The United States spends considerable money on health care. Unfortunately, the clinical return on investment has been coming up short for years, according to Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally, an oft-cited Commonwealth Fund study.
If you haven’t already heard about the negative impact of formulary restrictions on adherence, well here it is. With mixed messages regarding formulary restrictions’ impact on patients, a recently published systematic literature review, published by Happe, et al., sought to get to the bottom this.
We’ve known Michael O’Donnell, the publisher and editor in chief of the American Journal of Health Promotion, for 30 years. He is not prone to hyperbole. So he got our attention when he recently wrote that he had just published “the most extensive and well-conceived review conducted to date” on the financial impact of workplace health promotion.
He calls the paper “one of the best reviews ever conducted on any topic in workplace health promotion.” The study by Siyan Baxter and colleagues shows how the quality of the research methodologies used in the 51 interventions examined in their final analysis affected the magnitudes of the ROI’s reported. An archived webinar that summarizes the study findings is available free on this page at the American Journal of Health Promotion.
There is a time-honored belief among health services researchers that the more rigorous the methodology, the smaller the size of the differences between groups will be. This is precisely what Baxter and colleagues found with respect to return on investment, which they calculated as ROI = (benefits – program costs) / program costs rather than the more typical approach of reporting ROI as the ratio of benefits to costs, i.e., ROI = benefits : costs. Nevertheless, Baxter, who is a PhD candidate in medical research at Australia’s University of Tasmania, found ROIs averaging 0.26 ($1.26 per dollar invested) in the 18 high-quality studies and –0.22 ($0.78 per dollar invested) in 12 studies using the most rigorous methodology, namely, the randomized controlled trial (RCT). For the 43 less rigorous studies of moderate or low quality, Baxter found ROIs averaging 1.79 (i.e., benefits of $2.79 per dollar invested), which is consistent with the oft cited ROI of 3:1 reported in a recent review by Harvard Economist Katherine Baicker and her colleagues.
Next year is a big year for Medicare Advantage plans. In 2015, they will not receive bonuses unless they have a 4-star rating or above. Many health plans are feeling under pressure right now, and may even feel a little disgruntled, as their businesses could really take a hit next year if they fall even slightly below 4.
One way to view this challenge that may take the edge off the pain is that the CMS Five Star Quality Rating System for Medicare Advantage Plans is not just about being able to stay or earn a spot in the Medicare Advantage program. Taking steps to improve ratings can help Medicare Advantage plans and other health plans hoping to enter the program achieve the Triple Aim and move them even closer to getting the business results they really want.
This is my third installment on the Choosing Wisely Campaign from the American Board of Internal Medicine Foundation and Consumer Reports that brings into sharp focus, and in plain English, the things patients and we physicians should question. The Choosing Wisely campaign now includes submissions by more than 60 medical professional societies and organizations. Examples include:
Why scheduling early delivery of your baby is not a good idea
Treating sinusitis: Don't rush to antibiotics
Don't perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients
Bone density tests: When you need them and when you don't
Treating migraine headaches: Some drugs should rarely be used
What prompted this update is a new video in the zeitgeist of today, with light music, happily dancing people from seniors to millennials, and scrolling text.
I am hoping to prompt readers of Managed Care to help to take viral this video for the important campaign to reduce unneeded and in some cases harmful medical testing, treatments, and services. A wise choice!
Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey – Robert Wood Johnson Medical School, and is governor of the American College of Physicians, New Jersey South.
The question facing health care organizations today is daunting: “How are we going to efficiently and effectively care for millions of new patients, many with chronic illnesses, and many who have never had access to routine health care in the past?”
At Franciscan Health System in Tacoma, Washington, we face the same problems as other health care systems. With 12,000 employees, including 1,200 physicians, and 46,000 hospital admissions plus 460,000 outpatient procedures, we fully understand the challenges of health care delivery today. However, we’ve found that the best approach to population management lies in a culture shift from treating lives at risk to a system where we front-load our attention to preventive medicine. Two things will allow us to be successful:
Team-based care which opens up access and enables physicians to extend their reach by adding certified physician assistants (PAs), nurse practitioners (NPs), care managers, health coaches, pharmacists, and others to the medical care team.
Electronic health records (EHR) technology connecting all providers with a complete and up-to-date medical record.
There’s a gap in the proverbial health care safety net that’s big enough for a whale to swim through.
People who are incarcerated, on probation, or on parole — what a recent study calls the “justice-involved population” — make up 22% of the 13 million newly eligible people.
“The justice-involved population has a higher disease burden than the general population, yet as many as 90% of justice-involved people lack health insurance at the time of their release from incarceration,” says the study, published in Health Affairs. “This disparity between disease burden and access can drive up the cost of health care, result in worse outcomes, and cause patients to seek care later than appropriate and in care settings that are often isolated and lack care coordination.”
Uncertainty regarding health insurance exchanges is not going away. Changing enrollment deadlines and newly insured populations have brought challenges to payers and providers. Success will require staying competitive on price, network quality, and access.
To succeed, a health plan needs new capabilities, such as flexible network management and an unprecedented level of coordination between payers and providers. Payers must be agile enough to adjust network strategies on the fly, as they learn more about newly enrolled populations. They need the ability to administer more complex product designs, care delivery. and reimbursement initiatives quickly and efficiently.
Unfortunately, current network operations often struggle because of multiple sources of provider data, disconnected reimbursement systems, and manual loading between network management and contract management. As the need for administrative savings grows and networks and reimbursement arrangements increase in number and complexity, the problem with existing systems will increase.
The road ahead requires preparation and challenges to current assumptions. Here is a template for health plans to drive their activity on the health insurance exchange:
One of the more audacious promises of the accountable care organization (ACO) movement is the idea that providers of medical services can play a larger role in improving a population’s health. It stems from a notion that health care financing reforms will move the focus of providers from “the tyranny of the office visit” to activities where success will be judged according to improvement in clinical metrics whether a patient visits the office or not. It’s the right vision from a health promotion advocate’s vantage point because it may serve as a preamble to an era where medical and public health practices and public policies truly intersect. Dartmouth’s Jack Wennberg famously observed predictable provider-centric small-area variation in the use of clinical procedures while the Centers for Disease Control and many other public health observers have long shown that ZIP codes have more to do with health than do medical codes. Can the next generation of health reforms reconcile the tension between these loosely related truths?
Medicare plans are furiously working to develop an optimal 2015 bid to submit to the Centers for Medicare & Medicaid Services. The pressure is especially acute this year given the rapidly consolidating and fiercely competitive Part D environment. Missteps in the bid development process have always been costly — affecting member acquisition and retention and overall profitability for the plans. But in the current environment, bid errors paired with a poor star rating will severely reduce payments from CMS and likely put plans out of business.
It’s important to understand the implications of several changes CMS proposed affecting preferred networks and enhanced alternative plans.