Monday, February 8, 2016

Bro-pulation Health

The Population Health Blog wishes a health insurer would be as clever as the marketeers behind the Geico "Flextacular" commercial while extolling the virtues of its population health program.  For example, wellness with less bro'tatoe chips and bro'nuts and more bro'colli, bro'bacco cessation, and bro'ing to the gym for some exercise.

Persons with diabetes could strive for a lower Bro1c, hypertensives could seek a lower bro' pressure while persons with heart failure can 'bro to the doctor if their weight goes up by more than four kil'brograms in a 24 bro-ur period. 

Make that bro-pulation health.

Speaking of 'bro's, like many readers the PHB was also astonished by bad-boy "Pharma 'Bro's" smirking insolence during the Feb. 4 Congressional hearing on how Turing Pharmaceuticals turned a generic into a $750 pill.  That being said, the adult witnesses at the hearing later pointed out that the initial retail price - once the supply chain does its work - has little correlation with the final negotiated rate.  For Medicaid patients, that turned out to be "a penny a pill." 

The PHB suspects that the staff advising the House Committee on Oversight and Investigations knew this, but went along with their bosses' interest in publicly humiliating Mr. Shkreli.  While his bad behavior may be symptomatic of a deeper personal contempt for the rules, what this also demonstrates is that the U.S. is one of a handful of countries where we are able to publicly laugh at those in power and walk freely out of the room.  Good for us.  

Wednesday, February 3, 2016

An Update on the Evidence of the Impact of the Patient Centered Medical Home on Cost and Quality: Of Soup and Weather Vanes

In its work with a variety of payer and provider customers, the Population Health Blog has advised that primary care medical home planning is more "soup" than "soufflĂ©," and that outcomes are more a matter of direction than preciseness.  Naturally, the MBA-types that populate and advise the C-suites and Boards of our health institutions never liked hearing that, preferring instead to impose their notions of cookbook orderliness on what they disdain as inefficient.


Anyone who has had an underinsured patient in crisis in their clinic at 4 in the afternoon knows what the PHB is talking about.

Which is why the trained professionals who actually take care of primary care patients will find a lot to agree with in the Patient-Centered Primary Care Collaborative's report on the Patient Centered Medical Home's Impact on Cost and Quality

This is a summary of the 30 recent peer-reviewed, state, industry or federal publications examining medical homes' impact on cost, utilization or quality.  There are pages of tables that conveniently describe the initiatives, the payment methodology, their impact on cost/utilization (mostly good), and the impact on other outcomes (mostly good).  To the PCPCC's credit, the review is free of the trade association-style framing that can obscure neutral assessments of the data; it even includes an entire section dedicated to study limitations.  Good for them.

Two PHB Insights
Soup: While often portrayed as a caveat, one of the major insights of the report is that the PCMH is best thought of as a "model" of care defined by a set of "attributes" that include patient-centeredness, comprehensiveness, coordination of care, accessibility and quality/safety.  Do right by adapting those principles into a clinic and, to paraphrase Justice Stewart, you'll know it when you see it.  Turning to the "soup" analogy, if it's liquid, there's stock, the ingredients are softened and the flavors have been extracted into a broth, you've got something that will satisfy. 

Let a thousand medical home clinics bloom.

Direction: Another major point of the review is that outcomes vary considerably, and not just in terms of dollar impacts, but on various measures of utilization and outcomes.  The insight here is that the "directionality" of this model of care is "pointing" toward lower overall costs with better clinical outcomes.  Unfortunately for administrators and insurers everywhere, the answer to "how much" is that "it depends." 

Fortunately for patients, the wind is blowing in the right direction

There are some other interesting take-aways. 

As "alternative payment models" (reminding the PHB to also use acronym "APMs" whenever possible) expand, the funding for PCMHs is likely to grow. The Medicare Access and CHIP Reauthorization Act (another acronym "MACRA") has fans in the PCMH community. 

$4.90 per patient per month is an average payment for medical home services, with dollar add-ons possible from various measures of performance, shared savings, care coordination, pre-payment and risk adjustment (see above on how "it depends"). 

Multi-payer collaboration convening commercial and government payers is more likely to have an impact on PCMH outcomes than single payer programs. Based on experience, this reminds the PHB of a similarity between the PHB spouse and Medicare: compromise is always possible so long as you do it her way.

Next Steps

The PHB couldn't have said it better.  Advocates for the PCMH need to continue to share their design and outcomes in the public square so that everyone can better understand its strengths as well as weaknesses and to make this soup even better.  As the report concludes

"Investment (ROI) or “total cost of care” research is needed that assesses the costs associated with PCMH transformation (or “upstream” spending) that results in “downstream” savings, through reduced ER visits or hospitalizations. This would demonstrate the extent to which spending on primary care results in long term ROI to the overall health system."

"As in past years, there was a dearth of studies that evaluated cost or utilization measures together with patient experience or provider satisfaction and health outcomes, essential elements of the Triple Aim. As we evaluate cost outcomes associated with the model, we must increasingly evaluate the model as a whole to ensure that cost savings and better patient care go hand in hand."

Soup and vane images are from Wikipedia

Friday, January 29, 2016

The Latest Health Wonk Review Is Up!

The 10th Anniversary Edition of the Health Wonk Review is now up at Joe Paduda's Managed Care Matters.  The review summarizes and links some of the better postings of health-policy bloggers, with topics that range from (angry) unionizing docs to the proximity of hospitals to stockpiles of (explosive) ammonium nitrate.

Since ten years qualifies as an eon in web-time, the HWR must be doing something right.

Thursday, January 21, 2016

Ten Questions Publicly Traded Company Boards Should Ask about Employee Wellness

The Board reviews a company
health promotion program
As follow-up to this post about the peer-reviewed evidence linking company-sponsored employee wellness programs and total shareholder return (TSR), the Population Health Blog offers ten questions that these companies' boards of directors should consider when reviewing the topic with their management team:

1. Does the company have a wellness, health promotion, disease prevention or condition management program in place?  If not, why not?  If it does, what is the vision and strategy?

2. In addition to internal measures of "return on investment," are the costs of the program(s) worth the impact on total shareholder return (TSR) and will this pass muster with the due diligence of activist investors?

3. Do other companies competing in the same industry have wellness, health promotion, disease prevention or condition management programs? How have they fared?

4. Have the program(s) been subject to external review, such as Mercer, C. Everett Koop or CHAA

5. If the company is self-insured, what are the expectations about the impact of the program(s) on health insurance claims expense?

6. Is the programs' impact on recruitment, morale or productivity being assessed?  How, and can the results be subject to an internal audit or to third-party outside review?

7. How are regulators' and employees' concerns about discrimination or privacy being addressed?

8. Does a "Chief Health Officer" exist?  If not, why not?  If yes, does the job description include any oversight responsibility of employee health?

9. Who on the board can act as a lead in providing the necessary oversight of any of these programs?

10. Is low-cost, scalable digital technology "mHealth" being leveraged? How?

Thursday, January 14, 2016

The Link Between Corporate Wellness Programs and Total Shareholder Return

While employer-sponsored wellness, health promotion and disease prevention programs have been linked to "human capital," talent recruitment and retention, improvements in employee morale, reductions in absenteeism, reductions in presenteeism and bending the curve of claims expense, should shareholders care?

After all, according to President Obama's latest State of the Union Address, corporate America's pursuit of profits have resulted in greater automation, less competition, loss of worker leverage and "less loyalty to their communities." According to that narrative, employees are just another commodity on the road to total shareholder return.

Well, according to an expanding body of peer-reviewed scientific literature, shareholders should care.

The latest example of why is this publication by Ray Fabius and colleagues that appeared in the January issue of the Journal of Occupational and Environmental Medicine.

First, some background.  The Corporate Health Achievement Award (CHAA) was created by the American College of Occupational and Environmental Medicine (ACOEM) to recognize companies' workplace health and safety programs.  It relies on a thousand point-based assessment system of multiple standards in four categories of 1) Leadership, 2) Healthy Workforce, 3) Healthy Environment (including Safety) and 4) Organization.  Many of the companies that have participated in CHAA are household names.

In this study, the authors tracked the stock market performance of companies that applied for the CHAA from 1997 through 2014.  As the Population Health Blog understands it, all the privately held companies as well as those that scored 175 or lower in Organization and lower than 350 combined in the Workforce and Environment categories were excluded from the analysis. Of the remaining publicly companies, those scoring at or above the 37.5 median percentile in the four categories described above (defined as high CHAA achievers) were placed in six hypothetical stock portfolios of 5 to 22 companies.  The authors then mapped out what would have happened with a January 2001 investment of $10,000. As each year passed, new high scorers were added to "rebalance" the portfolios, while the stock of repeat high scorers were added.

The results? While the benchmark Standard and Poor's (S&P) return over the study period was 105%, the portfolios easily exceeded that with returns that ranged from just from over 200% to 333%. 

Now that's total shareholder return.

In another demonstration of why peer-review is so important, Dr. Fabius and his colleagues correctly point out that correlation is not the same as causation. As a result, there is no evidence that importing wellness programs into other companies will translate into better stock performance. In addition, elementary statistics tells us that corporate wellness and TSR won't necessarily correlate over shorter periods of time for individual companies.

Bottom line? The PHB doesn't think investors in public companies are necessarily interested in "causation" as they are in market signals. It stands to reason that a commitment to company wellness is an important signal about where to put their money. 

Which raises three questions....

1) This was raised by Fabius et al: should investors or regulators demand that companies publicly report whether they have employee wellness programs?

2) Should companies invest in a "Chief Health Officer?"

3) Why isn't corporate wellness part of the national conversation about capitalism in America?

Coda: For additional reading, see this link on the ten questions about employee wellness that should be asked by boards of directors.

The Latest Health Wonk Review is Up!

Hank Stern over at his InsureBlog naturally celebrates 11 years of blogging by hosting the latest Health Wonk Review, The Happy New Year Edition.  Check it out for the latest health policy insights that you won't get anywhere else.

Monday, January 4, 2016

2016 is the Breakout Year for mHealth: Savings vs. Value

In this post, the Population Health Blog predicts how and why mHealth will be covered by more commercial health insurers in 2016, and why the retail "over the counter" mHealth market outside of insurance coverage will also continue to grow. 
While you're reading, consider this simple question: What are the revolutions per minute (RPMs) of your automobile's engine as you ascend from stationary idling to freeway speed?
The Definition of mHealth: "the delivery of healthcare services via mobile communication devices." Other definitions can be found here.  Elements include handhelds, wireless communications, software, hardware, networking, social media, sensor technology, apps and cloud-based services. The World Health Organization says it's global and much is still in its infancy.
Three Population Health Blog predictions for mHealth in the United States:
1) 2016 will be a breakout year, because both the savings and value propositions will be clarified.
What does the PHB mean by this? 
The ultimate question for health services buyers, payers, providers and patients is whether mHealth technology is: 
Substitutive: achieving savings from displacing present or future high cost services,
Additive: co-existing with present, or increasing future utilization.
The same is true for many pharmaceuticals, population health programs and the medical home.   
2) Faced with the reemergence of unsustainable health care cost inflation, commercial health insurers will deploy today's premium to sponsor tomorrow's substitutive mHealth cost reductions.
Commercial insurers will look for mHealth that is "S3" or Smart, Synergistic and Scalable.
1. Smart: addresses the tailored needs of selected population segments; instead of being all things to all patients, think focusing mHealth on high risk patients with special needs
2. Synergistic: enhances, not replaces other incumbent resources, such as one-on-one care management or outreach telephony.  
3) Scalable: uses the economies of scale to provide a lower-cost service to larger numbers of consumers.  As more patients in a select population use mHealth, the cheaper it becomes. 
3) But.....Value-driven mHealth will also flourish in the direct-to-consumer, over-the-counter or retail market for three reasons:
1) Consumer notions of value: 
Interest in personal wellness, a cultural belief in the pervading merits of technology and the allure of every more innovative gadgetry will continue to outpace the underlying mHealth abandonment rate.
2) As Obamacare acquaints consumers with real healthcare costs, #mHealth will be viewed as a relative bargain.
Comparatively pricey physician encounters, emergency room visits or a hospital stays - especially for Bronze Plan enrollees - will only increase consumer appreciation for  mHealth's "over the counter" benefit-to-cost ratio: for a few extra bucks, why not have that weight-loss, blood-pressure, medication-management app or wearable, especially when you already have a handheld smart device and the bandwidth?
3) Some commercial insurers will "cover" wellness #mHealth, not because their actuaries support it, but because their customers (purchasers, brokers and consumers) demand it. 
"Coverage" will be in the form of a volume-based discount pricing borne by the consumer, not a value-based benefit covered by the insurer. If it increases customer loyalty/"stickiness," all the better.
Plus there's the mHealth "X-Factor." mHealth sponsors and their allies will collect, sell and use consumer data for marketing and surveillance.   The PHB calls it mining and monetizing
Back to the tachometer: Even though its dashboard displays it, the PHB doesn't know the vehicle's RPMs either. Aside from  the use of the tachometer by some car enthusiasts  to optimize manual gear shifting, it adds little to car performance or safety
Yet, it's standard and in the dashboard of just about every automobile being sold in the U.S.A.  Could gadgets, wearables, apps and mHealth physiologic monitoring become the healthcare tachometer?  Useful to a critical few and standard for everyone else?
So, What is the the Basis of the PHB's Predictions?
Growth potential:
If you think it's all about "Fitbit" or managing diabetes, think again. How about promoting mindfulnessmonitoring medication compliance, home-based high-risk pregnancy monitoring, in-home safety for the frail elderly, heart rhythm management, and home-based "pervasive" monitoring. Plus, mHealth style technology is being used outside of healthcare, such as in the automobile, for elite athletes and to promote safety in high-risk worksites
S = Savings
Smart: Here's a just-published JAMA study of a randomized clinical trial (RCT) that showed text-prompts had an clinically relevant impact on blood pressure in a group of select persons with coronary heart disease. Here's an rigorously conducted RCT that showed persons with Type 1 diabetes mellitus achieved better blood glucose control.  How about socioeconomically vulnerable patients with diabetes? Or patients with heart failure being discharged from a hospital?  The list of special populations with special needs goes on and on.
Synergy - This exhaustive peer-reviewed publication examining the merits of wellness mHealth for weight management, physical activity promotion, tobacco cessation, and cholesterol control shows that there's little evidence that it's better than existing therapies over the long-term.  Rather, the greatest promise appears to be in complementing existing interventions.  By the way, synergy does not mean overwhelming the system with data, but assisting the system with insight.
Scalable: While economists, policymakers and pundits legitimately worry whether bigger is better for healthcare in general, health system C-suites and boards of directors and their consultants are counting on information technology to drive economies of scale.  Papers like this and this suggest mHealth can be a part of that, especially if it can mitigate manpower constraints.
And an easy way to assess whether the insurer  really believes that it's sponsoring an S3 initiative is asking whether it pays for a handheld device for consumers that don't have one
Consumerism? Call it "the quantified patient." Here's a telling survey that shows the abiding faith in health information technology and a lack of privacy concerns.
 Bargain? The title of this peer-reviewed paper says it all" "It's like having a physician in your pocket!"
 Insurer discounts? The same thing happened to health club memberships.
The X-Factor: CIOs everywhere agree that they're not only apps, but software "vacuuming up data."

Friday, December 18, 2015

Three Health App Lessons from the James Bond Movie "Spectre" - Shaking and Stirring Health Care

The Population Health Blog took time out of its busy schedule to check out the latest James Bond movie. While posting anything that refers to a months-old movie is inconsistent with standards of modern social media, Spectre has some important lessons. 
The PHB begs its readers' forgiveness as it is filters out the improbable car chases, dubious gadgetry and staged fisticuffs and examines the underlying health app technology insights. 
Without revealing too much of the plot, Mr. Bond continues to recklessly expose himself and others to STDs while battling a global conspiracy that is led by a cryptic master criminal.  The bad guys want to exploit the weaknesses that come with combining the intelligence data of the world's democracies. 
And what are three cinematic health app teaching moments?
Health Information Technology vs. People is a Classic False Choice: In Spectre, British Intelligence seems ready to invest in a global big-data initiative and jettison the "Double O" programme; Whitehall apparently fails to realize combining both would be greater than either alone.  Think Deep Blue "versus" Kasparov, or Dr. Watson "versus" Dr. House. Yet, Bond prevails precisely because Ms. Moneypenny is his 24-7 data muse.  Smart health app designers understand that the best apps are the ones that synergistically enhance, not replace, what doctors and patients bring to their care planning.
For example: Asynchronous two-way HIPAA-compliant communication that allows consumer concerns to be mutually addressed in partnership with a nurse-provider before the emergency room becomes the best option.
Health Information Technology Needs Good People: No Bond movie is complete without legions of pistol-wielding bad guys who can't hit the side of data warehouse, which is why Bond prevails. Think putting an Acela locomotive on decades-old train tracks under AMTRAK's ossified management. The health technology insight here is that any health app that perpetuates health workers' can't-shoot-straight business-as-usual will enable incremental, not transformative change.
For example: During a recent health plan launch involving the medSolis app, the PHB had the pleasure of working with expert professionals who knew the purpose of the program (er, programme) initiative was to enable informed patient decision-making.  In response, we also began to alter long-standing health plan policy and procedure.  
All Things Equals No Outcomes: Other than pooling the intelligence data, none of spy-administrators seem to be able to articulate the purpose of their joint data initiative. While cleverly branded and all-purpose apps strive to "be" the intended outcome, truly successful health apps will be those that can be purposed for a defined population and prospectively aimed at a limited set of clinical, financial and patient-centered outcomes.
For example: Once the generic coding/architecture is set, a winning app's content, channel and outcomes can be tailored for, say, a precisely defined group of high risk persons with diabetes.  And, to borrow from the concept of "parallel processing," the app should also be able to be altered to simultaneously serve a parallel population that is prone to rehospitalization (outcome: reduce avoidable readmits), or who would benefit from weight loss (outcome: reduce BMI).
Conclusion: Health concerns aside, perhaps nothing signals Bond's adaptability better than his willingness to forego his long-standing "shaken, not stirred" workflow in favor of quaffing a "dirty" martini with the sultry Dr. Madeleine Swann.  Even the Bond franchise is not immune from the adage that "change happens."
The same should be true for traditional health care as it continues to import an emerging ecosystem of health apps.  Delivery systems, hospitals, clinics, ACOs and networks that understand that will win.
And "Cheers!" to that, Dr. Swann.

Thursday, December 17, 2015

The Latest Health Wonk Review is Up!

The latest Health Wonk Review is available at the Workers Comp Insider.  This one is a holiday-laced compendium of health policy musings on everything from Obamacare to sleep deprived trainees.

Thursday, December 3, 2015

The Latest Health Wonk Review is Up!

Contrary to simplistic nostrums of the advocates for or the detractors against Obamacare, the truth is that health reform continues to be a messy tangle of science, policy and economics.  If you like things simple, continue to bask in the echo-chambers in mainstream and social media, and keep your browser away from this link.

Peggy Salvatore of the Health System Ed blog is hosting the Health Wonk Review.