Monday, December 9, 2013
For instance, the exchanges attempted to guide consumers through the process by presenting premiums and designs of all the available plans, so quick cost comparisons could be made. That’s a good start for helping consumers choose the right plan, and a best practice already in place for most employers.
But it didn’t go far enough.
To be successful, the process is missing a key element: A truly personalized experience that would help a user get a handle on his or her specific situation – especially varying annual out-of-pocket costs, in addition to the plan premiums.
Employers have the capacity to help employees better understand those costs by providing actual claims data history during the decision-making process. That data history can paint an accurate picture of past out-of-pocket expenses. In addition, employers can ask a few questions about planned procedures and other anticipated costs for the coming year, and incorporate that information into the decision process.
Without this level of tailored, data-driven experience, your employees may simply choose a plan with the smallest premium, which doesn’t always pan out as the best option given other circumstances. Providing this type of detailed data can also help employees plan better pre-tax healthcare savings account contributions, too, and minimize surprises.
Of course, doing everything you can to help employees select their best-fit plan has benefits for your organization, as well. Employers using Truven Health Analytics personalized enrollment tools have seen results like a 60 percent decline in the number of over-insured employees and a 20 percent increase in consumer-driven health plan enrollment.
For more ideas on how to make next year’s open enrollment successful for both your employees and organization – despite growing complexities and costs – check out our complimentary insights brief, Six Best Practices for Open Enrollment.
Director, Product Management
Wednesday, November 27, 2013
A recent Wall Street Journal article highlights a strategy employers are using to manage rising healthcare costs: sharing more of the cost burden with employees. Benefit plans with higher out-of-pocket costs for consumers have been rising in popularity over the past few years in the employer-sponsored healthcare sector. Consumers considering new products on the state and federal insurance marketplaces will also find that their choices include plans with higher out-of-pocket costs. It is clear that American consumers will be taking on more of the cost burdens for their health care. The hope is that an educated consumer with financial accountability will take care of their health and make sound financial choices to manage it.
The question is: How do we get consumers to that state? Health plans and employers are looking at tools and services that will create more educated consumers. We need to support consumers as they navigate the healthcare maze and help them become engaged participants. Rather than our traditional point approach, where we engage at enrollment or when a treatment is needed, our industry needs to take a holistic view of the consumer and engage in ongoing and constant communication. We need to turn consumer health management into an everyday occurrence. New innovations in technology, consumer analytics learned from other industries, richer healthcare data, and improved analytics have put us in a better position to create more engaging consumer tools. Our next generation of tools must make healthcare a routine, easy, and intuitive part of every consumer’s day.
Vice President Market Planning and Strategy
Vice President Market Planning and Strategy
Friday, November 22, 2013
Many hospital executives around the country are cautiously communicating with their boards, medical staff, patients and community; attempting to explain why they are facing reimbursement penalties from processes or outcomes which failed to meet established benchmarks. Beyond these somewhat awkward conversations, what are these leaders expected to do next?
Of course, a natural response might be to find someone to blame, whether it be subordinates, physicians, payers or even government. Beyond perhaps feeling better having done so, it is not likely this will reduce the likelihood of facing similar penalties next year. Since credit is afforded to those institutions that make great improvement, many executives view a “low” starting point as an opportunity to recognize significant gains.
So where do you begin? Data. Not just any data. Validated, risk-adjusted and trusted data is the cornerstone upon which to build a strong yet flexible structure, anchored by transparency, accountability and empowerment. This information can be used to construct a pipeline of opportunities, at the procedural or diagnosis level, representing the greatest gap from best practice and impacting the largest number of patients. With a clear appreciation of organizational bandwidth, it is then possible to strategically launch, implement, and sustain initiatives that recognize inherent strengths while addressing barriers to best practice.
Given the uncertainty within the healthcare community, it is easy to become reflexive or even despondent. Yet, it is in these times of flux that innovation, courage and true leadership emerges. The data are there. The talent is there. The commitment to excellence is there. So now is the time to take charge on behalf of board members, medical staff, patients, and most importantly community!
Michael R. Udwin, MD, FACOG
National Medical Director
Tuesday, November 19, 2013
I read a recent commentary in which the author was struggling to understand the cost of a standard back x-ray. In the scenario described, the author had ‘pulled’ her back, so she went to the doctor who recommended a set of x-rays. The author went on to describe efforts to discover where the x-ray could be obtained and the price.
The result? Price information was nearly impossible to gather. Hospitals and imaging centers needed to know the insurance information and many other data points before determining the price. Unfortunately this is an all too common scenario. Why does this happen, and how can this situation be resolved? The “whys” are another topic, but I’d like to address the “hows”.
There is a definite trend toward developing tools to address this inability to learn about price of medical services. This trend is called “transparency,” and doctors, health plans and hospitals are facing more pressure to provide transparency tools to consumers. With new insurance markets and exchanges using consumer driven health plans, patients are paying higher out of pocket costs for medical services, and are rightly asking questions about the costs of services. In the past, patients paid very little of the healthcare bill and didn’t really care (or understand) the costs of the services they were receiving. In the post reform era, consumers are spending more of their own dollars and so are demanding price transparency. I think this is an important and timely trend.
But consumers need to ask more than the cost of the service. In our author’s situation, what are the questions she needs to ask about her diagnostic and treatment plan? (All aspects of the plan, including radiology, lab tests, treatments and procedures, are subjected to similar questions.) Here are the questions she needs to ask the doctor:
1. What is the benefit of the test you are recommending?
2. What is the cost, and what are the risks? For an x-ray, how much radiation exposure will I receive? For a medication, what are possible side effects?
3. Is this test or procedure even recommended for my situation? (In our back pain example, routine x-rays for this condition are not recommended, and shouldn’t be done in most cases.)
4. How will the test results change my treatment? If the results do not change the treatment, why do the test?
5. If a procedure is recommended, what information is available to determine the quality of the procedure?
6. Where is the best location for the test or procedure?
This seems like a lot of information, and will be less or more important depending on the cost or risk of a procedure. How can we expect the average consumer to be able to get these answers? To get back to the specific question of cost, however, at Truven Health Analytics, we understand consumers need this information and have developed a tool to provide answers. Our Treatment Cost Calculator uses our MarketScan® database, one of the largest of its kind, to provide the answers. Our research shows significant cost variation for the same test or procedure in different parts of the country, but surprisingly, also shows considerable price variation within a given market. For example, the same test may vary in price by several-fold in the same city. Our Treatment Cost Calculator allows the user to input the name of the test and the city where the test is offered; using MarketScan data, the tool shows the user all the locations for the test (including directions) and the range of prices for the test. Our tool also includes quality information when available.
Our intent is to arm the user with data about the necessity of the test, the range of prices being charged in the user’s location and data measuring the quality of the test. We don’t expect patients to make clinical decisions, but we want the patient to be able to ask intelligent questions about their treatment plan. We believe this level of transparency is necessary for a patient to be an active partner in their healthcare, not a passive recipient. This is the heart of patient centered care.
Michael L. Taylor, MD FACP
Chief Medical Officer
Michael L. Taylor, MD FACP
Chief Medical Officer
Most upper respiratory illnesses (colds, sinus infections and acute bronchitis) are caused by viruses. Typical antibiotics will not be helpful in curing these infections. In fact, overuse of antibiotics leads to bacterial resistance, a situation in which antibiotics lose their ability to kill bacteria. Antibiotic resistant infections have been estimated to cause 23,000 deaths annually.
To improve this situation, guidelines have been published around inappropriate antibiotic use. But as a nation, the US is not complying with these guidelines. A recent report from the NCQA showed that compliance with these guidelines has decreased, falling from 29% in 2009 to 24% in 2012. The report did show improvement in levels of compliance with guidelines for childhood obesity screening and pediatric immunizations.
Why do physicians follow guidelines at such a low level? There are several reasons:
- Some guidelines are overly complex – LDL cholesterol -lowering guidelines come to mind.
- In the example of antibiotics, some physicians don’t have the time to ‘negotiate’ with patients about the advisability of antibiotics in certain situations.
- Physicians have an incentive to keep patient satisfaction scores high, which may lead to ordering tests or treatments because patients want them, even if not needed.
- Clinical situations exist where guidelines do not apply.
As a nation, are we doing any better with other screening recommendations? Nation-wide, breast cancer screening rates (as of 2010) are 72%, cervical cancer screening rates are 83% and colon cancer screening rates are only 59% of those who are eligible.
It is hoped that changes in the Affordable Care Act (ACA) to cover these screening procedures with no out of pocket charges will improve compliance with the guidelines. But we cannot expect 100% coverage to solve the problem. Many employers have offered these services at 100% coverage for some time, and yet their employees’ screening rates are often quite low.
Fear of learning one has cancer
- Lack of knowledge about the test.
- Fear of the test causing pain or discomfort.
- Perception of cost.
- Not wanting to take the time to have the test.
- No personal primary care physician.
- Personal physician neglected to recommend the test.
- Perception that guidelines change often and may not be correct, as has been the case with breast and cervical cancer screening.
To improve compliance with guidelines, each of these factors should be considered. Educational materials need to be personalized and as specific as possible, and information about price transparency is a must.
Guidelines and templates for clinical care have the potential to improve the quality of medical care delivered, and better implementation of guidelines requires both patient and physician education and acceptance.
Chief Medical Officer
Thursday, November 14, 2013
At the business model level, as health systems, providers, and payers form new at-risk arrangements, they need to under gird those arrangements with the relevant flow of administrative and clinical data to manage performance and risk. Health plans that have been reticent to share claims data need to shift gears both culturally and operationally to help the new provider-driven networks understand costs.
In terms of format, the Federal government has been trying to stimulate interoperability standards through the ARRA HITECH roll out, but many vendors (particularly EMR vendors) have been fighting back to defend their proprietary data formats. As the volume of at-risk contracts grows, new at-risk entities will not be able to function without some form of interoperable gateway to share and receive patient data. So that means that EMR customers will be the ones to request and implement interoperable gateways from their vendors. And if they continue to resist, there is a new generation of interoperability platform vendors that will fill the need.
Finally, from a legal perspective, no one entity actually “owns” the patient data. The patient owns his/her own data. Yet this creates a quagmire of governance models that is bogged down in consent management policy and privacy mechanisms. If patients do not allow an at-risk network to see their data, the network cannot optimize performance. So we may see a new market dynamic whereby network participation requires upfront patient consent to data sharing (an opt-out consent model).
Director for Strategy and Business Development
Tuesday, November 5, 2013
In a newly released insights brief from Truven Health Analytics, The Time is Now: Immediate Actions for Employers Around Health Reform, we provide some key insights into what employers should be doing this year. One of the most important is to minimize exposure to the 40 percent “Cadillac” excise tax.
Most of us know that employers with self-funded arrangements will pay the tax on their high-cost plans; carriers will pay the tax on insured plans, presumably passing on costs in the form of higher premiums. Employers need to understand what cost-trend rates they need to maintain to minimize or avoid exposure to the tax. In addition, they will need to consider the impact of high-deductible and consumer-driven health plan designs on population health and health risk.
This means that organizations should be focused today on creating comprehensive healthcare cost projections using various trend and plan design assumptions to inform decisions on cost control measures and cost sharing approaches. Modeling “what-if” plans can help employers assess the viability of different benefit plan and premium contribution scenarios, including high-deductible and consumer-driven health plan designs.
Other items on the smart employer’s to-do list right now should be: determining if their plans meet the minimum value and affordability requirements, assessing the impact of the Patient-Centered Outcomes Research Trust Fund and Transitional Reinsurance fees, and determining the financial impact of exchange migration.
Download our recent insights brief, The Time is Now: Immediate Actions for Employers Around Health Reform.
Senior Director, Practice Leadership
Thursday, October 31, 2013
This is not the first time we have witnessed fraying in the physician-patient bond. Routinely, outpatient respiratory complaints are encouraged to visit an urgent care center rather than the family practitioner. And the days where the office internist also managed inpatient pneumonia care are long gone, as hospitalists now attend to a large portion of admissions.
CalPERS benefited from an innovative pricing structure designed to selectively encourage high-quality, lower-cost surgical settings. Such an outcome is certainly no surprise to anyone navigating a world of increasing co-payments and deductibles. Beside monetary considerations, are there other factors contributing to physician selection and retention? Of course, word of mouth, referrals, and accessibility are relevant. With enhanced transparency, perhaps quality and patient satisfaction scores will emerge as strong motivators.
The question still remains: “how strong is the physician-patient bond?” Sentimentally, I would like to believe that personal connectedness and longevity determine the strength of cohesion. Yet realistically, perhaps I should be content with the knowledge that if not now, then soon, patients will choose their doctor based on adherence to best practice, outstanding clinical outcomes and appropriate use of resources…and a great personality!
Michael R. Udwin, MD, FACOG
National Medical Director
Wednesday, October 30, 2013
Research continues to demonstrate that highly activated patients are more likely to have better outcomes:
- Highly activated patients have lower healthcare costs (1)
- Patients with higher activation levels are more likely to have normal systolic blood pressure, triglyceride and HDL levels, a healthy weight, and less likely to visit the emergency room or become hospitalized (2)
- Highly activated patients have more positive care experiences (3)
- Actionable. Instructions emphasize how to complete a task, including crucial details and steps describing the behavior a patient must change, or the actions a patient must perform.
- Direct. State information directly and concisely. The message is not complicated with extra words or unnecessary medical terms.
- Directive. Tell the patient what to do and what not to do, so the patient is not left to guess whether directions are necessary or merely suggested.
- Streamlined. Remove information that is not necessary in order to highlight need-to-know information.
What innovations is your hospital or staff making to promote activation and to ensure the patient experience is interactive? What do you think are the most critical imperatives for activation improvement? Post a reply and share your ideas. Sharing our collective experiences is a great way to learn what is and is not working among your peers.
Learn more about how our comprehensive editorial process and procedures promote patient activation to improve health literacy, motivate patient behavior, and increase compliance.
Heather Du Mez, RN, BSN
Monday, October 28, 2013
To test this theory, Chapin White, a senior researcher at the Center for Studying Health System Change, and I recently completed analyses to examine whether changes in Medicare prices were associated with changes in Medicare inpatient patient volume. We examined the relationship between market-level price trends and trends in the number of inpatient hospital discharges among the elderly (65+ years of age) across 10 states over a 15 year period (1995-2009).
Overall, we observed that by 2009, inpatient hospital stays were much shorter and patients received much more intensive treatment. Taking a closer look, we found that hospital markets with lower growth in Medicare prices had smaller increases in hospital utilization and greater decreases in length of stay compared to markets with higher growth in Medicare prices. These results suggest that Medicare price cuts lead hospitals to reduce capacity and provide fewer services to the elderly. When we simulated the effect of a 10 percent decrease in the Medicare price, we found that discharges of elderly patients decreased by 4.6 percent and the number of hospital staffed beds decreased by 6.3 percent.
Our findings run counter to the notion that hospitals will attempt to recoup losses from Medicare price cuts by increasing inpatient volume. Rather than leave beds empty, hospitals appear to constrain their scale of operations. In this way, hospitals appear to behave as profit-maximizing firms that increase output when they are paid higher prices and decrease output when the costs of production rise. Considered in the context of the ACA price cuts, findings suggest that Medicare savings may actually be larger than expected due to hospitals volume response. Conversely, if the Medicare provisions in the law were repealed, Medicare spending might increase by more than has been projected. Our findings also point to important questions for future research – in particular, examining the impact of Medicare price reductions on the quality of care beneficiaries receive, as well as their overall health outcomes.
Behavioral Health and Quality Research Division