Healthcare executives like to talk about transparency, but what efforts are made to ensure that very sick patients understand that payment schemes involving out-of-network physicians and services could add tens of thousands of dollars to their out-of-pocket expenses?
The Kaiser Family Foundation published a study this year which found that one in three Americans has difficulty paying for medical debts. KFF data further shows that 70% of people with medical debt are insured, and that people with employer-sponsored coverage represent 54% of medical debt cases.
In other words, responsible working people who are trying to provide health insurance coverage for themselves and their families and to protect their assets still face a likelihood of incurring life-altering medical debt if they get sick.
One reason for this is because most healthcare consumers are not experienced or sophisticated enough to protect themselves when they come into contact with the complicated, labyrinthine payment schemes designed by physicians and hospitals to extract money.
Case in point: The New York Times and the Tampa Bay Times recently detailed the practices of "drive-by doctoring" and balance billing—schemes that have been around for a while, but which have found new enthusiasts among providers as reimbursements shrink. The cases highlighted in the two newspapers are galling and brazen and indefensible.
There are common themes that run like this: An insured patient has a medical emergency that requires her to go to the hospital, arriving at the emergency department in great pain and duress. Fortunately, the hospital is in her network.
Unfortunately, and probably unbeknownst to the patient, the emergency physician, the hospitalist, the anesthesiologist and the rehab bed are contract hires who don't accept her insurance plan.
Healthcare executives like to talk about transparency, but what efforts are made to ensure that a frightened and injured patient understands that these out-of-network physicians and services could add tens of thousands of dollars to her out-of-pocket expenses?
And frankly, even if the patient knew this, what could she do about it while strapped to a gurney with a tube sticking out of her throat? What alternatives does she have?
Is there any other industry where that sort of business practice is allowed, or even legal? Imagine, for example, buying a house and learning after the fact that an appraiser you never met was hired without your knowledge or permission for a service you didn't ask for, and then sent you a bill for $10,000, and threatened to dun your wages and ruin your credit if you didn't pay. By this measure the home loan industry is a paragon of virtue when compared to the billing shenanigans practiced by some hospitals and physicians.
"It does happen all the time and people do get caught by it," says Karen Pollitz, a senior researcher with the Kaiser Family Foundation. "I don't know why it's showing [up in the media] now like we just discovered it. This isn't a new problem. But it does surprise people when it happens to them and as we found in some of our case studies in our medical debt report, this can bankrupt people. In one extreme example, one family lost their house."
Pollitz recalls speaking to one woman who was told that her seriously ill husband would be moved to a rehab bed within the hospital that was managed by an out-of-network provider.
"The wife was told, but what was she going to do? He's got a PICC line. He is barely breathing. He can't be discharged," Pollitz says. "They said 'we can't really move him anywhere but to the next floor' so she said 'OK." What was she going to say? 'No. I'm going to shop around. Just leave him in the elevator while I look.'"
We shouldn't lay blame on any one group, because there's plenty of blame to go around. And the response from providers and payers is to point the finger at one another. Do physicians and administrators making solid six-figure incomes stop to consider how these questionable billing practices have the potential to bankrupt their patients, most of whom reside in far lower tax brackets?
The median household income in the United States this year was $53,800, which is 4.8% lower than it was at the start of the Great Recession in 2007. One of the biggest reasons for wage stagnation is the rising cost of health insurance.
Everyone in the healthcare industry must understand the potential for blowback when a sizeable number of patients come to believe they've been fleeced by people they thought they could trust. Using social media patients can organize quickly, compare notes, and identify perpetrators. Patients have compelling cases and legitimate complaints that resonate with the larger public.
It's probably naïve to think that payers and providers can resolve this amongst themselves. This will require government. The Tampa Bay Times notes that the Patient Protection and Affordable Care Act offers some protections against insurance companies charging patients more for out-of-network emergency care, but it does nothing to address drive-by doctoring and balance billing by hospitals and physicians. Mandatory annual caps of out-of-pocket expenses are only for network care.
There are hodge-podge laws in several states that mitigate the expenses. New York State is considering a bill (Section H, page 160) that provides protections against billing schemes leveled at emergency medicine patients. They need to make it law.
Someone has to stand up for the consumers who are stuck with the tab for a dysfunctional relationship between payers and providers.
Despite a projected surge in primary care visits as a result of coverage expansion, only one in six recent medical school graduates say they will pursue primary care as their field of residency, survey data from UnitedHealth shows.
Better access to primary care doctors is linked to reduced hospital admissions and emergency department visits, a report from UnitedHealth Group's Center for Health Reform & Moderation shows.
"What this report does try to highlight is that primary care is a cornerstone of an effective and high-performing healthcare system," says Lewis G. Sandy, MD, an internist and executive vice president, clinical advancement, at UnitedHealth Group.
"We see the demand for primary care is growing, particularly now in the post-Affordable Care Act environment. There could be more than 25 million more primary care visits annually as a result of coverage expansion and the growth in the senior population and increasing rates of chronic illness."
Despite this correlation between better healthcare and reduced cost, the numbers of primary care office visits declined from 2013–14, and only one in six recent medical school graduates (16%) said they would pursue primary care as their field of residency, the study found.
"There is evidence that the vast majority of entering medical students have an interest in primary care but at the other end of the pipeline those numbers drop significantly," Sandy says.
"One of the reasons is that medical students and physicians in training don't always see how it is they can have a satisfying professional life that lets them practice in the way they want to practice on behalf of their patients if they don't see models where they can see themselves in the primary care picture."
Sandy says the sense that primary care physicians are overwhelmed is not limited to medical students or residents, and demonstrates the need for more physician-led primary care teams.
"One of the things I hear regularly from primary care physicians is about the significant amount of work they are asked to take on. They say it is too much for one person," he says.
"We say 'you're right. That is why you need a multidisciplinary care team in place to support you and let everyone work at the top of their expertise, doing what they do best on behalf of the patient.' There are many other reasons, including issues around role modeling, payment, and lifestyle issues. Those things need addressing as well."
Unfortunately, primary care physicians also gravitate away from poorer areas with higher rates of uninsured, and rural areas, where their services are needed more acutely.
"There are real challenges, particularly in rural areas," Sandy says. "The good news is that there are practical solutions that can offer new access points in those locales. For example, the growth of retail clinics. These are new opportunities for people to get primary care services where they live. The use of technology like telemedicine allows the barriers of time and distance to be overcome and connect people to services. Everyone should have a primary care physician, but they may not need a face-to-face visit. So technology can help address those issues as well."
The UnitedHealth Group report offers these recommendations to improve care and stabilize costs:
Implement payment models that reward value. Government programs and private health plans should continue partneringwith physicians, hospitals and other providers to emphasize primary care in aneffort to improve quality and reduce costs.
Expand the roles of nurse practitioners and physician assistants. While laws governing scope of practice vary by state, there are opportunities to better utilize these skilled providers to boost capacity and improve access to primary care.
Create multi-disciplinary care teams. It would take 17 hours per day for a primary care physician to provide all recommended care to a panel of 2,000 patients – and many have larger panels than that. In addition to NPs and PAs, care teams should expand the role of medical assistants and health coaches.
Use electronic health records and other HIT to share information and coordinate care in real time. HIT alone will not achieve dramatic improvements in primary care delivery but it enables practices to use resources more efficiently andeffectively.
Sandy says payers can play a critical role in bringing about these recommendations by "continuing to support innovation in care delivery."
"To develop not only the care model, but also—and this is clearly in the wheelhouse of the payer—to start modernizing the payment model that emphasizes payment for value, payment for outcomes, and support for these new models. For example the patient-centered medical home, where we typically use a blended payment model combining fee for service and other elements to support that new model: That new model came from the primary care community itself," he says.
"If we work together, we can grow this and build a new payment approach. That is what the payer community can do and we believe strongly in doing that, which is why we wrote this report.
The American Medical Association says it supports the National Governors Association's recommendations, which "closely align with AMA's policy supporting healthcare teams that draw on telemedicine and the unique strengths of physicians and physician assistants."
The National Governors Association says states should review and consider easing scope-of-practice restrictions on physician assistants so they can help with growing patient workloads anticipated under healthcare reform and the Medicaid expansion.
"PAs are an important component of developing strategies to deliver healthcare more efficiently and effectively," Washington Gov. Jay Inslee (D) said in prepared remarks accompanying the release of The Role of Physician Assistants in Health Care Delivery.
"Finding ways to eliminate the regulatory barriers that exist for PAs is crucial to growing the profession," he said.
The report identifies barriers that prevent PAs from practicing at the top of their license, and offers suggestions for state policy leaders who are trying to maximize the efficiencies of their PA workforce.
For starters, the NGA report says states should review their existing laws and regulatory framework for PAs to ensure they aren't antiquated, unduly narrow, or overly burdensome on the profession, and that they're not restricting the future supply of PAs.
In addition, the report recommends that all states grant PAs legal standing to provide care under laws governing medical practice. The report also recommends that states create greater educational opportunities for PAs.
"Our state has an effective program, and one that educates returning veterans, typically medics, to become PAs to fill important primary care jobs," Inslee said. Physician associations have offered guarded and conditional support for PAs as members of a care team led by physicians.
"The American Medical Association commends the National Governors Association for its examination of the role of physician assistants in health care delivery," said Robert M. Wah, MD, president of the American Medical Association, in a media statement.
"The NGA's recommendations closely align with AMA's policy supporting healthcare teams that draw on telemedicine and the unique strengths of physicians and physician assistants to ensure access to coordinated, patient-centered quality care."
American Academy of Physician Assistants President John McGinnity, MS, PA-C, reached last week, says he is delighted by the report, and not surprised by its recommendations.
"We've been saying this for two or three years now, that folks are recognizing the role that PAs can play in healthcare. Now it is exciting to see everybody starting to believe in things we've been doing for many years," McGinnity says.
"For a long time I've been saying we are the best-trained most flexible profession to handle our nation's healthcare needs. When you look at the average PA who's been in practice for more than 10 years, they've changed specialties at least twice. That's a unique flexibility that PAs offer the healthcare team, the flexibility to go where marketplace needs are."
McGinnity says the number PAs has more than doubled each decade since the profession was created in 1967. "We have over 100,000 practicing PAs. We have 191 programs in the nation and we are graduating more than 6,000 PAs each year. I see barriers falling left and right," he says.
"The problem is that when these laws were written, PAs really weren't around. The states need to go back and update antiquated laws to say 'OK, how can we have all clinicians, no matter who they are, practicing as a team?' That is really the key. We've been doing team before team was cool. We wanted to partner with everyone in healthcare just to improve patient outcomes."
McGinnity argues that regulations for PAs should "equate" to regulations for physicians.
"They should treat PAs as they do physicians," he says. "We practice medicine. We're trained in the medical model and we need to remove those barriers to improve access for patients. This is truly about the patient."
While scope-of-practice skirmishes continue with physicians, McGinnity believes there is also a growing mutual respect in both camps and a sense that they need each other. "You've now got states where the medical society and the PA groups are saying 'Hey listen. Medicine is a team sport,'" he says.
"Do we all agree 100% of the time? No! Are we working together to try to come up with solutions? Absolutely!"
A bill introduced by Rep. John P. Sarbanes (D-MD) would address the nation's primary care physician shortage by funding pilot programs for mid-career, retired, and retiring physicians to continue practicing medicine.
It's called the Primary Care Physician Reentry Act. It's sponsored by Rep. John P. Sarbanes, (D-MD), and there's plenty to like about it.
Essentially, the bill would address the nation's primary care physician shortage by funding pilot programs at medical schools, hospitals, and non-profit providers across the country. These demonstration programs would provide training, financial assistance, and streamlined reaccreditation processes for physicians wishing to re-enter the workforce.
In exchange, physicians who complete the re-entry program agree to provide primary care either full- or part-time for at least two years at community health centers, VA medical centers or school-based health centers.
What works in this legislation is the relatively light touch of the federal government. The bill addresses the need, identifies the objective, creates loose parameters, and provides funding. Providers are given leeway to design programs that they believe will be most effective.
The American Academy of Pediatrics, the American Association of Colleges of Osteopathic Medicine, the Federation of State Medical Boards, the American Osteopathic Association and the School-Based Health Alliance have provided endorsements.
The bill has been around since at least 2012, but hasn't done much in the highly partisan Congress. Rep. Sarbanes says he doesn't expect any action until a new Congress is sworn in next year, but he says he is building bipartisan support.
"I am not going to tell you that this is going to pass in the next six months; there is very little that is going to pass in the next six months," Sarbanes says. "But if you want pieces of legislation that can appeal to Republicans and Democrats here in the House this is definitely one of them."
"We will reintroduce it first thing in the next legislative session, so we are talking January or February. There are some touchstones we can point at to get people to pay attention to this. Not just the overall physician shortage, which I think folks are aware of, but, for example, this VA medical center scandal that we just had with the wait times."
Rep. Sarbanes spoke with me about this week about the bill. The following is an edited transcript.
HLM: What is the status of the bill?
JS: We introduced it in the last few days. We wanted to put it down as a marker again. We introduced it in the last Congress. We were encouraged that we were able to begin building bipartisan support for this. There are Republican colleagues of mine who expressed an interest and we are hoping that will continue and grow.
There is a general recognition from both sides of the aisle that, wherever people may be on the Affordable Care Act, there is a shortage of physicians out there, particularly in the primary care arena, and if we can find some nontraditional pipelines for bringing people to meet that shortage, then it's worth exploring.
HLM: Has the bill been scored for cost?
JS: I don't think we've gotten it scored yet. It is a relatively limited demonstration project. The idea is to see if this can work and if it does work then we can begin to invest more resources into it going forward.
The cost of that in relative terms will be pretty modest, which is why I think we can get interest even from those, and I include myself, who want to make sure that government is being efficient and fiscally responsible.
HLM: How much leeway will these pilot programs have?
JS: We expect to have them present a pretty comprehensive proposal for how to handle people who may be coming with different levels of expertise and training. So, it could be a pretty flexible design and one that is customized to the kind of practitioner who is interested in the re-entry opportunity.
We are going to learn both on the front end in terms of the best way to design the training to take full advantage of this pool of potential primary care physicians that can re-enter as well as learning from their actual deployment into these different environments where they can provide the care. It will be a fascinating project if we can get it on line.
HLM: What are the origins of this bill?
JS: There are different groups that come and meet with us on the Hill who represent primary care providers or clinics or other healthcare institutions that are equally focused on where these shortages are.
We began to hear about some physician re-entry programs that have been designed in a number of places across the country. We thought maybe we can come at this a little more systematically, look at the potential for federal resources to get behind this because you can really leverage a tremendous amount of resources on the back end of the investment.
HLM: Why did you include federal tort protections?
JS: You're talking about family medicine, internal medicine, OB/GYN, and in that arena, the issue of malpractice insurance is very salient. To be able to include that as a component of the proposal was critical and will be critical.
It's something that helps us build support across the aisle because when it comes to the malpractice debate, that can get pretty heated. We're trying to neutralize it with a mechanism by which the liability that these physicians would face can be addressed. It exists now. We just want to broaden it a little bit to cover these particular facilities and locations where they will be practicing.
HLM: It looks like you've created the rough frame and have left the details to the pilot projects.
JS: That's fair to say. We've got a certain amount of the structure set forth in our bill; mainly, who qualifies to set up these programs; who qualifies to participate in the programs; and where will these physicians who re-enter the practice be deployed?
But, we are looking forward to the kinds of proposals that come forward in terms of the specific design. In awarding the grants, I would anticipate that we'd want to experiment with a number of different approaches to see what works best when it comes time to take it to the next level we have some good data to look at.
HLM: What are the chances for this bill?
JS: There are things happening out there that allow us to bring this proposal in a compelling way, and it will be compelling to both Democrats and Republicans as we move forward. Let me be optimistic. I think we could get something like this passed in the next session of Congress.
A year after the healthcare reform law was implemented, HHS Secretary Sylvia M. Burwell says "the evidence points to a clear conclusion: The Affordable Care Act is working, and families, businesses, and taxpayers are better off as a result."
Sylvia Matthews Burwell
Secretary, Health and Human Services
An additional 77 health insurance issuers will offer plans on state and federal Marketplaces in 44 states next year, offsetting the 14 issuers that are "exiting" the Marketplaces, the Department of Health and Human Services said Tuesday.
"Today, we're able to announce that in 2015 there will be a 25% increase in the total number of issuers selling health insurance plans in the Marketplace," HHS Secretary Sylvia M. Burwell said Tuesday in a speech at the Brookings Institution.
"When you consider the law through the lens of affordability, access, and quality, the evidence points to a clear conclusion: The Affordable Care Act is working, and families, businesses, and taxpayers are better off as a result."
The HHS preliminary data, gleanedfrom 36 state-affiliated Federal Marketplaces and eight state-run Marketplaces, also found that:
Federal Marketplace states alone will have 248 issuers in 2015, 57 more than in 2014, a 30% net increase.
The eight state-based Marketplaces where data is already available will have a total of 67 issuers offering plans, six more than in 2014, a 10% net increase.
Four of the 36 states in the Federal Marketplace will have at least double the number of issuers they had in 2014.
In total, 36 states of the 44 will have at least one new issuer next year.
Ten plans on the Federal Marketplace and four plans on the state Marketplace are withdrawing.
HHS said the coverage expansion involves some of the nation's largest insurance companies that will be offering plans in more than one dozen new states.
Evidence suggests that the expanded coverage options will reduce premiums for consumers too. "Specifically, an increase of one issuer in a rating area is associated with a 4% decline in the second-lowest cost silver plan premium, on average," HHS said in a media release.
"There is already real evidence these plans are affordable," Burwell said. "Just last week, the Commonwealth Fund released a study showing that 70% of Americans with Marketplace insurance plans feel they can now afford care if they get sick, and a majority say their premiums are easy to afford."
What a Difference One Year Makes
Burwell used her 21-minute Brookings Institution speech to tout the PPACA's accomplishments in its first year of implementation, which came after the rollout debacle last fall had critics questioning the ability of the PPACA to meet critical metrics.
"Back in March, news reports suggested it would take 'something close to a miracle' to get to 6 million people," Burwell said. "Last week we announced that 7.3 million people signed up for Marketplace plans, paid their premiums, and accessed quality, affordable coverage."
"[Tuesday] we released another significant number: 8 million people enrolled in Medicaid or CHIP since the beginning of Open Enrollment – that's an increase of nearly 14% compared to average monthly signups before October 1st."
"In just one year, we've reduced the number of uninsured adults by 26%. Said another way, 10.3 million fewer adults are uninsured today than in 2013," she said. "I firmly believe this is the key measure we should all be looking at, because it represents historic progress on an issue that has eluded our country for more than a century. There isn't a business in America that wouldn't be ecstatic with this kind of growth."
Even with the apparent success of the program, polls show that the PPACA remains unpopular, and Republicans have said they will consider repealing the reforms if they gain control of Senate.
Burwell conceded that PPACA supporters "haven't done a very good job of explaining why middle-class families who already had insurance are better off."
"Many middle-class families have more money in their budgets because their insurance company is now required to spend at least 80% of their premium on their care, as opposed to things like marketing. Families have saved an average of $80—money they can put into their electric bill or back into their grocery budget," she said.
"Meanwhile, millions of seniors are saving billions of dollars on their prescription drugs as we phase out the donut hole. More than 8.2 million seniors have saved more than $11.5 billion since 2010.
"Ultimately, a healthier and more financially secure middle class is good for businesses, who benefit from a healthy workforce and consumers with more disposable income," she said.
4 Steps for the PPACA
Burwell said HHS will improve upon the ACA's successes and correct failures.
"Every business in America worth its salt learns from both what went right, and what went wrong," she says. "We're taking the same approach, and we have a four-part strategy for moving forward."
Those steps include:
Improving access and affordability through the Marketplace. That includes improving management systems, testing, security, and backend functionality.
Testing new models in Medicare and Medicaid to find cost-effective care options as the healthcare sector evolves from volume to value-base care delivery.
Bringing more states into the Medicaid expansion.
Helping consumers understand how to use their new coverage – including the role of prevention and wellness.
Burwell also made a plea for civility in what continues to be a charged partisan debate over the future of "Obamacare."
"As we work through these issues, I think we need a bit of a course correction in this country when it comes to how we talk about these issues, and it starts with collectively turning down the volume a bit," she said. "Surely, we'd all agree that the back-and-forth hasn't been particularly helpful to anyone—least of all the hardworking families who we all want to help."
Wake Forest Baptist Medical Center, WakeMed Health & Hospitals, and Vidant Health have no geographic overlap and are not in competition with one another, but the deal should enable them to attain benefits of scale while retaining their independence.
Three of the largest health systems in North Carolina have created a shared services operating company.
Donald Gintzig
President and CEO of WakeMed
Senior leaders at Vidant Health in Greenville, Wake Forest Baptist Medical Center in Winston-Salem, and WakeMed Health & Hospitals in Raleigh have announced jointly that the new organization, which has yet to be named, will allow the three systems to gain benefits of scale while enabling each system to maintain its independence.
"We have three very large successful organizations all committed to improving the health of their communities and all committed to remaining independent in service to their communities," said Donald Gintzig, president/CEO of WakeMed, who was reached for comment Friday.
"This model made the most sense for us trying to explore ways we can work together to improve quality within our healthcare systems and the communities and to help make healthcare more affordable."
"This gives us the ability to still focus on those aspects that are community focused while at the same time tying our efforts around that quality/affordability piece, and working on those things that make sense as we start to build it and evolve the organizational efforts going forward."
Gintzig said that the agreement was facilitated by the fact that the three health systems have no geographic overlap and are not in competition with one another.
The looser shared services model also means the deal will not be subject to rigorous anti-trust or stringent and lengthy regulatory review which is required for traditional mergers and acquisition. This "again makes it more effective in both the near- and the longer-term in pushing initiatives forward," Gintzig said.
"It in no way could be viewed as anticompetitive because our markets don't overlap, and that is one of the beauties of us partnering with these other two entities that are committed to remaining independent."
The model is designed in anticipation of healthcare reform, the decline in Medicare/Medicaid reimbursements, and the shift away from volume toward value. Gintzig says the model could adapt to support Accountable Care Organizations and population health initiatives through business and clinical efficiencies that include clinical protocols, supply chain, IT and infrastructure management.
"We are all three outstanding health systems and if we just move each other up to each other's best practice we will significantly improve quality in our region," he said. "As we improve the quality piece, we are able to drive value and it positions us well to be able to encourage and support the transition from predominantly healthcare to both a healthcare and a health world."
The company is formed as a separate limited liability company with a board made up of representatives from the three health systems. "There will be an operating committee and a governance committee along those lines," Gintzig says.
"It is going to start out small. Potentially it could grow, but it will have between five and 10 employees; some external who are brought in from the outside with the expertise to help lead this effort, and I am sure some internal."
Gintzig says the savings will come when the three systems leverage their market size and identify redundancies and efficiencies.
"Together we are well over $6 billion," he says. "Wake Forrest, Baptist, and Vidant are all affiliated with medical schools. We are a very large training site and a tertiary hospital that partners with University of North Carolina for educating and training physicians."
"We have the ability to partner together to bring some scale for group purchasing, the ability to come together to share services at some point for some back office requirements that may be needed both now and in the future. We all three are at various stages of implementing our electronic health record [systems] and we all use the same vendor for that, which is Epic."
For example, Gintzig says the three health systems could save considerable money by pooling resources on data storage and retrieval. "Instead of all three of us having to build redundant systems, maybe we build one and use it to support all three entities," he says.
Eventually, he believes, the model could be expanded to include other health systems, physicians' groups or lab companies.
"The options are significant to explore," he says. "Although, part of the reason that this was able to be agreed upon and analyzed in a short a period of time was through starting small enough. We were not trying to bring eight organizations, but three committed organizations all with a significant amount of expertise and scale in their areas."
Kaiser Foundation, Tufts, and Harvard Pilgrim dominate this year's list of the nation’s top health plans according to the National Committee for Quality Assurance.
In our April Intelligence Report, the top challenge cited by leaders for their primary care redesign efforts is to get patients engaged in their own care. HealthLeaders Media Council members discuss why this is so difficult, and what steps their organization is taking in this area.
This article first appeared in the November 2014 issue of HealthLeaders magazine.
Michael Schaffrinna, MD
Chief Medical Officer
Community Health of Central Washington
Yakima, WA
There are two pieces. One, patient engagement in their own health is challenged by provider use of the electronic health record, and second is the social determinants, such as financial resources and education, of the patient population.
We are a community health center, so the patients we care for tend to be more disadvantaged Medicare and Medicaid and indigent populations. We don't have necessarily the educational background or the fiscal resources to be able to engage in the way that people need. That would be the No. 1 barrier, just the social determinants. Otherwise, most people have access to smartphones and things like that, so using the portal to help them become more engaged in their healthcare is certainly available to the vast majority of folks.
The challenge there is providing information through our EHRs in a way that is easy to understand. Providers across the country are being forced to adapt to EHRs that are not necessarily making life easier for them. We adopted an EHR about two years ago now, and we are still trying to recover from that decision. It is like a road full of potholes, and we have to fill the potholes so that providers have more time to engage with the patients.
Sam J.W. Romeo, MD, MBA
CEO
Tower Health & Wellness Center
Turlock, CA
Patient engagement has always been a challenge, and typically the response is, people want to take a pill for a quick fix. Nobody wants to recognize that the majority of diabetes is based upon obesity and 75% of most of the chronic illnesses are based on lifestyle issues. That is the challenge. How do we adjust the lifestyle?
I don't think the medical profession has done a good job at all. I spent 25 years in academia, and I can assure you that the impact of the importance of wellness, prevention, and lifestyle issues is almost zero. There are economic pressures. You get paid for taking care of diseases, not people. And patient engagement requires that you begin to think about what motivates people. We are more than disease. We are body, mind, and spirit, and mind and spirit have been undervalued, underassessed, and undertreated. If you think about those two components that is oftentimes what defines the negative effects that impact the body.
The economic incentives are beginning to change, which is a positive. People taking care of people instead of disease, where providers can effectively become more involved with the care of patients with prevention, wellness and lifestyle issues are a positive direction. High-deductible health plans increases the responsibilities of people making decisions on their own and wellness and prevention as a priority, and that is an important piece.
Tricia Nguyen, MD
President
Texas Health Population Health, Education & Innovation Center
Arlington, TX
On the challenges of engagement: Healthcare is not as simple, especially if you are a patient with multiple comorbidities. That requires more knowledge and more things to do, and a lot of it relates to lifestyle modification, and it is hard to change behaviors. We are creatures of reactivity, and if you are not experiencing pain, you aren't going to do anything about it. But even then, if the medication controls their symptoms, they may feel there is no need to modify their lifestyle.
On strategies to promote engagement: It's really about whether we understand individual behavior and what motivates and inspires individuals to take action to improve their health. We have to look beyond just treating the physical medical condition and look at the other dimensions of health, such as mental, social, and financial health and how to motivate patients. We are addressing other dimensions of health to get at physical health through innovative, engaging outreach programs and other tools.
I believe in group intervention. The cliché “misery loves company” is true, and that is why group therapy works. Group functions work because of our competitive nature. Internally we always want to be at our best. And, if we saw that we weren't doing well against our peers, whether it is physicians or patients, it does get attention. But also there is that support structure to know that "I'm not alone. Someone else is going through this and this works for them, and maybe I should give it a go."
Don Beckstead, MD
Program Director
Altoona (PA.) Family Physicians
Why is it difficult? There are probably two major reasons. One is that some of the patients don't think that it is their primary responsibility. They feel it is my responsibility to “make them healthy.” That is just some, not everybody. There is a second contingent of people who are either too busy, too tired, too unmotivated or whatever it would be in order to follow directions.
It's not just insurance companies and the government, but the hospital systems in general that are being pressured on these quality measures, and they then are putting the pressure on the doctors and the medical staff to do all of these things. Of course we are trying to pass that along to the patients, because if they aren't willing to pitch in and help out, we aren't going to get the numbers we are all looking for.
We participate in a quality improvement initiative called Improving Performance in Practice. It is a collaborative of all of the family medicine residency programs in Pennsylvania.
The quality has improved. If you look at the percentage of our patients, the diabetics who had the hemoglobin A1Cs done in the past six months, those numbers are all better. The sad part is they are not getting better quickly or dramatically. But at least we are seeing statistically significant positive results, so it's enough of a reason to keep us going.
Many employers are looking at private exchanges not just as a way to just save money in the short-term, but as part of a long-term strategy to lower costs, says a PwC executive.
Growing numbers of larger employers are looking at private health insurance exchanges for their employees as a means of addressing rising regulatory requirements, providing more nuanced coverage options, and containing costs, according to PwC's Health Research Institute.
A PwC survey this summer of 1,200 employers across 35 different industries found that 32% of them are considering moving employees to private exchanges within the next three years.
Barbara Gniewek, principal at PwC's Human Resource Services practice, says the move by employers to adopt private exchanges will likely be a more drawn out and measured process than the recent rush to sign up eight million enrollees under the public exchanges that were created under the Patient Protection and Affordable Care Act.
"There is an incredible level of interest in private exchanges from large employers," Gniewek says. "If you go back about 12 years when consumer-driven healthcare and high deductible plans started to emerge in the market, most employers said they would never do it. Now we see in our survey that 44% of our employers are considering having only high deductible health plans."
Gniewek says many employers are looking at private exchanges not just as a way to just save money in the short-term, but to form a long-term strategic play at trying to bend the cost curve and creating a better experience for their employees.
"Some employers look at exchanges as a way of saving money and moved to defined contributions so they [could] control their costs on an ongoing basis, which they can do with or without an exchange," she says. "It's a way for them to put a stake in the ground and change the way they're doing things."
Switching employees to private exchanges will foist more of the decision-making onto employees. Gniewek says that's not unique to exchanges. Employees already have been taking on more of the cost of their care in traditional benefits plans but that exchanges will provide more benefits and price options that meet individualized needs and budgets.
"'Skin in the game' was happening anyhow. The difference with exchanges is there is a lot more transparency," she says. "Some exchanges have good tools in understanding which providers are more cost effective and have better outcomes as well. Giving employees more information to make them better consumers is a good thing. Without that just putting them into high-deductible plans you had this cost-shifting going on anyhow."
The growing interest in private exchanges comes as a new Kaiser Family Foundation/Health Research & Educational Trust 2014 Employer Health Benefits Survey shows that annual premiums for employer-sponsored family health coverage reached $16,834 this year, up 3% and continuing a recent trend of modest increases.
Workers on average paid $4,823 annually toward the cost of family coverage this year. Worker-only premiums averaged $6,025 this year, of which workers averaged $1,081 of the cost, according to the survey, which was published in Health Affairs.
In the longer term, the Kaiser/HRET survey and analysis found that premiums grew slower over the past five years than the preceding five years (26% vs. 34%) and well below the annual double-digit increases recorded in the late 1990s and early 2000s. These premium increases are roughly in line with this year's average annual 2.3% increase in workers' wages and a 2% increase in general inflation.
"The relatively slow growth in premiums this year is good news for employers and workers, though many workers now pay more when they get sick as deductibles continue to rise and skin-in-the-game insurance gradually becomes the norm," Foundation President and CEO Drew Altman said in prepared remarks.
In 2014, 80% of workers had an annual deductible, with the average at $1,217. Workers typically must pay this deductible before most services are covered by their health plans. Since 2009, the average deductible has risen 47% from $826, Kaiser/HRET reported.
"The deductibles for workers have crept higher over time, topping $1,200 on average this year," study lead author Gary Claxton said in prepared remarks. "Today, four in 10 covered workers face at least a $1,000 deductible, nearly double the share from just five years ago."
Gniewek says employees will be motivated and have the ability to find value and savings in the private exchanges, more than they would with a traditional one-size-fits-all package of benefits.
"Employers typically provide insurance for the average of the population. They try to offer a portfolio of benefits that meets the needs of everybody, but nobody is average. Everybody is different," she says.
"An exchange gives more options so people can buy what they want. Very often they will buy down. There is the savings that comes with people buying lesser coverage because they didn't need the level of coverage they had for whatever reasons."
"The savings also come from enhanced consumerism, the ability to have better-integrated wellness programs, and so all of the other things that employers are trying to do to engage their employees to become real consumers of healthcare, a lot of that can be facilitated through an exchange."
Cedars-Sinai, MemorialCare Health System, and UCLA Health are among the health systems that have joined with Anthem form an integrated healthcare network expected to challenge Kaiser Permanente's dominance in Southern California.
Anthem Blue Cross and seven health systems serving Los Angeles and Orange County, CA on Wednesday announced the creation of an integrated healthcare network called Anthem Blue Cross Vivity that is expected to challenge Kaiser Permanente's dominance in that market.
"Vivity is a very unique collaboration. This is the first time in the country than an insurer and seven competing top quality hospitals have completely aligned around maximizing health," Pam Kehaly, west region president for Anthem Blue Cross said on a webconference.
"The business model of old for hospitals has been to keep their beds full. Under the new model the eight of us are successful only when we keep people healthy and out of hospital beds."
The seven "founder" health system for Vivity are: Cedars-Sinai, Good Samaritan Hospital, Huntington Memorial Hospital, MemorialCare Health System, PIH Health, Torrance Memorial Medical Center, and UCLA Health. Senior executives from the seven systems joined Kehaly for the announcement.
Vivity, a limited liability company, gets its name from the Latin verb vivere; "to live." The plan will begin enrollment on Oct. 1, but only for companies with 50 employees or more, with coverage to begin on Jan. 1, 2015. CalPERS, the nation's second-largest purchaser of health benefits, has signed on to access Vivity within its Select HMO network in Los Angeles and Orange counties.
"We want to keep growth fairly controlled until we figure this out," Kehaly said. "At the point that we have all the basics down and we are doing this right, this group will talk about how we are going to expand the population and potentially even the geography. But we don't want to mess this up by overwhelming it with volume."
Profit Distribution
Under the business model, Anthem will collect premiums from enrollees, and use the money to pay for the cost of care and administration. "What's left over is put into a pool that is distributed amongst all of the founders," Kehaly said.
"The financing mechanism is, at the end of the day, the profit that is left over gets put back into the LLC and is distributed to all of folks standing up here."
Savings achieved through alignment, economies of scale, and eliminating waste and redundancies with the systems' 14 combined hospitals and more than 6,000 physicians will allow the plan to offer what Kehaly says are "premiums that will be lower than what exists in the market today."
To attract enrollees, Kehaly says Vivity has tried to simplify the benefits package for consumers. "We don't have deductibles where people get confused about what share they owe and what the insurance company is going to pay," she says.
"What is different is the actual experience once they're past the initial enrollment. The experience will be coordinated. We will wrap programs around this to create a patient-centered experience. We are all invested and coordinated to make sure that end-to-end care is managed and that we are to keep people out of the hospital through wellness programs and communications. The difference that an individual would see is a much more consumer-centric approach to managing health than they would in a standard benefits plan."
A Budding Rivalry with KP
With the announcement., media attention focused on the budding rivalry that Vivity creates with Kaiser Permanente, the dominant integrated care system in the region that controls more than one-third of the market.
Kaiser Permanente Senior Vice President Peter Andrade did not appear overly concerned by the prospect of a new player on the block
"So many California businesses people choose to offer Kaiser Permanente care and coverage to their employees and their families because we've figured out how to deliver the highest quality care, in the most seamless, integrated ways, at some of the most affordable rates available," Andrade said in prepared remarks. "The fact that our system is not just stitched together from existing parts, but has actually been built with this integration as the goal, will be difficult for others to copy."
"I'd say the same thing if I were sitting in his shoes," says Barry Arbuckle, CEO and president of MemorialCare Health System, the only Vivity system with a presence in Los Angeles and Orange counties.
Arbuckle, reached for comment Wednesday, says Vivity has attributes that would be hard to match. "Kaiser is a very good model, but I think we can be more nimble than what Kaiser might be," he said.
"Since we are bringing together organizations that in many cases have luminary physicians and providers, the market is going to say, 'So I can have Kaiser's good model and I can have access where I live and work.' Or, 'I can have hospitals and physicians who in many cases are the who's who in their field and for the same price point.'"
Arbuckle says physicians will be attracted to the diverse working models that Vivity offers.
"In our organization, we refer to it as wanting to meet the doctors where they are. It's not: 'You have to be employed. You have to follow this model,'" he says. "We all have integrated IPA physicians and integrated medical group physicians. These physicians are talking to each other now. It's an interesting series of opportunities in front of us."
Steve Valentine, president of The Camden Group, and LA-based national healthcare consulting firm, says Kaiser Permanente is "not going to be overly threatened."
"They will wait and see how this goes," he says. "We will certainly know by February or March because Vivity will be offered to CalPERS on Jan. 1. Then we will see how the enrollment goes and how much volume moved from Kaiser to Vivity."
Because it's a closed system, Kaiser enrollees generally don't access healthcare outside of the network, which means competitors can't access one-third of the market in the two county region.
"Now the systems that came together for Vivity are premier, well recognized, great reputation organizations," Valentine says. "They've teamed up with Anthem to offer what they've said is a no-deductible. You go see the doctor it doesn't cost money. Then they are saying their premium will be 10% below Kaiser. So it's good for consumers because it is now lower cost. And they removed a barrier to care by having these no deductibles going in."
Kehaly tried to downplay the rivalry with Kaiser. "This is not designed to go after Kaiser specifically. What we are recognizing is that the most effective delivery model is an integrated delivery model. The genesis of this initiative came from that recognition that we can reduce waste, improve quality of care, provide people access to the top facilities in the nation, frankly, and do that in an integrated way."
Arbuckle says he doesn't know what percentage of MemorialCare's patient volume will be made up of Vivity enrollees. "The answer to that question is something my board members want to hear as well," he said.
"It depends upon how the enrollment ramps up. We think this is going to work well together. We have the right people, the right systems, the right governance structure, but let's see how this thing goes before we try to get too big."
