The ever-blurring line between the practice of medicine and the business of profiting from unhealthy lifestyles was crossed again Wednesday, as Aetna announced a collaboration with two pharmaceutical companies to pitch their prescription weight loss drugs to selected Aetna members.
This announcement crosses multiple lines, not just one. First, no insurer has ever announced that it would openly direct a specific class of members to use particular proprietary drugs. Disease management (DM) programs rarely recommend specific drugs, and certainly in the exceptionally rare instances when they do, the recommendations are not specific brand-name drugs (in this case, Arena’s Belviq and Vivus’s Qsymia).
Instead, DM focuses on improving compliance with existing drug regimens, and DM firms encourage members “talk to their doctor” about changing therapies. While DM companies shy away from directing patients to specific products, physicians and pharmacists have discretion to discuss the full range of covered generic and brand products with patients, in order to optimize therapy and close algorithm-identified care gaps.
Second, there are no generally accepted care algorithms (other than those created by the manufacturers of those products) for these two drugs in the treatment of obesity. So there is no “gap” to fill. If there were an accepted protocol, these drugs might be blockbusters but instead Belviq’s recent quarterly sales were an anemic $4.8-million, “well below even reduced Wall Street expectations,” while QSymia sales are “flailing” at $6.4-million for the same period.
Obese people and their physicians seem to be avoiding these drugs in droves. Regardless of what Aetna and the manufacturers believe about their effectiveness, or whatever promotional deal they’ve cut, market reaction is telling a different story, and unfortunately for Aetna, Vivus, and Arena we live in a market economy.
October 1st marks the first ever public exchange open enrollment season. This means some of the speculation around consumer awareness and understanding, enrollment/uptake, premiums, and payer participation (not to mention the technical readiness of the exchanges) will finally subside and give way to a clearer picture of the PPACA’s initial success in mandating individual health coverage.
Despite this approaching level of clarity, however, several very significant “blind-spots” will continue to persist, principally for the health insurance carriers that choose to participate by offering PPACA compliant plans in the exchange.
This is due to the law’s guaranteed issue mandate prohibiting health carriers from denying coverage based on preexisting conditions. As a result, the traditional enrollment process which consists of a comprehensive assessment of each applicant’s health status and risk cast against the backdrop of time-tested underwriting guidelines is completely thrown out.
What takes its place is an extremely limited data set (i.e., the member’s age, tobacco/smoking status, geographic region, and family size) from which carriers can determine pre-approved premiums and variability therein. To use an analogy, health insurance companies no longer have a “bouncer at the door” turning people away, or a sign reading No shirt, No shoes, No service at the entrance.
In other words, everyone, regardless of their risk profile, must now be welcomed in with open arms and with very limited risk-adjusted rates.
This wouldn’t necessarily be a problem if the enrolling population comprised a well understood risk pool representing a true cross-section of the population. The reality, however, is that a predominantly unknown and potentially unhealthy population will flood the individual health insurance marketplace in a two weeks just as most states quickly phase out their high-risk pre-existing condition pools and shift them into the exchanges.
Last week, I reported on my informal survey of health insurance companies and their estimate for how much rates will rise on account of the Affordable Care Act (“Obamacare”).
Today, there are press reports quoting the CEO of Aetna with their estimate. The Aetna estimate is worse than mine.
Health insurance premiums may as much as double for some small businesses and individual buyers in the U.S. when the Affordable Care Act’s major provisions start in 2014, Aetna Inc. (AET)’s chief executive officer said.
While subsidies in the law will shield some people, other consumers who make too much for assistance are in for “premium rate shock,” Mark Bertolini, who runs the third-biggest U.S. health-insurance company, told analysts yesterday at a conference in New York. The prospect has spurred discussion of having Congress delay or phase in parts of the law, he said.
“We’ve shared it all with the people in Washington and I think it’s a big concern,” the CEO said. “We’re going to see some markets go up as much as as 100 percent.”
Matthew Holt spoke to Martha Wofford, head of Aetna’s CarePass platform, at the 2012 mHealth Summit in Washington, D.C. last week. Aetna CEO Mark Bertolini had just delivered a keynote and announced that his company will release the CarePass mobile app in March 2013. CarePass is a web portal where patients can connect data from their different personal applications. Here Holt speaks to Wofford about the development of Aetna’s technology offerings. He also asks her how much of an impact she thinks this tech can have on wasteful spending in the U.S. health care system.
On the weekend before the third annual “Health 2.0 Europe” conference, Health 2.0 and the international arm of Aetna (NYSE: AET), the global health solutions company, invited the best developers, designers, health experts and health tech entrepreneurs to compete for € 10.000 in prizes at Health 2.0’s Berlin Code-a-thon, Sponsored by Aetna International. Their challenge was to develop innovative mobile apps to promote health and wellness across the globe.
The event kicked off on November 3 with the participants pitching their mobile app ideas to attract the other developers to their projects. Then, the real work began—small groups spent the next 29 hours transforming their concepts into working prototypes. On the evening of November 4, a panel of expert judges that included representatives from Aetna International and Health 2.0 announced the best of the best.
The winning app was “Jog of War,” created by four talented developers and founders of start-ups from Slovenia, Macedonia, Finland and Colombia. The app is designed to motivate people to be more active outdoors by encouraging them to run through their cities, and in so doing, “conquer” territories. The app tracks the jogger’s positions and marks the corresponding areas of the city in a map. Other joggers who run in the same area can reclaim the territory by running through it themselves. Once a territory is occupied, rewards and discounts from local businesses will be unlocked to the users.
The San Francisco teams only had 2 days to create a solution and 3 minutes to present. It was a high-stakes, high-pressure event. If known the challenges it was entered for are in parentheses. AT&T, Aetna, Healthline, Food Essentials and athenhealth all offered separate challenges and prizes for this codeathon.
DIG*IT Mobile (AT&T): This app tried to use the “desire engine” concept to develop a medication adherence app specifically for patients with HIV. The app includes a news feed, a way to compare yourself to other people like you, easy contact buttons for providers and a quick health summary. Patients can see a graph of their lab values and their medication compliance, as well as a graph for adherence. Each day the app asks if a patient has taken their medication, as well as providing alerts that tell them to take their meds. The med component showed their pills and when their prescriptions are due. They plan to incorporate crowd-sourcing information later.
DocSays (Aetna & Healthline): This team took on the challenge of improving hospital discharge outcomes. Patients are overloaded with information at the time of discharge. Their app, titled Doc Says, gives them automatic reminders about everything from activity levels, foods, medication to reminders for appointments. It can also work on an SMS system, so it doesn’t have to be smart-phone based. Options on the screen include defining all doctors instructions as tasks. The steps are broken down so that “pick up your lisinopril” is a separate task from the more generic “take your medicine.”
This year at Health 2.0′s Annual Conference, two speakers split stage time during the opening keynote. Joe Flower, a health futurist, and Mark Bertolini, CEO of health insurer Aetna, don’t have a whole lot in common professionally. But in their talks they both made clear that they hold two beliefs in common: the United States health care system needs to react to the country’s cost crisis, and efforts to address health care costs will happen independently from federal reform.
Flower spoke first, laying out the tenets of what he calls the Next Health Care. For such an optimistic speech, it was filled with negatives. Flower went through step by step, talking about what the nation isn’t doing right now, who’s not invested in better care, and why all health care systems can’t just become Kaisers.
Though the talk certainly wasn’t meant to praise health care for all it does right, it was meant to point out the promise that the health care system could be on the brink of.
“Health care is undergoing fundamental economic changes,” Flower said. “These changes are driving us to what may well be better and cheaper health care for everyone.”
The Affordable Care Act isn’t what’s propelling those changes, according to Flower. It’s other factors including an aging population, the sheer cost of care in the U.S., and technological capability that we’ve never seen until now.
Chronic disease accounts for 70 to 75% of all health care costs, Flower said. And as many Americans know, obesity is a huge contributor to those costs. The maps looked at the projection of obesity rates in the U.S. over time, and as the slides passed it looked like the country was being eaten by the disease.
“Now, some of the best hopes for that future, honestly, we see right here at Health 2.0. But we are not there yet,” Flower said.
You may have received a refund check in the past few months from your health insurer. This is not your individual reward for staying healthy; it is your insurer’s punishment for making too much money because you did.
Obamacare includes what the health care technocracy calls the “MLR rule” – minimum requirements for medical-loss ratios – or the percentage of premiums collected by health insurers that must be spent on medical care or refunded. The inverse of the MLR is the percentage spent on administration and marketing, and earned as profit. Obamacare sets minimum MLRs of 80 percent for individual and small group plans, and 85 percent for large groups.
Aside from its obvious populist appeal, this profit regulation mechanism signifies a belief, now enshrined in legislation, that health insurance markets do not work. Without such a rule, the architects of Obamacare believe, insurers can name their prices, however inflated, and we all just pay.
In the short term, that is true. Most health insurance plans price only once per year, are subject to long delays in cost trending information and multi-year underwriting cycles, and endure the meddling of a carnival midway’s worth of employee benefits tinkerers, agents, brokers, consultants, and other conflicted middlemen. But in the long term, over multiple annual cycles, premiums do rise and fall, and the health insurance industry’s fortunes with them.
Gregg Masters reports on a recent Kaiser Health News article: Hospitals Look to Become Insurers, As Well as Providers of Care”.
This is the dumbest idea I’ve heard since “I’m going to invest all my money in Facebook’s IPO and get rich!”
Here are six reasons why:
1) You’re too late. Health insurance was an attractive and profitable business in the 00s, but after passage of the Accountable Care Act it’s been commoditized.
First, the health plan business model of the past decade is dead. That model was — “Avoid and shed risk” — or more simply, avoid insuring people who are already sick (preexisting conditions) and get rid of people who become sick (rescissions). Under the ACA, health insurers must take all comers and they can rescind policies only for fraud or intentional misrepresentation.
Second, the ACA institutes medical loss ratio restrictions on health insurers. Depending the the type of plan, insurers now must spend at least 80-85% of premium dollars on paying medical claims; if they spend less, they must return these “excess profits” as rebates to customers. As a result, health insurance has become a highly regulated quasi public utility.
This is why you see health plan CEOs like Mark Bertolini of Aetna declaring “Health insurers face extinction”. The old health insurance model is on a burning platform, and health plans are reformulating themselves as companies involved in health IT, analytics, data mining, etc.
2) You have bigger fish to fry. Focus on developing accountable care capabilities. The AHA estimated that hospitals will need to spend $11-25 million to develop an ACO. Get going.
You know we’ve gone through the looking glass when the hottest health care money on Wall Street is chasing Medicaid.
No, I didn’t mean Medicare, the $560 billion per year federal program for insuring the elderly that has launched a thousand IPOs. The current darling of health care investors is Medicaid, the hybrid federal-state program for insuring the poor that now dominates, and often overwhelms, state government budgets.
Last month, Wellpoint agreed to pay $4.5 billion for Amerigroup, a Medicaid managed care company, representing a nearly 50% premium over Amerigroup’s market price. Not to be outdone, Aetna this past week purchased Coventry for $5.7 billion, which also services Medicaid populations. These deals and several others like them rumored to be in the pipeline have driven up the share prices of Amerigroup’s competitors – other Medicaid managed care companies like Centene and Molinas – in anticipation of the latest round of monkey-see, monkey-acquire deals by health insurers.