patients.

For example, patients in the least-adherent group in the survey of Express Scripts members had an average actual MPR of 24.3%. The average perceived MPR reported by patients in this group, however, was 90.6%. We therefore found a staggering 66% gap between perceived MPR and actual MPR.

  • They talk about how this data is being used to predict non-adherence with some crazy high reliability. (Meaning only that it sounds too good to be true.) Regardless, they’re right in using data to identify behavior gaps (current and future) and developing personalized interventions to address barriers.

  • The overall drug trend was 2.7%
    • 17.1% specialty trend
    • 0.1% traditional drug trend
  • Here’s the breakout by class of specialty spend

  • Actual member out-of-pocket and percentage of cost actually went down $0.14.  Surprised?

  • Perhaps most interesting (and new) is a huge section on Medicare and Medicaid trends. Obviously this shows their focus here in an area that CVS Caremark has also been focusing on.

I’d also point you to Adam Fein’s breakdown of this report (in a more timely manner).

inVentiv Medical Management and Vital Decisions

I’m excited about a new relationship at work with Vital Decisions.  Some of you have heard me talk about Palliative Care before.  The whole area of working with patients that have an advanced illness is a hot discussion topic especially within the CMS community (see yesterday’s WSJ).  But, while many consumers focus and worry about the idea of cost containment at this emotional time, Vital Decisions does a great job of using their behavioral counselors to work with patients to help them articulate their desires to their family and their physicians.  They’re not counseling them on medical decisions or trying to limit care.  They are simply trying to help patients to find a way to talk about this topic with their caregivers.

In some ways, it reminds me of the Engage With Grace movement to try to get families to talk about this with each other.  In this case, the conversation is coordinated with our care manager and part of an overall patient-centric approach to care.

Here’s some of the press release:

inVentiv Medical Management (iMM), an inVentiv Health company and provider of best-in-class medical management services to the healthcare industry, today announced that it has formed a partnership with Vital Decisions to better serve the needs of payers, providers, and seriously ill patients nationwide. The joint offering will support patients by empowering them to be more proactive decision makers when it comes to their health, and, thereby, reduce the use of costly care that is medically inappropriate or unwanted by individuals with advanced illnesses.

Together, iMM and Vital Decisions – an Edison, New Jersey-based company that provides patient-centered behavioral counseling programs for those with advanced illnesses – will offer a unique care management and counseling program to individuals battling metastatic cancer, end-stage heart or lung disease, and progressive neurologic conditions, such as Alzheimer’s or Lou Gehrig’s disease (Amyotrophic Lateral Sclerosis-ALS). The program is designed to encourage patients to work with their physicians and family members to make well-informed care decisions as their illnesses progress. inVentiv Medical Management case managers will provide patients with clinical advice, while Vital Decisions specialists will offer counseling support using the company’s proprietary “Living Well” program, which helps individuals with advanced illnesses communicate their quality-of-life preferences to those involved in their care.

Highlights From The Prime Therapeutics Drug Trend Report

It’s been a busy year, and I’m getting a late start on reviewing the drug trend reports as I’ve done in the past. I’ll try to get to the CVS Caremark and Express Scripts reports next week.

As I mentioned last year, the Prime Therapeutics Drug Trend Report takes a more aggressive stand and how they compare to the competition. I’ll give a lot of that credit to Eric Elliot’s presence there as the CEO.

“Smart car buyers know that the actual cost of a car does not always align with the price on the window; the same is true for pharmacy benefits. Yet plan sponsors continually focus on “sticker price” measures such as brand-name discounts or manufacturer rebates — metrics that can be manipulated to make a deal look more attractive.”

The one thing which is noticeably different this year is that the document has more of a care management sound to some of the programs they talk about with an emphasis on total healthcare cost savings. Again, I attribute that to both being owned by the Blues and having several people in the management team that came from payers. Buried towards the back, they call themselves “total health focused” versus their competitors.

As always, here’s a few things that caught my attention:

  • A $4.73:$1 ROI for using the local pharmacist to address gaps-in-care.
  • 1.3% trend increase.
  • 74.7% generic fill rate.
  • 20.1% specialty trend increase.
  • 15.4% of client’s pharmacy spend is for specialty drugs which cost on average $2,654.
  • 0.4% of Rx claims processed are for specialty drugs.
  • Their Rxs PMPY have gone up to 12.4 which I think is closer to industry.
    • This is an interesting one. I pointed out a few years ago that they were below average which I wasn’t sure if this was due to plan design, member mix, or client mix.
    • They seem to be going up even though some industry data suggests a downturn in Rxs filled which again is something I can’t explain.
    • It could simply be more people >50 years old are staying in the insured mix…and they use more drugs.
  • Their average net costs per Rx were:
    • $165.33 brand
    • $17.95 generic
    • $57.53 combined
  • They breakdown specialty spend by category and also show how it’s growing and is projected to grow as a percentage of total drug spend.
  • Of course, another big piece of the specialty picture is how the spend breaks out between medical and pharmacy benefits. This is why blending data to understand the complete picture is important.
  • I thought the list of specialty drug management tools was a good starting point although I expected to see more here about how to integrate with the payers especially around categories like oncology and what BCBS of Florida is doing around an oncology ACO solution.

 

Some ACO Facts From Modern Healthcare and CMS

In a Modern Healthcare article about ACOs, there was the following graphic which is a quick snapshot.  The key here is that companies are rapidly moving forward with ACOs (commercial and Medicare).  The initial data is positive, and it seems like everyone is jumping on board.

Scary Infographic On the Effects Of Soda

The scariest stat in here is that kids ages 1 and 2 are drinking soda on a daily basis.

Now, the fact that we’re fat and drink too much soda isn’t the soda’s company’s fault.  We drink soda of our own free will, but this is a contributor to our obesity and this is why the NY soda law makes sense.  (And, IMHO, this is why the soda companies supported removing their drinks from schools and went into the business of selling non-soda beverages…they know there are issues regardless of what they say.)

Soda Infographic

Drug Trend Reports: Quick Summary Of Big Three PBMs

“Comparative” is a very loose word to use here since each PBM has a slightly different approach to their analysis.

But, while it’s truly impossible to compare apples to apples and I will continue to argue that trend may be an irrelevant metric, I know may consultants and others are focused on these metrics.

With that in mind, I pulled the trend numbers (overall and specialty) along with the generic fill rate from the Express Scripts, CVS Caremark, and Prime Therapeutics trend reports.

 

Overall Rx Trend

Specialty Trend

GFR

CVS Caremark

2.2%

19.1%

74.1%

Express Scripts

2.7%

17.1%

75.0%

Prime Therapeutics

1.3%

20.1%

74.7%

Notes:

  • I used the CVS Caremark health plan overall and specialty trend data which I thought would be most comparable to Prime’s data.
  • Express Scripts reports their overall trend (without specialty) being 0.1%.
  • CVS Caremark provides a break out of trend along with best practices by sector (see below).

     

How Often Do Patients Receive Needed Preventative Care?

I thought this image from Optum was very telling.  This is why coordinated care is so important and why it’s important to leverage technology to engage consumers and support their care team. 

Interview With Michael Graves On Healthcare Design

When I was in architecture school, Michael Graves was one of those architects that we studied.  Everyone wanted to be like him designing cool building like this one below.  Since then, he’s gone on to be even more famous both from an architecture perspective and a design perspective (even having his own Target line).

But, since he was left paralyzed from the chest down in 2003, he’s had an incredible focus on redesigning healthcare from the perspective of the patient.  [I would put him in a similar e-patient category as e-Patient Dave, but while Dave is focused on technology and data, Michael is focused on furniture and spatial experience.)

I was thrilled to get the chance to talk with him yesterday to see how this effort was taking off, and on a personal note, to see if this idea of architecture influencing outcomes would be generally accepted.  My general takeaway after talking with him was that he’s getting a very positive response as he talks to people about it, but you’re not seeing a sea-change in terms of clients focusing on this or his fellow architects embracing this.  But, as someone in healthcare, this isn’t surprising.  We know it takes physicians 17 years to adopt new standards…why should it take the administrators of those physicians any less.

At the same time, there is a huge focus on the patient experience and on outcomes these days.  Both of those can be improved through a focus on the physical experience.  I asked him whether he was seeing interest from both inpatient and outpatient facilities.  He indicated that the dialogue is all happening around hospitals which isn’t surprising given their investments in new facilities and the industry shift around ACOs and PCMHs.  But, any of us that have sat in a physician’s office looking at posters from the drug companies, outdated magazines, or just an overly sterile room, know that these things don’t relax you or make you comfortable.

Michael tells a story that I’d seen in other articles about how he first came to understand all the problems with the physical space in the hospital.  He wanted to shave one day and realized that he couldn’t see himself in the mirror and he couldn’t reach the water to turn it on.  It was all designed by someone that hadn’t put themselves in the patient’s shoes (or wheelchair) to understand their perspective on the space.

Since “evidence-based medicine” is all the buzz in the healthcare area, I asked him about the term “evidence-based design” which is used in several articles and on his website.  As he pointed out, it’s basically about just using common sense, but I do think there’s more there (to eventually sell this).  To me, this implies a level of rigor linking more practical furniture and spatial redesign to clinical outcomes and patient satisfaction.  These are the things that are going to motivate the CFO to open the purse strings to make a change.  Unfortunately in our healthcare system, there aren’t a lot of changes made just because the patient wants them or they make sense.  Otherwise, we’d have a healthcare system not a sick care system.

The final topic we discussed was moving beyond furniture to look at art and color and other things that could effect the patient’s experience.  He told me that he’s also a painter (which I didn’t know) and mentioned that one of his clients had bought some of his art and furniture for their facility.  He also reinforced a study that I’d seen before about not using abstract art but focusing more on natural scenes within the patient setting (also mentioned below).

Here’s a few articles from other interviews and a link to the work he’s doing with Stryker on medical equipment / furniture.  You can also see a press release on his upcoming presentation at the end of this post.

And, while Michael is focused on the furniture and spatial experience, there are others focused on the art, colors, and other aspects of the hospital experience.  I found this text from The Atlantic from a few years back that even talks about some of the studies that have been done.  [Maybe case managers should be asking for specific rooms in facilities!]

Such “evidence-based design,” which draws its principles from controlled studies, is the great hope of professionals who want to upgrade the look and feel of medical centers. Much of this research follows a seminal 1984 Science article by Roger S. Ulrich, now at the Center for Health Systems and Design at Texas A&M. He looked at patients recovering from gallbladder surgery in a hospital that had some rooms overlooking a grove of trees and identical rooms facing a brick wall. The patients were matched to control for characteristics, such as age or obesity, that might influence their recovery. The results were striking. Patients with a view of the trees had shorter hospital stays (7.96 days versus 8.70 days) and required significantly less high-powered, expensive pain medication.

Along similar lines, a 2005 study compared patients recovering from elective spinal surgery whose rooms were on the sunny side of a ward with those on the dimmer side. Those in the sunnier rooms rated their stress and pain lower and took 22 percent less pain medication each hour, incurring only 80 percent of the pain-medication costs of the patients in gloomier rooms. Other studies, with subjects ranging from the severely burned to cancer patients to those receiving painful bronchoscopies, have found that looking at nature images significantly reduces anxiety and increases pain tolerance. Not all distractions are good, however. Ulrich and others have found that inescapable TV broadcasts and “chaotic abstract art” can increase patients’ stress.

Press release about his upcoming presentation:

World-Renown Architect Becomes Healthcare Advocate After Rare Illness Leaves Him Paralyzed

Michael Graves to speak at medical conference about his passion for healthcare design


Michael Graves, the award-winning architect and product designer famous for his collection of home products sold at Target, will address the country’s top healthcare professionals during a special reception at the 2012 Health Forum and the American Hospital Association Leadership Summit next month.  He will give a personal account about how paralysis fueled his desire to improve healthcare design.

Graves, who was recently named the 2012 recipient of the Richard H. Driehaus Prize and applies his design philosophy to designing better hospitals and home care environments, will be the featured speaker immediately following the welcome reception of the 2012 AHA Summit, at the San Francisco Marriott Marquis, at 7 p.m., Thursday, July 19.

In his lecture, “People First: Redesigning the Hospital Room,” Graves will discuss his own experience with a sinus infection that left him paralyzed from the chest down and how undergoing hospitalization and rehabilitation in inadequately designed hospital rooms has inspired his healthcare designs.

Graves talk will focus on design solutions for Stryker Medical, including a collection of hospital patient room furniture that addresses common hospital problems such as infection control, patient falls and clinician back.

“We are thrilled to have such a highly-acclaimed and gifted architect speaking before the healthcare community about ways of improving the hospital setting,” said Harold Michels, senior vice president of the Copper Development Association (CDA), the organization hosting the dinner event with Graves.  “This is a can’t-miss event that will certainly have hospital CEO’s and healthcare advocates talking about way after it’s over.”

Graves has said that spending months in hospitals during his recovery in 2003 opened his eyes to poorly designed patient rooms, and made him realize the patient experience could be improved by design.  He immediately began to sketch ideas for improving hospital buildings, room and furniture.

The event is being presented by CDA’s Antimicrobial Copper team, which is working to advance the message that copper surfaces intrinsically kill disease-causing bacteria.  On display will be a variety of antimicrobial copper products, which can play a pivotal role in healthcare facilities by killing bacteria that cause hospital-acquired infections and by reducing costs.

Laboratory testing has demonstrated that antimicrobial copper surfaces kill more than 99.9% of the following HAI causing bacteria within 2 hours of exposure:  MRSA, VRE, Staphylococcus aureus, Enterobacter aerogenes, Pseudomonas aeruginosa, and E. coli O157:H7.

Graves is internationally recognized as a healthcare design advocate, and in 2010, the Center for Health Design named Michael Graves one of the Top 25 Most Influential People in Healthcare Design.  Graves regularly gives lectures to major healthcare advocacy groups, including AARP, the Healthcare Design Conference, Medicine X and TED MED.

About Michael Graves & Associates

Michael Graves & Associates has been in the forefront of architecture and design since AIA Gold Medalist Michael Graves founded his practice in 1964. Today, the practice comprises two firms run by eight principals. Michael Graves & Associates (MGA) provides planning, architecture and interior design services, and Michael Graves Design Group (MGDG) specializes in product design, graphics and branding. MGA has designed many master plans and the architecture and interiors of over 350 buildings worldwide, including hotels and resorts, restaurants, retail stores, civic and cultural projects, office buildings, healthcare, residences and a wide variety of academic facilities. MGDG has designed and brought to market over 2,000 products for clients such as JC Penney, Target, Alessi, Stryker and Disney. Graves and the firms have received over 200 awards for design excellence. With a unique, highly integrated multidisciplinary practice, the Michael Graves Companies offer strategic advantages to clients worldwide. For more information, visit www.michaelgraves.com.

About the Copper Development Association

The Copper Development Association Inc. is the market development, engineering and information services arm of the copper industry, chartered to enhance and expand markets for copper and its alloys in North America. Learn more on ourblog. Follow us on Twitter.

Do You Push Your 10 Year Old To Be An Olympian?

When I was watching the movie The Tooth Fairy last week, it really got me thinking about how some people push their kids so hard into sports at such an early age.  I heard one 10 year old parents talk about their kid being in the next Olympics (when their not even the best at their sport that I know). 

Here’s some examples of what I’ve seen which seem wrong:

  • A 6-year old that is home schooled so he has more time for private lessons in his sport
  • A kid who is only rewarded if she sets 3 records this summer
  • A kid who is paid to beat certain people at her sport
  • A kid who is punished by extra practice if she doesn’t perform perfectly
  • Multiple kids playing on 2 or 3 different teams simulateously in the same sport
  • Kids training 4-5 hours per day / 6 days a week at age 9

I see more and more parents (of kids under 11) video tapping their performances and then breaking down their play after they perform with them.  The focus is always on the negative.  As I heard one kid say, “be my parent not my coach”.  I think that’s important.  Parents can’t project their expectations of paying for college and fame on their kids at such an early age. 

This leads to self-esteem issues.  It leads to burnout.  It leads to over training.  And, it can lead to false expectations that manifest themselves in poor sportsmanship. 

For example, I know one kid that my kid has to compete with came up to her and said “why are competing on this team…I can’t win if you compete”.  Never mind the team spirit.  This kid wants the personal recognition even in a category that she doesn’t compete in year-round, but she thinks she should be a star in whatever she does.  This is what leads kids to cheat and be bullies. 

Here’s a few other articles on this topic:

Here’s a quote from an interview with David Ellis a sports nutritionist about specializing too early:

Early bloomers typically have an advantage on these AAA teams, and while they dominate the domestic stage with their early maturity and specialization, they are not as competitive on the international stage once other competitors have matured. In fact there is evidence that the athlete who didn’t specialize early and was a little later in maturation might end up being the better athlete! Why you ask?

That multi-sport athlete kept on developing motor skills and competitive vision that might have been more challenging in totality than the narrowed focus of the specialized athlete. These multi-sport athletes are hungry to compete as they approach their prime, and because many were late bloomers, they had to be smarter players to make up for their lack of size and strength. So when their bodies do catch up maturation-wise, they often times have a sharper set of skills, and the net result is an athlete who has the tools and the motivation to compete at an elite level versus the burn out early specialized athlete who often seems to have peaked too early and below their net potential.

Healthcare Transparency, Out-Of-Network Claims, and Technology Solutions

Another big focus area these days is around the creation of transparency solutions to enable consumers to make better cost decisions about their healthcare.  While several companies have sprung up to work directly with consumers, the large payers have begun to rollout their own solutions.   And, as you can see from the Towers Watson and National Business Group on Health 2012 Survey, this issue of transparency was the 3rd biggest focus area for 2013. 

If you havent’ heard much about the topic, here’s several articles about the challenge of price discrepancies and surprise bills to consumers:

Here’s what UHG and Aetna are doing:

A few of the companies to look at are:

Companies like GoodRx are creating solutions in this area. 

You also might enjoy this infographic from Change Healthcare.

 

If you don’t believe this is a big issue in terms of price differentials, take a look at this data from the Healthcare Blue Book.  This shows a huge swing in prices which depending on your plan design can directly impact your out-of-pocket spend. 

Test or treatment Low Fair High
Brain MRI $ 504 $ 560 $ 2,520
Chest X-ray 40 44 255
Colonoscopy 800 1,110 3,160
Complete blood count 15 23 105
Hip replacement 19,500 21,148 43,875
Hysterectomy 8,000 8,546 16,480
Knee replacement 17,800 19,791 42,750
Knee arthroscopy 3,000 3,675 7,350
Laminectomy (spine surgery) 8,150 11,744 25,760
Laparoscopic gallbladder removal 5,000 6,459 12,480
Tubal ligation 2,865 3,183 5,729
Transurethral prostate removal 4,000 4,409 8,875
Ultrasound, fetal 120 169 480
Vasectomy 700 1,003 2,100

CellScope – Another Smartphone Bolt-On

Turning your smartphone into a diagnostic device seems to be a large focus right now.  I just saw another one called CellScope.  They allow you to take a picture of your inner ear or your  skin and submit those for review. 

 

From a recent article:

Khosla Ventures also recently invested $1 million in CellScope, an alum from Rock Health’s first class of startups in 2011. The company is developing smartphone peripheral devices designed for consumers to use for at-home diagnosis.

Think of it as a “modern-day digital first aid kit.”

CellScope’s first offering will be a smartphone-enabled otoscope that will enable physicians to remotely diagnose ear infections in children. Parents will be able to use the peripheral, which attaches to a smartphone camera lens, to send an image of their child’s inner ear that physicians can use to make a diagnosis and then write a prescription if need be. CellScope says ear infections in children make up 30 million doctor visits annually in the US alone. The consumer device would help parents miss less work and potentially cut down on late night emergency room visits, according to the startup.

The startup traces its origins to bioengineering Professor Dan Fletcher’s lab at UC Berkeley, where CellScope founders Erik Douglas and Amy Sheng were developing cellphone-microscopy for remote diagnosis in developing countries. CellScope expects to launch future products focused on throat and skin exams, including non-clinical apps for consumer skincare.

A Few Diabetes Facts From Express Scripts

Here’s a summary of some of the data from the latest Express Scripts Drug Trend Report relative to Diabetes.

  • 26M Americans have diabetes
  • 15% of Americans (or 39M) will have diabetes by 2020
  • Diabetes costs $194B per year (health spending) and that is expected to rise to $500B by the end of the decade
  • 41% of diabetes are non-adherent to their medications
  • 60% of diabetics using insulin don’t regularly self-monitor their blood glucose levels
  • The drug costs are $81.12 PMPY (based on high utilization of metformin (a generic)) with 14.91 Rxs per user per year (which seems low since the average diabetic takes 5 medications from what I know)

This gives you some data, but I pulled this data from an older blog post of mine from the ADA…

I found this list of diabetes fact from the American Diabetes Association in an article I was reading:

  • 25.8M children and adults in the US have diabetes (8.3% of the population).  This includes 7.0M who haven’t yet been diagnosed.
  • 1.9M new cases of diabetes were diagnosed in people 20+ in 2010.
  • 215,000 or 0.26% of all people under 20 have diabetes.
  • In 2007, diabetes was listed as the underlying cause of death on 71,382 death certificates and as a contributing factor on another 160.022 death certificates.
  • Adults with diabetes have heart disease death rates 2-4x higher than adults without diabetes.
  • The risk for stroke is 2-4x higher for people with diabetes.
  • Diabetes is the leading cause of blindness among adults ages 20-74.
  • Diabetes is the leading cause of failure accounting for 44% of new cases in 2008.
  • Total cost of diagnosed diabetes in the US was $174B in 2007.

And, depending on if you focus on pre-diabetics, the population becomes even larger.  I expect with more and more companies doing onsite biometric screening that the population in diabetes management programs will increase significantly over the next few years.  The keys will be treating them differently based on risk, disease understanding, and patient preferences to make the programs cost effective.

Setting Expectations As First Line Therapy

I read a great article the other day about adherence.  It took a great big picture view of the topic.

You can’t expect a patient to be adherence to a medication or compliant with your orders if they don’t understand their condition and/or the medication.  This is a very necessary topic even if they’re not a newly diagnosed patient.

This brings into account their literacy level, their plan design, their experience with you as a provider, their experience with the drug, their home life, and many other factors.

I’m going to use an experience from this past week outside medicine to reinforce this point…

I was down in the Destin Beach area this past week and wanted to go out on a charter fishing boat with my family.  We finally found a boat and rented it.  At 6:30 am when we were about to get there, the captain called to cancel because the boat wouldn’t start.  We were disappointed, but I’d rather be stuck on land then trapped at sea.

But, with 4 others in tow, I wanted to make good on my coordinated plan so I walked the docks for 20 minutes and found a captain who’s charter had no showed.  I’ve been on a few charters so I had some expectations.  But, in the end, I was very disappointed.

  • The captain drove the boat like a madman bouncing all of us around and never really gave any directions.
  • His first mate had only been doing this for 2 weeks and while more personable wasn’t much help.
  • Apparently, they have to catch their live bait every morning which ate up over an hour of our trip before someone shared some of theirs with him.
  • And, after a 4 hour trip, we only caught two catfish.

To make it worse, when we pulled in there were boats unloading all kinds of huge fish.

So, did we hire the wrong boat?  Did we get ripped off?

I don’t know, but I know that the paper said that the waves were so ruff that 4 boats capsized the day before leaving fishers in the water being tossed around and requiring the coast guard to save them.  (This was certainly not what I wanted.)  I also know I had a choice between bay fishing (more calm) and gulf fishing (more rough).

My point with this comparison was:

  • Although I’ve been fishing before, like a patient going to a new provider, they could have set some expectations for me by knowing what they do compared to others.
  • Communications are key.  If the captain had provided some perspective on what he was doing instead of just doing it, I might have had a better expectation and perspective.  Do fish bite in rough water?  Why would they catch a lot in the gulf and nothing in the bay?  Were others catching more?

Now if only fishing would move to a pay-for-performance experience then I would have left there disappointed but not having paid for being disappointed.

NY Law On Soda Is Simply A Nudge To Be Healthy

I know we can all complain about the government telling us what to do, but at the end of the day, they’re not saying we can’t drink soda.  As far as I know, you can still have unlimited refills in NY.  They are simply reframing one aspect of drinking soda to try to nudge us into being healthier.  Ultimately, this should be a good thing for us for several reasons.

  1. We eat or drink whatever is put in front of us.  Just look at this research.
  2. Soda and other sugary drinks are generally not good for us.  Just look at the infographic below.
  3. We have an obesity problem in this country (in case you didn’t know it).
  4. Obesity drives diabetes, kidney problems, hypertension, and many other problems that are driving up our healthcare costs and turning us into the first generation to potentially live shorter lives than our parents.
  5. Nudging people into behavior change works.

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.