While senators battle on Capitol Hill this week about the Senate Finance Committee's health reform proposal, I'm left wondering what will actually stick.
Will the public option make it through the sausage factory on Capitol Hill? I don't think so. Will health reform include meaningful cost controls? That's possible, but not probable.
One idea that could make it as a compromise to the public option and insurance co-operatives is an insurance exchange that could be run federally or more likely at the state level with seed money from the feds.
The benefit to the insurance exchange is that there is a test case at the state level. As part of its massive health reform plan in 2006, Massachusetts created the Commonwealth Health Insurance Connector Authority, which oversees the reform effort.
A key part of the program is the insurance exchange Web site that allows Bay Staters to compare available health plans by costs and benefit designs. Federal policymakers and health leaders can learn from the Massachusetts program when creating an exchange.
Greg DeBor, a partner in CSC's Healthcare Group, partnered with the commonwealth to develop the Connector Web site, and coauthor of a white paper about the Massachusetts experience, says The Bay State's experiment is the "best learning lab for policymakers on the Hill."
Here are four lessons from Massachusetts' insurance exchange:
If you don't require coverage, don't expect many to sign up As I wrote in March, I am surprised the individual mandate is still even part of the debate. It's not that I don't think it's a good idea, but when Hillary Clinton withdrew from the presidential race last summer, I thought any hope of an individual mandate left with her.
At the time, both remaining major presidential candidates were against the idea, but President Barack Obama now says he's open to the individual mandate as part of a larger health reform package.
Requiring everyone to have health insurance will be a tough sell in Congress, but the Massachusetts experience shows that the mandate is needed if lawmakers expect millions—especially the young and healthy—to buy insurance.
Massachusetts officials found that the uninsured didn't flock to the Connector Web site to find a plan until they were required to buy insurance or face a fine.
In other words, if you don't force people to buy health insurance, they will find more enjoyable ways to spend their money.
DeBor says a mandate would "make it easier."
"People simply weren't looking for a simpler way to buy insurance and then rushed out and bought it. They had to be told that this was required of them," says DeBor.
Educate prospective members about healthcare and health insurance
When creating the exchange Web site, Massachusetts learned education was the first step—and not just education about the plans that are available. They needed to know the very basics. What is insurance? What's a premium? How do you find a doctor? These questions are common knowledge to the insured, but for those without insurance they are foreign concepts.
Program officials had to first tell the uninsured about insurance and why they needed it—and speak at a level that everyone could understand. Plus, for those shopping for individual health insurance, program leaders needed to educate people who were covered through an employer previously about the individual health insurance market.
Plan for an extensive marketing campaign
DeBor says two of the biggest keys to the Massachusetts exchange have been marketing and Web site design. He adds the two work in concert to deliver the education piece, both about healthcare and the individual mandate.
Massachusetts was inundated with marketing about the reform program in the months before the coverage deadline. There were countless commercials, ads on sides of buses and billboards, and collaboration with Boston sports teams to promote the idea.
As I mentioned earlier, this education included not just information about the mandate, but also explained the healthcare system, the definition of health insurance, and why—nearly every Massachusetts resident must have it.
Expect future enhancements
Once the insurance exchange is created, don't expect that the shiny new Web site means the journey is over. Massachusetts has also improved the site through enhancements, such as a benefits calculator and plans to add Web 2.0 offerings, such as a list of what other people are buying.
The redesigned Web site also separates the pathways for users depending on the customers' needs (such as whether they are searching for an individual or subsidized plan). This allows the individual purchaser to navigate easier.
As these insurance exchange tips show, approving a new health reform law is the easy part. If a comprehensive health reform plan actually makes it through Congress this year, policymakers and health leaders should remember these items from Massachusetts and spend a great amount of time studying the Massachusetts experience and learn from both its successes and failures.
But it's not just policymakers who can learn. Health insurance plans that are looking to promote their individual offerings should also learn from Massachusetts. That learning will become more important as the employer-based health insurance market continues to erode.
Kurt is a young athlete and student who has survived cancer. Jane is a hula-hoop-loving fourth grader who has juvenile diabetes. Kavan is an active toddler who spent the first weeks of his live in intensive care. Although these youths' stories are different, they have one thing in common. They each have a dedicated Web page on the University of Minnesota Amplatz Children's Hospital site that tells their stories in words, videos, and photos.
The Minneapolis hospital created detailed Web pages like these for nine patients as part of its fall advertising campaign, which launched on September 14. The campaign's initial flight includes newspaper, magazine, billboard, TV, Web, and social media elements.
"In thinking about the best way to educate and inform Twin Cities parents about what we offer for mothers and children, we feel the best way is to feature real patients who have had real experiences at University of Minnesota Amplatz Children's Hospital with our providers and had great outcomes," says Kelli Salvo, marketing and public relations consultant for the hospital. "They provide the best insight into what care is actually about here at our children's hospital."
The ads, too, feature the young patients and direct consumers to the specific patient's Web page to learn more. Once there, parents can also find links to related content and services and view a virtual tour of the hospital's new facility that is set to open in 2011.
"Our market research indicates that consumers, particularly parents, favor a peer-to-peer message," Salvo says. "The creative look and feel centers around the patient and their family's experience at University of Minnesota Amplatz Children's Hospital with a peer-to-peer message."
I've lived most all of my life in Massachusetts and I'm quite familiar with the local Tufts brand. I know about Tufts University's medical, dental, and veterinary schools. And I know all about Tufts Medical Center.
Or so I thought.
I did know that Tufts University and Tufts Medical Center were affiliated—although I did not know that was not always the case. I did know Tufts Medical Center is a teaching hospital but I did not think of it as a place to go for routine care. Amazingly—I am almost embarrassed to admit this—I assumed Tufts Medical Center was located in Medford, MA, home to the university's undergraduate campus. Nope, it's in Chinatown, a neighborhood of Boston.
I'm not the only one who was misinformed about the 350-bed hospital. Market research found about 50% of consumers did not know that the hospital and the university are affiliated. They didn't think of the hospital as a convenient, "in your own backyard" choice. Awareness of high-end services was low—people didn't see the hospital as cutting-edge. On the other hand, people considered Tufts a good choice for high-risk pregnancies and fetal care, but did not think of it for routine deliveries.
If you ever wondered what might happen if your marketing department were to go away, look to Tufts for the answer. Facing tumult on a variety of fronts—from leadership to financial—the hospital "went dark," halting its marketing efforts.
And, eventually, that caught up with them. And although that wasn't good news for Tufts, it is encouraging for healthcare marketers who believe that budget cuts to marketing departments can do more harm than good, especially long-term.
It's also good news for those who want to overcome negative perceptions that branding campaigns are soft and fluffy. Branding efforts can do a lot, says Tony Cotrupi, president of PARTNERS+simons, the Boston-based brand communications firm that worked on the Tufts campaign. For example, he says, they can:
drive volume
build name recognition and brand equity
attract and retain physicians
lay groundwork for development efforts
encourage donors and potential donors
validate the decision of current, recent, and prospective patients
position the institution as a bedrock of the community
position the institution as innovative, vibrant, and alive
You can read about how Tufts turned things around with its new branding campaign, emerging with a new name, a stronger brand, and measurable results, including heightened awareness among consumers, in this month's HealthLeaders magazine story, A New Name.
Note: You can sign up to receive HealthLeaders Media Marketing, a free weekly e-newsletter that will guide you through the complex and constantly-changing field of healthcare marketing.
Edmund Pezalla, MD, MPH, national medical director and chief clinical officer at Aetna Pharmacy Management, speaks about how pharmacy benefit managers can receive higher levels of medication adherence.[Sponsored by Emdeon]
Last week, the population health management industry paused to consider the implications of a bankruptcy filing by LifeMasters Supported SelfCare, a long-time leader in disease management and population health management. Health Plan Insider readers were asked to consider whether the event represented an isolated case or a barometer for an entire industry. But the question reflects an out-of-date perspective on the services that innovative companies in the industry provide and left a false impression on casual observers.
Certainly, those who follow the industry closely recognize that events leading to LifeMasters' Chapter 11 filing were both unfortunate for, and unique to, that organization. But one unique and unfortunate occurrence does not a trend make.
Only those not directly involved in the development, implementation or evaluation of population health management programs would fail to recognize the industry's evolution to one that bases services on the needs and resources of the populations and providers served. Close observers of the industry recognize its significant transformation through adoption of multiple intervention modalities in addition and complementary to the traditional call center model.
Today, leading industry organizations are deploying proven health promotion, prevention and chronic care management services spanning an entire populations' continuum of health—the well, at-risk, and chronically ill. Organizations throughout the industry have developed more collaborative and innovative models of care delivery to fully integrate services with practicing physicians to support individuals in adherence to physician-led care plans.
Further, significant new opportunities for the population health management industry are contemplated by ongoing federal activities to enact healthcare reform legislation. Congressional leaders and the Obama administration have strongly emphasized the importance of prevention and wellness activities, sought to improve access to care coordination and coaching support programs to targeted beneficiaries, and promoted the widespread adoption of health information technologies to collect, share, and analyze health-related data.
These proposals and others, including a proposal to establish an "Innovations Center" within the Centers for Medicare and Medicaid Services to test a variety of care models and interventions in Medicare fee-for-service, were included in a proposal put forward last week by Sen. Max Baucus, D-MT, chair of the powerful Finance Committee.
The industry's strength and diversity is best seen in the membership of its leading voice, DMAA: The Care Continuum Alliance, which continues to expand its reach across many healthcare industry segments. This week, more than 700 leaders in population health management convened in San Diego for DMAA's 11th annual meeting, The Forum 09. Attendees heard industry leaders speak about a variety of successful interventions, collaborative delivery models, and innovative approaches to care.
The Forum attendees and the broader DMAA membership would identify a clear trend in the population health management industry: A trend of continuing innovative evolution and expansion, built on both past successes and lessons learned, to provide health promotion, prevention, and chronic care management services to all in a continuing effort to significantly improve the health of the nation and reduce the costs of care.
Tracey Moorhead is the president and CEO of DMAA: The Care Continuum Alliance.
On the opening day of hearings on Tuesday, Senate Finance Committee Chairman Max Baucus (D-MT) released modifications to his bill—addressing some of the criticisms that some part of his bill would unfairly impact some low- and middle-income individuals and families.
Before heading into the second round of hearings yesterday, Baucus issued the changes that incorporated dozens of the 564 amendments—including several from Republicans—before the debate got underway. The additions slightly raise the price tag of the legislation to just under $900 billion over 10 years.
Among the changes were:
Manufacturers of Class I devices (such as elastic bandages and examination gloves) and Class II devices that are sold at retail for up to $100 per unit would be exempted from an annual fee.
An exemption would be created to allow health plan sponsors to encourage beneficiaries to use lower-cost generic drugs by allowing them to waive copays as an incentive.
Low and middle income families would get slightly larger tax credits to help pay for insurance premiums: those earning $32,490 to $43,320, for example, would be eligible for a credit covering premiums that exceed 12% of income.
The maximum fine imposed on families who do not meet a requirement to buy insurance would decrease to $1,900 from $3,800.
The terms of an excise tax were modified that would exempt policies that cover high risk workers, such as firefighters and coal miners, but increase the tax rate from 35% to 40%.
An annual cap on tax free contributions to flexible spending accounts would rise to $2,500, up from the $2,000 ceiling initially proposed.
Dell's acquisition of information technology specialists Perot Systems in a transaction valued at $3.9 billion is a clear signal that the computer hardware giant plans to jump into the healthcare information technology sector with both feet.
The acquisition is expected to make Dell—already a major computer hardware manufacturer—a key player on the software and interactive side for healthcare information technology sector, which is the subject of a $20 billion government-financed incentive program.
"We haven't seen a transaction like this in 10 years, much less the last 18 months," says Mark Reiboldt, vice president of Atlanta-based Coker Capital Advisers. "Dell has had strategic focus on healthcare for a while. They saw the writing on the wall. Everybody was getting in. Their overall strategy in the last two years was to entrench themselves a little deeper in the solutions and services base and not be so reliant on hardware."
Over the past four quarters, Dell and Perot Systems had a combined $16 billion in enterprise-hardware and IT-services revenue, with about $8 billion from enhanced services and support.
Under the agreement, Dell will commence a cash offer to acquire all of the outstanding common stock of Perot Systems for $30 per share. The transaction is expected to close next quarter, pending government review.
When the acquisition is completed, Perot Systems will become Dell's services unit and be led by Peter Altabef, the current Perot CEO. Ross Perot Jr., Perot' chairman, is expected to be appointed to the Dell board.
Reiboldt says he doesn't understand why Dell paid $3.9 billion for Perot, which represents a 68% premium on the value of the stock at the close of business last week. "A lot of people are thinking they paid too much. There could be something we are missing and Perot is a great company, but I'm not sure I see the rationale behind the valuation as it is today," he says.
Reiboldt says he anticipates more mergers and acquisitions in the coming months in the HIT arena as more companies position themselves for the $20 billion government windfall in HIT. "Healthcare as a whole is leading the way in terms of deals coming back into the market. This integration on HIT is coming at all levels. We are seeing a $4 billion Dell-Perot acquisition and we are seeing a lot of middle-market buzz."
"The path now is not going to be the IPO. Acquisitions and consolidation is the name of the game for HIT, particularly when you're talking about the stimulus money out there," Reiboldt says. "Companies' mouths are still watering, trying to wrap their heads around how that is going to play out."
California healthcare has put a big sign on itself that reads "Allied Health Workers Wanted Now."
To be exact, it needs to train about one million more people by the year 2030 to take jobs in the allied health professions, which excludes physicians and nurses. That's more than 11 states currently have in their total workforces.
With 605,153 allied health professionals now employed in about 50 types of skills—from medical assistants to lab technicians to dental hygienists—this so-called "hidden workforce" keeps the flow of patients moving through every type of care setting.
It includes physical therapists, physicians assistants, medical assistants, nursing aides, cardiovascular techs, ambulance drivers and emergency medical technicians and psychiatric aides.
But by 2030, the state will need to not only replace many of those 605,153 workers who retire, die, or choose to work elsewhere or in other occupations, it must train new workers to care for the growing number of senior citizens who will require care, to reach an allied professional workforce demand for 988,000.
That's according to a 35-page report released Tuesday under a grant from The California Wellness Foundation. It uses data from the U.S. Bureau of Labor Statistics, U.S. Census Bureau, and several agencies to document current and future workforce needs.
Susan Chapman, a nurse and director of Allied Health Workforce Studies at the University of California San Francisco, helped coordinate the report. She says the effort targets the state's education system, specifically community colleges, to help attract more students into allied health training courses.
The community college system faces a challenge though. Instructors could get paid more money actually doing the work than teaching. "Sometimes programs suffer from a lack of faculty to run them, and we need to figure out the best way to give those incentives."
It may be that the systems need to recruit allied health professionals to teach and pursue a clinical career simultaneously.
On top of that challenge, Chapman says, the state's budget crisis is reducing the systems' ability to offer the classes, which in many cases have relatively high equipment and material costs.
Chapman hopes that proliferation of advanced communication technologies may reduce some of this expense. For example, students in a number of smaller classes throughout the state's community college system may be able to attend the same class, as it's offered either on the Web or by video. That technology must be made available to those classrooms, however, she says.
The report added that the allied health sector workforce already generates a payroll of $23 billion, an amount that is expected to more than double every 10 years.
On the positive side, about half of the allied health professional jobs that will be required in the state by 2030 are entry-level positions, which don't require post-secondary training or certification. Those positions can be filled with people who have a high school education.
However, the rest of the workers will require more education. "However, researchers estimate that California's universities and community colleges will only have capacity to train 634,000 of the needed workers, between 63% and 79% of the allied workers the state will require," the report added.
"Unless California increases the capacity of its education system, by 2030 there will be between 170,000 and 375,000 jobs that must be filled either by out-of-state workers or by Californians who would be forced to leave the state to get the necessary training. Already today, there are allied health training programs with waiting lists of one year or more," according to the state.
Ambulatory care settings are the largest employer of allied health workers, far more than hospitals or nursing and residential care facilities.
The report concluded, "If the state does not provide sufficient training opportunities in allied health, this situation will represent a missed opportunity for hundreds of thousands of Californians looking for family-sustaining wages and job security."
Cheryl Clark is a senior editor and California correspondent for HealthLeaders Media Online. She can be reached atcclark@healthleadersmedia.com.
Congress, the White House, and the public still don't appreciate the essential need to strengthen rapid response expertise within hospitals, says a coalition of emergency room doctors who launched yet another campaign to set the record straight.
"The national health reform debate is coming to a head," says Gordon Wheeler, spokesman for the American College of Emergency Physicians. "But despite the letters we've written and our own activities on the Hill, we keep hearing that if we just pass legislation to get more primary care physicians, and got everyone insured, people wouldn't need to go to the emergency room.
"Well, we know that's not true. We know that many of those 120 million patient visits to the emergency room a year will continue, some of them at the behest of their physicians. So what are we doing to invest in our emergency medicine infrastructure? Not very much."
The organization, which represents some 28,000 emergency room doctors in the U.S., has felt bruised and underappreciated since President Obama took office. First, ACEP was excluded from an early White House health reform summit in March.
Second, state by state, policymakers seem to be un-phased by the growing number of emergency room patients being "boarded" in hallways and broom closets, an indication of overcrowding and the decline in the number of emergency rooms nationally.
And third, they feel insulted by Kathleen Sebelius, Health and Human Services secretary, who they say keeps trivializing the importance of emergency room care. She suggests that most patients who go there could have had their medical issues dealt with in other, less expensive and more efficient settings. That's simply not true, the group maintains.
The campaign points to four "myths" about health reform that ACEP believes are being perpetuated in the health reform debate. And the group wants to clear the air.
Myth: America's emergency departments are full of people who don't need to be there.
Fact: Arguably, only 12% of patients who go to an emergency room don't really need to be there. And many of those have symptoms of a medical emergency that turns out, after appropriate exams and testing, are determined to not be emergencies. But the patients needed to be in the emergency room to find that out, according to ACEP.
Myth: Emergency care is inefficient and expensive, and decreasing visits will save significant amounts of healthcare dollars.
Fact: Emergency care is only 3% of total yearly healthcare spending. "Keeping personnel and facilities open 24 hours a day does cost more than keeping an office with no emergency room open 40 hours a week. No matter when patients are sick, we are open," says ACEP.
Myth: Demand for emergency care will decrease when health reforms are passed.
Fact: Massachusetts experienced a 7% increase in emergency visits after providing universal coverage. "Emergency providers are the front-line for natural and man-made disasters, and as such, will be in even greater demand," says ACEP.
Myth: Emergency care will be there when you need it.
Fact: With the decline in the number of hospitals with operational emergency rooms in recent years, there are far fewer facilities to see patients and they are farther apart. Emergency visits have increased an average of three million patients per year over the past decade. And boarding, the practice of leaving patients in the emergency department instead of placing them in inpatient hospital beds, leads to 30% of the nation's emergency beds as unusable for new emergency patients.
So as health reform language is punched, squeezed, and twisted into various marks this month, ACEP is spending $110,000 on a print, broadcast and Web-based campaign to get their message across. They want lawmakers and the public to give emergency room care more attention, more resources, and more respect.
"We expect significant increases in emergency visits across the national if national universal coverage is enacted," noted ACEP president Nick Jouriles, MD.
The campaign calls for these overall policy changes:
Tort reform, so emergency room physicians won't spend what ACEP estimates is billions of dollars on defensive medicine. Emergency physicians order more care out of fear of litigation than many other specialty providers, Wheeler says.
Computerized systems that link emergency departments with the medical record files in the systems of patients' physicians and other caregivers, so drug, blood, and imaging tests that have already been performed aren't repeated. "Even if the physician is sound asleep (in the middle of the night), an emergency room doctor could see the patient's files, and know that he or she had already had an MRI, and see the doctor's notes. It would make a huge difference," Wheeler says.
Elimination of the practice of boarding, in which patients are allowed to stay in hallways and even closets when the emergency room backs up while they wait for an inpatient bed to become available.
National surge capacity plans to help emergency departments prepare for H1N1 or other infectious disease pandemic, a terrorist attack or other catastrophe.
Health reform proposals that may be included in some of the many amendments under discussion this week include a 5% pay differential that would enable physicians to sign up for emergency department call, and not worry about a loss of income if they end up providing too much uncompensated care. "There's a tremendous problem with the supply of on-call physicians," Wheeler says.
Democrats and Republicans formed battle lines as the Senate Finance Committee opened the debate on healthcare legislation proposed by the panel's chairman. Both sides found plenty to criticize in Sen. Max Baucus's bill, particularly its requirement that all U.S. citizens must buy health insurance at potentially high costs, according to the Washington Post.
