Participation and Engagement Are Not The Same Thing

I gave a talk to a group of businesses on the transactional side of health care the other day. My topic was to provide my perspective of approaching “consumer engagement” for the transactional side of health care from the lessons learned from the health and wellness side.

I spent a lot of time thinking about the topic. The politically correct approach would have been to provide all of the appropriate statistics to show how incentives, benefit designs, and the other “economic” approaches were improving participation in wellness programs (47% participation in completing a Health Risk Questionnaire with an incentive and 26% without) and how innovative communication/marketing strategies improve participation, and all of the other stuff. The politically correct approach would have been to say to just take what we’re doing so well on the health care side and use it in some of the other areas.

But, my topic was engagement, not participation.

Engagement, to me, is deeper. Engagement is commitment, its understanding the context, it’s taking steps beyond the minimum necessary to get by or getting paid to do it; it’s becoming part of the solution.

As I put my thoughts research together I began to realize (actually I had always assumed) that consumers aren’t engaged in health care. Seventy-five percent don’t understand it and many continue to be frustrated by it. Yes, the participation numbers may be improving for some of the wellness/preventive components (25% on average but higher for some program areas and for some organizations in general). However with such a high confusion factor and a health care literacy rate of only around 15% we could do much better. Add to that an industry “trust ranking” of Health Insurance and Managed Care only above Telecommunications, Oil, and Tobacco I concluded we might have a problem with real engagement.

My message to this transactional group ended up being that they need to be aware that they may be “branded by a brand” in health care and the health care brand with consumers right now is not all that hot (except with hospitals and doctors). I told them that they need to be aware that consumers were being asked to play many roles in health care today (Benefit Manager, Financial Manager, Care Navigator, Legal Manager, Information Manager, Personal/Family Wellness Manager) and they need to look at consumers in the total context as they develop products or strategies impacting a single one. I told them they would need to provide the appropriate guidance to consumers to help them fill their role as an Informed Health Care Consumer. And, building trust with the consumer would be a key to building engagement.

Yes, you can certainly improve the participation numbers by paying people and designing benefits to influence what they do. For most, the participation will only be short-term and dependent on continuing to pay them or maintaining the benefit structure directing them what to do. However, if you have them engaged, the participation numbers will be longer-term and the approaches you can use are more flexible. You may not even need to pay people to get them to do the right thing.

This transactional group was only interested in participation- not real engagement. They wanted to hear how incentives and economic structures could drive people to their businesses. They wanted to hear me validate what they were doing today and how participation (how many bodies) was the real indicator- not engagement. I think they wanted to hear the standard stuff. They didn’t want to hear about reality of the consumer perception of health care today.

Well, I still believe building trust in this industry is the real key to engagement. And, building trust starts with confronting the reality of where you are today and what may need to do to change. You build trust with open communication, honesty, integrity, and partnerships. You build trust with collaboration and dialogue. Building trust is more than just a software application, an incentive program, or an HRA. It’s about building a relationship with an individual.

Transactional health care may still be focused on participation. The real solution is engagement- and that’s tougher to earn.

From Minnesota- No Piling On Please!!!

I have to admit, living in Minnesota is never dull.

In addition to being the home of ten thousand lakes, beautiful communities, good people, and some innovative businesses we have created quite a collection of politicians to guide our state to where it is today including: Humphrey, Mondale, Wellstone, Ventura and more recently Pawlenty, and Bachmann. It’s quite the collection of personalities when you think about it. Minnesotan’s have become a pretty versatile people. We’re always looking for the right combination of personalities that can get something done. We’re willing to take some chances.

While historically Democrat, slowly but surely (just like the rest of the country), Minnesota has become ideologically partisan and divided. Last November, we elected a Democratic Governor, and a Republican legislature that work so well together we are now beginning the third week of a government shut-down.

What is the primary issue?; Balancing an “out-of-control” budget combining the right balance of expense reduction with revenue. The right and the left couldn't come to an agreement and is at a stalemate. Now, only the “essential services” in government are funded, the rest of the state is closed.

State parks are shut down (during the 4^th of July holiday), rest areas are closed, renewing your driver’s license or getting a fishing license (almost a requirement to live in Minnesota) is unavailable. Because the politicians could not do their jobs the rest of us are being asked to “suck it up” and live with it. In the meantime, Minnesota’s credit rating was devalued resulting in increased interest costs at a time we don’t need any additional costs.

In Washington we’re now in the midst of heated debate concerning raising the debt limit. What is the primary issue?; Addressing an “out-of-control” budget by combining the right balance of expense reduction with revenue (Sound familiar?) At this point, we’re at a similar stalemate at the federal level and we’re nearing the point that the effects could be worse than what is already being experienced in Minnesota if some resolution isn’t reached.

Since 1962, the debt limit has been increased 74 times. Many times it was increased as a part of some other legislation and never received much attention. Over the past 10 years, however, the debt limit has increased 10 times as the debt of our nation has exploded because of weak economic growth, the 2001 and 2003 tax cuts, funding two wars, and a stimulus package that was intended to prevent us falling into a bigger recession than we already experienced. Both sides need to assume some responsibility for the crisis we now face.

Unfortunately, the debt limit vote this time has become political instead of rational. Politicians are covering their asses as they protect their special interests and are already looking to use the process for leverage in the 2012 Presidential and Congressional elections. As in Minnesota, neither side is budging.

Some argue we aren’t really at any crisis point and can get through by simply juggling how we pay our bills until some resolution is reached. I would ask these people to just take a look at the fragile nature of the global markets. Whether these people want to accept it or not, August 2 is a “real date” to the markets- they will react accordingly.

So, once again (and as predicted when the federal budget was passed to avoid a federal shut-down), we’re going to go down to the wire. Because of the political reality of today, if a deal is reached it will not nearly be what is needed to address the crisis we are facing. If a deal is not reached, we will just have to wait and see what the market reaction will be- and it won’t be pretty.

Either way, once again the American people will be left living with the effects of a partisan political quagmire. We’re already going to have to live with the mess created by shutting down the government in Minnesota- we don’t need the federal government piling on.

Both sides are to blame on this one- so, get to work, put your politics aside, and do what is right for the country.

The Collaboration Health Care Elevator Speech

I’ve been asked many times over the years for the “elevator speech” for Collaboration Health Care. Honestly, I’ve sometimes been at a loss to respond because when I say, “I want to change the way the general population “thinks” about health care,” nobody cares.

Despite the different types of projects we have been involved in over the years, they seem to still boil down to the same thing- we’re still trying to change the way all of the stakeholders look at and think about health care. But still, nobody seems to look at it that way.

It’s still all about ROI, production, diagnosis, measurement, and all of the “transactional” aspects now involved with health care. It’s all about regulations and bureaucracy and following an established set of rules and processes as opposed to looking at the world a little different and trying to have a basic understanding of why all of this is necessary in the first place.

Don’t get me wrong. Measurement and accountability is important. We’re just now going to the extreme and don’t seem to be solving the problem.

Solving our health care cost crisis is not going to be solved in a partisan manner. The Affordable Care Act was a very partisan piece of legislation and needs to be modified. Repealing it is not the answer either. We need to have a basic framework in place we can all work from. We aren’t working from it together today.

And, most of the general population is confused. We’re more knowledgeable than we were before all of this health care talk started- but we’ve been informed from very partisan sources. We really don’t know who to believe.

Despite much of the population still indicating they are relatively satisfied with the way things are, there is a very rapidly growing segment saying they aren’t. More are feeling the affects the rising health care costs are having on their personal finances. And, it’s only going to get worse if something doesn’t change- and change fast.

Our health care costs eat up a substantial portion of our national budget and are a key component of our national debt. The “unfunded” liability (what isn’t paid for) for Medicare over the next several decades will reach $46 trillion. Health care costs have the real potential to be the final straw to bring down our economic foundation if they are not addressed.

So, I suppose the elevator speech should be changed; “Helping stakeholders change the way they think about health care” doesn’t seem to matter much to anyone.

How about, " Protecting our national and personal economic future by changing the way stakeholders think about and interact with the health care system- through education, information, partnerships, and dialogue.”?

It’s a little long, but maybe more folks will get it.

Newt's Comment Is Right- But He Got Creamed For Saying It

Newt Gingrich has been a guest on Meet the Press thirty-five times. He’s covered a lot of territory on the show over the years. During his visit on May 15th, host David Gregory asked Newt his opinion of Paul Ryan’s approach to address the budget deficit and ultimately addressing the unsustainable costs of Medicare. He replied, “I don’t think right-wing social engineering is any more desirable than left-wing social engineering.”

His defection from the party-line quickly reverberated throughout the conservative ranks raising a huge obstacle to his chances of becoming the Republican nomination to challenge President Obama in the 2012 presidential elections.

Despite speaking the truth, and despite being accurate in his assessment- his thirty-fifth visit cost him a lot. The reaction he received from the Republicans illustrated how far apart we are as a country to address the challenges we are facing. Unfortunately, we are being guided by the far-right or far-left politics when the real solutions are somewhere in between.

In the meantime, our health care costs continue to rise. Price Waterhouse Coopers released a new assessment of the medical cost trends for 2012 (Behind the Numbers; Medical Cost Trends for 2012). While medical cost trends increased 7.5% in 2010, they are projected to increase 8% in 2011, and 8.5% in 2012. As the economy struggles along at 2-3% growth (or less) we just continue to lose ground. Any possibilities for relief through initiatives included in the Affordable Care Act will not be felt for several more years- if at all.

The PWC assessment commented, “An interesting blend of reactions to the recession, the slow recovery, health reform, and other variables will affect the medical cost trend in 2012.” The problem is only going to get deeper the longer we wait to take real action beyond the party-lines of the politics and special interests.

Quite simply, the philosophies of the free-market purists will not solve this problem. The theories of the government-control liberals will not solve it either. We need a rational collaboration of both public and private initiatives to eliminate the waste, reduce the inefficiencies, and develop a solution that makes sense for the country.

We need to be able to talk about some of the solutions that are not necessarily “right” or “left.”

Newt’s comment on Meet the Press reflects what we need. Unfortunately he was creamed for saying it.

2011 Physician Compensation Report- An Interesting Picture

Whenever we start talking about the increase in health care costs we invariably start to think about the amount of money made by the providers. The costs of paying the providers make up 30% of the cost of care so it’s pretty easy to make them a target.

Medscape WebMD recently published their Physician Compensation Report for 2011. It paints a pretty interesting picture of the current economics of the general provider community.

Overall, the average “salary” for the 15,794 physicians across 22 specialty areas averaged somewhere around $250,000 a year. Orthopedic Surgery and Radiology did the best at around $350,000 and Primary Care and Pediatrics received the least at slightly under $200,000 per year.

About half of the respondents indicated their income “remained the same” between the years 2009-2010, but more indicated their incomes increased than decreased during this time.

Those in the North Central U.S. averaged the most ($225,000) and those in the Southwest and Northeast averaged the least ($190,000).

All respondents felt they should be earning more and less than half of the Primary Care practitioners felt they are currently fairly compensated for their efforts.

They all work a lot of hours and spend way too much time on paperwork and non-patient administration.

Almost a third are not so sure they would choose medicine as a career if they had to do it all again. They would either go into business, law, or teach.

When looking at the pure numbers we need to remember these amounts don’t include the general costs of education, general overhead, malpractice insurance, staffing, and all the other costs that we require providers to assume as a part of participating in the health care system we have created.

The question isn’t really “how much” but what is the value? That is the challenge we just haven’t been able to determine very well.

So, before we look only to putting some arbitrary limits on the fees paid to providers as the sole way to control costs we should first look at the ways we can measure and improve the value of the dollars that are being spent; more electronic technology, accessing best-practices, reducing administrative nonsense, and creating more informed consumers come to mind. And, providers need to be accountable for the value they provide, just like we’re expecting other stakeholders to be accountable in their new roles as well. Providers can’t just do whatever they want any more and expect someone else to pick up the tab.

Princeton economist Uwe Reinheardt estimated that if you cut physician income across the board by 20% you would only shave 2% off national health spending. That’s not a very big dent.

While health care spending is a problem, how we’re spending the money is an even bigger one.

Just Wind The Clock- It's Going To Happen Again

Last Friday the leadership in Congress and the Executive branch finally came to a last-minute agreement to narrowly avert a government shutdown. As expected, everyone waited until the last minute before finally showing their hand.

A soldier in Afghanistan (supporting a family back home) wondered if he was going to be paid. Some of these heroes literally live paycheck-to-paycheck. So, while dodging Taliban snipers and trying to avoid IEDs planted in the road, he now had to worry if his wife and children would have the money they needed for support while he was gone.

It's inexcusable- unfortunately this is the world of politics, partisanship, and debt we live in today.

Congress will likely pass the $38 billion in "reductions" that were part of the final agreement to create the FY2011 budget (many months late). Just to add to the confusion surrounding what was actually accomplished, the CBO posted their analysis of the deal the day before the vote stating the number isn't really $38 billion but somewhere around $350 million for FY2011 due to the maze of IOUs, transfer accounts, and other accounting gimmicks included in our federal accounting process. To add more fuel, they posted their projections indicating our deficit for the first six months of the year will be about $800 billion- over $110 billion more than the same time last year. We aren't making much progress.

The politics are getting uglier- and Americans have no idea who to believe.

While the lights remain turned on for now, these last-minute agreements are unfortunately going to be the norm. The fiasco that occurred last week is a drop in the bucket compared to what we're going to experience when the votes to raise the debt ceiling and the 2012 budget debates really get underway. Quite honestly, the stability of our economy is at stake.

Republicans want to use the scorched-earth approach, Democrats want to protect self-interests. Most of us know the right answer is somewhere in between. It's now a game of chicken- and we're all on the receiving end.

We'd better brace ourselves. The coming months are not going to be pretty. Whether we want to accept reality or not- addressing health care and entitlements (Medicare, Medicaid, and Social Security) will be or should be central to the discussion.

The world has changed and America has changed and now is the time we'll really see what we're made of. We had just better be sure we don't ask those who are already sacrificing so much while they are protecting our freedoms in hostile environments to sacrifice more just because we can't get our act together here at home.

We're better than that.

The New Proposed Rules for ACOs- Can We Make 429 Pages Understandable?

The Department of Health and Human Services just released the “proposed rules” for creating Accountable Care Organizations. Accountable Care Organizations (ACOs) were legitimized in the Affordable Care Act as a way to try to curb the unsustainable Medicare costs occurring today by organizing the way beneficiaries receive care in a different way. I believe the idea could be simplified by simply saying they change the way providers are paid by working together better than they do today. These proposed rules (requesting comment from the public) are 429 pages and will be a field day of billable hours for policy consultants, actuaries, financial analysts, and statisticians. With all of the data requirements included, technology companies and the IT departments at health care organizations are going to have some great opportunities (and a lot of work) if they play it right. You can grab the proposed rules by clicking HERE (it’s a big PDF file so hopefully your computer won’t choke).

Accountable Care Organizations are part of the Medicare Shared Savings program included in the ACA and are intended to create organizations to “expand value-based purchasing, broaden quality reporting, improve the level of performance and feedback to suppliers, create incentives to enhance quality, improve beneficiary outcomes, and increase the value of care." The idea is to reward providers for delivering high quality, efficient clinical care for Medicare beneficiaries. The rules themselves sound remarkably similar to the HMOs that everybody hated- but ACOs are supposed to be different. They are going to be primarily run by hospitals and provider groups instead of insurance companies, and supposedly will be less restrictive with the patients and allow for individuals to see providers outside the network if they want. We'll see.

I read that the health care industry tends to operate with “kind of a herd behavior, rushing to implement an idea without working through the detailed business questions of how they’ll work.” ACO’s are the new hot topic in health care and the herd is building. They sound like a good idea (and could be a survival strategy for some provider organizations and hospitals) so many folks are jumping on-board, they just don’t know how it’s all going to work.

HHS estimates 5 million Medicare beneficiaries will be enrolled in ACOs in the next few years. Somewhere between 75 and 150 ACOs are supposed to be operational over the next three years and will cost around $1.75 million each to get set up. The start-up costs are primarily going to be borne by the private market. HHS believes Medicare will save a little over $500 million over the next 3 years (median number). That’s a pretty small portion of overall Medicare spending- but it’s a start.

Once again, I wonder about the patients.

The rules spend quite a bit of time talking about the importance of being “patient centered” but nobody is talking about how to get the patients and individuals ready to be “patient centered.” What will happen when a patient wants to go outside the network impacting any bonus payment the ACO might receive? What will happen when the patient wants every possible test and procedure that the ACO may not believe is necessary? That’s going to determine the real success of ACOs. Can health care finally relate to people on an individual level?

As they are outlined today, the rules acknowledge that public and patient support is going to be required to make all of this work- but doesn’t quite define how. The rules state, “The exercise of free choice, however, can be undermined or even nullified if beneficiaries do not possess adequate information to assess the possible consequences of available choices, or to evaluate which available options are most consistent with their values and preferences concerning their own health care.”

Health care is going to need to connect with people in new ways. Brochures, pamphlets, and marketing materials are not going to cut it any more. Individuals need to be educated and informed about the basics of ACOs to be able to participate like ACOs are going to need them to participate.

Consumer education needs to be a priority and not just an exercise shoved off to the marketing department or handled like health care has handled communication and education in the past. Consumers are having a tough time trusting health care right now- 429 pages of rules may be a billable hour windfall for the consulting companies, but it doesn’t make things any easier for those who are really going to need to know what is expected and are going to be asked to participate in ways they haven’t had to in the past.

Let's hope we can start connecting.