Monday, June 29, 2015

Commonly Used Medications Linked to Dementia

Cleaning out our medicine cabinet.
Every once in a awhile, I come across something that I want everyone I care about to read. The latest is a study that found a significant link between high use of anticholinergic drugs - including popular non-prescription sleep aids and the antihistamine Benadryl - and increased risk of developing dementia and Alzheimer's disease in older people.

Anticholinergic drugs block the action of acetylcholine which stimulates muscle contractions. They treat things like gastrointestinal problems, overactive bladder, respiratory disorders, insomnia, depression and allergies. Benadryl and Tylenol PM are commonly used anticholinergic that are sold over-the-counter. In the study, the drugs were found to have a cumulative effect that may not be reversible. 
You can view a list of anticholinergic drugs available by prescription on the Mayo Clinic Site. 

I'm going to assume you don't want me interpreting this kind of medical research for you, so I'm going to direct you to some good sources of additional information. 

If you're taking one of these medications, please talk with your doctor about the risks and your alternatives.

P.S. Just in case I peaked your interest, Spark is one of the other things I wish everyone would read.  

Wednesday, June 17, 2015

Does Your Organization Have a Glide Path to the Cadillac Tax?

Photo by Glenn Beltz --
Aircraft approaches San Diego Linbergh Field at Dusk
What's the Cadillac Tax?
The ACA expanded health coverage to millions. The Cadillac Tax helps to cover the cost of the expansion by taxing employers that provide "high-cost" health coverage to their employees. AKA -- Excise Tax.

What's a Glide Path?
When I was at the World Health Care Congress, I heard big employers like Disney refer to a glide path. They've projected how the tax will impact them and have plans in place that will allow them to limbo under the tax thresholds (more on that later.) FOMO (fear of missing out)-- I want ASHA to have a glide path too.

Isn't there a proposal in Congress to eliminate this tax?
Yes, two bills were introduced in the house earlier this year H.R. 879, the Ax the Tax on Middle Class Americans’ Health Plans Act and H.R. 2050 — Middle Class Health Benefits Tax Repeal Act. Nobody I've heard from on either side of the aisle thinks the tax will be repealed though. Feel free to keep your fingers crossed.

Why don't the experts think it will be repealed?
There is a financial hurdle to repeal. Expanding coverage via the exchanges cost 849 billion dollars and another 847 billion in Medicaid and CHIP outlays. This is being paid for in four ways:
  1. Penalty payments collected from uninsured people (43 billion)
  2. Penalty payments collected from employers (167 billion)
  3. Cadillac Tax (87 billion)
  4. Other which consists mainly of the effects of changes in taxable compensation on revenues (202 billion)
If you're thinking item four doesn't make sense, you have company. I don't get it either, but I've taken it right out of the Congressional Budget Office March 2015 report.

The Cadillac Tax estimate was adjusted down from an estimate of 149 billion in January 2015 because premiums are not expected to rise as much as originally thought. I suspect this is due in part to the changes employers are making in their plan designs, but there is a lot of pressure on cost containment throughout the system right now.

When does the tax go into effect?
The tax goes into effect January 2018, but employers are already restructuring their health care benefit offerings or increasing workers’ deductibles and copays to avoid the tax. SHRM reports that 21 percent of its' members expect to decrease their health benefits offerings in 2015 and 7 percent said they're planning to reduce non-health benefits (such as financial benefits and compensation or retirement savings and planning benefits) for 2015 in response to the pending tax.

How do you calculate the tax?
In simple terms and highlighting just what's most relative to ASHA and probably most of us in the association community, the formula looks like this.
Premium equivalent + HSA & HRA contributions + FSA contributions + EAP = Value

The value of coverage is compared to thresholds set in the ACA -- $10,200 for individual coverage and $27,500 for self + other. Any Value over the thresholds is taxed at 40%.

All employer and employee pre-tax contributions to HSAs and FSAs are included in the calculation. HIPAA excepted EAPs will probably be excluded. (EAPs that include face-to-face visits are subject to HIPAA.) 

There are some proposed adjustments for covered retirees that are at least 55, but not yet medicare eligible; high-risk professions like law enforcement; age and gender (if the age and gender characteristics of an employer's workforce are different from those of the national workforce. There is presently no adjustment for geographic location and that seems like a glaring omission to me. It's something we included in our comment letter to the IRS. State mandates impact the cost of coverage with heavily regulated states like Massachusetts and Maryland above the national average. This would create a double whammy for employers in these states.

Those thresholds sound more like a Camry than a Cadillac.
Yep, 33 percent of employers are expected to be subject to the tax in 2018.

Is it likely that the formula will change before the tax goes into effect?
Yes, the IRS just requested comments in Notice 2015-16. I helped to prepare ASHA's comment letter. (Bob Skelton at ASAE submitted a good one too.) It is expected that another IRS notice will be issued in 2016 and followed by another comment period and then the final regulations will be released in 2017.

So, what do we think this will cost?
For ASHA in 2018, the best case scenario is about $10,000; worst case scenario about $310,000. There will be a COLA adjustment to the tax after 2019, but the picture only gets worse. In 2020, our best case scenario is about $120,000 and the worst case scenario is $750,000.

You could drive a truck through the gap in those projections. Is that the best you can do?
We have to make a lot of assumptions about the cost of coverage and the choices ASHA staff will make to estimate our tax liability.

In the best case scenario, we included a 7 percent trend increase in the cost of coverage. We also assumed staff continue with their current HSA contributions and an average of the current FSA contributions. (The latter is a lousy placeholder, but it’s a start.)

In the worst case scenario, we assumed a 12 percent trend increase in the cost of coverage, increased the caps on the FSA by 2 percent and the HSA by 5 percent and then assumed the staff currently participating all max out their contributions.

When the IRS issues a final ruling on how the tax will be calculated and we get closer to 2018, I can narrow the gap.

Either way, that's a lot of mula! What can be done to minimize our potential tax liability?
ASHA's taken two big steps already by introducing a Consumer Driven Health Plan (CDHP) and self-insuring our benefits. Employers have lots of options and need to decide what plan of action is right for them. Many options take time to implement, so savvy employers are working on a three year plan now -- their glide path to 2018. 

To get started developing a list of options for your workplace, I recommend reading this white paper -- What Works in Healthcare Cost Containment -- developed by Aaron Davis and his team at NextLogical. Use the download code mcnichol to access a free copy.

Your broker should also be able to help you develop projections. I worked with Mark Sager at Alliant and Zack Pace at CBIZ

Friday, April 24, 2015

Five Big Ideas from the World Health Care Congress #WHCC15

I had the good fortune to attend the World Health CareCongress. The event pulls together some of the most respected leaders in healthcare and shares the issues of the day from diverse perspectives. I walked away with pages and pages of tweets and notes. Way too much to summarize session by session. I decided to let it sit for a while and then come back to it and share the ideas I continue to think about. 

One: Consumers Define Quality as Convenience

Image from
It was said that consumers define quality as convenience. That's pretty scary when you think about safety. How do you find the safest care? It's certainly confusing to see hospitals at the top of one list and the bottom of another. There was some agreement that quality data needs to be harnessed and coalesce around certain measures to be useful to consumers. I personally like what Leapfrog is doing in that respect. Beyond the obvious reasons to care about patient safety, the avoidance of complications has much more impact than price on the overall cost of care. 

There were a number of interesting tidbits from the Patients Take the Wheel study conducted by Trinity Health. In the same way people don't trust congress, but like their representative consumers lack confidence in the healthcare system, but trust their doctors. Millennials in particular are willing to change behavior to get affordable care. 54% of millennials will delay or avoid getting care because of the cost. Young consumers want convenience. They will travel an extra 30 minutes to receive care where the lab, x-ray and provider are all in one place. Many patients feel their doctors spend too much time looking at a computer and entering data during their visits. Millennials are embracing retail access to care -- 34% of millennials visited a retail clinic last year. Few people are presently negotiating what they pay for care, but it's expected to become a trend. Do you think Wal-Mart will become the biggest provider of care in the next five years?

A geriatric study revealed patients aged 65-93 are excited to use technology for healthcare according to Dr. Bloomfield at Duke Medicine. I’m a firm believe that assuming Millenials are driving all the desire for new technology and communication platforms will lead you astray. 

Interestingly, I’ve never seen a definition of an engaged healthcare consumer, so I’m working on developing one. People obviously need the right support to engage as consumers, but I think it also helps to be clear about what we’re asking people to do. I’d be grateful if you would share your thoughts.

More than one person recommended watching The Emperor of All Maladies a PBS documentary that illustrates the decision making process consumers go through when faced with a cancer diagnosis.

Two: The Data is a Mess, but the Vision of What's to Come is Powerful

Image from
The value of bringing payor and provider data together is immense when it comes to managing risk. There was lots of talk about electronic medical records. I was chatting with a hospital system medical director that said they used 11 different versions of Epic within their system and nothing was integrated. There was some discussion of when data collection becomes research and requires informed consent. For the most part though, that's not a big concern expressed by consumers. People are willing to share their information if it allows them to learn something useful in return. People are much more concerned about the security of their financial data than their health data. Younger people in particular express little concern. It's a small percentage of the population that cares, but they care deeply.

Everyone agrees that we have to identify and differentiate the people that need care the most and help them through the fragmented system. Imagine ordering a heart health kit or a diabetes health kit on Amazon. It would include everything you need to monitor your health conditions. All the data you capture would be visible on your iPhone and integrated into a dashboard that your physician views daily. The physician looks for outliers -- people whose blood pressure or blood sugar is trending outside acceptable norms -- then, the physician reaches out to these individuals.

Three: Employers are Driving Change

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The 80% of the population that is healthy may shop for care, but they only incur 20% of the cost. The critically ill don't shop for care. Therefore, you must incentivize doctors to carefully consider where they refer. Boeing seems to have accomplished this by creating its own ACO with Providence-Swedish Alliance.

The providers in the ACO have an incentive to effectively manage the cost of care and they consider the cost when they may referrals. Providence-Swedish reported that they're making progress by focusing on just the data points needed to take action on what is learned. (The small ball approach to data integration.) Consolidation in the marketplace creates a challenge for employers that just want to include top quality hospitals. You can't pick and choose, you have to include all the hospitals in a system. Consolidation is also worrisome because it's competition that drives down costs.

Twitter lit up when we heard from Harris Rosen from Rosen Hotels about their involvement in the delivery of care.  Whereas other hotel companies have a lot of turnover, Rosen says his company has single digit turnover. He credits the health plan. When Rosen employees visit the health clinic, they're on the clock. They'll even be given a ride if they need it. It's so successful, he's contemplating building his own hospital. He shared his vision of a hospital that is a healing environment with 24/7 room service and murphy beds in all the rooms for family members. Think about how bringing hospitality to medicine could change the experience. 

Gary Loveman from Caesars Palace closed the first day of the conference with a rousing talk about their wellness initiatives. He said that you overcome resistance with incentives, information, encouragement, choice and convenience. He mentioned his concern about the EEOC challenges to wellness programs. The actions necessary to qualify for an incentive can't become so trivial that they don't have an impact. He related the concern to financial management. What if an employer could attest to do the right thing and then face stiff penalties if they don't? Caesars is beginning to experiment with bundled payments for things like knee replacements. You can't argue that the casino industry knows how to create consumer engagement. It's nice to hear that they're using this knowledge to help people improve their health. 

Four: No Employers Plan to Pay the Cadillac Tax Putting an End to the Open Bar

Image from
The Cadillac Tax was referred to frequently as the tax that no one will pay. Employers are devising what Jeffrey Shapiro from Disney referred to as a glide path to 2018 and planning to limbo under the tax. Higher deductibles are one of the main strategies being employed, but there are also a lot of efforts to decrease the demand for care by keeping people healthy. Nobody on either side of the table thinks the ACA will be appealed. Tweaked maybe, but the horse is too far out of the barn. Union Pacific delivers incentives via payroll rather than through an HSA. You can see how this could become a common practice with the Cadillac Tax hits. Employers have also taken note that employee behavior changes once employees meet their deductible. If there is no coinsurance, it becomes an open bar.

Five: Telemedicine Could be a Real Game Changer in Behavioral Health

Image from
A session presented by Henry DePhillips, MD from Teladoc was packed and people asked tons of questions. Teladoc claims that two-thirds of ER visits could be handled virtually. He said 85% of people in emergency rooms just couldn't wait to see their primary care provider. On average, it takes 18.5 days to get an appointment with a new primary care doctor. 50% of Teladoc users don’t have a primary care doctor. Teladoc is also popular with people who need care when they’re traveling. You have to talk with a doctor licensed in the state you are calling from in telemed, so building the network is complicated. The doctors get paid per consult. Teladoc charges patients $40 per consult and the doctors earn between $23 and $28 per consult. Did you know you don't just rate Uber drivers, they rate you as a customer? Teladoc does the same thing. They offer both phone and video consultations, but 85% of patients choose a phone consultation. Now for what I think is a real game changer – Teladoc is adding a whole behavioral health component. Think about how that could break down the barriers people face to get care.

With a little luck, I'll be at #WHCC16. Hope to see you there!

Tuesday, March 31, 2015

Defining What it Means to be an Engaged Healthcare Consumer

In the health and wellness arena, everyone is talking about engaging consumers, but are we clear about what we're asking people to do? As far as I am aware, no one has defined what specific behaviors an engaged healthcare consumer demonstrates. I’d like to create a definition that outlines how an engaged consumer behaves. I plan to share it with our staff to clearly communicate what we are asking them to do. 

If you’re interested enough to have read this far, I’d like your help crowdsourcing a definition. I’ll get us started and I hope you’ll jump in and use the comment feature to share your thoughts. 

An engaged healthcare consumer:
  1. Has a primary care physician
  2. Asks the 5 questions recommended in the Choosing Wisely campaign before getting any test, treatment or procedure:
    1. Do I really need this test or procedure?
    2. What are the risks?
    3. Are there simpler, safer options?
    4. What happens if I don't do anything?
    5. How much does it cost?
  3. Reviews hospital safety data before deciding where to seek care
  4. Actively monitors and tracks their personal health indicators related to any existing conditions e.g., high blood pressure and diabetes
  5. Maintains a list of medication taken and shows it to medical providers when seeking care
  6. Takes medications as prescribed and instructed
  7. Develops a personal/family budget to manage healthcare expenses
  8. Uses available tools to make cost conscious decisions
This post was also shared on Medium. I welcome your comments here, there or in any way you'd like to share them!

Related reading:

Wednesday, March 11, 2015

Couponing for Prescription Drugs -- Guest Post by Reed Racette

Reed Racette published this article on LinkedIn and I'm sharing it here with his permission. Reed described his take on an experience he had from a customer service perspective, but it's just as illustrative from the perspective of managing prescription drug costs. In Reed's case, their pharmacist lead them through the process which is where the exceptional customer service came in. However, it's something you can do for yourself or a family member. I work with Reed's wife, Kellie, at ASHA and she told me the coupon they found covered the entire cost of the medication saving them more than $2,000. Many thanks to Reed and Kellie for sharing their story.

Customer Care - the Acceptable, the Expect-able and the Exceptional

Usually we only hear about customer care when something has gone horribly wrong. We have all been left in awe after hearing horror stories about frustrating experiences with cable companies, call centers, or DMV's. As consumers it's easy to criticize or complain, but as managers or service providers it's much more productive to find good examples to emulate. Recently I had a health issue that helped remind me of the value of truly exceptional care.

Background - Bear with me, this is relevant.

I’m pretty fortunate in that I am generally healthy and my family has excellent health insurance. But even with great coverage you don't always get great care.
Without going overboard with the details, last month I had severe swelling in my left calf. It had persisted for a while so I went to a doctor - expecting to be told to take aspirin. Long story short, I ended up in the ER. I felt fine, but fortunately the hospital took it seriously because as it turned out, it was deep vein thrombosis (DVT). Essentially I had a big clot in my leg, part which had broken off and made its way to my lungs, resulting in a pulmonary embolism. I stayed in the hospital for two nights while they ran many, many tests, and started me on blood thinners which probably saved my life. Upon discharge from the hospital, they gave me a four month prescription for an anticoagulant called Xarelto (from Janssen Pharmaceuticals). We left the hospital and went to the pharmacy for the meds. This is where the real story begins, because the customer care I received from my pharmacy - the Harris Teeter Pharmacy in Columbia, Maryland - is a textbook example of how customer care should be delivered.

The Problem

We have good health insurance but Xarelto is a very expensive drug. We (my wife and I) went to fill the initial prescription and found that our out-of-pocket expense for a two-week supply would be a little more than $500. The four-month prescription was going to cost thousands of dollars.


Before I go any further, please note that this is not a knock on pharmaceutical companies. They take huge risks and incur big losses on drugs that never make it to market, but they are helping us beat more diseases than ever before. So while Xarelto is expensive, it's better than not having it as an option.

The Point

Here is how the Harris Teeter pharmacy team demonstrated how to move from "Acceptable" to "Exceptional." When the Pharmacist and the Technician (Faithe and Brandon) realized how much the medicine was going to cost, they were concerned. They know me, my wife, and our kids and they care about us. The situation was sub-optimal and Brandon and Faithe were empathetic. But they don’t set the drug prices, so it was outside of their control. If the story ended there, I’d say I received an “acceptable” level of care.
Then they suggested calling the insurance company and the doctor to check on other possible alternatives - maybe a lower cost option was available. This was smart, kind, and also a good business practice. As a valued customer I would expect this of my pharmacy, and my expectations were met. So I checked. I learned that other options were available for less money, but for several reasons I chose to stick with Xarelto as the doctor had suggested. We would just have to deal with the cost. We asked Faithe to fill the prescription, and said we would pick it up later.
When we got home, Faithe called with an idea. She suggested that we look at the Xarelto and Janssen websites because drug companies often have special offers and coupons (I had no idea) so we might be able to save some money. This was an exceptional act of patient care. The pharmacy is very busy, but Faithe wanted to look out for us. She didn’t have to take the extra step. She went out of her way to try to help because she cares. Regardless of the result, this level of care is on a higher plane.
My wife found that there was a special offer on the web site. It was a re-usable coupon that saved us more than two thousand dollars. This was great news for us, and I couldn't help thinking how it would affect patients who have to take this drug for years, or for life. When Brandon saw the new price of the prescription he was so happy for us that it was almost as if he had saved thousands. Again, this was exceptional. It is not often that a vendor or service provider - even in the health care industry - sincerely expresses concern for a client. This is a team that really cares about me and my family.

Lesson Learned

After this experience, I started thinking about the level of service we provide for our customers - I work as an IT consultant at GovernmentCIO. We want the best for our customers and the folks on my team go out of their way to meet high expectations. I like to think we are providing the same level of care that I receive from Brandon and Faithe, but do our customers know how important they are to us? How have I shown them?
Companies don’t win customers and form long-term client relationships by providing “acceptable” service or by “meeting expectations.” They build and keep relationships by being exceptional. One way to be exceptional is to show your clients that you sincerely care about them.
Do you?
I am interested in your thoughts on what makes customer service exceptional. Please comment or contact me at rracette@governmentCIO,com
My 25 years of experience includes service as a military officer as well as time with large corporations, national non-profits, and small companies.
My Alphabet Soup includes: PMP, CSM, ITIL V3, Six Sigma
Thank you for reading.