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. 

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