Education Needed to Help Consumers Navigate Exchanges

A recent Politico article discusses the dilemma insurance exchange participation represents for health insurers. Exchanges could be a great way for health plans to gain millions of newly insured members. However, the regulatory and compliance requirements -- along with underwriting and pricing challenges -- make the decision to participate more complex. In addition, the general public has little understanding of health insurance basics. The federal government has agreed to do some education to ensure consumers are ready to navigate exchanges, but health insurers need to help.

The benefits of potential new membership seem to be outweighing the risks associated with the new heavily regulated marketplace. Come October 2013, if consumers come to the marketplace, our industry will find out whether the investments worked. Regardless of the year-one experience, health plans recognize that their businesses need to change to be more consumer-centric and are investing in solutions and services to support this change.

Anita Nair-Hartman
Vice President, Market Planning and Strategy

Using Data: Turning Information into Action

Professionals within the health care system are ‘awash’ in data, but that does not necessarily translate into actionable information.  As chief medical officer at Truven Health Analytics, I see this disconnect at all levels. Doctors using electronic medical records (EMRs) still have difficulty understanding the complete risk profile of their patients. Seemingly easy questions like: which of my patients need help to quit smoking? , or which of my patients with diabetes are not at goal for blood pressure? EMRs are good data collection tools, but may not always be effective in turning data into actionable information.

Employers are facing similar difficulties in their role of paying for health care for their employees. Health reform is a reality, and 2014 will be a year of major change and disruption. Employers are struggling to understand who they should use their health cost data to make good decisions about offering exchanges in place of traditional insurance for their employees. They need to know how employees can make better decisions about the best medical coverage plan for their families.

EMRs and databases seem to offer the hope of data-driven solutions, but having the data is not enough.  EMRs are useful tools, and are helpful in tracking a patient’s medical care. However, EMRs are not the best solution to understand the population for which a physician is caring.  Cost reports will not be up to the task in helping an employer understand which insurance products to offer their employees. Hospitals and health systems need help in determining how to succeed with new payment models that completely change their business strategy.

Answering these important healthcare questions requires more than having the data; answers require a deep understanding of content and context of the data, and thoughtful and complete analysis of the data. At Truven Health Analytics, this is the role we play as we help our clients make important decisions. With new models of health care payment such as Accountable Care Organizations (ACOs), bundled payment and risk contracting, employers, hospitals and health systems have a greater need than ever to understand what the data are telling them.  “Big Data” is not just a new buzzword—it is a necessary source of new data needed throughout all parts of the health system.

Michael L Taylor, MD FACP

Chief Medical Officer

ED Visits and Mental Health: Understanding Underlying Causes

A recent article in HealthLeaders about usage for emergency departments, as well as research we've done recently at Truven Health Analytics, highlight a number of issues around health care utilization. The article touches on the diversity of problems represented by repeat emergency room users, but the role of mental illness may be underrepresented in the figures. Emergency room records focus on acute treatment – for example, trauma, respiratory, or cardiac issues – and may ignore underlying factors that contribute to the acute condition.

In a sample from our MarketScan® database of commercially insured patients with ER visits in 2011, 45% of the patients with an ER visit had at least one more ER visit in 6 months of less. Overall, 13% of the ER visits were associated with patients having a diagnosis of psychosis some time during the year; but patients with a diagnosis of psychoses made up 29% of those patients having 5 or more ER visits within 6 months. 

I happened to look at Medicaid ER visits with an eye toward understanding whether mental health might play a role here too, and found that this pattern holds true and also there seems to be a gender-based utilization difference. Fifty-six percent of Medicaid ER visits in the sample were female; but ‘frequent flyers’ - patients with 5 or more visits to an ER in 6 months - who also have a diagnosis of psychoses, are 73% female.

If we consider some percentage of trips to the ER as being a failure to effectively treat and manage psychoses, then this indicates female psychoses patients appear to be associated with a higher number of acute failure episodes.

Brian Griffin

Director of Market Analytics 

ED Visits – Sometimes, It’s Difficult to Know Where to Find the ‘Right’ Care

Truven Health Analytics recently reported a study showing the majority of US Emergency Department (ED) visits were actually non-emergent. In this report, only 29% of patients required immediate medical attention in the ED.

Of the remainder:

• 24% did not require immediate attention

• 42% required care that could have safely been delivered in a primary care setting

• 6% received care that could have been preventable with prior proper care.

Importantly, in discussing these data, the report is NOT saying that 72% of ED visits should not have occurred, but given the current health system in the US and the lack of primary care, these visits are occurring. The paper further clarifies the issue by noting it is impossible to say with clarity that a visit was not necessary, only that for given percent of the time, it has been shown to be unnecessary.

These are important distinctions. To clarify this point, in a 2012 New England Journal of Medicine article by Kellerman and Weinick¹, the authors correctly pointed out there are many reasons these visits do occur. They cited work done by John Billings, a professor of Public Health Policy at New York University, describing why many of these visits occur. They stated:

“The fact that many ED visits could be managed in primary care settings does not mean that such care is available. In fact, Billings himself asserted that high rates of ED use for ambulatory care–sensitive conditions are a strong indicator of poor access to care — not poor judgment on the part of patients.”

Factors to consider:

• By necessity, this study looks at discharge diagnoses, which may not reflect the concern raised by the symptoms. Chest pain at midnight that turns out to be gastroesophageal reflux would be listed as a diagnosis that could be provided as an outpatient, but the patient could not be expected to know it was safe to wait.

• Most primary care physicians do not have extended office hours; patients with problems arising from 5 PM to 9 AM may have no other option.

• Many patients do not have access to primary care.

• Urgent care is not an option in many parts of the country.

You get the point—this is a complicated, multi-factorial challenge for society, and the solution is also complicated.  The answer is not to add an “ER co-pay”. These results are another call for a major overall of how healthcare is delivered and paid for in the US.

Michael L Taylor, MD FACP

Chief Medical Officer

¹Emergency Departments, Medicaid Costs, and Access to Primary Care — Understanding the Link

Arthur L. Kellermann, M.D., M.P.H., and Robin M. Weinick, Ph.D.

N Engl J Med 2012; 366:2141-2143

Price Transparency – Our Experience Shows It Can Lead To Lower Costs

A truism in economic theory is that if two products are equal in value, the consumer will choose the cheaper of the two. It just makes sense. If I am looking at two bicycles that are the same, but one is $50 higher and otherwise I can’t see any difference, why would I buy the higher priced bicycle? I wouldn’t, and that's a perfectly logical decision.

Unfortunately, in medical decision-making, this logic falls apart. Let’s say I need an MRI and I have a choice between two facilities. There are at least 4 decision points: cost, quality, convenience, and my doctor’s recommendation. 

• Cost – I have a $500 deductible, so that is the same for me.
• Quality – I have no ability to discern any quality differences, and no data are typically available.
• Convenience – I can tell which option is better.
• Doctor recommendation – likely the deciding factor.

Notice the price is not an issue at all. If I knew the total cost, and if that mattered to me, would that make a difference in my decision? If I am an ethical person and an engaged employee who cares about costs, it probably would. Truven Health Analytics has some data supporting that hypothesis. We looked at a regional market and examined the choices consumers made if they had the total price information about a selected service. Consumers had the option of using a price transparency tool that gave information about total costs at various locations.  Interestingly, for a colonoscopy with biopsy, when given the total cost comparisons, those who used the transparency tool averaged $750 less cost than those who did not use the transparency tool. Users of the tool saved $78,000 (from a $3.5M spend) on outpatient surgery and saved $60,000 (from a $2.9M spend) on radiology.

These data are early, specific to a region, and have not yet been replicated in other markets. But the data are encouraging, and suggest with proper patient education and a motivated consumer, price transparency can result in savings. Consumers cannot be expected to make medical decisions, such as whether the MRI was even indicated, but we can expect consumers to act on price information. The next step is to develop reliable quality measures. Stay tuned.

Least Cost Site of Care Takes Coordination & Reflection

Reducing cost while preserving effective care requires real-time coordination and analytic reflection – and as the healthcare system changes, the need for both is becoming ever more apparent. Walgreen’s announcement of retail healthcare services for the chronically ill opens a discussion of the impact of new innovation.  

Truven Health research shows over $4b savings potential when 20% of the ED visits are redirected to other sites, and 63% of ED visits are urgent but not emergent, there is room for change.  This journey is not new; nearly 5 years ago, 73% of national ED visits were urgent (not emergent).  Between more time conscious consumers, the rise of market driven urgent care centers and hospitals placing new walk-in programs on campus – the needle has moved. Shifting care from the most expensive resource calls for consumer driven self assessment and provider recommendation. 

Based on our 2012 consumer studies, 89% of retail service users are not replacing their primary care provider, as they report having one.  They are supplementing the services offered by their PCP, and generally for a lower cost. We see there is room and demand less costly care, but we recognize that this calls for coordination at the point of care, and reflectively and realistically reviewing the rearview mirror in consolidated datastreams.  One of our clients moved $1.5M of business to lower cost settings, just by direct messaging to frequent fliers to save their funds and go to another source.  Consumers hearing the trusted provider voice can take action on coordination.  Providers knowing the truth of analytic reflection can take action to ‘prescribe’ right site of care for the right reason.  And our healthcare system will be the better for coordination, cost and care.

Linda MacCracken
Vice President

Hooray for CMS, Agreeing to Reconsider a Longstanding Program!

After restricting Medicare payment for bariatric surgery to only Medicare approved centers of excellence for seven years, CMS has agreed to reassess its policy. That does not mean that the policy will be adjusted to broaden access to the procedure, but at least CMS will review the previous decision. That reflects a lot of flexibility for a government agency.

What is the cause for the policy reassessment? Results of research by Justin B. Dimick, M.D., Director of Policy Research at the University of Michigan’s Center for Health Care Outcomes and Policy, demonstrated that the Medicare policy made no difference, except to limit access to the procedure. The policy did not drive improvement. The policy did not improve complication rates or outcomes.

Almost everybody thinks development of Centers of Excellence is a great idea – including me! But I must admit that I am chastened by this example. Dr. Dimick allows the data to speak , which we do routinely within the 100 Top research group. Objective data often produces results that are contrary to what seems logical. Dr. Dimick’s results suggest a very uncomfortable idea. Maybe CMS’s channeling of patients to Centers of Excellence is a misguided good idea. Maybe a Center of Excellence makes people feel safer, but might cost them more out of pocket or cause them to seek no care. 

Let’s contrast this approach with the other side of the government coin, the National Cancer Institute, which is unrelated to payment for care. The National Cancer Institute created the National Cancer Information Service (NCIS) because of the huge disparity in physician and patient access to the latest treatments for various types of cancer. The NCIS enables cancer patients to directly call 800-4-CANCER to find out about new diagnostics and treatments as well as clinical trials so that the best possible options are known to all. Maybe the NCIS model which makes vetted, trustworthy diagnostic, treatment and clinical trial information available as widely as possible is a better approach. The NCIS model increases patient knowledge and patient involvement in decision-making. That may be a better approach than CMS deciding for us.

Jean Chenoweth

Senior Vice President, Performance Improvement and 100 Top Hospitals

 

Better Design Needed for Accurate, Effective HIT

Recently the ECRI Institute Patient Safety Organization (PSO) received a report that was the outcome of a voluntary effort of 36 hospitals to better understand how the Health IT (HIT) revolution is impacting care, including patient safety issues. HealthLeaders Media highlighted the 171 patient safety issues that were reported over a nine week period.

Slightly more than 50% of the errors were attributed to medication mismanagement issues, and 30% were due to errors in the clinical documentation systems and lab systems. The errors fell into two broad categories: 56% due to the IT system itself and 46% due to human error.

In another HIT area, the medical literature has reported on problems due to physicians “copying and pasting” medical record notes and its deleterious effect on quality of care.

These two reports highlight the need for a rigorous approach to managing healthcare data. Converting from a paper system to an electronic format by itself does not solve the patient safety issues in our medical sector – smart analytical tools are needed to improve care processes and outcomes. As an example, Truven Health Analytics has developed “360 Care Insights”. This tool helps with medication safety by providing medication alerts, dosages and adverse drug effect monitoring. It also uses the EMR to predict severe infections.

As the ECRI PSO report highlights, an electronic record, as part of the HIT solution, needs to be supplemented with tools for decision support, pharmacy safety, patient monitoring. It should enhance team-based medical decision-making among physicians, nurses and other health care professionals. It must be carefully designed to support and extend activities that lead to better results while avoiding errors due to ineffective practices and data ignorance.

Dr Michael Taylor

Chief Medical Officer

Helping Consumers Navigate Insurance Exchanges

A recent Kaiser Health News article questions consumers’ ability to navigate insurance exchanges. State-sponsored and federally facilitated insurance exchanges are building their technology platforms, selecting qualified health plans, and setting up their infrastructure. The underlying assumption is that in October 2013, when open enrollment begins, consumers will be prepared.  

The consumer’s ability to navigate exchanges is perhaps the most critical component of success. The Federal Government, recognizing that this process might confuse consumers, has funded Exchange Navigators to help consumers understand eligibility, subsidies, enrollment rules and processes, and the specifics of Qualified Health Plan (QHP) design provisions. 

Consumers and Navigators need robust information and efficient tools to manage this process. Improved consumer education benefits not only the consumer and the exchange but also the health plans — by ensuring that individuals select the plan that’s right for their situation and have a great customer experience while doing so. Increasing a consumer’s ongoing engagement in their own healthcare management can lower costs and increase their plan loyalty and satisfaction — which is especially important in this new marketplace. 

For exchanges to succeed, we must elevate consumer interest and participation in healthcare decision making to the same level as other important life decisions. States, the Federal Government, and health plans all need to share the responsibility to make that happen.

Anita Nair-Hartman

Vice President

Hospitals Need Analytics to Focus Interventions, Prevent Readmissions

As suggested in the New York Times article of March 29^th, hospitals are confronting expanded readmissions penalties without clear direction on which interventions are likely to yield the greatest impact relative to their unique circumstances. To paraphrase Occam’s Razor, often the simplest explanation is best.

How does this apply to readmissions? Over the years, Truven Health has helped its CareDiscovery customers connect the dots; linking patient populations across the spectrum of care from outpatient setting to hospital to post-discharge facility, and testing the impact of both process and practice on outcome. By following the patient path through risk-adjusted models, we can test and quantify the results of competing readmission theories.

As you might expect, it is often the simplest theory that prevails. Of course, such analytics not only validate the theory but serve to identify the drivers behind the higher than expected readmissions. Only at this point can one be assured that the application of evidence-based protocols can optimally address the highlighted opportunity. With diminished reimbursements and expanded disease burden, now more than ever hospitals must harness true and proven analytics to ensure a thriving population and future.  

Michael R Udwin, MD, FACOG

Medical Director