DTCC saves money, improves clinical measures and prevention
Report: Medicare Advantage ‘extra payments’ will reach $11.4 billion this ye
Washington insider questions whether reforms, Medicare Advantage cuts will actually happen this year
Using microsegmentation to reach at-risk patients
Health plans need to prepare for climate change threats
CDHP patients do not put off preventive care
PBM sale highlights dilemma for health plans
Reports show benefits, problems with public option
Health plans must adapt to changes—or perish
DTCC saves money, improves clinical measures and prevention
Pharmacists have taken on a greater presence on the healthcare team in programs such as the Asheville Project and Medicare’s Medication Therapy Management, which have shown that pharmacist coaches can help improve patient health and reduce costs.
The final economic and clinical results for the Diabetes Ten City Challenge (DTCC) concur with those findings and show that combining pharmacist coaches with value-based insurance design helped diabetic patients manage their chronic disease.
According to the study that was published in the May/June Journal of the American Pharmacists Association, average healthcare costs for those involved in the project were reduced by $1,079 per patient annually, and the participants saved an average of $593 per year on their diabetes medications and supplies because DTCC employers waived copays. (See Figure 1 on p. 3.)
The program also improved patients’ key clinical measures, including lowering A1C and cholesterol levels to achieve American Diabetes Association and National Cholesterol Education Program goals and lowering diastolic/systolic blood pressure levels to below the 130/80 goal. The project also fostered improvements in preventive care measures, including flu vaccinations and current foot and eye exams. (See Figures 2 and 3 on p. 4.)
The results show that pharmacist coaches could affect chronic disease, reduce adverse drug events, and improve medication compliance, says William M. Ellis, CEO of the American Pharmacists Association (APhA) Foundation in Washington, DC, who coauthored the study.
Pharmacist coaches can meet with patients longer than doctors, who are stretched for time, and they can help fill a gap left by physician shortages.
“Physicians today are asked to do so much in an office visit in a really short amount of time,” Ellis says. “The things they have to cover with a patient are really more than I think can be done in a lot of office visits. To have the extra support of a pharmacist to reinforce those things is valuable ... I think the opportunity for more one-on-one interaction with the pharmacist is an area where there is a huge opportunity in healthcare that can certainly pay dividends down the road.”
DTCC built upon the foundation of the Asheville Project, a successful pharmacist-driven diabetes program implemented in the city of Asheville, NC. Through DTCC, the APhA Foundation expanded the pharmacist coach model nationally to prove it can be replicated in diverse geographies and various employer types. (See Figure 4 on p. 5 for a list of locations.)
According to the study, the APhA Foundation found that successful pharmacist coaching programs feature the following:
“This whole area, I think, is emerging from pharmacy networks that are based on drug distribution to the emergence of pharmacy networks that will be based on patient care,” says Ellis.
Pharmacist coaches plus value-based design
The DTCC program included the following:
DTCC was offered in community independent pharmacies, community chain pharmacies, ambulatory care clinics, and on-site workplace locations. The sites provided:
The employers that took part were self-insured, so they were at risk for both medical and prescription costs for their employees and beneficiaries. The employers/health plans created incentives for patients and pharmacists, including waived copays for medications and certain supplies, and pharmacists were paid for their services.
During regularly scheduled appointments, pharmacists “applied a prescribed process of care that focuses on clinical assessments and progress toward clinical goals and work with each patient to establish self-management goals. In addition, they worked with other healthcare providers and could recommend adjustments in the patients’ treatment plans when appropriate,” according to the study.
These private visits allowed patients to ask questions, and the pharmacists were able to identify problems and teach self-management skills.
The APhA Foundation focused on diabetes because of the number of Americans with the disease and diabetes’ influence on other health problems. According to the American Diabetes Association, nearly 18 million Americans have been diagnosed with diabetes, and another 5.7 million people are unaware they have the disease.
Diabetes is more than a health concern; it affects the nation’s economy. In 2007, the direct cost of diabetes was $174 billion, which is about $1 for every $5 spent on healthcare, according to the DTCC final study.
The disease also affects productivity. Diabetes accounted for 120 million lost workdays and reduced productivity by $58 billion in 2007, according to the study.
Northwest Georgia Healthcare Partnership
The Northwest Georgia Healthcare Partnership (NGHP), based in Dalton, led one of the 10 DTCC sites. The nonprofit includes healthcare providers, business, industry, payers, government, and educators, who look to improve the health of residents in Whitfield and Murray counties.
Nancy Kennedy, executive director of NGHP, says the organization recognizes gaps in healthcare, offers solutions, attains funding to test possible solutions, and then evaluates those programs’ return on investment and their effects on the community.
NGHP recruited four local employers to participate: Hamilton Health Care System, Dalton Utilities, city of Dalton, and Whitfield County. The Georgia Pharmacists Association coordinated the Northwest Georgia program, which featured 11 independent and community pharmacists.
Kennedy says an important part of the DTCC is that pharmacists are not replacing doctors or diabetes educators. Instead, they are there to help patients between doctors’ appointments and update the physicians about their patients’ health.
Similar to many parts of the nation, Northwest Georgia is facing a primary care physician shortage. Through visits with patients, the pharmacists are able to provide face-to-face case management.
In effect, pharmacists go from dispensing prescriptions to being educators. Patients feel a close bond with pharmacists and aren’t afraid to ask them medical questions, says Kennedy. Having that friendly relationship also allows for more honest communication.
“That accountability, face-to-face accountability, with someone in your community that you know, that you see on a regular basis, to me is what makes this program so phenomenal and strong,” says Kennedy.
One of the businesses that participated in Northwest Georgia, Hamilton Health Care System, contracted with the Georgia Pharmacists Association to provide the pharmacist coaches, who met with employees in conference rooms.
The health system project was not merely a freebie for diabetics. The patients had to follow their prescription regimen, exercise regularly, and maintain a proper diet to remain in the program.
Both employees and employers “have skin in the game, so to speak,” says Jason Hopkins, HR director at Hamilton Health Care System. “That helps both the investment we put forth to these individuals, but also, in theory, motivates them to comply.”
Although Hamilton did not achieve great financial savings and probably broke even in the DTCC, Hopkins says, the health system should realize preventive savings through diabetics taking better care of themselves.
Faced with rising health costs, many businesses are reactive. They pass rising costs onto employees by increasing copays and deductibles. That works to a certain extent, but employers must draw the line, Hopkins says.
“What this tells the healthcare community is that one, you can incentivize your associates to take better care of themselves—that’s what the healthcare providers want to see. But from the industry standpoint, I think this proves to them that they don’t have to push off more cost onto their employees. They can actually pay more but ultimately in the long run see better financial outcomes because [employees] are taking better care of themselves,” he says.
What is next for concept and DTCC?
Although DTCC showed positive results, most pharmacies could not offer the same level of services at this point. To have more pharmacist coaches, Ellis says the following should happen:
Ellis says pharmacists add value to the healthcare system by providing evidence-based treatments that can improve patients’ health. Better health means lower employer costs and increased productivity.
“We’re at a point now in healthcare that a lot of people are looking at the healthcare system in total and looking at how can we revitalize it, how can we change it, how can we improve it. This is an example of the promising practices that could lead to a reformed healthcare system in this country,” says Ellis.
The APhA Foundation is now looking to expand the tenets of the DTCC to other disease states, including hypertension, low back pain, asthma, and chronic obstructive pulmonary disorder.
Report: Medicare Advantage ‘extra payments’ will reach $11.4 billion this year
The federal government will pay private insurers $11.4 billion more for Medicare Advantage plans this year than what the same beneficiaries would cost traditional Medicare, according to a new report from The Commonwealth Fund.
The report adds more ammunition for critics, including the Obama administration and Democrats, who think the private Medicare program is too expensive.
Brian Biles, professor of health policy at George Washington University, and his coauthors reported in the analysis that private insurers have received $43 billion in “extra payments” since 2004. The extra Medicare Advantage payments this year will amount to an average of $1,138 or 13% over the fee-for-service costs for the 10 million Medicare beneficiaries enrolled in Medicare Advantage. The $11.4 billion figure is a 34% increase over 2008 payments, which totaled $8.5 billion. The increase was because of payment rate and plan enrollment increases, the authors wrote. (See Figures 5–9 on pp. 6–8.)
Medicare Advantage, which was created in the Medicare Prescription Drug, Improvement and Modernization Act of 2003, was an attempt by the Republican-controlled White House and Congress to privatize Medicare. Medicare Advantage has seen its enrollment more than double since 2004. In fact, Health Affairs and the Robert Wood Johnson Foundation recently reported that one in four Medicare beneficiaries is in Medicare Advantage, including 41% of Oregon beneficiaries and 34% of California beneficiaries.
Since Obama took office, the president and Democrats have taken aim at the program. CMS lowered Medicare Advantage reimbursements to health insurers by between 4% and 4.5% for 2010.
The Obama administration also implemented stricter terms for health insurers that offer Medicare Advantage. In the new regulations, health insurers will not be able to charge sick, low-income patients more than they would pay under traditional Medicare. The administration’s move was a preemptive strike to prevent Medicare Advantage insurers from transferring costs onto the most vulnerable beneficiaries once the payment cuts went into effect.
The Commonwealth Fund president Karen Davis said Medicare Advantage payment cuts are an “excellent first step,” but warned that policymakers should review whether the government could spend Medicare Advantage dollars more wisely.
The report’s authors wrote that eliminating the extra payments to private insurers would provide $150 billion in savings over 10 years, which could help fund expanded health coverage to the 47 million uninsured Americans or offset the costs of Medicare policy improvements, such as reducing the Part B premiums or increasing eligibility for low-income Americans.
Given Obama’s statements that private Medicare plans should be paid at the same levels as traditional fee-for-service Medicare, the authors suggested that future analysis could focus on creating a way to make the payments more comparable to Medicare fee-for-service costs.
They added that any Medicare Advantage payment reform should “provide increased incentives for private plans to better accomplish their intended role—to develop innovations in quality, efficiency, and patient service; to spur traditional Medicare to better performance; and to offer beneficiaries a choice of the best of both worlds.”
Although the private Medicare program has been bashed by Democrats, Medicare Advantage supporters say the program offers benefits beyond traditional Medicare, including care coordination and vision and drug coverage. Medicare Advantage is also the home of special needs plans, which cover institutionalized beneficiaries who are dual-eligibles and suffer from disabling chronic diseases.
Washington insider questions whether reforms, Medicare Advantage cuts will actually happen this year
A leading Washington, DC, healthcare expert is questioning whether any major healthcare reform will happen this year or even whether the proposed Medicare Advantage payment cuts will get through Congress.
Robert Laszewski, president of Health Policy and Strategy Associates, LLC, in Washington, DC, has been outspoken in his belief that policymakers have simply not found enough money to fund major healthcare reform. For example, a major healthcare reform effort supported by Obama would cost $1.2 trillion over 10 years, but federal leaders have only been able to find $316 billion over 10 years through payment reforms, Laszewski says.
Because lawmakers haven’t found a way to fund a major healthcare plan, Laszewski says interest groups and Washington insiders are presenting their own Plan Bs, which include minor tweaks to healthcare rather than wholesale reforms.
“There is a whole other scenario starting to brew out there, and it’s not clear what it’s going to look like—but it ain’t major healthcare reform,” he says. “How it impacts Medicare Advantage is in no way certain.”
Support for major healthcare reform is getting dimmer. “The rats are headed off the ship ... Everybody is covering their own butt,” he says.
Laszewski has predicted major Medicare Advantage payment cuts over the past two years because the Democrats oppose the program. But times are changing rapidly. Healthcare reform is “floundering” on Capitol Hill, and the Congressional Budget Office keeps rejecting healthcare reform funding programs.
Plus, Laszewski says so-called Blue Dog Dems, which are about 50 House moderate and conservative deficit hawks, have agreed to give a two-year patch to Medicare physician fee reductions, including the 21% cut planned for January 1, 2010. In effect, that means Medicare payments won’t be required to follow the statutory pay-go requirement, which means Congress won’t have to find the $38 billion that would have been saved through physician cuts by cutting other programs. Instead, the $38 billion winds up being tagged onto the federal deficit.
Although Obama has been vocal in his opposition of Medicare Advantage and the need to cut health insurers’ payments, Laszewski is not sure whether Congress will ultimately approve those cuts.
Medicare Advantage payment cuts have always been linked to physician payment cuts. The thinking has been that the money saved by paying private insurers less would offset delaying physician payment cuts for another year. Now, with physician payment reductions not following pay-go, Laszewski suggests that Medicare Advantage supporters could push to not make Medicare Advantage payment cuts because they won’t need to offset the physician payment reductions.
“What I think is interesting ... is we have always tied the Medicare Advantage money to fixing the doc problem, but now that the docs seem to have worked a side deal and healthcare reform is floundering, there is a scenario you can paint that Medicare Advantage does not get touched this year,” Laszewski says.
Alternative to HRAs
Using microsegmentation to reach at-risk patients
Tobacco and food companies find potential customers by using demographic and consumer attitude information, but those kinds of data are usually not used by healthcare companies.
Instead, most health insurers and population health companies try to find at-risk members through health risk assessments (HRA) and medical claims information.
HRAs ask members and employees about their health status and their desire to change their lifestyle habits. Although HRAs find individuals who are ready to improve their health, many people don’t fill out HRAs because they feel the information is intrusive and that their employer or health plan will use it against them. This often leads to low participation rates.
As a way to more effectively find at-risk people and increase engagement rates in wellness programs, Boston-based population health company Health Dialog created the Wellness SegmenterTM. The challenge is that health and wellness outreach efforts are usually either broad-based and poorly targeted or focus only on the few people who fill out an HRA, making it difficult for health plans and employers to engage individuals who may benefit from health and wellness programs, says Elizabeth Barbeau, ScD, MPH, senior vice president at Health Dialog.
Many employers, population health companies, and health plans use HRAs to find people who need intervention, but Barbeau says the assessments often don’t find at-risk people. In fact, 40% of those who are identified as smokers by their providers on a medical claim do not self-report smoking on HRAs. And that doesn’t even include the people who refuse to fill out an HRA.
Although adding incentives for completing HRAs increases compliance, Barbeau says that doesn’t mean that individuals are truthful on them, particularly if the HRA responses, such as smoking status, are used to determine qualifications for benefits, such as reduced premiums.
HRAs provide important information but are insufficient to target a total population, Barbeau says.
“We’re spending way too much money on HRAs to solely identify individuals,” she says. “There are other ways to do this, and we can look outside our industry to do it.”
The issue is threefold: few people bother to fill out an HRA, those who do aren’t always truthful, and medical claims often don’t properly identify obesity and smokers. This means the net is too small and not effective.
Health Dialog’s solution uses predictive models that leverage third-party demographic and consumer data to more effectively identify and target members for health and wellness outreach interventions, says Barbeau.
The idea is to move away from the so-called “spray and pray” method, which means reaching out to all members regardless of risk profile. This means you provide a broad audience with generic messaging, which is expensive and ineffective. And this method sidesteps the “cherry-picking” that comes with only targeting the small percentage of people who fill out an HRA, says Barbeau.
Instead, Health Dialog promotes the idea of using third-party demographic and consumer data to find people who are most likely at risk of specific diseases or lifestyle issues, such as smokers; reaching out to that group; and personalizing the message. Barbeau studied the way the tobacco industry reaches its client base and found some parallels for healthcare companies looking to engage patients.
The underlying premise is that there are specific patterns of demographic characteristics, consumer behaviors, and lifestyle-related medical conditions, which, when taken together, can predict lifestyle behaviors and risks, says Barbeau.
The Wellness Segmenter is a suite of lifestyle-based predictive models that identify individuals with a high probability of being a current smoker or obese. Although obesity is a national problem, obesity rates are higher in some regions. Those are the areas in which the Wellness Segmenter could find possible at-risk members.
In this model, Health Dialog uses community data, such as age, consumer spending, language/ethnicity, and education level; claims data, such as costs and procedures; utilization, such as provider visits and types, ER visits, and frequency of visits; and additional sources, such as HRA and personal health record data.
Barbeau says Health Dialog microsegments populations by using ZIP code plus four, which corresponds to approximately 16 households, and combines it with the other information specific to these microsegments. Each individual is assigned a risk score for obesity and smoking.
“What is really important in this is that it can all be done in the absence of the HRA data,” explains Barbeau. “We can then identify a stratified list of individuals who are likely to fall into those categories [smokers and obese].”
When Health Dialog built the models, the company let the empirical data tell it how to weigh claims, community, utilization, and additional sources to come up with the best prediction. “We created a laundry list from medical claims and consumer segmentation data that we thought would likely be associated with an individual identifying on an HRA and rigorously evaluated which ones have the highest predictive value in identifying obesity and smoking,” says Barbeau.
Health Dialog has found that by using the lifestyle-based predictive model for obesity, the company doubles its chances of correctly identifying obese individuals. By zeroing in on a key 15% of the population, Health Dialog was able to more accurately find at-risk patients than by simply using HRAs, according to the company. (See Figure 10 below and Figure 11 on p. 12.)
“It’s a pretty powerful indicator,” says Barbeau about the Wellness Segmenter.
With that information, the company is also able to target resources to reach out to members with a personalized and meaningful message that resonates with the individuals’ lifestyles and will lead to higher engagements, she says.
Barbeau adds that the Wellness Segmenter could actually help reduce racial disparities in healthcare.
“I think one of the things that got me so excited when I joined Health Dialog about this consumer model is it represents an effective way to tackle health disparities,” she says. “If we keep doing the same health behavior and health interventions, we are going to see an exacerbation of health disparities by race, income, and educational attainment. We need to find ways to identify and engage all members of a population, including those who public and commercial entities have had a hard time reaching to date.”
Health Net tries Wellness Segmenter
Health Net, the Woodland, CA–based health insurer with more than 6 million members, is an example of a health plan eager to sharpen its wellness program participation rates. Although Health Net has traditionally used HRAs and set up numerous avenues to reach out to members, it is stepping up efforts to bolster participation rates.
Jennifer Christian-Herman, PhD, vice president of national integrated health improvement at Health Net, says that in the past, the insurer has tried to find at-risk members through HRAs, claims data, and laboratory data, but it still can be difficult to pinpoint the right individuals.
“One of the things we found was that by doing broad outreach without targeting the specific population, you are not necessarily identifying the people who would benefit most from a particular wellness program,” says Christian-Herman.
One of Health Net’s key areas of interest is supporting individuals with cardiometabolic risk, which is a combination of risk factors (including smoking; blood pressure; key lab values, such as fasting blood sugar, triglycerides, and HDL cholesterol; and girth measurement) that strongly predict future heart disease, diabetes, and other preventable health conditions. The insurer has worked with Health Dialog, and by now integrating the Wellness Segmenter, the insurer and population health company broadened their relationship.
Christian-Herman says Health Net is interested in identifying its patient population with a cardiometabolic risk and performing targeted outreach. In the short-term, Health Net will gauge smoking cessation rates and weight loss and track lab results. In the long-term, the insurer will track whether the program is preventing the clinical outcomes associated with metabolic syndrome.
Christian-Herman says the program is part of a larger integrated whole-person approach. “An important aspect of our Decision Power Health and Wellness program is offering multiple ways to reach out to people,” she says. “We have integrated our Web strategy and our online tools with our health coaching and telephonic programs. We know that people have multiple ways of learning and choosing to engage in behavior change, and we try to meet them where they are clinically and support them in how they would like to learn or to change.”
Health plans need to prepare for climate change threats
A new regulation will require health insurers to think about climate change and how it could affect their companies, investments, and members.
Although property insurance companies have been preparing for possible climate change, health insurers have not been focused on the issue. Property insurance has tackled the issue of climate change because of possible catastrophic events, such as rising seas wiping out oceanfront property.
On the surface, climate change may not appear to have as much of a direct effect on health insurance companies, but health insurers face their own climate change issues.
In hopes of getting health insurance companies focused on the issue, the National Association of Insurance Commissioners (NAIC) recently adopted a regulation that requires insurance companies to complete an annual eight-question survey about their financial risks associated with climate change and what actions they are taking to respond to those risks. The survey will assess insurers’ risk assessment and management efforts and allow regulators to follow up with questions if necessary, according to the NAIC.
The policy will require all insurance companies with annual premiums of $500 million or more to complete the Insurer Climate Risk Disclosure Survey and submit them to the state insurance commissioner where the company is domesticated. The first reporting deadline is May 1, 2010.
The survey includes questions about what insurers are doing to reduce greenhouse gas emissions, whether they have a climate change statement of policy, whether they consider climate change as they choose investments, what they have done to encourage policyholders to reduce losses caused by climate-influenced events, how they are engaging their members on the topic of climate change, and how climate change could affect the insurer’s investment portfolio. (See Figure 12 below for a list of questions and where there is overlap with the Carbon Disclosure Project.)
“Climate change will have huge impacts on the insurance industry, and we need better information on how insurers are responding to the challenge,” Pennsylvania Insurance Commissioner Joel Ario, who chairs the NAIC Climate Change and Global Warming Task Force, said in a recent announcement about the new requirement. The task force released a white paper, The Potential Impact of Climate Change on Insurance Regulation, in 2008. Insurance commissioners point to several potential issues for health insurers:
“At a very basic level, human health will be impacted by climate change in ways that are not yet fully understood nor anticipated,” the NAIC wrote in its white paper.
Speaking in front of the U.S. Senate Committee on Commerce, Science, and Transportation in March, Wisconsin Insurance Commissioner Sean Dilweg said that regulations must examine how climate change will “impact the investments hold and establish regulatory standards for the investment practices of insurers.” This is critical because insurance companies and consumers “would be among the first to feel the effects of climate change, so the evolution of climate science is of keen interest to us as regulators and is a key tool for the companies to regulate,” said Dilweg.
“Insurance regulators must assess and, to the extent possible, mitigate the impact that climate change will have on insurance and encourage insurers to provide incentives for policyholders to engage in practices that will ultimately strive to limit losses,” he added.
Michael Gresty, president of Kinetix Business Ecology, a New York City–based sustainability consultancy, says health insurers have not seen climate change as an issue that affects them. “I would argue from anecdotal information that they are all behind the curve on this. None of them is really ready to respond,” Gresty says about health plans.
With its new regulation, the NAIC is forcing insurers to take action, he says.
“[Health insurers] don’t want to look any less aware or smart than they appear and they certainly want to do the due diligence on thinking through what these implications are as much as they possibly can. I think it’s a call to action,” says Gresty.
On the surface, the eight-question survey may seem simple enough, but Gresty suggests health insurers could face problems finding out more about their investments. For example, a health insurer probably won’t have a problem asking a major manufacturer about a climate risk plan. However, getting a “meaningful response” from a municipality could take years, he says.
Gresty says property and casualty insurers have been ahead of health insurers on the issue, but climate change could strain the healthcare system. It’s not that no one has been speaking out about health insurers and climate change. Six years ago, Paul R. Epstein, MD, MPH, associate director of the Center for Health and the Global Environment at Harvard Medical School, spoke before Congress about how global warming could affect health insurers.
“All of this is going to make a huge impact on the ability of healthcare systems to provide services to affected populations. They are going to be overwhelmed in some cases by pandemics that they are not able to manage or control,” says Gresty.
In addition to completing the NAIC survey, Gresty says health plans should do the following immediately:
The NAIC says the survey is the first of its kind, and the regulators hope it will serve as a model for financial institutions to discover how climate change is affecting industries.
CDHP patients do not put off preventive care
Whenever there is talk about consumer-directed health plans (CDHP), the recurring questions revolve around whether the plans force patients to delay preventive care and whether they actually create more educated consumers.
In a six-year study of healthcare claims and utilization, health insurer Aetna found that members in the insurer’s consumer-directed plan, called HealthFund, received chronic and preventive care, used generic drugs, and accessed online tools and information more often than Aetna’s PPO members. The study also found sustained savings over that time period.
In addition, HealthFund members didn’t visit the ER as often as PPO members, which Aetna suggested is because members of the consumer-directed plan are better informed about where to access healthcare.
“What we were able to find is that we were able to sustain control of costs over time without sacrificing care,” says Kathy Campbell, director of CDHPs at Aetna in Hartford, CT.
Campbell says the insurer conducted the study because it wanted to test whether HealthFund has long-term cost savings and improves consumerism over a longer period.
Aetna studied 2.6 million Aetna members, including 410,000 HealthFund members with a health reimbursement arrangement (HRA) or health savings account (HSA) and 2.1 million members enrolled in PPOs. The study looked at 200 employers with the HealthFund plan.
CDHPs often enjoy a first-year savings when the new plan is offered, but Campbell says the study showed that the savings continue in following years.
The study also found that:
“In these difficult economic times, employers are looking for tried-and-true strategies that will allow them to continue to offer their employees a comprehensive and affordable benefits package,” Aetna president Mark Bertolini said in a statement. “As the first national health plan to offer consumer-directed products, Aetna has the longest experience with these plans and the best insight into what strategies are successful.”
Aetna doesn’t charge members for preventive care, which Campbell says removes cost barriers to care so members get the preventive care they need to ward off future health problems.
The study found that Aetna HealthFund members accessed the same or higher levels of preventive, diabetes-related, and chronic care. Researchers also discovered that ER usage decreased for HealthFund members, which resulted in 5%–10% lower ER use than the control group. Aetna said this shows members are not using the ER for nonurgent care and getting the necessary preventive services.
Five strategies of best-in-class employers
To find the employers that are effectively implementing consumerism practices, Aetna looked at 11 best-in-class customers, which included more than 144,000 employees. The Aetna study found that best-in-class performers used five strategies for success:
The best-in-class performers introduced coordinated strategies in the areas of benefit structure, information and tools, and a culture that fostered engagement, such as getting management to lead the effort through example.
“If the management team—and this is from the top down—understands how important this is, it makes a difference. Also, engaging people so they enroll in the plans—that made a difference in the results,” says Campbell.
The best-in-class also helped employees and their families make informed decisions to better manage their health, spending, and overall wellness through providing cost of care, benefits information, and the Aetna Navigator member Web site. They also reduced employee premium contributions for those in HealthFund.
Consumerism practices are evident not only in best-in-class performers. Aetna found that the gap between best-in-class and average customers closed during the study. Campbell says best-in-class remained at the same levels, whereas the average customer moved closer to its high-performing peers. This greater member education is also evident in PPOs where the consumerism movement has stretched into those plans, including doctor ratings and quality information.
“It’s not because the best-in-class has gotten worse, but that a lot more plan sponsors are figuring out the right strategies,” says Campbell.
Through offering incentives for completing health risk appraisals and taking wellness programs, employers are getting smarter about how to use their dollars. Campbell says Aetna’s study results show that properly designed consumer-directed plans can reduce costs while improving overall health.
“This is a viable option for employers who are looking to engage their employees in taking better care of their health and being a better healthcare consumer, and [consumer plans] do save money,” says Campbell.
Alexander Domaszewicz, principal at Mercer in Newport Beach, CA, said in a statement that the analysis shows the importance of “providing credible data that will help employers evaluate the performance of these plans.
“The study reinforces the evidence we’ve seen emerge throughout the decade—that strategies, such as encouraging employee financial responsibility, offering robust coverage for preventive care, and providing a full suite of online tools and information, is helping employers achieve cost savings, promote a healthier work force, and still meet plan sponsor attraction, retention, and employee satisfaction goals. We need to recognize, however, that many employees need high-touch outreach and face-to-face support when they face complex illnesses. The ideal strategy when implementing consumer-directed health plans combines all of these approaches in the right way,” Domaszewicz said.
Campbell says Aetna plans to conduct the same study next year and investigate member engagement further.
PBM sale highlights dilemma for health plans
In a move that will rocket Express Scripts to the upper reaches of the pharmacy benefit management (PBM) stratosphere, the company announced it will buy WellPoint’s PBM for $4.68 billion.
The deal, which is expected to close in the second quarter of 2009, includes a combination of cash and up to $1.4 billion in stock. The deal also features a 10-year contract for Express Scripts to provide pharmacy benefit management services to WellPoint, which is the nation’s largest health insurer by enrollment.
WellPoint’s PBM, which is called NextRx, is the nation’s fourth largest PBM by number of annual prescriptions managed, trailing Medco Health Solutions, CVS Caremark, and Express Scripts. It managed 268 million prescriptions in 2008, compared to Express Scripts’ 506 million prescriptions.
Combining the third and fourth largest PBMs will make Express Scripts the No. 2 PBM, slightly behind Medco. The purchase comes two years after retail pharmacy chain CVS purchased Caremark.
The new, larger PBM will promote trend management tools, such as generics, home delivery, and specialty pharmacy, George Paz, chair and CEO of Express Scripts, said in a prepared statement. Angela F. Braly, president and CEO of WellPoint, added that the sale will allow members to enjoy integrated health benefits, deliver significant value to shareholders, and create health cost savings.
Healthcare experts are not surprised by WellPoint’s decision to sell its PBM. Many analysts predicted that large insurers such as WellPoint, Aetna, and UnitedHealth could sell their PBM businesses as a way to refocus their offerings in this difficult economy. Joseph Paduda, principal of Health Strategy Associates in Madison, CT, says the health insurance/PBM world is “consolidating horizontally,” meaning that within each segment, the large companies are getting bigger. Paduda says there are two takeaways from NextRx’s sale.
“First, health plans are looking to focus on their core business,” he says. “PBM is growing increasingly specialized and complex; health plans are focusing on readying themselves for whatever form health reform takes. The economy’s impact is also being felt by health plans. Thus they are looking to sell noncore assets to raise cash. Second, the PBM market is well into maturity. Mature markets consolidate, and that is precisely what we are seeing.”
Health insurers face a dilemma. Do they outsource PBM and disease management services and return to core business strategies, such as plan administration, claims payment, and member outreach? Or do they keep these services in-house and have more control over member information and a steady revenue stream from PBM business?
On the one hand, stand-alone PBMs can negotiate lower drug prices because of their size and have been more successful in lowering costs through mail-order business.
However, insurers with in-house PBMs say they can track members through immediate pharmacy claims data. This is especially helpful in the area of disease management. Having up-to-date claims information allows an insurer to reach a member for health coaching if its PBM sees prescriptions that would lead it to believe the person needed immediate outreach, such as prescriptions for chronic disease–related drugs.
George Van Antwerp, vice president of solutions strategy at Silverlink Communications, Inc., in Burlington, MA, says health plans can benefit from having their own PBMs if they use them properly.
“I think that it’s beneficial to plans to own their own PBM if they can integrate data and create a better member experience; make the tradeoff between increased pharmacy spend and lower medical loss ratio; and manage to get most of the economies of scale in terms of operations and negotiation,” Van Antwerp says. “That has proven hard to do within health plans, and therefore, there will be short-term interest in capitalizing on the valuation of the PBM business.”
With three large PBMs left after the pending purchase, Van Antwerp says the trio will “race to the bottom in terms of negotiating scale leverage.” He predicts the remaining PBMs will ultimately try to differentiate themselves by offering healthcare management through member engagement, greater transparency, and a renewed focus on health outcomes.
Paduda says the PBM market has become increasingly tough. He suggests the market will ultimately feature a couple of giants and several smaller specialty PBMs—many of which will look to get acquired. “PBMs can only grow by taking business from each other or via acquisition, so PBMs can expect continued price pressure,” he says.
Reports show benefits, problems with public option
A leading proponent of creating a public insurance option recently released a 27-page report that serves as a blueprint for how the public plan could compete on a level playing field with private insurers. But another recent study suggested a public option could have a disastrous effect on private health insurers and cause physician payments to plummet.
Backed by President Obama, U.S. Department of Health and Human Services secretary Kathleen Sebelius, and Senate Finance Committee chair Max Baucus, the public insurance option would create a competing public plan that would allow Americans to choose between public and private insurance plans.
Supporters of the public option, such as Jacob Hacker, PhD, a UC Berkeley professor, who recently published a policy brief that highlighted how a public plan would work, says that creating a public insurance option would expand coverage, lower healthcare costs, and serve as a check for private insurers.
Hacker says a public option would cut costs by providing direct competition with insurers. Public insurance is better at containing costs because of lower administrative expenses and greater bargaining power than private plans, he says.
“What I’m arguing for is a system in which public and private plans, with their strengths and weaknesses, could coexist side by side so that all Americans, not just the elderly or the poor, have access to the distinctive strengths of a public health insurance plan as well as the strengths of private plans,” he says.
Although Hacker speaks positively about a public option, The Lewin Group presented a much more negative picture in its paper The Cost and Coverage Impacts of a Public Plan: Alternative Design Options.
John Sheils, senior vice president at The Lewin Group, a healthcare policy research and management consulting firm owned by Ingenix, which is a wholly owned subsidiary of UnitedHealth Group, says one public insurance scenario could push 70% of private insurance members into public plans.
Because proponents have not created a definitive public insurance plan, The Lewin Group looked at different public options, including one that would allow all private insurance members to switch to a public plan as well as an option that would allow only small employers, individuals, and the self-employed access to a public plan.
Private insurers could lose 70% of their business if the former option is implemented, which could force private insurers to cut a similar percentage of their work force, Sheils says.
Under that option, “private insurance would have trouble surviving,” he says. “Maybe there would be some consolidations, but I’m not sure if private health insurance plans would be the most valuable investment in the world at that point.”
If the public plan was available to all employees and the government paid at Medicare levels, The Lewin Group estimated that 131 million Americans would enroll in the public plan, with 119 million coming from private health plans. This would mean an exodus of two-thirds of currently enrolled private plan members. (See Figures 13–18 on pp. 20–22.)
If the public option was limited to small employers, individuals, and the self-employed, The Lewin Group estimated that the public plan would include nearly 43 million Americans, with 32 million coming from private insurance.
Because the feds have also not offered a payment structure for the public insurance plan, The Lewin Group evaluated the effect of two possible payment routes: the same payment level as Medicare and paying the same amount as private insurers.
Sheils says that if the federal government decides to use Medicare payment levels, public option premiums would be 30% less than comparable private coverage. This would mean a savings of about $200 per family per month on average.
Those lower premiums would woo many people with employer-based coverage to the public plan. However, if the public option paid at private insurance levels, which would lead to higher premiums, fewer insured Americans would be tempted to enroll in a private plan, according to The Lewin Group.
The Lewin Group also found that hospitals and physicians would see less money if a public option is open to all employer-based members. Hospitals would actually benefit financially if the public option is limited to small employers, self-insured, and individual plan members because uncompensated care cost savings would more than offset lower payments.
Physicians, on the other hand, would have more patients and get paid less under Medicare-level funding. Despite potentially lower payments in a public plan, many doctors support the option because it would cut down on administrative costs. Their offices would not have to perform as much utilization management or review, says Sheils. “That’s a very expensive thing for physicians to comply with. It takes up physician time,” he says. “They usually employ a nurse to handle a lot of that. It’s an expense and a headache that a lot of them feel they could do without and would be willing to live with the lower payment levels.”
Although The Lewin Group painted a potentially negative picture, Hacker’s proposal, which was published by the Berkeley Center on Health, Economic & Family Security and the Institute for America’s Future, suggested a public plan would cut healthcare costs and guarantee a quality and affordable system.
Hacker’s proposal would build on Medicare’s administrative infrastructure and basic coverage framework. One difference is that the government would make a self-sustaining public insurance option that would be separate from Medicare, says Hacker, who has written extensively about the public insurance option and the failures of other reform plans. Other healthcare reform proposals might expand coverage, such as individual and employer mandates, but they do not contain costs, he says.
Hacker says a public option is needed because the current healthcare system does not provide “healthy competition.” Having a public insurance option competing side-by-side with private insurers would allow individuals to choose between the plans based on their strengths and provide a safety net so Americans can stay insured.
A private insurer’s strengths include integrated systems and care management programs, Hacker says, whereas a public option’s strengths would be in the areas of stability, transparency, affordable premiums, and provider access. “These are hallmarks of public plans that private plans have inherent difficulties providing,” he says.
To establish a workable public/private competition, Hacker says a healthcare system needs three Rs:
Hacker says a public option would be built on Medicare’s foundation, but suggests that the nation needs to broaden the benefit package, focus on value and efficiency, increase payments to primary care physicians, and move to a bundled payment model.
Another supporter of the public insurance option, Institute for America’s Future codirector Roger Hickey, says other attempts at major healthcare reform, most notably in Massachusetts, simply “subsidize people to buy private insurance” and don’t tackle spiraling healthcare costs.
“[The Massachusetts model] simply expands the number of people who are able to buy private insurance,” says Hickey. “Some people are under the impression by simply mandating individuals that buying insurance means comprehensive coverage.
“What it’s more likely to mean is either really lousy healthcare plans or a very unaffordable healthcare plan for many people and a lot of resentment if you don’t have the structures in place to ensure good health insurance at decent prices,” he says.
Health plans must adapt to changes—or perish
Health insurers will need to cut costs, increase efficiency, collaborate with providers, and change the way they pay physicians if they are going to thrive in the changing healthcare marketplace, according to Computer Sciences Corporation’s (CSC) report Next Generation Health Plan.
The Falls Church, VA–based global business and technology consultants suggest the Next Generation Health Plan faces several challenges:
Insurers will need to adapt to these changes or perish, CSC warned.
The common thread in all healthcare issues is costs, and CSC suggested the Next Generation Health Plan must operate at maximum efficiency. (See Figure 19 on p. 24 for growth of member costs.)
Health insurers have the greatest control over plan margin and overhead, but those costs pale in comparison to direct medical costs. Health plan medical loss ratio is often around 85%–90%, which means the majority of money is going to direct medical care.
“You can squeeze the administrative and overhead bubble all you want and you are still going to be affecting a small percentage of the healthcare dollar,” says Jordan Battani, principal researcher in CSC’s Emerging Practices Group and author of the report. Rather than focusing on health plan overhead, insurers could work with providers to help reduce practice administrative costs that are influenced by health insurer programs and policies, Battani says.
Health insurers have historically been unable to control costs because they have not involved providers, she says.
“If you’re going to get at the inflation and escalation of healthcare costs, the payers have to partner more effectively ... with people who are trained and are able to make clinical decisions. That’s going to take some work for the industry to get to that place,” says Battani.
Rather than health insurers trying to manage care on their own, CSC said the Next Generation Health Plan will need to engage stakeholders and create integrated health management programs that combine traditional medical management with wellness, self-management, and disease management programs. Health plans could achieve this through giving incentives to providers and offering providers the technology and tools that help them provide care coordination.
Health insurers and physicians have rarely been on the same page, and that friction has not helped healthcare. Instead, the Next Generation Health Plan must help providers manage and moderate healthcare service demands while providing incentives to spark an interest in primary care.
Battani predicts Medicare will lead the way in physician payment reforms, but suggests health plans should prepare to tweak physician reimbursements to send higher payments to primary care.
An important takeaway from the Next Generation Health Plan is that insurers shouldn’t expect to discover new, untapped funding sources, Battani says. Instead, they should reform payments, restructure care, and improve quality.
“The opportunity for bringing new money into the system to pay for things is very, very limited,” she says. “What really needs to happen is repurpose and redirect the funds that are available now.”