Frank Diamond's blog

The appropriate cliché at the appropriate moment can have an impact. For instance, hearing “the right hand doesn’t know what the left hand is doing” in a hospital might be enough to spin you right back out the revolving door. You know the horror stories. Wrong limb amputated. Forgotten utensils cozying up to innards for the long haul. Those are the sensational examples, but care coordination — or lack of it — was and remains a vexing problem. This story by Kaiser Health News describes it as health care’s “dirty little secret” but it’s something we’ve been reporting on for a long time.

Another phrase that goes way back: physician buy-in. Well, turns out that physicians may buy into care coordination in a big way. About 20 percent of physician practices now employ care coordinators, according to the 2013 Staff Salary Survey by Physicians Practice magazine, a practice management publication for doctors.

Editorial Director Bob Keaveney says that the time was right to include care coordinators in the publication’s survey. “Health care is changing,” says Keaveney. “We are theoretically doing away with the volume-based system of reimbursing providers and transforming into a value-based system that will pay for outcomes and quality of care. Outpatient medical practices typically have five or fewer physicians, and traditionally have not tried to perform complex, holistic case-management that might track patients on everything from their diet to their mental health status.

“That’s why we didn’t have it in the survey before. But in this era of accountable care, practices are realizing that outcome-based population-management is how they will increasingly be paid, and that will require coordination. So we thought it was time to ask whether practices are hiring care coordinators. Still, I was surprised to see that 20 percent have already done so.”

We’re betting that medical directors are pleasantly surprised as well. 

Frank Diamond is managing editor of Managed Care.

Many economists wonder if health insurance exchanges will actually perform one of their primary functions when they open in October — increasing the competition among health insurers offering products to millions of new beneficiaries. This according to Stateline, a wire service for the Pew Charitable Trusts (http://tinyurl.com/Pew-exchanges).

States in which multiple insurers already compete are likely to see a continuation. States where one plan dominates — and Stateline lists 10 of them — won’t see any difference, according to economists. Of course, there’s always the possibility that insurers, attracted by a burgeoning market, will take the leap, but “Insurance companies have been mostly silent about their plans, with some citing uncertainty about federal and state rules as a reason for holding back,” according to Stateline.

Insurance companies might not be the only ones not to show for the party. The educated consumer, that much-talked-about but seldom-sighted person of interest, might also hold out. The Kaiser Family Foundation finds that a majority of Americans don’t know what exchanges are (http://tinyurl.com/exchanges-survey). 

The study was done in March, so hope, if you wish, that a lot of education has gone on in the intervening months. But education is one thing; learning’s another. The Affordable Care Act did foresee the possibility that the uninsured might need some help getting coverage for the first time. So the ACA includes “navigators,” who will help people choose the coverage they need. But will there be enough of them?

California, for instance, wants 21,000 navigators. All of this adds to the costs which adds to the headaches which adds up, some would say, to a fine mess. And the starting pistol has not even been fired. 

Frank Diamond is managing editor of Managed Care.

Sisyphus had to roll that boulder up the hill as punishment for deceit. Telling the truth has its own rewards, thankfully, because sometimes that too can seem a Sisyphean enterprise. Yet another warning that antibiotics are being overprescribed, this time in a letter in the April 11 issue of the New England Journal of Medicine (http://tinyurl.com/antibiotic-prescribing). The authors note that over 50 percent of antibiotics are distributed unnecessarily and find — surprise! — wide variation in prescribing patterns based on provider specialty, patient age, and location.

“Prescribing rates were higher among persons younger than 10 years of age and persons 65 years of age or older,” write authors Lauri A. Hicks, DO, and Thomas H. Taylor, Jr., MS. They examined 2010 data in the IMS Health Xponent database and found that 258 million courses of antibiotics were prescribed. Prescribing rates were highest in the South. The most frequently prescribed antibiotic agent was azithromycin.

Here’s some context: Almost 90 percent of Americans know that antibiotics can treat bacterial infections, but a third also believe that they can fight viral infections as well, according to a poll by the Centers for Disease Control and Prevention last year. More context? How about the soaring growth of antibiotic-resistant superbugs? Keep pushing that rock.  

Clinician executives at health insurance plans can stop worrying about whether consumers are savvy enough to navigate the changing landscape of coverage and start worrying about how small businesses will fare under the Affordable Care Act. (Well, keep worrying about both because both will continue to be problems.)

Let’s just look at small businesses for now. Expect a learning curve, to say the least, according to a study by EHealth, the parent company of eHealthInsurance, a private health insurance exchange. (See:"Small Employer Health Insurance Survey" )

Only about 18 percent of the 259 small businesses that buy insurance through eHealthInsurance.com can confidently explain what a health insurance exchange is, while 62 percent say they don’t understand the concept at all. Another 20 percent have “only a vague understanding of the role that exchanges are expected to play.”

Government run exchanges will be launched in October.  Not far away.

Fifty-six percent of businesses with fewer than 50 employees think that they need to provide coverage to workers or be fined, but the fine applies only to businesses with more than 50 people working at least 30 hours a week.

“I think chaos is not too strong of a word to describe what’s going on in this market,” Robert Hurley, EHealth’s senior vice president for sales and operations, tells Bloomberg Businessweek, a publication that minces no words in its headline: “Small Employers Are Clueless About Obamacare.”

For health plans, it might be a matter of “So little time; so much education that needs to be done.” Or is that the government’s job? What do you think?

Frank Diamond is Managing Editor of Managed Care

Steve Jobs famously staked his claim at the intersection of technology and creativity. Health insurers are looking for the intersection of technology and benefits knowledge, but are not quite sure how to get there. Do you hire information technicians and train them in the ways of health coverage, or do you hire (or promote from within) people who know insurance and train them to be IT savvy? It’s a pressing question given that the government anticipates a shortage of about 50,000 qualified health information technology (HIT) workers between 2010 and 2015, according to the PwC study “Solving the Talent Equation for Health IT” .

“Across the health sector, senior executives describe a challenging paradox: just as they are preparing to make major increases in technology investments they are encountering shortages in key personnel and are concerned about the industry’s ability to absorb change and integrate new workflows with HIT,” the study states.

The Affordable Care Act, with its emphasis on accountable care organizations and health insurance exchanges, means that insurers will have to sell to patients more than they did in the past. “In many ways they are playing catch up with many other industries — such as retail — in attracting, engaging and building loyalty among consumers.”

Gary Harvey, vice president of information technology at Blue Cross Blue Shield of Michigan, told researchers that “We can easily find someone who knows a tool, how to extract data from using it, and how to technically layer the data. But it’s very difficult to find someone who can look at the data and determine whether it is the right data to answer a business question or solve a problem. We see a huge gap in the talent pool for analytics talent. And it’s even harder for us to find people with clinical expertise.”

Remember the adage about giving someone a fish as opposed to teaching him to fish? Well, it doesn’t apply here. But your thoughts do, so please do tell. What are you doing about this problem?

The author is managing editor of Managed Care.

Forty-four thousand dollars is certainly a meaningful amount of money to me, but apparently not so meaningful as to encourage a sizeable portion of physicians to adopt meaningful use standards for electronic health records.

“As of May 2012, a total of 62,226 eligible professionals had attested to meaningful use under the Medicare program,” according to a letter in the February 21 edition of the New England Journal of Medicine. “This represents 12.2 percent of the estimated 509,328 eligible physicians in the United States, including 9.8 percent of specialists and 17.8 percent of primary care providers.”

So while the growth in the number of participating doctors might seem dramatic at first glance (see our chart from the January issue of Managed Care), the actual numbers are underwhelming, according to the letter written by Adam Wright, PhD, of Brigham and Women’s Hospital. (Reach him at awright@partners.org.)

“Although these data suggest rapid growth in the number of providers achieving meaningful use, this pace must accelerate for most eligible professionals to avoid penalties in 2015,” he writes. “Barriers to EHR adoption and meaningful use include cost, lack of knowledge, workflow challenges, and lack of interoperability.”

There are 15 core objectives that must be met in order for the government to underwrite up to $44,000 in new technology costs per physician, but the Centers for Disease Control and Prevention noted in January that doctors are flailing. “Some physicians with systems supporting the 13 core objectives examined in this report may not have a system that supports the remaining two objectives, as well as 5 of the 10 Menu Set objectives required for payment.”

Stories about underdogs (David and Goliath, Rocky, the 1969 Mets, the 2008 Barack Obama) are as much about overconfidence as they are about confidence. Yes, the challenger is scrappy. The favorite, on the other hand, needs just enough hubris to make his or her downfall ensure that the lesson resonates with every would-be David and Goliath — and in its entirety because we all have a little of each in us.

Many insurers want to participate in health benefit exchanges, one of the bedrocks of the Affordable Care Act. We’ve been following this at Managed Care. See, for example, here (http://tinyurl.com/Carroll-Exchanges), here (http://tinyurl.com/gov-exchanges), and here (http://tinyurl.com/vision-exchanges).

Of course, in the exchanges, insurers won’t face just one antagonist but a whole marketplace full. It might be enough to give them pause and, in fact, it may have. They’re still confident, though, according to a recent survey by KPMG, the audit, tax, and consulting company. Take a look:

Assuming your organization’s participation, how confident are you in your management’s ability to successfully participate in an exchange?

I suppose that’s the attitude an organization needs when it’s about to step into the unknown. Perhaps it’s because they feel they have implementation under control.

By when do you expect your organization to start marketing and delivering products that are consumer-focused?

As KPMG notes, success will mean “transforming their marketing efforts from a business-to-business focus to a business-to-customer focus.” That’s not the only concern and while insurers — and about two thirds of KPMG respondents are commercial health plans — may be confident, they’re not blind to the challenges.

What is the biggest challenge in building out a customer-centric organization?

That 58 percent say “all of the above” to this question might signal, again, the level of effort and focus being displayed. Or, to a more skeptical viewer, it might — just might — suggest that organizations are scurrying about in a bit of a panic. Please, weigh in.

— Frank Diamond, Managing Editor