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Infographic: Improving Primary Care With Pharmacists

This is an infographic on an interesting program out of USC which received money from the CMS innovation fund.

Infographic Expanded Role Of Pharmacists

Infographic: How Patients Learn In The Digital Age

 

I found this infographic here – http://www.hitconsultant.net/2012/07/25/how-patients-learn-in-the-digital-age-infographic/.

How-Patients-Learn-in-the-Digital-Age-Infographic-1

Updated: What Is A PBM? Pharmacy Benefit Manager

The short answer is that a PBM is the company hired by your employer (either directly or through your health insurance company) to manage your pharmacy benefits.  When you use your pharmacy card at the retail pharmacy to get a prescription, the pharmacy interacts with your PBM electronically to find out if the drug is covered and the copay to you the consumer.

*****************

Back when I first started blogging, I used a lot of my experiences at Express Scripts to shape some of my perspectives about the PBM or Pharmacy Benefit Manager industry.  It took me a few months before I realized that some people reading the blog didn’t know what a PBM was.  That led me to my all time most popular blog post – “What Is A PBM?

Since that was over 5 years ago, I figured it was time for an update.

The market has shifted in the past 5 years especially with Express Scripts purchase of Medco to become the largest player in this space.  Walgreens has also divested their PBM to CatalystRx which was then bought by SXC and the new entity renamed CatamaranRx.  At the same time, you’ve seen United Healthcare insource their PBM business from Medco to combine it with their old Pacificare PBM to create OptumRx.  You’ve also seen Humana’s PBM business and mail order business – RightSourceRx – grow significantly.

There are other big PBMs which I didn’t mention such as CVS Caremark which after years of rumors about them splitting back up seems to have proven their case as an integrated, retail-owned PBM.  There is MedImpact which has 32M lives according to the latest PBMI market share report, and Prime Therapeutics which is a PBM owned by several of the BCBS plans.  Additionally, Aetna, Cigna, and several other managed care companies also have their own PBMs.

While I would have argued that the PBM wasn’t typically known to consumers 5 years ago, I think that the very public dispute between Walgreens and Express Scripts has changed some of this.

But, what a PBM does is relatively simple:

  • Process pharmacy claims (i.e., when you go to your retail pharmacy, the pharmacist enters your prescription and electronically submits it for adjudication. The claim is routed to the PBM where it is checked for eligibility and then to see if it pays and what copayment you owe.)
  • Set up pharmacy benefits (i.e., based on the plan selected by your employer or payor, the PBM codes what drugs are covered and the copayment structure).
  • Administer rebates…since large pharma companies (e.g., Pfizer) pay rebates for having their drugs on formulary (aka preferred drug list), someone has to manage the negotiations and billing of this.
  • Set up clinical programs (i.e., most PBMs have a clinical committee which evaluates new drugs and looks at market data to help employers choose coverage options).  This also includes programs to look for drug-drug interactions and pharmacy adherence.
  • Establish a retail pharmacy network (i.e., work with retailers to get them to agree to discounts on drugs) and are a big part of SureScripts which is the hub to enable electronic prescribing between physicians, pharmacies, and PBMs.
  • Communicate with patients and physicians (i.e., look at pharmacy claims data and help find ways to save money or identify clinical issues to inform the patient or physician about).
  • Provide cross pharmacy data for drug-drug interactions…this is a critical function since many people use more than one pharmacy for claims.
  • And, last but not least, most PBMs provide a mail order and often specialty pharmacy where they ship prescriptions to patients.

The PBM’s clients are employers who are self-insured, government entities (i.e., state employees, Department of Defense), unions, TPAs (third party administrators), and managed care companies (i.e., BCBS of).

PBMs are sometimes referred to as middlemen, but I will point to a few other posts on this:

In general, if you’re looking for more information on PBMs, I would point you to several sources:

The only other blogger who really offers any coverage of this space is Adam Fein which his blog – Drug Channels.

What Do MDs Tell Patients About Their Rx … with only 99 seconds?

As part of a new study mentioned on The Doctor Weighs In, it shows that physicians spend an average of 10 minutes and 10 seconds with patients in an average visit.  Of that, 99 seconds (or 16% of the time) they are discussion prescriptions.  The big question is what are they discussing.

MD Rx discussions

A 2006 study showed the following:

74 percent of the doctors mentioned the trade or generic name of the medicine, and 87 percent stated its purpose. Sixty-six percent said nothing about how long to take the medicine, 45 percent did not say what dosage to take and 42 percent failed to mention the timing or frequency of doses. Physicians mentioned adverse side effects only 35 percent of the time.

Of course, research on the physician and patient dialogue around prescriptions should also include looking at these studies:

That is asking a lot of the money spent by the manufacturers on the physicians.

Detailing to physicians, nurse practitioners, and physicians’ assistants cost $12 billion, accounting for more than half of that promotional spending (see Figure 1). Drug companies spent another $3.4 billion sponsoring professional meetings and events and about $0.4 billion placing advertisements in professional journals. Pharmaceutical manufacturers spent the rest of their promotional budgets, $4.7 billion in 2008, on direct-to-consumer advertising.

46% Of Physicians Say Transparency Will Increase Costs

trans·par·en·cy [trans-pair-uh n-see]

noun, plural trans·par·en·cies.

1. Also, trans·par·ence. the quality or state of being transparent.

2. something transparent, especially a picture, design, or the like on glass or some translucent substance, made visible by light shining through from behind.

3. Photography .

a. the proportion of the light that is passed through the emulsion on an area of a photographic image.

b. a photographic print on a clear base for viewing by transmitted light.


This is the dictionary.com definition of a term that gets thrown around in healthcare all the time.  I’ve talked about transparency several times this year, and I expect a lot from companies like Change Healthcare in 2013. 

That being said, I found an article in HealthLeaders in November 2012 very interesting.  It referenced a study showing the answer to this question – “how will greater transparency on healthcare costs affect your organization’s cost of care”?  I just assumed the answer would be that it would decrease costs.  The data didn’t support that.

While 56% of health plans thought that transparency would decrease costs…

  • Only 28% of hospitals thought it would decrease costs
  • Only 26% of health systems thought it would decrease costs
  • Only 14% of physicians thought it would decrease costs

31% Happy With Their Health Insurance

In a CNNMoney.com poll, 31% of those polled responded that “yes, it’s fine” to the question “are you happy with your health insurance”?

  • 36% said “it’s a mixed bag”
  • 30% said “no, I’d like to switch”
  • 3% were uninsured

In the October 2012 edition, they shared a few other stats:

  • 35% of Americans consider themselves “well insured” and another 56% feel adequately insured
  • 21% of healt insurance complaints ahve been about delays in processing claims (the most common complaint)
  • 65% of those insured by their employer wouldn’t trade a smaller provider network for smaller premiums

At the same time, healthcare costs continue to be out of control, and we need massive reform to a system that Americans aren’t excited about but yet have no fire forcing them to change.

Diabetes Innovation – mHealth; Quantified Self; Business Model

I’m not a diabetic, but I’ve been researching the topic to understand the space and what innovation is occurring around diabetes. This is a space where there are lots of applications, tools, devices, communities, and research. The ADA estimates the total US cost at $218B with very high prevalence. If you expand that on a global scale, the costs and impact is staggering.

  • Total: 25.8 million children and adults in the United States—8.3% of the population—have diabetes.
  • Diagnosed: 18.8 million people
  • Undiagnosed: 7.0 million people
  • Prediabetes: 79 million people*
  • New Cases: 1.9 million new cases of diabetes are diagnosed in people aged 20 years and older in 2010.

So, what’s being done about it? And, what opportunities exist? I think you’ve certainly seen a lot of innovation events being sponsored by pharma and others.

You’ve seen a shift from drug to engagement for a few years as evidenced in this old post about Roche – http://www.diabetesmine.com/2009/10/a-visit-to-the-roche-new-concept-incubator.html

You’ve seen a proliferation of diabetes apps. (A prime opportunity for Happtique.)

From my traditional PBM/Pharmacy focus, you’ve seen several efforts there:

Obviously, Medco (pre-Express Scripts acquisition) thought enough of this space to buy Liberty Medical.

I pulled some screen shots and examples into a deck that I posted on SlideShare. I’d welcome people’s thoughts on what’s missing or what are the key pain points from a diabetes perspective (e.g., not integrated devices).

While I was doing my research, I found a few interesting things worth sharing.

Several interesting studies:

Some good slide decks:

Additionally a few videos:

I also posted some diabetes infographics on my blog – https://georgevanantwerp.com/2012/12/13/more-diabetes-infographics/

And, while I started to pull together a list of diabetes twitter accounts below, you can follow @AskManny’s list with 360 people already tagged in it. https://twitter.com/askmanny/diabetes

My starting twitter List:

More Diabetes Infographics

I’m sharing a few more here, but you can also go to Pinterest to see some shared there – http://pinterest.com/diabetesforum/diabetes-infographics/.

Diabetes_Info_Graphic

diabetes infographic

Help for Depression

Interview With BodyMedia CEO at mHealth Summit #mhs12

BodyMedia 1

Last week at the mHealth Summit in DC, I had a chance to sit down and visit with Christine Robins who is the CEO of BodyMedia. (see bio below)  One of the most exciting things (mentioned at the end) is their new disposable solution coming out.

Christine Robins is currently the Chief Executive Officer of BodyMedia, Inc., a pioneering market leader in wearable body monitors. BodyMedia’s devices are unparalleled in the marketplace, and equip professionals and consumers with rich information to manage a range of health conditions impacted by lifestyle choices.

Prior to joining BodyMedia, Christine was the CEO of Philips Oral Healthcare where she led the global Sonicare® brand to significant sales and share growth. Christine also has extensive experience in a wide range of marketing and finance capacities gained during her 17 years at S.C. Johnson, where she ran notable brands such as Raid® insecticides, Glade® air fresheners, and Aveeno® skin care. With this background rooted in global multi-national companies and an entrepreneurial zeal essential to lead a high technology upstart, Chris is passionate about developing turnaround strategies, building teams, and driving innovation.

A noted speaker, Christine has delivered presentations at universities such as Harvard, Stanford and Duke, as well as keynotes at industry shows such as the Consumer Electronics Show, Health 2.0 and CTIA. She holds a degree in Marketing and Finance from the University of Wisconsin-Madison and an MBA from Marquette University.

If you’re not familiar with BodyMedia, it’s definitely a company to know from a Quantified Self perspective. They have been around since 1999 providing solutions and have 150 global studies about the effectiveness of their devices in weight loss (see one chart below). The devices that they use continue to get smaller and smaller with time and are registered with the FDA as Class II medical devices.

clinical charts_2012_updated

Their devices track 5,000 data points per minute using 4 different sensors. Here are a few screen shots from the mobile apps that they have.

bodymedia iOS 3

And, as you can see, they map well to the chart below which shows what data consumers and physicians want to track with weight, calories, physical activity, and sleep patterns.

Quantified Self 2

For food tracking, they work with MyFitnessPal which provides them with data on products you eat. I think a good example can be seen in this screen shot from the Android app.

bodymedia 4

But, honestly, a lot of what I was really intrigued by was a new offering they’re rolling out called the “PATCH” which will be a 7-day, disposable body monitoring system that does everything the full blown system does. I don’t know the price point yet, but this is really exciting as a way to pull new people into the market and to use as a strategy for setting a baseline with a patient to understand their data. It could then lead to recommendations around disease management.

Another thing that Christine talked about was they’re approach to partnering with places like the Biggest Loser and other to allow for a customized content approach to your messaging from the system. She also showed me how the device will project where you will end up at the end of the day based on your past history.

They also have a module for a coach or weight loss professional to help manage and view data across all the people they’re working with.

(And, I just grabbed this image from their website since it points out the 3 key things to weight loss.)

My Top 11 Healthcare Predictions For 2013

It’s always fun to predict what will happen in the next year. No one is ever right, but you can hope to be directionally correct. With that in mind, here’s a few of my thoughts for what will happen in 2013…

  1. Reform (PPACA aka ObamaCare) will happen. While the Republicans will fight it, with Obama’s re-election and the Supreme Court decision. Reform will continue to happen. The states will mess up the Exchanges which will create many issues, but private exchanges will come to the “rescue”.
  2. Big Data” will be a focus at every healthcare company. What data to store? How to mine the data? What data to integrate? How to bring in unstructured data such as physician’s notes? What to do with consumer reported and consumer tracked data from all the different devices?
  3. Physicians will emerge back in the power seat. With Accountable Care Organizations and Patient Centered Medical Homes, consumers are finally becoming more aware of all the shortcomings in our sick care system. They trust their physicians although somewhat blindly given ongoing challenges with evidence-based care and quality which are often the result of our Fee For Service system (too little time) combined with an abundance of new research happening concurrently.
  4. mHealth will be the buzz word and exciting space as entrepreneurs from outside healthcare and people with personal healthcare experiences will attempt to capitalize on the technology gap and chaos within the health system. This will create lots of innovation, but adoption will lag as consumers struggle with 15,000+ apps and the sickest patients (often older patients) are the slowest to adopt.
  5. Device proliferation will go hand in hand with mHealth and with the Quantified Self movement. This will create general health devices, fitness devices, diabetes solutions, hypertension solutions, and many other devices for wellness and home monitoring for elderly patients. Like mHealth, this will foster lots of innovation but be overwhelming for consumers and lead to opportunities for device agnostic solutions for capturing data and integrating that data for payors and providers to use.
  6. The focus on incentives will shift in two ways. Technology vendors will begin to look more and more at the gamification of healthcare and how to use gaming theory and technology to drive initial and sustained engagement. At the same time, the recent ruling will allow employers to shift from rewards to “penalties” in the form of premium differentials where patients who don’t do certain things such as take biometric screenings or engage with a case manager will pay more. In 2014 and 2015, this shift will be from penalties with activity to penalties tied to outcomes.
  7. Consumer based testing will drive greater regulation. With the focus on home based testing (e.g., HIV or High Cholesterol) and the increased interest in genetic testing especially when tied to a medication, the FDA and other government agencies will have to address this market with new regulations to close gaps such as life insurance companies being able to force disclosure of genetic testing in order to get coverage (even though the testing isn’t necessarily deterministic).
  8. Clinics will prepare for 2014. With the increase number of consumers being covered in 2014, there will be an access challenge for patients to see a provider. This will drive buildout and utilization of health clinics such as TakeCare or MinuteClinic. Clinics will have to look at how to adapt their workflow to create a patient relationship which will create potential integration points with TeleHealth and bring back up the issue of whether they should or could replace the traditional Primary Care Provider (PCP) relationship or not.
  9. Telemedicine will hit a tipping point and begin to Cross the Chasm. They now have better technology and adoption within major employers. This will start to create more and more business cases and social awareness of the solution. With utilization, we will see great adoption and the increasing use of smart phones for healthcare will drive telemedicine into an accelerated growth stage.
  10. Transparency solutions will continue to be a hot area with CastLight and Change Healthcare leading the way. Their independence and consumer engagement approaches based on critical moments (i.e., pointing out how to save money on Rxs just before a refill) and using multiple channels will show high ROI which will also increase broader healthcare awareness making them part of the population health solution.
  11. Generics will no longer be a talked about issue. With generic fill rates running so high across different groups and being front page news, PBMs, pharmacies, and pharma will truly begin to move forward to embrace the specialty market with a clear vengeance (at least in the US).

There are still a few longer term trends that I’m watching, but I don’t think that 2013 is the primary year for them.

  1. The evolving role of pharmacists within the Medical Home and with vaccines.
  2. A significant shift from mail order to 90-day at retail fulfilled by massive central fill facilities.
  3. Pharma co-opetition where they begin to collaborate at the disease state level realizing the a rising tide is good for all boats.
  4. Integration of data from all types of solutions and actions into workflow triggers that automatically create new events within the care management infrastructure using Service Oriented Architecture and Business Process Management.

FitBit One Goes To The Gym – Last Challenge

I’ve shared a few tests with you about my FitBit One which included comparisons against my Garmin and versus a pedometer. Today, I got to take it to the gym with me and tested it for distance and calorie count relative to several pieces of equipment from LifeFitness – treadmill, stationary bike, and elliptical. For the treadmill, I also looked it two ways: (1) running at an 8 minute mile pace and (2) walking at a 15 minute mile pace at a 15% slope.

As you can see before, the FitBit was much better aligned on distance with the treadmill, but it was not as aligned on calorie count. I’m have no hypothesis here. I will say that I was surprised that the uphill walking didn’t somehow register as steps. I say that because I went on an outside run the other day up and down hills, and the FitBit did a great job of tracking my uphill runs and translating that into floors climbed.

As a side note, I think this does a nice job (if you believe the equipment calorie count) on showing how a slow walk up a steep slope can burn lots of calories compared to a fast run.

Stay Moving Avoid Sitting Disease

A clinician was talking to me he other day about “sitting disease“. They said that our increasingly sedentary lifestyles are causing all kinds of problems – not least of them being obesity.

With that in mind, I thought I’d share this article and Infographic…

Office workers can exercise at their desk to get into better shape

Stuck working in an office with no time to hit the gym on a regular basis? There are ways to burn off a few calories during office hours, says Selen Razon, a physical education professor at Ball State.

“Studies have shown that long periods of inactivity — including sitting at your desk — increase the risk of cardiovascular disease and cancer,” she says. “I suggest that people do a few simple exercises to get their bodies moving and then stretching and toning at your desk. Moving a little goes a long way.”

Razon suggests:
• Start exercising before arriving at your desk by first parking your car as far away from the building as possible and then walking.
• Take the stairs whenever possible.
• Do exercises at your desk, including flexing arms, legs and abs on 30-second intervals.
• Get rid of a chair and sit on a medicine/fitness ball while working. Sitting on a ball will tone and strengthen your abs.
• Stand up and/or take short walks every 20 minutes at desk. Studies show even simple frequent standing breaks significantly decrease your chances of getting diabetes.
• Exchange the typical desk for one that allows you to stand, which burns more calories.
• Bring gadgets to the office. Hand grippers and stretch cords are relatively cheap and can provide great outlets for keeping active while you look at your screen.

FitBit vs Garmin – Test #2

As I mentioned, I got my new FitBit One the other day. I’ve been experimenting with it each day. Yesterday, I showed how it performed versus a pedometer. Today, I focused on how it performed versus my Garmin Forerunner watch that I use to track my distance and speed when running outside. While the data relative to the pedometer was pretty similar, there was a 15-16% discrepancy between the FitBit and my Garmin.

According to the Garmin, the FitBit was underestimating my distance traveled. To validate the distance, I also used www.walkjogrun.net to calculate the distance (which they estimated to be 0.82 miles).

At the same time, I also wanted to see if there was a difference between just having it sitting in the bottom of my pocket versus putting it on my belt loop. Location didn’t seem to matter.

 

(Note: This chart shows distance in miles.)

FitBit vs. Pedometer – Test One

I’ve been enjoying the FitBit One for a few days now.  I decided there were a few tests that I’d like to do.  The first one was to compare it to the step count from a pedometer that I’ve had. 

It hasn’t been a highly active day (as I’ve been working from my home office), but there doesn’t seem to be much of a difference. 

1/3rd Of Diabetes Develop Chronic Kidney Disease #WorldDiabetesDay

With 347M diabetics worldwide and another 79M in the US alone with pre-diabetes, we hear a lot about this condition, and its cost impact. But, I’m always surprised that there’s not more focus on the fact that 1/3rd of diabetics will develop Chronic Kidney Disease (CKD). CKD is a progressive condition for most patients where they eventually end up on dialysis which is very expensive and has a significant impact on patient’s quality of life.

So what can diabetics do to avoid developing CKD:

  • Control your blood sugar level
  • Keep blood pressure under control
  • Check your blood pressure as often as your doctor recommends
  • Ask your doctor to test you for kidney disease at least once each year
  • Take medicines to help control your blood glucose, cholesterol, and blood pressure if your doctor orders them for you
  • Follow your diet for diabetes
  • Get regular exercise
  • Avoid alcohol
  • Do not smoke
  • See your doctor as often as you are told

Top Diabetic Bloggers And Infographic

I found this site listing some of the top diabetic bloggers and also found this infographic there.

http://www.sharecare.com/static/sharecare-now-diabetes

Infographic: Obesity

Unfortunately, I don’t think a lot of this will surprise many of you, but it’s scary to think about the impact of obesity across different industries.  For some of them this is big business.  And, while I don’t think employers have fully realized how to focus on this from a “wellness” or “disease management” perspective, I think that will change. 

Are You Part Of The Quantified Self “Movement”?

I’m not sure whether to call it a movement or a trend or some other term, but I think it’s very interesting.  This idea of capturing and tracking data manually and through devices fits very well with the idea of “Know Your Numbers” in healthcare.

Here’s the descriptionof Quantified Self from Wikipedia:

The Quantified Self is a movement to incorporate technology into data acquisition on aspects of a person’s daily life in terms of inputs (e.g. food consumed, quality of surrounding air), states (e.g. mood, arousal, blood oxygen levels), and performance (mental and physical).

The movement was started by Wired Magazine editors Gary Wolf and Kevin Kelly in 2007as “a collaboration of users and tool makers who share[d] an interest in self knowledge through self-tracking”. In 2010, Wolf spoke about the movement at TED, and in May 2011 the first international conference was held in Mountain View, California.

Quantified Self is also known as self-tracking, body data and life-hacking. It is described in articles such as this one in the Economist and this in Forbes.

With an increasing amount of devices on the market that can be integrated (e.g, FitBit), we will see a huge rise in remote patient monitoring where the patient takes a greater role in this effort.  Even know you are seeing more efforts to integrate devices into the “smart home” with a focus on older patients, but I think this smart home concept will continue to grow. 

This Slideshare presentation is a nice summary…

 

 

Stand Up To Cancer At World Series

If you were like me, you were surprised and impressed to see all the Stand Up To Cancer signs at last night’s World Series game in San Francisco. It was impressive, but it made me wonder who this company was. Here’s some text from one of their press releases.

Stand Up To Cancer (SU2C) — a program of the Entertainment Industry Foundation (EIF), a 501(c)3 charitable organization — raises funds to hasten the pace of groundbreaking translational research that can get new therapies to patients quickly and save lives. In the fall of 2007, a group of women whose lives have all been affected by cancer in profound ways began working together to marshal the resources of the media and entertainment industries in the fight against this disease.

SU2C’s “Dream Team” approach to funding translational cancer research enables scientists from different disciplines at research centers across the country and internationally to collaborate on projects geared toward getting new, less toxic treatments to patients as quickly as possible. Monies also support innovative cancer research projects that are often deemed “too risky” by conventional funding sources. Sixty-five institutions are currently involved. As SU2C’s scientific collaborator, the American Association for Cancer Research, led by a prestigious SU2C Scientific Advisory Committee, provides scientific oversight, expert review of the research projects and grants administration.

I also grabbed a screenshot of some of the factoids from their website:

Less Than 20% Trust A Pharmacist To Help Them Make Healthcare Decisions – Surprising?

Whenever you go to the pharmacy, they always ask you if you have questions and make you sign off that you were offered counseling.  It begs the question of whether anyone actually does.  I just got this survey data e-mailed to me, and I wanted to share it since it was surprising to me and from RxAlly

I also found it surprising that people don’t think their pharmacist can help them make healthcare decisions.  This is certainly relevant in the Medicare world where AARP and others have partnered with pharmacists traditionally.  Additionally, I think it limits some of the longer term opportunities for pharmacy, pharmacists, and PBMs.  I’ve always thought that given their frequency of patient intervention that there would be lots of opportunities to leverage the pharmacist at the POS to close care gaps and be very engaged in the overall care and driving health outcomes. 

Only 15 percent of U.S. adults have ever discussed a medication maintenance regimen with a pharmacist and only 49 percent have discussed any new medication with a pharmacist. Less than 20 percent (18%) of U.S. adults trust a pharmacist most to help guide and inform healthcare decisions for themselves and their families. A majority of people trust their doctor most (72%), followed by friends and family (36%), spouses or significant others (36%) and the internet (22%).

Source: RxAlly
http://rxally.com/rxally-news.html

The Real Bears YouTube Video – Creative Attack On The Soda Industry

This video is a little slower going than I had imagined, but it makes a series of tough points about the soda industry and its impact on our healthcare.  See http://therealbears.org for more information.

Infographic: Laughter As Medicine (And Equals Working Out)

I think we’ve all heard this at some point or another although I was surprised by the comparisons to the health values of sleep and working out.  I wonder how hard I have to laugh to accomplish that.

Go Patch Adams!

Laughter Infographic

 

Will You Be Charged More For Not Participating In Wellness Programs?

Thus, the major factors that insurance companies traditionally use to charge higher premiums – such as health status, the use of health services, and gender – will no longer be allowed under the ACA. However, the ACA does permit employment-based health plans to charge employees up to 30 percent more on their premiums (and potentially up to 50 percent more) if they fail to participate in a wellness program or meet specified health goals.  [From Kaiser document]

Traditionally, health plans and employers have rewarded consumers for taking some basic action (e.g., $100 for completing an HRA)…although some companies prefer penalties versus incentives.

At that same time, there is some evolution happening here with companies moving from simply paying for an action to requiring participation in a program (e.g., disease management).  The next step that a few companies are engaging in is actually incenting or penalizing consumers based on health outcomes.  This will certainly open some doors for legal challenges where people will argue that they are genetically pre-disposed to some factor that limits their ability to lose weight or lower their cholesterol or some other measure of health.

But, in one of the first legal challenges in FL, the court recently upheld the idea of rewarding (or penalizing) consumers based on taking a specific action (like completing a biometric screening).  With that, I expect companies will be more empowered to take advantage of the fact that under health reform they can charge consumers up to 30% more for their healthcare for either not participating or not achieving a specific health outcome.

With an average monthly premium of $468 per month of single person coverage and consumers paying an average of 21% of their healthcare costs (or $97 per month), this means that a consumer could pay an additional $29 per month (or $349 per year).  [If I interpret all of this correctly…if it’s 30% of the total health premium (not just the consumer’s share), then this jumps up dramatically.]

Not surprisingly, employees aren’t real excited about this.  In a survey by the National Business Group on Health, 62% oppose charging employees more for health coverage if they do not participate in wellness programs.  And, 68% oppose requiring employees to participate in a wellness program in order to qualify for health insurance.

And, according to the survey, the most effective cost control tactic was believed to be Consumer Driven Health Plans by 43% and wellness programs by 19% while 60% of employers plan to increase the premium paid by employees (i.e., cost shifting).

But, if companies throw out a life preserver (i.e., wellness program) to a drowing individual (i.e., unhealthy individual), why isn’t it a reasonable expectation that the individual has to grab it (i.e., participate in the program)?

Infographic: Inactivity Pandemic

I always love a good infographic with good data elements on a topic I care about.

Inactivity Infographic

Absenteeism And Presenteeism Costs > Medical Costs

I always hear people talk about ROI around population health programs.  The problem is that most people struggle to estimate the absenteeism and presenteeism costs associated with poor health.  Various studies continue to reinforce that these costs actually exceed the medical and pharmacy cost savings.

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