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Patients Win When Payers and Providers Speak the Same Language

By CECI CONNOLLY

Discouraging headlines remind us daily of the ugly battles between payers and providers. Fighting for their slice of the $3.5 trillion health care pie, these companies often seem to leave the consumer out of the equation.  But it is not the case across the board. Our latest research documents that when doctors and health plans drop their guards, align incentives and focus on the mutual goal of delivering the best possible care, patients win.

For example, when SelectHealth in Utah partnered with obstetricians and refused to pay for medically unnecessary — often  dangerous — early inductions of labor, procedure rates dropped from 28% to zero, leading to shorter labors, fewer C-sections and $2.5 million in annual savings for all. When Kaiser Foundation Health Plan execs collaborated with Permanente doctors around opioid safety, prescriptions for the often-deadly drugs dropped 40%. And, when Security Health Plan in Wisconsin enlisted physicians and surgeons to develop a new outpatient surgery and rehab center, health outcomes improved; patient satisfaction jumped to 98%; and they saved $4.7 million in the first two years.

These productive partnerships occur in multiple communities across the nation as illustrated in in “Accelerating Adoption of Evidence-Based Care: Payer-Provider Partnerships,” a new report by the Alliance of Community Health Plans. With funding from the Patient-Centered Outcomes Research Institute (PCORI), the 18-month project uncovered five best practices in effective collaboration for health plans:

  1. Build consensus and commitment to change;
  2. Create a team that includes the necessary skill sets, perspectives and staff roles;
  3. Customize education, tools and access to specialized knowledge that the audience needs;
  4. Share timely and accurate data and feedback in a culture of transparency, accountability and healthy competition; and
  5. Align financial investments with clinical and patient experience goals.

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The Prescription for High Drug Costs? Transparency for Starters

Ceci ConnollyFor most Americans, $280,000 might represent the price of a home or perhaps their entire retirement savings. But for the 1.3 million people in this country stricken by rheumatoid arthritis (RA)that quarter million dollars could be their drug bill.

Rheumatoid arthritis is a debilitating disease that causes painful inflammation and swelling of the joints. Left untreated, it can lead to permanent disability. Thankfully medications such as Enbrel, Humira and Zeljanzcan keep patients healthy enough to stay active and keep working. Yet the price tag is quickly becoming out of reach.

One recent report from Express Scripts found that spending on drugs that treat inflammatory conditions such as arthritis rose 25 percent in the last year alone. The annual cost of treating the nation’s RA sufferers is expected to reach $9.3 billion by 2020 – a 45 percent jump from 2013.

For a 45-year-old patient recently diagnosed with RA, the lifetime cost of medication is likely to exceed $1.4 million. Even if that person has 80 percent of their costs covered through insurance, the math works out to $280,000 in copays alone.

There’s something out of kilter when families may be forced to choose between investing in a home or easing a loved one’s pain. Yet that is exactly the sort of Catch-22 some will face if we do not find a sensible way to price drugs.

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Not Quite DOA: Why Reports of the Demise of the President’s Budget May be Exaggerated

Ceci ConnollyAnyone who has spent a few years in Washington knows the federal budget dance: President stands behind podium with a fancy seal and flags and unveils a giant tome. The next morning newspapers declare the tome DOA, Dead on Arrival. And we all return to regularly scheduled programming.

This year was no exception. Even the White House seemed to acknowledge the fact by releasing the 182-page blueprint on the same day as the Iowa caucuses with Donald Trump, Bernie Sanders and Ted Cruz grabbing the headlines.

But budget nuggets have a way of seeping into the policy fabric and eventually taking hold. Legislative staff scrub the document for ideas, not to mention numbers. Candidates steal liberally, adding favorites to their rhetorical arsenal. Eventually, some of those candidates become lawmakers, cabinet secretaries and even president. So the ideas live on.

Happily, President Obama chose his final budget proposal to draw attention to the inexplicable, indefensible rise in drug prices in this country. Our nonprofit, provider-sponsored plans know better than most the clinical value of so many of today’s medications. At ACHP, we have the privilege of partnering with organizations that are in pursuit of the 4Rs – the Right patients receive the Right treatments at the Right time for the Right price. From Capital Health Plan’s Center for Chronic Care, which reduces health costs for the entire community by providing concierge-type care for the sickest one percent of Capital members, to Group Health Cooperative of South Central Wisconsin’s pioneering initiative embedding pharmacists in primary care clinics to track patients who may need additional treatment management, ACHP members are working to ensure patients always receive the medications they need.

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Tele Taking Off

Ceci ConnollyIn Washington, sometimes the most significant developments quietly creep up on you. No epic debate or triumphant bill-signing ceremony, but rather a collection of seemingly small events begin to tip the scales.

That’s what is happening today with telehealth. Almost under the radar, federal and state officials have been giving a much-needed push in support of virtual care. Though the technology has long existed, until recently the money had not followed. And sadly in our current fee-for-service healthcare system, little gets done without a payment code, even if it makes eminent medical and economic sense.

Consider some of the recent action. In November, the Department of Agriculture released more than $8.5 million in health-related grants to 31 recipients in rural communities. Many are using the money to purchase telehealth equipment such as high-quality cameras and broadband Internet.

The previous month the federal government issued rules expanding Medicare payment for a range of telehealth services. Caregivers can earn about $42 per month for chronic care management under the new regulations. Seven new procedure codes were also added, covering such services as annual wellness visits and psychotherapy.

And the end-of-year spending bill approved by Congress designates more than $26 million for telemedicine programs largely in rural communities and through the Veteran’s Administration.Continue reading…

The Self-Health Era

Ceci Connolly

If you’re wearing a wristband that counts your steps, a patch that monitors your vital signs or a watch that tracks your heart rate, you are in the minority. And if you paid $300 or more for any of those items, you are among the nation’s quantified self-health elites.

Judging by the chatter streaming across our social media feeds, one would think every man, woman, child is sporting a health “wearable.” But in reality, these are the early days of the devices that promise to help us live longer, healthier, more active lives.

Despite the buzz, just 21% of Americans own a health wearable, according to a new consumer survey by PwC’s Health Research Institute, and only 10% of them use it daily. Even fewer consumers – 5% of respondents — expressed a willingness to spend at least $300 for a device. Many wearables today are a passing fancy – worn for a few months then tucked away in a drawer awaiting a battery charge or fresh inspiration to get up and get moving again.

As Genentech CEO Ian Clark recently put it, health wearables are “a bit trivial right now.”[1] And it seems even the folks claiming to be wearing the devices can’t be trusted – reports have begun circulating of employees enlisting their more active coworkers to wear the device and collect fitness points on their behalf.

Yet wearables present remarkable opportunities for a nation and industry grappling with the twin challenges of improving health and controlling healthcare spending. Across the board, consumers, clinicians, insurers and employers express high hopes for the power of these new devices.

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Ceci Connolly: Will Technology Replace Doctors?

Ceci ConnollyIt’s a provocative question, but it’s also the wrong one.

The question ought to be: When will healthcare fully embrace technology and all it has to offer?

It’s widely known that the $2.8 trillion US health system has significant waste and errors – between 25% and 30% of our health dollars go to services that do not improve health. Technology has the ability to put a big dent in that through standardization, real-time insights, convenient gadgets and complex data analysis the human brain simply cannot perform.

Consider some of the early innovators. There’s the heart monitor in the phone. The wristbands that count steps. And then there’s Oto, the cellphone attachment that snaps an image of the inner ear sparing frazzled parents one more trip to the doctor’s office for yet another infection.

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Early Exchange Outlook 2015

Ceci ConnollyStates in more than half the nation have reported individual market premium rate requests for 2015, making this an opportune time to assess how the second year of the ACA’s new marketplaces is shaping up.

With rate filings in for 27 states plus the District of Columbia, the early word on 2015 appears to be expansion. At least 15 of the 28 jurisdictions in 2015 will offer new individual plans this year. Thirty-seven of the 176 health plan filings are new, according to analysis by PwC’s Health Research Institute (HRI).

Major national insurers such as UnitedHealth Group, as well as newbie Consumer Operated and Oriented Plans (Co-Ops), plan to add both products and states when exchange open enrollment begins in the fall. In Virginia, five new plan bids have been submitted to the state; Washington, Arkansas and Tennessee show three new plans each.

UnitedHealth’s CEO Stephen J. Helmsley estimates that UnitedHealth will sell on public exchanges in about two dozen states. In short, the ACA’s subsidized exchange markets represent growth opportunities for the health sector.

At the same time at least three non-profit health Co-Ops will move into additional markets. As of late April, Co-Ops operating in 23 states had 400,000 members, according to the National Alliance of State Health Co-Ops. Not every Co-Op drew big numbers, especially those in states such as Maryland, where the online marketplace never really got off the ground. And it’s far too early to say how many new entrants will be left standing as plans are forced to pay back $2 billion in federal loans over the next several years.

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