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How do wellness programs save lives? May 9, 2013

Posted by medvision in Cancer Care, Employee Wellness, health data, Insurance Plans, Risk Management, Uncategorized.
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Employee wellness programs and screenings can provide early detection and better outcomes for patients.  Just watch this cancer survival story of a teacher working for our client Manatee County School District.

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Blind Faith: Self-Funded Health Plan Management and Hospital Billings November 16, 2012

Posted by medvision in Chronic Disease, Employee Wellness, health data, Healthcare Costs, Healthcare Reform, Insurance Plans, Risk Management, Rx Costs, Uncategorized.
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Blind Faith: Self-Funded Health Plan Management and Hospital Billings

 Health CostsMany things concerning our current healthcare situation leave me in amazement. For example, today an article featured in “The Hill” highlighted a 4-5% decrease in healthcare inflation, which is a positive sounding reduction. http://tinyurl.com/czmmdz4  The national consultant attributed this to America’s adoption of high deductible health plan programs. This would seem logical if our national problems were based upon members utilizing too many $100 doctor visits. In other words, make patients 100% responsible for funding doctor visits, prescription medications and other high-value, low-cost health services. This sounds terrific until one discovers an excess of 75% of our national healthcare expenditures go to mitigate/control existing chronic disease. So is the logic “prevent the low-cost services to inflate high cost chronic disease services”?

 Unfortunately, the above can only make sense to plan managers who have no independent, actionable data. One simple exhibit, the expense distribution analysis, would show plan managers that a very small number of their members account for huge expenditures of claim dollars. Let’s assume a plan provides health benefits for 10,000 members (employees, spouses and children). If together the plan sustains $36 million in annual claims, a typical report would note a per-member-per-year, PMPY, expenses equaling $3600.  If the real expense distribution analysis was available, one would see:

-Top 1% (100 members) incur annual average claims of $90,000 each;

-Next 4% (400 members) incur $35,000 each;

-Next 25% (2500 members) incur $3000 each;

-Next 20% (2000 members) incur $1500 each; and

-Bottom 50% (5000 members) incur $500 each.

Notice the above does not include member paid coinsurance or monthly payroll deductions for coverage. Now, the plan manager is  advised to increase the deductible to $2000 per member before any plan benefits are payable. Why? Give members skin in the game! Immediately, it’s easy to see 50% are completely disenfranchised from any benefit payable. Does it make sense for the plan sponsor to eliminate benefits payable for the bottom 50% to 60%?  How much impact will the new $2,000 deductible have on the top 1% members spending an average of $90,000 per year?

Remember that very sick members are not consumers in the sense of purchasing an automobile. They are fighting for their lives. The bottom 50% of members are not consumers either, as the vast majority are not in life or death disease struggles.  Due to the 100% expense, these 50% are foregoing necessary wellness visits and other necessary disease management services. From a risk management standpoint, this plan design doesn’t compute.  I think this builds a speed lane into the top 5%/1%!

 The centerpiece of my consulting practice at Med-Vision is actionable, independent, HIPAA compliant, patient centric health plan data. Recently, while digging through a client’s outpatient hospital data, I noticed a $7 million paid run of charges recorded under revenue codes entitled — other pharmacy IV solutions and pharmacy incidental to radiology. These have no detail, no backup, and will require the administrator to request itemized billings to investigate. This could be totally legitimate, but I find it amazing clients are scouring the lunch tabs of their sales force and increasing the deductible for needed member preventative health services, while blindly paying $7 million for possible saline injections.  If this isn’t a home run example of the necessity of actionable data, nothing else is.

I often joke that many large self-funded health plans could be purchasing someone a brand-new Mercedes- Benz, S-500, each month with no notice.  It’s time for employers to take notice, evaluate their plans, implement solutions, and gain control of their healthcare costs.  What’s more, with the right plan design and data analytics, costs can be cut while simultaneously enhancing benefits and improving the quality of care.

                                                                                           

Ominous threat to employer sponsored healthcare July 25, 2012

Posted by medvision in Chronic Disease, Employee Wellness, health data, Healthcare Costs, Healthcare Reform, Insurance Plans, Risk Management, Rx Costs, Uncategorized.
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If your job involves managing employer sponsored health plans, on behalf of employers, there’s an article out (http://tinyurl.com/d836mol) that  says the following:

One in 10 employers plan to drop health benefits.

Employee Health, Wellness, Health Plan, DataI hope this is a huge wake-up call for employers.  Over the past 10 years, I’ve pounded the pavement trying to explain the necessity for plan executives to utilize actionable, independent, member-centric data to manage the financial and clinical aspects of their health plans. Some employers have adopted this model and, as a result, their trend/health inflation has become virtually nonexistent over the past several years. Just look at Med-Vision’s news page for examples.  Many others, however, have declined and are flying, virtually blind.

Let’s think about the impending threat to our current system of healthcare delivered at work. First, which types of employer plans are at the highest risk? To make my point, I’m borrowing from the comedic styling of Georgian funnyman, Jeff Foxworthy:

(1)        If you report to an elected board, commission, mayor or any other type of politician who grovels every few years to be reelected, you might have a problem

(2)        If your annual per employee plan costs are $8,000 plus, versus the penalty of $2000 PEPY to drop coverage, you might have a problem

(3)        If your plan design pays claims for an unlimited maximum, while you attempt to save money by preventing care during the first $10,000 of expense, you might have a problem

(4)        If your plan advisors, broker, consultants tell you your existing 10% trend fits the norm, you might have a problem

(5)        If your plan pays hundreds of thousand dollars annually for disease management and the only result you see is one out of 100 members talking to a nurse, you might have a problem

So, maybe you fall into a few of the top Foxworthy-isms. Believe it or not, this performance can be turned around in as little as a year or two. What do you do?  Here’s my advice:

•           Work with advisors/vendors who win solely when you win. If you’re partnering with a public company, MCO/consultant/broker, look at their financial performance on one of the multiple finance websites. Yahoo finance is a great spot. How is their stock, profits, cash flow performance? If they are succeeding wildly while your plan fails, you probably are not receiving the best advice? Why would you pay more in fees and commission while your plan performs negatively? Pay for performance and zero for failure. Make your advisors stay awake at night worrying about the care/lack of care your members receive. If your plan is failing, yell, scream and threaten firing all vendors. Here’s a nice take-away. MCOs are dumping huge sums of cash into client wellness funds to be selected during bidding competition. If you are humming along with an MCO/TPA, demand some wellness cash!  Ask $40K per thousand employees covered.

•           Are you treating plan reports, performance metrics from your MCO/TPA as gospel? Do you think they report on failures/weaknesses concerning your plan while you pay fat ASO fees? (If so, I have some beautiful, airboat accessible, home sites in the center of the Everglades for you to consider purchasing). This is where plan managers fly blind. Identify and implement services from an independent, patient centric deep data mining company. Analyze health data as a risk manager focusing on prevention, disease mitigation and financial accuracy. Read and analyze your existing employee benefits contracts closely. With your data mining functionality you’ll be able to determine if your plan is paying 2000% markups for cheap generic drugs delivered via mail. PBM performance is an easy way for plans to save $10-$15 PEPM. Ask simple questions like, what percent of our women members are receiving breast cancer screenings past age 50?

•           Where is your health plan money being spent by service category? Plans performing in the top 10% spend over 15% of their total budget on primary care services. The vast majority I see spend less than 10% on primary care.

Furthermore, please don’t be assured a Republican win in November will clear the threat. The “right” wants to remove the corporate tax deductions for employer sponsored healthcare.  An era of employer-driven healthcare reform is needed to mitigate risks and lower costs.

And a last thought. Worry about your plan members receiving appropriate health care services in the same manner you worry about your family members receiving correct care. The higher the quality, the lower the cost!

As Geoffrey Hickson said: “If you forget you have to struggle for improvement you go backward.

Healthcare price transparency and the empty airplane seat July 6, 2012

Posted by medvision in Chronic Disease, Employee Wellness, health data, Healthcare Costs, Healthcare Reform, Insurance Plans, Risk Management, Uncategorized.
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health, paying for healthcareAnyone paying attention to our current national healthcare situation has surely seen published examples of pricing defying all realms of logic. For example, MRIs priced at $3000 for individuals without insurance, $1500 for individuals with insurance and, wow, $300 for individuals paying cash. Here’s the result of a recent Consumer Reports Study! http://tinyurl.com/7pnj4wx

I know, things like this make you want to pull your hair out. It’s simply a function of no transparency, infused with high utilization rewards/fee-for-service, plus a lack of value measurement, coupled with oversupply, fragmentation of care and unaccountably from spending someone else’s money. Our healthcare system lacks basic laws of supply and demand, accountability and economic reality. On the good side no place on earth can provide better care needed for critically ill patients.

For plan managers, such marketplace disruption can create some phenomenal opportunities to provide member care while sequentially saving vast dollars sums. For example, let’s say you’ve swallowed the consultant’s Kool-Aid and have a HDHP plan design w $3000 deductible while allowing members to make deposits into an HSA. Yes, yes, we all know annual physicals are covered at 100%, assuming nothing is diagnosed. However, you’ve adopted a plan design which essentially prevents members from receiving the lowest cost, highest value healthcare delivered to prevent chronic disease or manage emerging disease. For the sake of argument, let’s assume the same plan design in place but look to the crazy pricing variances for ways to cover the underinsured risk, i.e. the first $3000 annually:

  • Primary care. If your members are within a distinct geographic area/areas, why not contact a few of the larger primary care practices and ask for a capitated, or cash deal to treat your members? Cash deal means completely outside of your plan. Members would have no co-pays for doc visits and blood tests. Common low-cost generic drugs could be paid by the member or reimbursed by the employer, in or outside of the plan. What kind dollars would be involved here? Maybe an initial $100 cash payment when a member goes to the physician followed by a $40 per member per month payment.
  • Ancillary care. From the press we know pricing differences are amazing. Cash prices for CAT Scans can be 10% of the insured price. Simply coach members with the option of calling providers and asking for the cash price without mentioning they have coverage under a high deductible plan. These vastly reduced cash prices will not go towards the satisfaction of the deductible however from an economic perspective this practice makes perfect economic sense.
  • Inpatient hospital care. This is what insurance is for, so have members utilize the discounts available under the high deductible plan.

Empty airplane seat? I use is simply as an explanation of why such extreme variances exist in the health care system. A jetliner taking off with empty seats is simply losing seat revenue. This is why such wild price variances exist in the airline industry. It’s better to collect $.50 from a dollar ticket then receiving zero from an empty seat. The exact same thing happens with healthcare procedures. As an example, hospital A purchases a $2 million dollar CAT Scan machine. The hospital’s fixed cost is exactly the same whether it’s being utilized or not. Their expense includes capital outlay, interest and personnel necessary to operate the equipment. If they normally received $2000 per procedure and equipment is not utilized 50% of the time, it makes perfect sense to collect $300 per procedure during the time the machine is not being utilized for the $2000 procedure. Pricing information is invisible to consumers and the fact they charge either $2000 or $300 isn’t a problem.

How to plan managers take advantage of these situations? The answer is simple. The same way we purchase cheap airline seats. We explore, question, investigate and ask. The attached link shows a physician perspective.  http://tinyurl.com/chx8quh

The light of free markets slipping into employer sponsored health care! March 6, 2012

Posted by medvision in Employee Wellness, health data, Healthcare Costs, Insurance Plans, Risk Management, Uncategorized.
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Free market practices appear to breaking through the screens covering our American health care system. Healthcare is a unique marketplace in which our current lack of financial and quality transparency produces high cost and poor clinical outcomes. How many patients will flock to a hospital experiencing 300% increases in cardiac death for heart surgery?  Read this physician’s post: Why we are busier than we’ve ever been.

Self-Funded plan management–take a close look at disease management results February 27, 2012

Posted by medvision in Employee Wellness, health data, Healthcare Costs, Insurance Plans, Risk Management, Uncategorized.
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Recently results of Medicare’s largest commercial disease management study were republished in the New England Journal of Medicine.

This study should refocus plan managers on the issue of disease management because 75% of all plan dollars are spent on chronic disease. Preventing the production of disease and the management of existing disease states is the entire ball game with respect to healthcare. Back to the Medicare pilot. In the Medicare Modernization Act of 2003, CMS was required to test the commercial disease management industries services with respect to the Medicare fee-for-service program. The program engaged eight of the industry’s DM providers, 250,000 Medicare beneficiaries with serious cardiovascular disease and spent $400 million over the four-year program. The conclusion was reported: In this large study, commercial disease-management programs using nurse-based call centers achieved only modest improvements in quality-of-care measures, with no demonstrable reduction in the utilization of acute care or the costs of care.

How should this be viewed in today’s environment? I’ve always felt the practice of nurses calling healthcare members they do not know, usually from a different state while attempting to offer advice concerning very personal aspects of one’s health is very problematic. Why? (1) Everyone, especially working folks, have very limited time during home hours (2) Not many are comfortable discussing their health issues with strangers and (3) nurses calling many times have limited, or worse, incorrect data about the medical conditions associated with the member.

My impressions of commercial disease management reports being delivered to clients today seem to be verified by the Medicare study as having, essentially, no positive results. But, Medicare members are very different from commercial health plan members? Yes in some ways, however they are mainly at home available so members have time to speak with nurse managers, this pilot targeted serious states of disease, and still, no demonstrable reduction. In what ways should plan managers react when delivered industry standard reports?

  1.  Don’t allow a 50 page DM document impress. DM providers have a strategy of creating member silos in which they describe all silo members as participants in the plan. A member not complaining about monthly mailings is “not” a participant! How many of us pitch 3/4ths of the mail we receive in the trash can? Probably over 90%. The only participants are the ones in continuous monthly/weekly phone calls with nurse managers. Usually this class never exceeds 1-3% of total members.
  2. Health claims metrics reported by the DM vendor probably will contain positive results. These must be verified from independent data in order to be considered valid. Many times DM providers attempt to “prove the negative’ by claiming their efforts created an absence of claims. Even worse are “vapor” attempts to prove savings by producing some type of productivity gain metrics! Sorry but this business in not akin to a college philosophy class.
  3. Each year $100s of millions are simply wasted on telephonic DM. If you cannot see the results clearly, the result didn’t happen.
  4. If you are offering a sole HDHP don’t assume a short-term claims reductions are necessarily good news. In today’s economic climate many are forgoing important medical care. As water recedes prior to a tsunami, an absence of claims this year may be indicative of an avalanche of future chronic disease.

Now the good news. If it isn’t working, try another approach. I’ve seen clients spend $250K through $500,000 with no clear results. How about using the dollars to hire, through a vendor/or directly, on site full-time nurses to reach out to members, face to face? People trust others they meet, trust and recognize!

The greatest opportunity in healthcare is for employer purchasers of healthcare to start demanding the results they want/need from vendors. Vendors which perform win should be rewarded and the many failing need to be sent packing!

Wellness screenings covered at 100%–read the small print! December 28, 2011

Posted by medvision in Cancer Care, Chronic Disease, Employee Wellness, health data, Healthcare Costs, Insurance Plans, Risk Management, Uncategorized.
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Here’s an egregious practice unfortunately common in the managed care industry. A member, trying to maintain health, participates in a “no cost” wellness procedure. While sedated, or undergoing the procedure, the physician identifies a minor medical issue and fixes it. Then “whack” the member wakes up facing a fat charge due to a diagnostic in place of a screening code.  One could argue it’s a “technical event” allowing insurance companies a manner to collect additional revenue. http://tinyurl.com/7lxz32l

Here’s the work place problem. For example, colon cancer is the 2nd leading cause of cancer death in the US. The main weapon to fight this cancer is early detection by colonoscopy. It’s hard to imagine this procedure being abused by members, recreational colonoscopies? Due to these hidden charges, one has to wonder how many colon cancer deaths result? If a plan is self-funded, the plan managers need to prevent ASO claims payors from implementing these processes. If fully insured, employers should pick up/pay for the additional fees.

High deductible plans not working? Here’s what works, 0 deductible! December 10, 2011

Posted by medvision in Cancer Care, Chronic Disease, Employee Wellness, health data, Healthcare Costs, Healthcare Reform, Insurance Plans, Rx Costs, Uncategorized.
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My initial introduction to consumer driven plans, HDHPs, was presented in a group setting by a national carrier, or, “industry speak” a BUCA. We were first told the reason for explosive trend is a combination of easy physician access due to low copays, better technology, our legal environment and expensive drugs. Then came the HSA regulatory part. (I used to think the 401K regs were somewhat complex)! Today, from my years of data experience, I know explosive health inflation is driven by a small percentage of members suffering worsening states of chronic disease.

Anyway, a troubling thing is sneaking up on the disciples of HDHPs and their concept of member consumerism. It’s the rapid adoption of on/near site clinics by 20%+ of employers with a thousand or more employees.

Hmm. In one corner we have plans requiring members to spend the 1st $1,000 – $10,000 before plan benefits start, And, in the other corner, all-inclusive primary care benefits with no, 0, member dollars needed. If fact, a few BUCAs are big proponents of both plans! Sort of an AC/DC strategy.

The clear winner is immediate and easy access to primary care, preferably in scenarios in which the physicians are significantly rewarded for “great” member health. A great plan discount occurs when large claims don’t occur due to prevention/early disease identification. Guess how many $70 primary care visits can be purchased for the cost of a $250K annual claim paid on behalf of a member facing end-stage renal failure? A great physician can he hired for $200K annually. So, how many members can a physician see in 12 months? Here’s a good opinion article on employer clinics! http://tinyurl.com/7rvm7sm

Accountable patients. What patients with heart disease need to learn from cancer patients. November 18, 2011

Posted by medvision in Cancer Care, Employee Wellness, Healthcare Costs, Uncategorized.
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My personal experiences in providing care for, and knowing the journey faced by, cancer sufferers is truly humbling. Under the term “courage” in the dictionary, an example should describe challenges faced by cancer patients undergoing cycles of chemotherapy and radiation therapy. Cancer patients exhibit amazing courage in battling cancer.

Many times we see an exact opposite behavior exhibited by heart disease patients so clearly stated by this doctor.

http://tinyurl.com/79fywck

The doctor/patient relationship-Why not have our docs drive national reform? October 9, 2011

Posted by medvision in Chronic Disease, Employee Wellness, health data, Uncategorized.
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Over the past 25 years we’ve (insurance & consulting industry) created practically every process imaginable to control the financial aspects of employer sponsored health care. Indemnity, HMO, PPO, EPO, HDHP, HRA, HSA, consumerism, wellness, disease management, care management: All failing to control cost or quality.

The following was posted by English heart surgeon, Norman Biffra, MD,” Every Doctor and Medical Student must see this”

If this video doesn’t “rock you” you may be in the wrong field!  http://tinyurl.com/3jf7stz

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