Wednesday, April 16, 2014

How Safe Are the Hospitals We Use?

If you're a regular reader, you know that I've been focused on hospital safety recently. I asked UnitedHealthcare for a report showing the hospitals participants in our plan used in the past 12 months. Then, I used Leapfrog's Hospital Safety Score to see how each of the hospitals we used are graded. 
The Hospital Safety Score grades hospitals on how safe they are for patients. Each A, B, C, D, or F score assigned to a hospital comes from expert analysis of infections, injuries, and medical and medication errors that frequently cause harm or death during a hospital stay. The score is calculated using publicly available data from the Center for Medicare & Medicaid Services (CMS), the Leapfrog Hospital Survey (where applicable), and secondary data sources. The Hospital Safety Score methodology has been peer-reviewed and published in the Journal of Patient Safety.
You can pull up the letter grades of the hospitals anywhere right on your smartphone with the Leapfrog Hospital Safety app. (If you don't have it, download it now.) The hospitals in the DC Metro area range from an A to a F. There are other tools out there, but I really appreciate how Leapfrog differentiates the choices for patients. I urge you to look at the scores before going to a hospital. And, if you wind up at one with a poor rating in an emergency, remember you can move to a different hospital once you're stabilized.  

Unfortunately, the hospitals in Maryland are not scored. Maryland hospitals have their own payment system for reimbursement and they're not required to submit data to the Centers for Medicare and Medicaid Services (CMS); therefore, organization like Leapfrog don't have access to the data. Maryland operates the nation's only all-payer hospital rate regulation system and they're the only state that does not share its' data publicly. There are also some critical access hospitals, specialty hospitals such as children's hospital, and cancer hospitals for which there is insufficient data to assign a score.

This is how the hospitals we used are rated. I hope we can shift more of our utilization to the A's and B's. We really don't want sponges left inside of us, surgery on wrong body parts, and secondary infections just to name a few of the "never events" that occur too frequently at the hospitals that received poor ratings.  

FYI: I can see the number of inpatient admissions, the number of inpatient days, the number of outpatient services and the net paid. No information is included that indicates what types of services were received or who sought the services. 

Monday, April 14, 2014

Sharing Information with Airbo

I mentioned how we're using Airbo during my presentations at the Health and Benefits Leadership Conference and the World Health Care Conference. A number of folks inquired about the product, so I thought I'd share this case study Airbo has posted about ASHA

We find that it's a very useful and affordable communication tool -- over 90% of our staff participate. I can't say enough good things about working with Vlad Gyster and Kate Bernier -- they seek our feedback, are incredibly responsive, routinely role out new features we've suggested, and they're fun. You can read more about our pilot with them in this post. (Note: Airbo used to be called H.Engage.)

Wednesday, April 9, 2014

Trends in Health Care from #BenefitsConf and #WHCC14

I had the pleasure of attending both the Health and Benefits Leadership Conference and the World Health Care Congress recently. I've heard some inspiring things, connected with true thought leaders and learned a lot. I'll share some of the things here that I keep turning over again and again in my mind. 

Patient Centered Medical Homes
Large employers like Zappos, Intel and Dartmouth College shared their stories about setting up Patient Centered Medical Homes (PCMH). They all were compelled by wanting to provide high quality, high value, care for their employees. Employees that receive care at a PCMH can be steered toward specialty physicians with high quality ratings and a reputation for adhering to evidence-based medicine. They all employ health coaches to work with patients on life-style related issues. Rushika Fernandopulle, MD, MPP from Iora Health that runs Dartmouth's PCMH told a compelling story about how a coach gave a patient pedicures as a way to develop a connection and get her to come in weekly to discuss the management of her diabetes. All the initiatives are quite new, but they're reporting a high level of satisfaction from their employees and a positive impact on measures like patient compliance with disease management. 

Dr. Zubin Damania of Turntable Health that delivers Zappos's PCMH delivered a particularly engaging presentation during the Ideas and Innovators Forum at the Health and Benefits Leadership Conference. He's a rapper, comedian, MD that knows how to command a crowd. Check out the Turntable story on YouTube

At this point, I don't see any real application of PCMH for small employer unless they form coalitions within their communities. I also think this is more appealing to employees that work in areas where good medical care as not as abundant as it is in the Washington, DC area where I work.

Narrow Quality Focused Networks
We're also hearing a lot about narrow networks. Years ago narrow networks were created of providers that had agreed to the steepest discounts with the network managers. Today narrow networks are being created around providers that meet quality measures. In HR, we've traditionally evaluated health plans based on how many providers were in network -- the more the better. The broader the network the greater choice our employees would have and the more likely their existing providers would take part. When employees complained that a provider they wanted to use wasn't covered, we in turn went to the network manager to complain. Today's savvy benefits managers are taking more of a leadership role. They're insisting that providers with poor quality measure are excluded. Others are building a new tier into their benefits design to push employees toward higher quality providers. 

I got into an interesting discussion about this recently -- a colleague presented a case that employees should have the right to chose. I agree to a point. I believe those of us with the most information have a responsibility to present good choices to those we serve. Let's say I'm a real-estate agent in a beach community and I'm helping you rent a beach house for the summer. There are four properties that meet the criteria that you're looking for, but I know one is poorly constructed. It has a deck that isn't to code and it has a high likelihood of collapsing while you sit on it enjoying your morning cup of coffee, it also has shoddy wiring that greatly increases the likelihood that it will catch on fire while you sleep. Am I doing you a service by including this house so that you have four options instead of three? Likewise, do we want to include irresponsible investment options in our defined contribution plans just to say we provide greater choice? We know that having more options doesn't lead to greater satisfaction among consumers. The article, The Tyranny of Choice that ran in The Economist eloquently makes this point. 
Tom Emerick and I during our presentation.
I am inspired and humbled by the thought leaders
I met at these conferences over the past weeks. 

I presented with Tom Emerick during the World Health Care Congress. I'd read Tom's book Cracking Health Care Costs and found many of the points he'd made compelling, but we had not met before. We spent a couple hours before our presentation talking and that was some of the most valuable time I spent at the conference. Tom pointed out that a true leader would narrow the choices to the good options and be willing to take the heat from employees that complain that a poor hospital is no longer in the network. Tom makes a good case for having a broad primary care network, but a narrower, high quality specialty and hospital network. If there is any low hanging fruit here, (this is an easy argument to make conceptually, but a much harder one to implement) it would be to start by eliminating non-emergency coverage at hospitals with unacceptable safety ratings.

Focus on Hospital Safety
Another highlight of the World Health Care Congress was hearing from Leah Binder of the Leapfrog Group. Leapfrog was formed in 1998 by a group of large employers that wanted to be able to assess differences in and compare the quality of care between health care providers. Leapfrog scores hospitals in 38 regions with 1,300 hospitals voluntarily participating in their survey. In a lot of instances, employers are compelling their local hospitals to participate. The result is that each hospital receives a letter grade A-F based on four factors -- computer physical order entry, evidence based hospital referral, ICU physician staffing, and a safe practices score. The safe practices score is based on the frequency of "never events" like pressure ulcers, falls, air embolisms, and objects left inside a patient. It includes infection rates for three of the most common and deadly hospital-acquired infections and the rates of other generally preventable harm or death to patients. 

Leah Binder likened the occurrence of "never events" in a hospital to US Airways Flight 1549. How did US Air respond? They sent a letter of apology to all the passengers. They explained how the National Transportation Safety Board had begun an investigation and how they were cooperating. And, they reimbursed people for the cost of their tickets plus $5,000 to assist with immediate needs. What happens in a hospital? Hospitals don't apologize and they continue to bill patients and insurance companies for the cost of the care to correct their errors. Can you imagine US Airways sending passengers a bill for the cost of the rescue? 

Leapfrog listing
for the DC area.
You can actually pull up the letter grades of the hospitals anywhere right on your smartphone with the Leapfrog Hospital Safety app. (If you don't have it, download it now.) The hospitals in the DC Metro area range from an A to a F. There are other tools out there, but I really appreciate how Leapfrog differentiates the choices for patients. Scoring systems and accreditation that make all hospitals look equal don't help patients differentiate their choices -- Leapfrog clearly does. 

Unfortunately, Maryland doesn't share hospital data. It's the only state in the nation that doesn't and I'm still trying to fully understand why. I could go on and on about how Maryland is a difficult state for employers to operate from a benefits perspective, but this issue frustrates me more than most. 

Focus on Medical Necessity and Evidence-Based Medicine
In addition to quality, there are issues of medical necessity. Tom shared a statistics that I can't shake out of my mind -- 40% of transplants are unnecessary. Can you imagine having a transplant that you didn't need and how that would alter your life? I find this absolutely horrifying. And, this was the focus of Dr. Mary Bourland's presentation at the World Health Care Congress. She is the Medical Director -- Compliance for Mercy Destination Medicine and Centers for Medical Excellence. (This is where you want to go if you're told you need spine surgery.) She said, 
"More than 57,000 people die needlessly each year because physicians' practice vary from standard practice/evidence based guidelines... what medical science tells us they should get. These deaths should not be confused with those attributable to medical errors or lack of access to care." 
Later, Dr. Bourland pointed out that patients need to take the time to evaluate their options. It's rare that patients will be harmed by not rushing into treatment. We know that when patients have more information, they chose less invasive therapy and have a higher satisfaction rate. People need to take the time to make informed decisions. 

What Next
I think it was Patricia Spellman from Dartmouth College that pointed out that employers shouldn't have to be this involved in health care, but it is our reality. Truer words were never spoken. I may not be able to influence what goes on at the national level, but I have a responsibility to provide access to the best care possible for the ASHA staff. I intend to make up for the roadblocks we hit because of our small size by educating our staff to be savvy healthcare consumers. Lots more on that to come. 

You can review the Twitter Feed from the Health and Benefits Leadership Conference and the one from the World Health Care Congress thanks to Carol Harnett. Be sure to check out Carol's post on private exchanges. She covered it so well, I saw no need to rehash it here. I'm also compiling a reading list from the two conferences that I'll share in a separate post. 

Monday, March 31, 2014

Are tobacco-free employers prohibiting e-cigs?

Yesterday I was asked what are policy is on e-cigarettes. Hmmm, I should have anticipated that question, but I had not even contemplated it. ASHA has been a smoke-free workplace for many years. When we moved to our current office in 2007, we expended the prohibition to become a smoke-free property. I guess now it's time for us to choose a stance on vaping in the office.

Jim Watson/AFP/Getty Images
The use of electronic cigarettes (e-cigarettes or e-cigs) is on the rise. They were first introduced in China in 2004. E-cigarettes are not currently subject to FDA limitations because they're not considered drug or medical devices. The FDA announced that it would issue proposed rules in November 2013, but they have not been released yet. Most agree that e-cigarettes seem to be safer than combustible ones, but the health impact of inhaling nicotine mixed with food-grade vapors is not yet known. There have been no conclusive studies to date. 

I understand The American Cancer Society, American Heart Association, The Campaign for Tobacco-free Kids, and the American Lung Association all recommend that smoke-free laws and policies prohibit the use of e-cigarettes. 29 states and the District of Columbia prohibit smoking in the workplace, but most polices do not specifically address e-cigarettes. Chicago is banning the use of e-cigs in enclosed public places and enclosed places of employment in the city effective April 29, 2014. New York City has extended a similar ban and a few states have now included e-cigarettes in their indoor smoking regulations.  Smoking prohibitions in airplanes also apply to e-cigarettes. However, there are school districts that ban yoga pants and chewing gum, but not e-cigarettes. (Leaving parents like Maggie McGary shacking their heads.) 

Employers are really just starting to address the issue, so there's not a lot of benchmark data available yet. I did see the results of a BLR HR poll that showed
"half of respondents (50 percent) say that their organization has not addressed e-cigarettes in their smoking policy—and close to a third of respondents (31 percent) say they haven’t thought about it yet!"
I'm recommending that ASHA ban the use of e-cigarettes in the office. Anything less just feels like a step backwards. I'm also recommending that we expand our current smoke-free policy to a tobacco-free policy. I'm not sure why we went with smoke-free rather than tobacco-free to begin with, but my theory is that it just never came up. You don't see many people chewing tobacco in the Washington, DC metro area and it's never been an issue for us.
It's official, ASHA is now a tobacco and e-cig free property. Our new policy reads "The ASHA National Office is a tobacco-free property. Use of all tobacco products and electronic cigarettes is prohibited on our grounds." (No fooling.)

Monday, March 24, 2014

The ROI of Wellness

There has been a lot of talk about the ROI of wellness programs lately. Some of the most discussed studies being the one published in 2010 by Harvard economist Katherine Baicker, the 2013 RAND corporation study of employee wellness and the 2014 PepsiCo disease management and wellness study. In the simplest terms: 

  • The Harvard study showed ”medical costs fall by about $3.27 for every dollar spent on wellness programs.” 
  • The RAND study concluded that "Participation in a wellness program over five years is associated with lower health care costs and decreasing health care use. The average annual difference is an estimated $157, but the change is not statistically significant." 
  • The PepsiCo study demonstrated: "When we looked at each component [disease management and lifestyle management] individually, we found that the disease management component was associated with lower costs and that the lifestyle management component was not. We estimate disease management to reduce health care costs by $136 per member per month, driven by a 29 percent reduction in hospital admissions." 

Here's my take. First, wellness programs are the right thing to do. And, no one disagrees that done well, they send a strong message that you care about your employees. There is also a lot of agreement that they have a positive impact on engagement and help you recruit and retain people that want to work in a healthy environment. Wellness programs may positively impact attendance and productivity too, but the evidence there is not as strong.

Second, you have to know your workforce. Carol Harnett reported that another thought leader, Dee Edington concluded"on average, the best-performing wellness program in terms of return-on-investment was a smoking cessation initiative. The caveat, however, was that it takes -- on average -- about eight years before a positive ROI is captured. For all the other wellness-related schemes, approximately 16 years must go by before you realize a return on the money spent." When I look at those numbers, I'm not so quick to shrug them off. Our average tenure is 8.5 years, so we have a lot of staff members that have been at ASHA more than 16 years. We also provide health insurance coverage to our retirees, so we have a very long term investment in the health of our staff. We focus on making the healthy choice the easy choice and implementing wellness initiatives that are tailored to our staff and our needs. Matter-of-fact, that's what James Sumortin from Twitter and I just talked about during our presentation at the Health and Benefits Leadership Conference

Third, there is general agreement that 20% of the members of a health plan are responsible for 80% of the claims in any given year. There are valuable programs like disease management (if you believe the PepsiCo study) and Centers of Excellence that target this 20% and direct them toward high quality care (which is also cost effective.) But, 59% of the next years top 20% are in this years 80%. We have to develop interventions that stop the migration of people from the healthy 80% into the unhealthy 20%. Aaron Davis and I discussed this over lunch last Friday and this is what his company Switchbridge is focused on.

My take on all this is filtered through a population health mindset. I just read What Great Corporate Wellness Programs Do. In the introduction, the authors suggest that workplaces have a unique power to reframe the mindset around health. That got me to thinking about the effect smoke-free workplaces have on smoking behavior. Studies prove that smoke-free workplaces encourage smokers to quit or reduce consumption.
"Totally smoke-free workplaces are associated with reductions in prevalence of smoking of 3.8% ... and 3.1 ... fewer cigarettes smoked per day per continuing smoker... If all workplaces became smoke-free, consumption per capita in the entire population would drop by 4.5% in the United States and 7.6% in the United Kingdom..."
I'm a believer that it takes a village. Employers have the opportunity to create little Blue Zones within their workplaces and influence what goes on in the communities where they're located. If we do, maybe we'll see obesity trends start to fall the way that smoking has declined.

Recommended Reading:

Monday, March 17, 2014

Test Your Healthcare Savvy

Healthcare Savvy tiles on Airbo
At the beginning of the year, I shared a story about how I created a presentation to help my friends become more Healthcare Savvy. Vlad Gyster and Kate Bernier at Airbo saw it and offered to help me create this deck of tiles with the material to share it with others.

I’m finding myself on sort of a mission to help the ASHA staff, my friends and family, and others understand how their health insurance coverage works, chose a plan that’s the right fit for their needs and get the most out of their coverage when they need it. Take a few minutes to flip through the tiles to test your knowledge. I’ll be adding and editing as I gain insights into what’s most useful to people, so please revisit them if you find them helpful. And, please share your feedback with me. 

Learn more about how we're using Airbo as a communication tool at ASHA. (Airbo used to be called H.Engage.) The folks at Airbo are wonderful to work with and the product is fun and easy to use. They're launching new features based on feedback from their customers at an impressive speed. 

Thursday, February 13, 2014

More Exercise, More Money, More Sex?

We have a snow day here in the DC area and it gave me the opportunity to scroll through a bunch of posts I started and never finished. We're six weeks into the new year and I know people are wavering on those new year's resolutions to exercise regularly, so I think this was still worth sharing now. Especially since most of us on the east cost have an opportunity to get some exercise shoveling and Valentine's Day is tomorrow... 

A year ago, I wrote this post about a study published in the Journal of Labor Research that showed people who exercise regularly earn 6 to 10 percent more than their more sedentary counterparts. Last summer, I saw a WSJ story that people who have sex more than four times per week earn 5% more. It doesn't say whether the relationship is correlative or causal. Which raises a question, if you exercise regularly do you get paid more and have more sex? Something worth contemplating if the money wasn't enough incentive to get you to the gym.