Category: Uncategorized

PepsiCo’s Wellness Program Falls Flat

Jan 6, 2014• 41

By Al Lewis and Vik Khanna

For those of us who actually think wellness outcomes should be evidence-based, a landmark study was released today: the first evidence provided by a major organization voluntarily (as opposed to being outed by us, like British Petroleum and Nebraska) that wellness doesn’t work. January’s Health Affairs features a case study of PepsiCo, authored by RAND Wellness Referee Soeren Mattke and others, in which a major wellness program was shown to fall far short of breaking even.

The specific highlights of the PepsiCo study are as follows:

Disease management alone was highly impactful, with an ROI of almost 4-to-1;
Wellness alone was a money sink, with each dollar invested returning only $0.48 in savings;
The wellness savings were attributed to an alleged reduction in absenteeism, as self-reported by participants. There was no measurable reduction in health spending due to wellness.

Even though the wellness ROI was far underwater, we suspect that the ROI was nonetheless dramatically overstated, for several reasons. First, the authors acknowledge underestimating the likely costs of these programs, focusing only on the vendor fees without considering lost work time, program staff expense and false positives. Second, no matter how hard one tries to “match” participants with non-participants (the wellness industry’s most utilized measurement scheme), it simply isn’t possible to compare mindsets of the two groups. We learned from one of Health Fitness Corporation’s many missteps that participants always outperform non-participants, simply because they are more motivated. Third, the absenteeism reductions were self-reported, by participants.

Finally, PepsiCo’s human resources department, having made the mistake of accepting Mercer’s advice to implement one of these programs, was already taking some political risk by acknowledging failure. Had they incorporated the adverse morale impact, lost productivity due to workers fretting about false positives, Mercer fees and staff costs, participant bias, and self-reporting bias, the ROI could easily have turned negative (meaning the program would have been a loser even if the vendor had given it away) and the HR staff could have been taking serious career risk.

Actually, We’d Probably All Be Better Off With Our Health Records on Facebook

Jan 6, 2014• 19

By Melissa McCormack

A Facebook user’s timeline provides both a snapshot of who that user is and a historical record of the user’s activity on Facebook. My Facebook timeline is about me, and fittingly, I control it. It’s also one, single profile. Anyone I allow to view my timeline views my timeline—they don’t each create their own copies of it.

Intuitive, right? So why don’t medical records work that way? There is no unified, single patient record—every doctor I’ve ever visited has his or her own separate copy of my records. And in an age where we can conduct banking transactions on my smartphone, many patients still can’t access or contribute to the medical records their doctors keep for them.

My proposal? Medical records should follow Facebook’s lead.

Cross-industry innovation isn’t new. BMW borrowed from the tech world to create its iDrive; Fischer Sports reduced the oscillation of its skis by using a technologycreated for stringed instruments. So I asked myself: Who has mastered the user-centric storing and sharing platform? The more I thought about it, the more I decided a Facebook timeline approach could be just what medical records need.

To see what I mean, let’s explore some of Facebook timeline’s key features to see how each could map to features of the ideal medical record.

“About” for Complete, Patient-Informed Medical History

On Facebook: The “about” section is the one that most closely resembles the concept of a user profile. It includes a picture selected by the user and lists information such as gender; relationship status; age, political and religious views; interests and hobbies; favorite quotes, books and movies; and free-form biographical information added by the user.

In medical records: The “about” section would be a snapshot of the patient’s health and background. It should include the patient’s age, gender, smoking status, height, weight, address, phone number, and emergency contact information; the patient’s primary care provider; and insurance information. This section would include a summary list of the patient’s current diagnoses and medications, as well as family history. And importantly, both the doctor and the patient would be able to add details.

“Privacy Settings” and “Permissions” for Controlled Sharing

On Facebook: Privacy settings allow users to control who can see the information they post or that is posted about them. For example, in my general privacy settings I can choose to make my photos visible only to the people I’ve accepted as “friends.” However, if I post a photo I want the entire world to see, I can change the default setting for that photo to be visible publicly instead.

Facebook also allows users to grant “permissions” for outside applications to access their profiles. For example, let’s say I use TripAdvisor to read travel reviews. TripAdvisor lets me sign in to its site using my Facebook account, rather than creating a separate TripAdvisor account. But, to do this I must grant TripAdvisor “permission” to access my Facebook account.

In medical records: Patients could use “privacy settings” to control whether all or part of their information can be seen by a family member or caregiver. For
example, if my aging mother wanted to give me access to her “events” (upcoming doctor’s appointments), she could do so. If my college-aged son who is still on my health plan wanted to give me access to his knee X-rays, he could.

Ten Health and Wellness Resolutions Not to Make in 2014

Jan 5, 2014• 22

By Vik Khanna & Al Lewis

We don’t make a lot of New Year’s predictions, but we are happy to make this one: 2014 will be the year the get-well-quick mentality driving corporate and individual health choices implodes…and people start taking genuine steps to be healthy. The way to ensure that 2014 is your year for good health? Start with a double negative: (a) wellness industry advice is almost always wrong; and (b) most people don’t keep their New Year’s resolutions. Hence, making the New Year’s resolutions recommended by the wellness industry is not the best way of ensuring your good health in 2014.

For simplicity, we’ll divide this list into individual and corporate wellness industry resolutions, and start with individual ones.

Take more health advice from celebrities. Whether it’s hoping that Kim Kardashian’s personal trainer can help you or pining for Dr. Oz to cure what ails you with green coffee bean extract and raspberry ketones, a good way to put off doing worthwhile things is to do worthless ones.
Start a weight loss program. The medical establishment could not head off the obesity dilemma at the pass, and they have no solution for it now, other than to crow about more drug companies diving into this expanding market. There is zero evidence that weight loss programs can produce sustainable long-term weight loss (and much evidence that they don’t), and we don’t know of a single one shown to improve fitness. That will not, however, prevent weight loss companies from trying to claim their little piece of the wellness landscape because they are losing so many individual customers to free dieting apps, such as LoseIt.com. Improve the quality of your diet first, and weight loss may follow, which is a bonus.
Give yourself a cleanse. America’s obsession with cleanliness is now running smack into the reality of evolution and human physiology. Surely if bacteria in your colon were bad for you, mankind would have died out eons ago.
Stock up on supplements. The only things better than raspberry ketones and green coffee bean extract: all the other vitamin and mineral supplements on the market that fail to make sick people better or healthy people healthier. Who’s left to try to help, Martians? Never mind that risk is not endlessly reducible and the four most important things you can do for your health don’t come out of a bottle of magic jujubes: exercise, don’t smoke, eat well, and keep as close to a healthy weight as you can.
Remove saturated fat from your diet. Just like in the 1960s, when we all traded in “the high-priced spread” for sticks of partially hydrogenated vegetable oils fit for a king to avoid saturated fat, we may be mis-demonizing this longstanding and naturally occurring component of our diet. The entire nutrition dialectic in our culture over the past 20 years has focused on a string of individual no-nos: fat, saturated fat, cholesterol, and now refined grains and sugars (because we bought the government’s wrong advice to eat low-fat). It’s time to revive the notion of healthy eating patterns, not healthy eating isolates. In fact, here is the world’s simplest diet advice for 2014: eat less junk. That alone would be a landmark nutritional achievement for Americans.
Eat organic and stay away from Starbucks. Within a week of each other, the New York Times published an account of a woman damaging her health eating an obsessively healthy and organic diet, and USA Today wrote of another who ate exclusively at Starbucks for a year, with no apparent ill effects and no weight gain.

Twelve Things We’re Pretty Sure We’ll See Happen In Health Care In 2014

Jan 3, 2014• 11

By Jaan Sidorov, MD

While your humble columnist eschewed forecasting for 2013, he has decided to reverse course and inaugurate the 2014 blogging season with a contrarian duodecimal exercise in futurism. Will this antidecimal augury align with the mysterious cosmic order and governing perfection? Let the readers be the judge in January 2015……

1. Obamacare will neither succeed or fail. This hugely complex law will have too many outcomes, statistics and analyses that will be subject to too much spin by both supporters and detractors. Like puppies clamoring for the mother’s attention, the loudest wins, but only in 15 minute media increments.

2. Inflation returns, with a vengeance: While we won’t know it until well into 2015 or 2016, 2014 will be the year that the sleeping giant of healthcare costs awakens. Millions of new insureds in an improving economy will finally get their pent-up pricey preference-sensitive health care needs fulfilled.

3. Duh, it’s the delays stupid: While low income Americans will appreciate having access to subsidized health insurance and Medicaid, the middle class’ unsubsidized sticker shock will threaten the fall 2014 elections. Caught between conflicting advice of insurance actuaries and political hacks, the White House’s regulatory choices will be obvious.

4. Commercial scientific misconduct: Unable to resist the allure of bonus payments (like this) or the branding that is dependent on the public release of quality outcomes, at least one large health entity will be caught committing “reporting fraud.”

5. Snowden blow-back: as the promise of big-data grows, fearful health care consumers will be even less inclined toward allowing access to their health information. Too bad they won’t be given a say.

6. Innovator’s Dilemma for health tech: solutions that are simple, transparent and modular will continue to make ‘from the bottom’ inroads into a tech industry that – like early data storage – is too complex, opaque and entangled.

7. Speaking of health tech, patient-monitoring solutions that offer more insight and less data will grab market share. Instead of a series of blood glucose results dumped into an electronic inbox, think algorithms that suggest insulin dose adjustments.

How Health Plan Risk Adjustment Models May Change Under the ACA

Jan 3, 2014• 4

By KIP PIPER

Risk adjustment is a key mechanism to ensuring appropriate payments for Medicare Advantage plans, Medicare Part D drug plans, and Medicaid health plans. Since health plans vary in their mix of healthy and sick enrollees, risk adjustment modifies premium payments to better reflect the projected costs of members served and compensate plans that enroll high-cost patients.

Historically, risk adjustment was only used in Medicaid and Medicare – in effect, redistributing some revenue from health or drug plans with a relatively healthier mix of members to those plans with a more costly enrollment profile. However, the Affordable Care Act (ACA) extends risk adjustment to the individual and small group health insurance markets starting in 2014.

A new brief from The Synthesis Project tackles the issue and makes several interesting recommendations for how to improve risk adjustment methods for the post-ACA market. Without accurate risk adjustment, health plans have a strong financial incentive to seek out only the healthiest enrollees, especially under ACA-mandated adjusted community rating. Under adjusted community rating, health plans may not vary premiums based on health status or sex and are limited in how much they may vary premiums based on age. Under ACA, the healthy, the young, and men subsidize the health costs of the unhealthy, the older, and women.

Risk adjustment is therefore a necessary factor in stabilizing the dramatically new post-ACA health insurance marketplace, particularly the new Health Insurance Exchanges. Even then, the ACA is a giant game of musical chairs. The market under ACA will be chaotic and challenging, with a mix of winners and losers once the music stops and the dust settles, which will take at least three to five years.

Headlines You’ll See in 2014

Jan 2, 2014• 59

By Paul Keckley

Affordable Care Act major issue in Campaign 2014; ‘fix and repair’ new focus. ObamaCare will be the defining issue in the coming election cycle, but the political debate will not be Healthcare.gov glitches or enrollment.

Rather, the issue will be sticker shock in insurance premiums and the complaints from doctors and hospitals that they’re being driven out of business. “Repeal and Replace” will not be heard; the new slogan will be ‘fix and repair’ for both friends and foes of the ACA.

Hospitals battle for survival. Faced with negative operating margins, sequester cuts and mounting bad debt, state and local officials and hospital boards will take dramatic steps to insure acute services survive. Some will merge local hospitals to be operated as a public utility.

Some academic medical centers will spin off their research enterprises into commercial ventures with bio-pharma and device partnerships. Some will merge or sell out to larger systems with stronger balance sheets.

And all will reduce operating costs and purge clinical programs no longer affordable. As patient demand and their severity increase, hospitals will operate their inpatient business as a cost center, and their enterprises as regional care management organizations assuming risk for costs, outcomes and safety. But none is delusional: hospitals face a battle for survival.

Physicians go it alone; holy war for future of the profession taking shape. Led by the American Medical Group Association and several specialty societies, large medical groups will join forces to advance a physician-centric platform for health reforms that protect physician-patient relationships, position primary care physicians as gatekeepers, and assume financial and clinical risk in contracts with insurers and employers via fully integrated health plans operated by the group.

Physicians will step up their political activism in 2014, armed with data showing their net incomes have suffered and their clinical autonomy compromised since the onset of health reform. In 2014, they’ll wage unsuccessful battles for replacement of the SGR and liability reform again.

And they’ll dust off advocacy advertising campaigns to drum up resentment of market pressures that threaten to deduce their profession to a guild employed by plans or hospitals. For doctors, 2014 will look like a last stand for the profession.

Occupy Health Care Breaks out; profits with purpose sought. Income inequality in the U.S. will spill over into health care in 2014. The social media fueled visibility of earnings and executive compensation in every sector of health care will spark local political activism.And interest in a single payer system will begin to build heading into the 2016 election cycle.

Just as value will be challenged, so will the morality of the U.S. health system, and a populist campaign to align profit with purpose sought.

An Epic Fail for Massive Open Online Courses?

Jan 1, 2014• 2

By MICHAEL B. HORN

Coursera, the popular massive open online course (MOOC) platform, intrigues. With over 5 million students served and $85 million raised—both numbers are first among the “MOOC platforms”—it’s the type of company that captures the imagination of people in Silicon Valley who dream of transforming sectors.

Its reach and emerging focus on K–12 professional development were prime reasons that we at the Clayton Christensen Institute, along with the Silicon Schools Fund and the New Teacher Center, recently offered a MOOC on blended learning through Coursera.

But Coursera has always given me reason to pause as well. It’s never felt to me like its initial incarnation could possibly disrupt higher education. Why? As I’ve told its team, offering courses from the top universities online and claiming that at last, anyone anywhere can access the best learning in the world isn’t correct.

The reason is that the top universities do not offer the best teaching and learning experiences. Instead, their faculty members are incentivized heavily to focus on research at the expense of teaching. If a professor seeking tenure at one of these institutions receives a teaching award, it is often said that that professor has just received the kiss of death for her tenure hopes. If students learn at these institutions, it’s often not because the teaching is so good, but because the students are so talented that they can absorb anything thrown at them (and it’s worth noting that just because a professor is entertaining, does not mean it’s a good learning experience).

Putting these courses online often makes them worse. Not only do professors not know how to teach well in person, but also their lack of understanding of the basic principles of sound learning design causes them to exacerbate these problems as they put these experiences online, which can become more problematic as students from all walks of life with many different learning needs are now theoretically able to take these courses.

The Hospice Will See You Now

Dec 31, 2013

By John Schumann, MD

Doctors are asked to sign things all the time: Prescriptions, home nursing care plans, death certificates, diabetic shoe forms.

Less frequently, hospice verifications.

Why was I asked to sign hospice orders for Mr. Taylor? Sure, he was old. Eighty-seven.

He’d survived decades of high blood pressure, two major surgeries, unintentional weight loss, chronic pain, headaches, even a benign brain tumor. But I had never referred him to hospice.

I wouldn’t have diagnosed him as “terminal,” i.e. expected to live six months or less. As far as I could tell, he’d just keep on truckin’ for another year or three.

So why was I being asked to sign hospice paperwork for him? How did this come about?

“Mr. Taylor, why are you in hospice? Are you dying?”

-Not that he knew of. He’d just been told that he’d get more ‘home services’ that way.

“Who set this up for you?”

-It was one of those “home doctors.” Geriatric care providers that offer house calls to infirm seniors when it’s too hard for them to come to a doctor’s office.

Thing is, he was still plenty able to come to my office. And did so regularly.

Apparently, though, the opportunity to get more home services was too good to pass up.

The agency that was providing him at-home medical services referred him to a for-profit hospice firm–one that could collect the daily Medicare fee for a hospice enrollee.

Is it any wonder, then, that we’ve seen a surge in hospice enrollments in the last few years?

Finally, someone has written something about it. Thank you, Washington Post.

John H. Schumann, MD (@GlassHospital) is a general internist and medical educator at the University of Oklahoma School of Community Medicine in Tulsa, OK . He is also author of the blog, GlassHospital , where this post originally appeared.

Healthcare.Gov’s Numbers at the Deadline

Dec 30, 2013• 32

By Robert Laszewski

After the disastrous launch of Obamacare the enrollment of 1.1 million people in the 36 state exchanges run by the feds is a major accomplishment. It is likely that the enrollment in the 14 state-run exchanges will take total Obamacare’s private insurance enrollment to near 2 million for the year.

Does this mean that Obamacare is finally on track and moving toward success?

At least the front-end of HealthCare.gov is now clearly working.

I will suggest there are still some very important questions for Obamacare that need to be answered.

First, how many of these new enrollments are people whose policies have been cancelled under Obamacare?
As I have said on this blog before, I expect at least 80% of those in the existing individual health insurance market to lose their coverage by the end of 2014. Half of the market bought their coverage after March 2010 and therefore cannot continue while most of the other half of the market will not qualify under the Obama administration’s stringent grandfather rules.

What we don’t know is just how many of these people had to buy new coverage on January 1 given the widespread offers by carriers to “early renew” their coverage into late 2014. Then the President asked insurers and states to allow people to keep their coverage another year. It appears about two-thirds of the states went along with that request. Then many of the cancellations won’t occur until they renew throughout calendar year 2014.

We do know that California did not allow insurers to continue coverage for another year leading to 800,000 cancellations on January 1 and 200,000 cancellations by March. The state exchange has said that 300,000 of these are subsidy eligible and they can only get a subsidized policy on the exchange.

California will likely announce they have signed-up about 600,000 people this year. But given the cancellations that are occurring by January 1, is this a big accomplishment?

Washington State cancelled 260,000 policies and also did not allow the cancelled policies to continue past January 1. Half of these polices are subsidy eligible and can only get a subsidized policy in the state insurance exchange. Washington State might report 100,000 private plan enrollments by year-end. But if they cancelled 130,000 people who can only get a subsidized policy in their exchange, is this a big accomplishment?

The good news is that Obamacare will likely enroll almost 2 million people in 2013.

Even if we ignore that fact that many of these people were previously insured and had to replace cancelled policies (there were more than 400,000 subsidy eligible cancellations in California and Washington alone), 2 million people are only 10% of the 20 million uninsured in the U.S. who are eligible to buy coverage in the health insurance exchanges.

Why You Shouldn’t Succumb to Defeatism About the Affordable Care Act

Dec 29, 2013• 22

By Robert Reich

Whatever happened to American can-do optimism? Even before the Affordable Care Act covers its first beneficiary, the nattering nabobs of negativism are out in full force.

“Tens of millions more Americans will lose their coverage and find that new ObamaCare plans have higher premiums, larger deductibles, and fewer doctors,” predicts Republican operative Karl Rove. “Enrollment numbers will be smaller than projected and budget outlays will be higher.”

Rove is joined by a chorus of conservative Cassandra’s, from Fox News to the editorial pages of the Wall Street Journal, all warning that the new law will be a disaster.

Robert Laszewski, president of Health Policy and Strategy Associates, anticipates a shortage of doctors. “There just aren’t going to be enough of them.”

Professor John Cochrane of the University of Chicago predicts the individual mandate will “unravel” when “we see how sick the people are who signed up on exchanges, and if our government really is going to penalize voters for not buying health insurance.”

The round-the-clock nay-saying is having an effect. Support for the law has plummeted to 35 percent of those questioned in a recent CNN poll, a 5-point drop in less than a month. Sixty-two percent now say they oppose the law, up four points from November.

Even liberal-leaning commentators are openly worrying. On ABC’s “This Week,” Cokie Roberts responded to my view that the law eventually would prove popular by warning of “a whole other wave of reaction against it” if employers start dropping their insurance.

Some congressional Democrats are getting cold feet. West Virginia Senator Joe Manchin recently fretted that “if it’s so much more expensive than what we anticipated and if the coverage is not as good as what we had, you’ve got a complete meltdown.”

Get a grip.

If the past is any guide, some fixes will probably be necessary – but so what? Our current healthcare system is the real disaster — the most expensive and least effective among all developed countries, according Bloomberg’s recent ranking. We’d be collectively insane if we didn’t try to overhaul it.