Health Care Reform- Cable News Has A Role

The Kaiser Family Foundation's May Tracking Poll results of consumers might be an indication that emotions are starting to stabilize a little since the health care legislation was enacted a few months ago. The public may be a little less confused, but a solid minority (44%)still remains uncertain with how the legislation is going to impact them personally.

While the general framework of a system redesign may be in place, the health care system is now waiting for the rules to be written to define exactly how all of this is going to work. The country has moved on to other things for now. It’s now up to the health care system to execute whatever rules are written- and hope it all works. Business strategies for all stakeholders are already changing as a result.

While the intense emotions that we witnessed over the past year may not be visible, you can bet they are still there. Health care reform remains a very partisan social issue. Those that supported the reform structure ultimately enacted still do- just not as intense as in the past. Those who have been against the approach still are- and are just as intense in their disapproval as before. This divide will become visible again if any surprises occur. And, you can be sure there will be some surprises along the way.

The rumors and myths of the legislation continue to fly around to further confuse the general public. Recently, a mass e-mail was sent stating that the new legislation required employers to start including the health care contributions they make on the W-2 of each employee- and this contribution would be included as taxable income thus, increasing the taxes for all who receive employer contributions for their health care benefits. The e-mail called for a “call to arms” to all recipients to reject this tax increase and pass it on. The first part of the author’s contention is true- the second part is not. However, the message created quite the stir in the internet world. Such is the world of instant communication with the internet- whether the information is accurate or not.

Kaiser’s May Poll shows most consumers access family and friends, cable TV (Fox, CNN, MSNBC), and the broadcast networks most frequently to obtain their information about health care reform. Cable TV received the highest weighting when determining the “primary” source of health reform information. The slant used by these venues has a significant impact on the consumer’s perceptions of health care reform and ultimately on their desire to engage in the system. Cable news could be a tremendous asset to help consumers become more engaged by sharing fair and accurate information and helping consumers understand, or they could be a tremendous obstacle. Only time will tell what the result will be.

The country has moved on to some of the many other pressing problems we face. Even though the emotions of health care reform may have subsided for the moment, we can’t forget that fixing our health care mess is a very key component to fixing our economy. Engaged consumers are a critical part of the solution. We need to provide them with the tools and information they need to make the informed decisions and become a part of the solution, not drive them further apart.

Prometheus- A Titan In Payment Reform?

One of the basic lessons you learn in Economics 101 is the fact that price is always a function of supply and demand. At least it should be. But, as we’ve seen, that doesn’t always apply to health care. Health care pricing has turned into a convoluted mess of cost shifting and political negotiations with little relationship to supply and demand. The ultimate result- those that deliver the care usually receive less “per unit” and total costs to the system continue to go up.

The Patient Protection and Affordability Act sets minimum standards for what health plans (or other payers) are required to pay in “medical costs” and what they may retain in “administrative costs.” This will ultimately drive the setting of prices set with employers and consumers. A study of literature by the Deloitte Center for Health Solutions found health plan administrative costs ranged from 9% to 41%. Obviously, there is no set definition of what is included as an administrative cost from a health plan perspective. You can expect the pricing manipulations to continue as the PPAA rolls out.

One thing is clear- how our health care system reimburses care providers needs to change if we’re going to get a handle on the costs. Until it changes, those responsible for the financing of health care (the health plans, the government, and payers) are going to continue to focus on obtaining lower per unit costs for services or eliminating them altogether if there is no evidence that the service works. This process will ultimately impact the quality of care received from the patient.

We’re starting to see some movement to changing the fee-for-service/volume-driven payment system we have today. The American Board of Internal Medicine (ABIM) Foundation recently put forward some guiding principles designed to “produce a health care system that reflects societal values more accurately than do those inherent in existing payment methodologies.” Almost everyone agrees on the need to change the financing and payment for health care services.

We’re seeing pay-for-performance methods, episode-based payment models, accountable care organizations, and medical homes as the new financing ideas for health care delivery. There are already many derivations off of the main ideas (baskets of care, etc.) Each idea has strengths and weaknesses but none have proven to be the “silver bullet” that will encompass all aspects of care delivery, reasonably reimburse providers, and assure quality care and manage the costs of delivery.

The Robert Wood Johnson Foundation has put a lot of money into the Prometheus Payment System to explore new payment models in care delivery (go to www.prometheuspayment.org). Prometheus (Provider Payment Reform for Outcomes, Margins, Evidence, Transparency, Hassle-reduction, Excellence, Understanding, and Sustainability) is an episode-based payment structure. The idea is to determine a total budget for all providers involved in treating a particular episode of care. Prometheus has developed 21 Evidence-Informed Case Rates (ECR) that establishes a comprehensive budget within which a payer or multiple providers negotiate their price to provide all of the care for a specific patient for a specific condition.

In its payment algorithms, Prometheus also establishes a budget amount for Potentially Avoidable Complications (PAC) that have been identified in specific cases as the “deficiencies in care that cause harm to the patient yet might have been avoided with more proactive care.” The Prometheus data indicate up to 40% of every dollar spent on chronic conditions are a result of PAC. If PACs are avoided, the providers keep the money.

We've included a study on our web site providing more details of the Prometheus model as it applies to primary care and medical homes.

The Prometheus model is currently being tested in four markets with expansion planned in the future.

Prometheus obviously had to stretch quite a bit to make an acronym for what it intends to do. However, the definition of Prometheus (defiantly creative) seems to define the intentions best.

We need more defiantly creative ideas introduced that can change the way health care thinks and begin to fix the mess we continue to face today.

Be Well

Social Determinents of Health- How We Live Influences Our Health

Several months ago a doctor and I were discussing the challenges facing us in health care today. I have always been a big believer in the concept of “integrative healthcare” and the need to expand our definition of health as a society to fix the mess we’ve created. From a purely business and consumer perspective I had always wondered how we can expect to change the trajectory of increasing costs when all we are talking about is fixing the end-result (the diseases). My arguments didn’t go very far inside the system. The system is still focused on only addressing the end-result.

Yes, the system has created the idea of health coaching and health promotion but it’s all still very clinical from my perspective. Health care has not embraced them as critical elements to the solution. The incentives are in treatment- not in the other stuff. We’re identifying risks, then trying to get people enrolled in specific programs to address the risks. We’ve had moderate success. The new reform legislation includes rules and initiatives focused on prevention, health promotion, and community health but they remain a separate world from the developments in technology, telemedicine, pharmaceuticals, and all the rest that are more part of our “standard” sickness system. We have not yet integrated our culture and social well-being into the equation. We’re talking about it- but we have a long way to go.

The doctor turned me on to the work of Sir Michael Marmot. Professor Marmot is a professor of epidemiology at University College London. His work looks at the social aspects that can have a dramatic influence on the health of any population. His conclusions: the social (cultural) factors we encounter each day can influence how healthy or how “sick” we are. We’ve posted the World Health Organization’s Social Determinants of Health (of which Professor Marmot was a contributor) on our web site. You can get it by clicking here.

This report looked at nine different social influence's that have a dramatic impact on the health of a population. These included:

*Stress- which is largely influenced by the socioeconomic status and self-perception of an individual

*Early Life- which includes how we set the foundation and example for our children early in life.

*Social Exclusion- which evaluates the social connectedness we have in our lives

*Work- looking at the relationships and satisfaction in our work

*Unemployment- evaluating the effects our professional lives have on our health, and especially when a person is out of work

*Social Support- the culture of support and guidance available to a population

*Addiction- the impact drugs, alcohol, and tobacco have on health and well-being

*Food- The nutritional make-up of our lives

*Transport- which essentially equates to getting out of the cars and exercising by walking and looking at other means of transportation.

These factors have a dramatic influence on the health of any population. Employers are making some progress individually but the engagement rate of consumers in the “risk based” models being introduced today remain relatively low. Some of the social factors identified by the WHO report are dealt with indirectly but are certainly not part of the overall platform that is evolving in the health care system we have today.

Our culture is stressed, 71% are not enamored with their work, our unemployment rate is high, we’re overweight and don’t exercise, and the social support available is being reduced simply due to the economy. We are not a healthy population.

It’s time we start building these social factors into what we traditionally define as “health care.” Until we do, all the medical homes, baskets of care, and other new ideas in the world aren’t going to make a difference to the costs we will pay if we just keep getting sicker.

A Broader Definition of Health

Eva Makvoort was 25 when she died. Eva Makvoort created a blog to communicate with her friends and growing community of followers as she struggled with the ravages of cystic fibrosis. It’s a beautiful blog and you can go to it by clicking here. You could tell that despite her physical challenges she loved life, appreciated each moment, and would give anything for a clear and unobstructed breath of fresh air.

We wrote about Randy Pausch in our July, 2008 Newsletter. He was the Carnegie Mellon professor who created a huge following with his talk to students at the university that resulted in his book “The Last Lecture.” Randy Pausch’s message to others was to always, fearlessly, pursue your dreams. He gave this lecture knowing his cancer was terminal and he died in 2007 not long after his book was published. Despite the physical challenges, the other aspects of his life remained strong. He maintained a positive perspective of life to the end.

These two individuals are examples of the idea that “health” is a much broader term than traditionally used in health care today. While we’re used to the diagnosis, prognosis, prescriptions, interventions, and measurement of the physical aspects of health we really don’t dive into all of the other areas of life that have an impact our overall health and well being as a standard part of the health care delivery process. The emotional health, spiritual health, intellectual health, and social health of a person can dramatically influence the way a person maintains when the physical health breaks down. They may also have some influence in determining what ultimately results to the physical health as well. We need to start paying more attention to these aspects in our definition of health as we change the paradigm in health care delivery from sickness to health.

The CDC’s latest report on the U.S. National Health and Nutrition Survey indicates almost half of US adults now have risk factors contributing to heart disease. We all know the obesity statistics. A study to be released in the Archives of Internal Medicine found that the lifestyle habits of a study population in Britain cut longevity by 12 years. We all know the simple lifestyle decisions made each day are contributing to the enormous costs of the care needed today and the care that will be needed tomorrow.

Reed Tuckson, M.D. of the UnitedHealth Foundation put it this way, “Unless there is urgent action across our society, our already burdened care system will be swamped by a tsunami of cost and demands from preventable chronic disease.” Our system simply can’t afford the lifestyles our society has embraced.

While Eva Makvoort’s and Randy Pausch’s physical health failed, the other aspects of their lives remained strong giving them the best quality of life they could achieve given the circumstances. Their physical options were limited.

But, most have a choice and have the opportunity to make the decisions we all know are necessary to improve both health and quality of life. We just need to make the commitment and do it and provide the support and resources along the way to help make it happen. While the physical health may remain the “standard marker” for defining a healthy person we’ll need to consider the emotional, social, spiritual, and intellectual aspects of health as well. They are all related.

One of Eva’s followers wrote, “I felt so selfish when I stumbled across your [LiveJournal] on here, because I’ve been smoking cigarettes for yours, taking my lungs for granted. You’ve helped me quit the worst habit I’ve ever had.”

Sometimes it just may take appreciating what you have to get started.

Checklists and Decision Trees

According to a study by PriceWaterhouse Coopers over $1 trillion of the $2.2 trillion we spend on health care in this country is wasted. While the definitions of waste in the study are pretty broad- defensive medicine, treating for lifestyle conditions, etc.; the point is made. There is a significant amount of waste in the system we have today.

Health care consumers and providers of care have pushed-back significantly when attempting to introduce protocols or decision making tools in the process. The thought being you cannot reduce something as complex as health care to a series of algorithms.

Two books provide some indication that the emphasis on standardized decision making in health care will not go away. The research cited, in-fact, provides credibility that by using simple decision making methodologies outcomes may improve, may cost less, and provides more transparency to varous stakeholders throughout the system.

The Checklist Manifesto, by Harvard surgeon and New Yorker staff writer Atul Gawande, M.D. introduces the simple idea of using “checklists” as part of the care delivery process. His premise is simple- no matter how much of an expert you may be, you can always improve your outcome with well designed checklists to guide you through the key steps of any complex procedure. Click here to go to Gawande's web site- he's got some cool checklists already developed.

While Gawande believes his checklist idea is applicable for many other areas of life, his experience in the health care field lends credibility to his argument for designing simple methods to assist in the decision making process resulting in better outcomes and lower costs over time.


Thomas Goetz, a journalist and Executive Editor of Wired Magazine presents a different approach- but this time for health care consumers.

His book, The Decision Tree: Taking Control of Your Health in the New Era of Personalized Medicine introduces a methodology to assist individuals in making health care decisions. Much like Gawande argues in The Checklist Manifesto, Goetz recognizes the decisions we make today are much more complex than ever before. Health care consumers are usually left to their own devices to acquire the information they need to make decisions concerning their health and are at the mercy of the health care system when confronted with it. The Decision Tree presents a method and device for individuals to formalize health care decisions and externalize the choices made in their health and health care they typically make without thinking. The studies he cites confirm the fact that those individuals who actively participate in the decision making process are more engaged, and achieve better results. Click here to go to the Decision Tree web site. Take a look at the video to get a better idea of the concept.

Our health care system has been fighting the battle of “protocols” and processes for many years. While one side recognizes the possibilities for improved efficiency the other side views them as barriers that obstruct the delivery of care and the relationship with the patient. Consumers are accessing and becoming overwhelmed with a growing body of research and information (both good and bad) from which to base their decisions- and have not always been welcomed when trying to participate in the decision making process.

With such a significant amount of money being wasted in our health care system the need to at least set a framework for making decisions by all stakeholders will only increase. Gawande and Goetz provide some food for thought with some simple ideas to consider with the support behind them to show that outcomes will improve, engagement will increase, and costs will go down.

They are certainly worth a good discussion at the water cooler.

OpenNotes and Medical Record Transparency

If there is one group of stakeholders totally confused by the health care system we have, it’s the individual consumer. The consumers don’t understand the legal jargon included in most health plan Certificates of Coverage (COC), they don’t understand how to navigate around the primary care/specialty care maze we send them through, and they don’t understand how the pricing and financial structure works. I’m not saying consumers are ignorant. They simply have not been provided the information they need to participate effectively. Our health care system has been very good at keeping information in silos. Consumers have had to rely on other sources to try to get the information they require to make the decisions they need to make. We can safely assume this lack of “transparency” impacts efficiency, cost, compliance, and possibly the outcomes associated with particular medical events.

The Journal of General Internal Medicine recently published an article highlighting the fact that consumers want full access to all their records and are willing to make some privacy concessions in the interest of making their medical records completely transparent. Consumers want more information than they are being provided today.

Through a $1.2 million grant from the Robert Wood Johnson Foundation and with the participation of 75-130 primary care physicians connected to Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in Danville, Pa, and Harborview Medical Center in Seattle, a project is underway to answer a basic question: Can improving communication with the patient lead to better health care outcomes?

The answer seems obvious.

Through the OpenNotes project http://www.myopennotes.org/, health care providers will be using processes to provide patients with access to their primary care physician’s visit notes through an electronic medical record. While EMRs traditionally include such things as lab results, biometrics, and medication lists the office notes themselves are traditionally not accessible to the patient. This project is designed to determine if the office notes themselves can be repositioned to be “for the patient, instead of about the patient.”

Not all providers are enthralled with the idea. Some believe that providing access to the notes only adds to the possibility for misinterpretation and miscommunication. They believe the office notes are clinical and cannot be useful to the average consumer.

This argument highlights one of the more significant problems in health care- everybody is talking in different languages.

The OpenNotes project hopes to address the following:

1. Create a more transparent and democratic health care environment
2. Enhance patient-doctor communication
3. Improve the accuracy of provider notes- ultimately reducing the possibility for litigation
4. Increase shared decision-making and improve patient satisfaction
5. Help patients and families become more actively involved in follow-up and compliance
6. Improve patient recall after a visit.

The goals are admirable and the intent of the project is certainly heading in the right direction for the consumer and patient. Sometimes I just wonder if we need $1.2 million and a 12-month research project to do what we know is the right thing anyway.

Be Well

Will Wellness Incentives Work In Health Care?

Last year the average incentive paid to participants in an employer-sponsored wellness program was a little over $300 a year. Some employers paid a lot more- one paid $4,000 to employees just to complete an HRA- and some less, but the overall average increased over the previous year.

A lot of dollars are being thrown at employees to get them involved. Why is it that still only 11% of the employees actually are?

Daniel Pink’s new book “Drive; The Surprising Truth About What Motivates Us” provides an interesting perspective.

Pink delivers his argument from a historical perspective and simply comes to the conclusion that the way individuals were motivated in the past no longer applies today. He describes the historical way we have tried to motivate individuals as Motivation 2.0. Motivation 2.0 assumed “the way to improve performance, increase productivity, and encourage excellence is to reward the good and punish the bad.” It was the old carrot and stick model.

The carrot and stick model worked fine when the actions you were trying to change were repetitive and measurable and there was no consideration of external forces influencing an individual. If you produced more widgets, you were paid more. If you didn’t meet your quota, you might not have the job for much longer. The measurements were simple.

Pink argues that our culture no longer works that way. The dynamics of the workplace and the characteristics of our demographics are dramatically changing. He believes that we are moving toward Motivation 3.0. Motivation 3.0 “concerns itself less with the external rewards to which an activity leads and more with the inherent satisfaction of the activity itself.” Individuals don’t always respond to the carrot and the stick approach any more.

Individuals are looking for more in their lives (including their work) than they ever have before. Pink believes motivation to take action at any level is based upon an individual’s desire for three things: 1. Autonomy- the desire to direct our own lives; 2. Mastery- the urge to get better and better at something that matters; and 3. Purpose- the yearning to do what we do in the service of something larger than ourselves

Focusing on material incentives (money and gifts) may sometimes work to achieve short-term results but will probably not work to achieve the real goal of engagement and active participation. Actually, Pink cites examples where the carrot and stick approach worked in reverse. In health care, engagement and participation of the individual consumer is crucial. We can’t get much lower engagement than where we already are.

Getting employees engaged in this new health care world will require more than a carrot and stick approach. It will require creating the culture around the individual that meets their personal requirements of feeling they are in control of their lives (autonomy), continually improving their health because they know it matters (mastery), and participating because they know its not just about themselves (service).

Pink writes, “In our offices and our classrooms we have way too much compliance and way too little engagement. The former gets you through the day, but only the latter will get you through the night.”

If we can move to Motivation 3.0 in health care maybe we’ll have more than 11% of the individuals engaged in sponsored programs and we won’t have to pay $4,000 to get someone to complete an HRA.

Be Well.