Category: Health Analytics

Jeff Brenner – final meeting

Met with Jeff Brenner, Medical Director at Camden Coalition of Healthcare Providers.

Learned about him after listening to these freakonomics podcasts:

link

link

An eloquent, thoughtful keen student of the history of epidemiology, public health’s political success and a tireless advocate for the underserved communities of Camden, NJ.

Holds a strong, long-term, systems view of change in public health and healthcare.

Currently engaged in a loss-avoidance play as an ACO demonstration site – geographically defined, shared savings project, which has protection from federal anti-trust laws to allow providers to collaborate.

Doubts the claims of most preventive health organisations, on basis of the Medicare Chronic Care Demonstration Project in the 80s where only 3 of 15 corporate participants survived a randomised control trial of preventive interventions after a year.

The game changer in many examples of public health shift are the troubling personal experiences of decision makers.

Emotional, visceral, aesthetic impact.

Tapped into Grenny’s observation about Don Berwick needing to get hospital CEOs to run the analysis of patient harm personally rather than to delegate in order to experience first hand the damage their institutions were doing to their patients.

Examples of AU Health Minister’s personal experience of the harms of tobacco driving the change to plain packaging.

Complex systems are kept in place by:

  • goodwill
  • money
  • tax dollars
  • positive media
  • These foundations need to be eroded one by one to effect change.

For a venture capitalist, they’ll need a pitch that appeals to their outrage at the lack of evidence or transparency around the way that healthcare works.

For someone on the left, the conversation will need to be nuanced around the human tragedy of chronic disease, and the need for humanity to do better.

Don’t get wedded to the strategy, just the outcome.

There is a 100 year gulf between the way corporations collect and use data, and the way that government uses the same resource.

Analytics allow us to surveil, segment, target and measure interventions, then tell a good story of why things happen.

Dual System Utilizers – healthcare and law enforcement

On the way to the meeting, came up with a name for the concept – the QALYBOND – will grab the domain name.

References

http://www.macfound.org/fellows/886/

  1. “Bury the Chains” – end of slavery
  1. “The Children” – civils rights movement
  1. The fight to roll out covered sewers, welfare reform (fixed by the right)
  1. Adverse Childhood Event Study – Vince Felitti, KP

NYT: Out of pocket cost tool to be mandated by HHS

 

http://www.nytimes.com/2015/05/09/us/politics/health-care-law-consumer-complaints-to-get-addressed-by-white-house.html

White House Moves to Fix 2 Key Consumer Complaints About Health Care Law

By

WASHINGTON — The White House is moving to address two of the most common consumer complaints about the sale of health insurance under the Affordable Care Act: thatdoctor directories are inaccurate, and that patients are hit with unexpected bills for costs not covered by insurance.

Federal health officials said this week that they would require insurers to update and correct “provider directories” at least once a month, with financial penalties for insurers that failed to do so. In addition, they hope to provide an “out-of-pocket cost calculator” to estimate the total annual cost under a given health insurance plan. The calculator would take account of premiums, subsidies, co-payments, deductibles and other out-of-pocket costs, as well as a person’s age and medical needs.

Since insurers began selling coverage through public marketplaces 19 months ago, many consumers and doctors have complained that the physician directories are full of inaccuracies. “These directories are almost out of date as soon as they are printed,” said Kevin J. Counihan, the chief executive of the federal insurance marketplace.

Medicare and Medicaid officials have found similar problems in the directories of insurance companies that manage care for beneficiaries of those programs. In December, federal investigators said that more than a third of doctors listed as participating in Medicaid plans could not be found at the locations listed.

The Obama administration recently adopted stricter standards stating that each insurer in the federal marketplace “must publish an up-to-date, accurate and complete provider directory, including information on which providers are accepting new patients, the provider’s location, contact information, specialty, medical group and any institutional affiliations.”

In addition, Mr. Counihan said, the administration will require insurers to provide physician information in a format that software developers can use to create tools to help consumers find health plans in which their doctors participate. Consumer advocates like Robert M. Krughoff, the president of the Center for the Study of Services, also known as Consumers’ Checkbook, said such tools could be a boon to consumers.

The new standards significantly strengthen an earlier rule, which required insurers to publish directories online and to make paper copies available on request. In the federal exchange, violations are subject to civil penalties of up to $100 a day for each person adversely affected.

Federal officials said that inaccurate provider directories could be a sign of larger problems. If doctors listed in a directory are not available or are not taking new patients, consumers may not have access to covered services, and the insurers may not meet federal standards for “network adequacy,” the officials said. Consumers must often pay extra when they use doctors outside the network of their health plan, so an inaccurate directory could also lead to higher costs for patients.

Moreover, doctors said that they too need accurate directories so they can refer patients to physicians in the network when specialized treatment is required.

“The impact of inaccurate provider directories on consumers can be devastating, especially on those consumers who need to carefully examine networks for specific subspecialists, cancer centers or children’s hospitals,” the American Medical Association told state insurance officials in a recent letter endorsed by dozens of health care provider and patient groups.

But insurers say that the problems might not be easy to fix, and that doctors are partly to blame for the directory errors. Insurers “are unable to guarantee the accuracy of the provider’s status” in a directory because doctors often “stop accepting particular health plans’ members off and on throughout the year and fail to notify the plan in a timely manner,” America’s Health Insurance Plans, the chief lobby for the industry, said in a letter to the Obama administration.

In its online doctor directory, Blue Cross and Blue Shield of Texas says that it makes every effort to provide correct information, but that it “cannot be responsible for omissions or errors in the provider details.” Aetna says that data in its directory is “subject to change at any time.” UnitedHealth tells Medicare beneficiaries, “A doctor listed in the directory when you enroll in a plan may not be available when your benefits become effective.”

The problems that consumers face with unexpected costs may result, in part, from the way plans are listed on HealthCare.gov, the website for the federal marketplace. More than 8.5 million people are in private health plans selected through the site, and the plans are listed in order of their premiums, from lowest to highest.

This encourages consumers to focus on premiums rather than total costs, said Mr. Krughoff, the Consumers’ Checkbook president, and they often spend hundreds or thousands of dollars more than they need to.

Mr. Krughoff’s group has been publishing a guide to health plans for federal employees for more than 30 years, and a version of its online toolfor comparing health plans is available on the website of the federal marketplace in Illinois. “It’s been a great tool,” said Jose M. Muñoz, a spokesman for Get Covered Illinois, the state agency that promotes enrollment.

The tool can perform searches tailored to a person’s needs and priorities. It asks consumers to describe their health status, offering five levels from excellent to poor, and to list “expected medical procedures” like childbirth,knee replacement or prostate removal. It also provides an estimate of total yearly costs for the user.

Federal officials said that they might link HealthCare.gov to an out-of-pocket cost calculator later this year, and that they hoped to make such comparisons a standard part of the shopping experience at the site in later years.

“We know that we have work to do to make it easier for consumers to find plans that meet their needs,” said Lori Lodes, a spokeswoman at the Centers for Medicare and Medicaid Services, which runs the federal marketplace serving more than 30 states.

A few state-run exchanges are developing similar tools. Peter Nichol, the information technology director for the state insurance exchange in Connecticut, said it would add a “cost calculator” to its website this summer.

The Obama administration is also taking steps to increase the accuracy of doctor directories in Medicare. About 30 percent of the 55 million beneficiaries are in private Medicare Advantage plans that typically use networks of doctors to care for patients.

The Medicare agency said it had received complaints about insurance company directories that included doctors who “have retired from practice, have moved locations or are deceased.” New federal rules will require insurers to update their Medicare directories each month, “with specific notations to highlight those providers who are closed or not accepting new patients.”

A version of this article appears in print on May 9, 2015, on page A13 of the New York edition with the headline: White House Moves to Fix 2 Key Consumer Complaints About Health Care Law. Order Reprints| Today’s Paper|Subscribe

ProPublica – US Medicare Part D Pharmaceutical Prescribing Data Release

 

http://linkis.com/www.propublica.org/a/mxEES

Government Releases Massive Trove of Data on Doctors’ Prescribing Patterns

The move follows a ProPublica investigation showing that Medicare did little to find dangerous prescribing by doctors to seniors and the disabled. It is also part of the government’s new push to bring transparency to taxpayer-supported medical care.

by Charles Ornstein
ProPublica, April 30, 2015, 4:01 p.m.

This story has been updated to include a statement from the American Medical Association.

The federal government released detailed data today on nearly 1.4 billion prescriptions dispensed to seniors and disabled people in the Medicare program in 2013, bringing more openness to the medication choices of doctors nationwide.

The data release comes two years after ProPublica reported that the Centers for Medicare and Medicaid Services had done little to detect or deter hazardous prescribing in its drug program, known as Medicare Part D. ProPublica analyzed several years’ worth of prescription data, obtained under the Freedom of Information Act, and created a tool called Prescriber Checkup that lets users compare individual physicians to others in the same specialty and state.

But Medicare itself hadn’t made this information easily accessible—until now.

“This transparency will give patients, researchers, and providers access to information that will help shape the future of our nation’s health for the better,” said acting CMS Administrator Andy Slavitt in a statement accompanying the data’s release.

The information released by CMS is part of the agency’s data transparency initiative. In recent years, CMS has released data on hospital charges, geographic variations in the way health care is delivered, and Medicare’s payments to doctors. The payment data, first released last year, came after the Wall Street Journal and its parent company challenged a long-standing legal injunction that had kept the information private.

Medicare changed its approach to overseeing Part D after the ProPublica reports.

Before, agency officials insisted that monitoring problem prescription patterns fell to the private health plans that administer the program, not the government itself. Congress never intended for CMS to second-guess doctors – and didn’t give it that authority, officials said.

Doctors didn’t even have to be enrolled in Medicare to prescribe to patients in Part D, making it impossible for the program to know basic facts about whether the prescriptions these doctors wrote were appropriate.

Since our reports, CMS has moved to fix Part D’s excesses and blind spots. In May 2014,the agency gave itself the authority to expel physicians from Medicare if they are found to prescribe drugs in abusive ways. Beginning next month, the agency also will compel health providers to enroll in Medicare to order medications for patients in Part D, closing the loophole that has allowed some practitioners to operate with little or no oversight.

Medicare Part D is popular among seniors for helping to lower their drug costs. But experts have complained that since Part D began in 2006, Medicare has placed a higher priority on getting prescriptions into patients’ hands than on targeting problem prescribers. The U.S. Department of Health and Human Services’ inspector general has repeatedly called for tighter controls.

Among ProPublica’s findings:

  • Medicare had failed to use its own records to flag doctors who prescribed thousands of dangerous, inappropriate or unnecessary medications.One Miami psychiatrist, for example, wrote 8,900 prescriptions in 2010 for powerful antipsychotics to patients older than 65, including many with dementia. A black-box warning on the drugs says they should not be used by such patients because it increases their risk of death. The doctor said he’d never been contacted by Medicare.

    ProPublica also found that many of the top prescribers of the most abused painkillers had been charged with crimes, convicted, disciplined by their state medical boards or terminated from Medicaid. Nearly all remained eligible to prescribe in Medicare.

  • Medicare wasted hundreds of millions of dollars a year by failing to rein in doctors who routinely give patients pricey name-brand drugs when cheaper generic alternatives are available.
  • The top prescribers of some drugs received speaking payments from the companies that made them.
  • Medicare’s process of flagging fraud was so convoluted and ineffective that the program was losing millions of dollars to schemes. Though the number of prescriptions attributed to Florida kidney specialist Carmen Ortiz-Butcher more than quadrupled in a year and the cost of her drugs to Medicare spiked from $282,000 to $4 million, Medicare didn’t ask any questions until Ortiz-Butcher realized that her prescription pads had been stolen and falsified.

The data released by Medicare today includes summary information, such as the total number of prescriptions written by each doctor in 2013, as well as more detailed information about each drug a doctor prescribed. It covers prescriptions worth more than $103 billion, not including rebates that lower the cost by an undisclosed amount.

The top prescribed drug in the program in 2013 was the blood pressure drug Lisinopril, prescribed 36.9 million times, including refills. Medicare spent the most on Nexium, $2.5 billion, not including rebates. The drug taken by the most Part D patients was the narcotic hydrocodone-acetaminophen. More than 8 million users filled at least one prescription for it.

Eric Hammelman, a vice president at the consulting firm Avalere Health, said the prescribing data could unlock clues about differences in how doctors practice medicine. Take, for instance, antibiotics, he said, which are often prescribed for inappropriate reasons. While the new data won’t show which prescriptions are inappropriate, it may flag providers who should be asked questions because they prescribe the drugs to a high proportion of their patients.

Beyond that, if consumers compare the prescribing data to data on the payments drug companies have made to doctors, they can see how often doctors prescribe products sold by companies with whom they have financial relationships.

“Knock on wood, these files are coming out on a regular basis. I think some of the doctors and manufacturers would prefer this goes away,” Hammelman said.

Robert M. Wah, president of the American Medical Association, said in a statement that the data “is much more complex than initially meets the eye. The limitations of it should be more comprehensively listed and highlighted more prominently so that patients can clearly understand them.”

ProPublica will be analyzing the information in coming weeks and incorporating the data into our Prescriber Checkup tool.

WIRED: IHME

Decent story about IHME, the development of DALY’s, WHO’s reluctance to return to politically sensitive measures and how Australia apparently used the measures to improve its health system.

http://www.wired.com/2015/04/epic-measures

ONE DOCTOR’S QUEST TO SAVE THE WORLD WITH DATA

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PHIL ASHLEY/GETTY IMAGES

IN RWANDA, PEOPLE have to deal with all kinds of threats to their health: malaria, HIV/AIDS, severe diarrhea. But in late 2012, Agnes Binagwaho, Rwanda’s Minister of Health, realized her country’s key health enemy was  something far more innocuous. The thing causing the most harm to her people, the leading risk factor for premature death and disability, was inside their own homes: Dirty indoor air, from cooking food over burning dung and vegetation in poorly ventilated huts. Within weeks, Binagwaho announced a program to distribute one million clean cookstoves to the poorest households in the young, mostly rural country.

Binagwaho was able to improve millions of lives thanks to a new kind of medical record-keeping, only possible in this era of big data. Just as Billy Beane, general manager of the Oakland Athletics, used sabermetrics to maximize wins, epidemiologists can crunch data to determine the so-called global burden of disease—information that can be used to optimize the health of a neighborhood, nation, or the entire globe. Call it Moneyball for public health.

You might think that policymakers and health czars would jump at the chance to save the maximum number of lives with a minimum of investment. But it hasn’t always been easy going for Christopher Murray, the godfather of the approach, who today directs the Institute for Health Metrics and Evaluation at the University of Washington. In Epic Measures, published earlier this month, health journalist Jeremy Smith recounts Murray’s struggle to index the global burden of disease—and the political obstacles he encountered in publishing and distributing his findings.

A Precocious Pharmacist

The roots of the global burden of disease stretch back to Murray’s childhood. At 10 years old, his family traveled to Niger to help run a rural hospital. After traveling more than a month through the Saharan desert to get there, they found no power, no water, no medical supplies and no other staff. At 10 years old, Murray was promoted to role of hospital pharmacist. In his role, he saw children sick with malaria and suffering from malnourishment, along with a fair share of donkey bite victims.

Those experiences shaped the rest of his life: “It gave me my primary question, which I continue to try to get the answer to,” Murray says. “What are people’s main problems and what can you do to fix them in a way that transcends individual clinical practice?”

More than 20 years later, as a leader at the World Health Organization (the United Nation’s health arm), Murray noticed that official reports and analyses of those main problems didn’t quite reflect medical reality. In fact, the numbers—many of which came from advocacy groups, seeking money and attention for specific causes—didn’t make sense. “If you added things up,” he says, “people were dying three times over.”

So Murray took a different approach. He and his collaborators—not advocacy groups—calculated disease impacts, double checking to ensure they matched the total number of people who had died. And he revised a strategy he and medical demographer Alan Lopez had pioneered in the early 1990s at the Harvard School of Public Health, where they created a new metric for quality of life and health loss (disability-adjusted life years, or DALYs). Using DALYs as a quality of life measure makes it possible to compare one disease to another, giving a complete view of the global burden of disease.

“It’s a study of everything wrong with everyone everywhere, in all countries for all time,” says Smith. “I mean everything that makes people sick, everything that kills people, everything that causes pain and suffering and the risk factors for those things.” That can include anything from whether you live with an abusive partner to how much lunch meat you consume.

Explosive Results

In 2000 Murray’s team released a new version of the global burden of disease data, analyzing world health between 1990 and 2000 and adding new insights. Rankings of national health systems performance were among those additions—including the famous statistic that the United States has the 37th best health system, despite spending the most per capita.

Controversy erupted. “That generated much greater reaction than anything else,” Murray says. “When you start talking about performance of health systems, you get very close to the job description of the minister of health in a country.”

Some politicians and ministers felt the ranking was a direct threat, an evaluation of how well they did their jobs. (Murray says the clever ones used the results to push for more money.) José Serra was the health minister of Brazil at the time, running a presidential election campaign. “He really went after us at the WHO at the time,” says Murray, “saying that this was not appropriate for the UN to do this. I think the WHO still shows the scars.” Since the conflict, Murray says, the WHO has been enormously reluctant to venture near health care system performance.

A Third Life for GBD

But Murray’s quest still lives. The study’s current iteration, housed at the Institute for Health Metrics and Evaluation in Seattle, analyzes global health data up to 2013. A super-computing cluster is busily whirring away at the University of Washington—supported by more than $100 million in funding from the Gates Foundation—crunching information from sources like hospital and police records to output more than a billion data points.

That data and the approach it drives will go on to accomplish grand things, Murray hopes. Already it’s racking up success stories. Australia used the data to re-map their health systems: In 1970 the life expectancy of the average Australian man was about the same as a man in the United States (about 71). Now, Australia is neck and neck with Japan (80 years).

The same approach worked in Colombia, where Rodrigo Guerrero, mayor of Cali, analyzed data to understand patterns of violence. Deaths were concentrated on weekends, he found, particularly near paydays. Drugs and gangs weren’t the sole cause of gun violence and murders—the devil, in this case, was the dangerous combination of young men, alcohol, and an already violent culture. Guerrero changed where and when booze could be sold and instituted gun bans, cutting shootings and murders nearly by half.

The information Murray and his more than 500 collaborators have gathered is designed to help you lead a better life, too. One of best health interventions for Americans, turns out, is simply to eat more fruit, helping to prevent heart disease and stroke. That’s the beauty of the DALY: It works to identify the root cause of the greatest health threats, whether it’s a dung-filled fire, alcohol-fueled violence, or in the case of American men in their late 30s, processed meat. Sorry, guys: The data doesn’t lie.

Health Evolution Summit – Overview

 

http://www.healthevolutionsummit.com/Default.aspx?PageID=16199729

1:00 pm – 2:15 pm

Pre-Summit Sessions (concurrent)

CEOs of leading providers/payers share their outlook on their critical innovation priorities and highlight respective approaches to vet solutions. A variety of provider/payer executives then connect with innovative CEOs from relevant service, IT and product companies to learn about new solutions and provide insights on the solutions’ value to the market.

Pavillions IV & V

Payer Connect: Where payer executives and innovative CEOs meet

Select health plan CEOs will share their strategic forecasts and the critical innovations necessary to remain competitive in a dynamic market. Payer executives and CEOs of relevant health service, IT and product companies will network briefly to share ideas and make a plan to reconnect pending mutual benefit.

Moderator:
Mike Gaffney, Co-Founder and Managing Director, EDG Partners

Speakers:
Dan Hilferty, President and CEO, Independence Blue Cross
Steve S. Martin, President and CEO, Blue Cross and Blue Shield of Nebraska, Summit Chair

Networking tables will be hosted by:
Aetna – Bjorn Thaler, VP, Head of Corporate Development
Blue Cross & Blue Shield of Nebraska – Steve S. Martin, CEO and Lew Trowbridge, President and Chief Operating Officer
Blue Cross & Blue Shield of North Carolina – Andy Brynes, VP, Strategic Development, Mosaic Health Solutions
Cambia Health Solutions – Ben Albert, Operating Partner, Rob Coppedge, SVP Strategic Investment & Corporate Development
Highmark Health – Nanette DeTurk, EVP, Chief Administrative and Strategy Officer and Treasurer
Independence Blue Cross – Terry Booker, VP of Corporate Development and Innovation, and Tom Olenzak, Managing Director Strategic Innovation Portfolio

Salons I & II

Provider Connect: Where provider executives and innovative CEOs meet

Select provider CEOs will share their strategic forecasts and the critical innovations necessary for their organizations to remain relevant and competitive. Provider executives and CEOs of relevant health service, IT and product companies will briefly network to share ideas and make a plan to reconnect pending mutual benefit.

Moderator:
Robert Wah, MD, Chief Medical Officer, CSC; President, AMA

Speakers:
John Brooks, President and CEO, Joslin Diabetes Center
John D. Doyle, President and CEO, Ascension Holdings
Michael Wagner, MD, FACP, President and CEO, Tufts Medical Center

Networking tables will be hosted by:
Dignity Health – Richard Roth, Chief Strategic Innovation Officer
Hospital Corporation of America – Chip Blaufuss, AVP of Strategic Innovation
Kaiser Permanente – Chris Stenzel, VP of Business Development and Innovation
Stanford Health Care – Kash Kapadia, VP and General Manager, Digital Health
Sutter Health – Peter Anderson, Chief Strategy Officer
Swedish Medical Group – Ralph Pascualy, Chief Executive

2:15 pm – 3:15 pm
The Monarch Bay Sunset Terrace

Alumni Reception

Before the Summit begins, relax and reconnect with fellow alumni. All Summit alumni welcome to attend.

2:15 pm – 3:15 pm
Monarch Pool Terrace

First-Time Participant Welcome

Meet fellow first-time Summit participants. All first-time Summit participants welcome.

General Session: Emerging (and Decaying) Models

The Summit explores the macro implications of emerging (and decaying) models in health and the micro implications that flow from them through a lens that cuts across traditional industry lines of health care services, health IT and life science. Sessions explore the economic underbelly of big issues in search of sustainable business models, directional opportunities and Beachheads.

3:30 pm – 3:45 pm
Salons III & IV

Opening Comments

Patrick Geraghty, Chairman and CEO, GuideWell and Florida Blue, Summit Chair
Ann H. Lamont, Managing Partner, Oak HC/FT Partners, Summit Innovation Chair
Charlie Martin, Chairman and CEO, Martin Ventures
Julie Murchinson, CEO, Health Evolution Summit

3:45 pm – 4:30 pm
Salons III & IV

A Perspective with Steve Hemsley

Interviewer:
Todd Cozzens, Partner, Sequoia Capital, Summit Innovation Chair

Speaker:
Steve Hemsley, CEO, UnitedHealth Group

4:30 pm – 5:20 pm
Salons III & IV

Building the Business Case for High-Priced Therapeutics

Specialty drugs in the U.S. now comprise more than 25% of total pharmaceutical spend and the annual cost per patient can be as high as $100,000 per year. By 2020, the cost of specialty drugs is projected to quadruple and cost the nation more than $400 billion. Is the high-priced approach the new business model for innovation? Are there economically rational reimbursement approaches for certain high-costs diseases? Leaders with high stakes in the game will explore these trade-offs, emerging approaches and financing mechanisms.

Moderator:
Arnold Milstein, MD, MPH, Professor of Medicine, Director of Clinical Excellence Research Center, Stanford University

Speakers:
Joshua Ofman, MD, MSHS, SVP, Global Value and Access and Policy, Amgen
Tim Wentworth, President, Express Scripts

5:20 pm – 6:00 pm
Salons III & IV

The Consumer-Engaged Enterprise

To both attract and retain customers, even the most well-established, integrated delivery networks are striving to re-engineer their approach to consumer-centric convenience and service. Meanwhile, newer companies are striving to demonstrate an entirely new level of consumer experience with tools and delivery models that speak to consumer interests. Hear from an established integrated delivery system and a novel primary care model on what is working and where they are headed.

Moderator:
Brad Fluegel, Chief Strategy and Business, Development Officer, Walgreens Boots Alliance,Summit Partner Committee

Speakers:
Rushika Fernandopulle, MD, MPP, CEO and Co-Founder, Iora Health
Glenn D. Steele Jr., MD, PhD, President and CEO, Geisinger Health System

6:00 pm – 9:00 pm
Dana Lawn

Welcome Event

Dinner served

9:00 pm – 11:00 pm
The Terrace Salon Balcony

Après Dessert and Digestifs

 

APRIL
30
THURSDAY
Print Full Agenda
6:00 am – 7:00 am
The Gazebo

Morning Fitness Boost

Summit Run, hosted by HealthLine

7:00 am – 6:00 pm
Salon Foyer

Registration Open

7:00 am – 8:00 am
The Monarch Bay Courtyard

Breakfast

7:00 am – 8:00 am
Salon I

Breakfast Session

Profitable Innovation: Invention, Commercialization, Execution
Facilitated by Dentons

Facilitated by: Bruce Fried, Partner, Dentons with panelists: Ronald Kuerbitz, CEO, Fresenius Medical Care North America and Ed Dougherty, Principal, Dentons

Senior executives in every sector of the industry are charged with delivering value. Some need to shorten time to market, others need to produce near term ROI, and others still need to deliver quality healthcare services and improve treatment outcomes in an increasingly price-sensitive environment.

On the eve of the Kentucky Derby, we award the ‘Triple Crown’ to healthcare executives, whose success depends on winning multiple races: being responsive to investors, compliant with regulators and innovators, and delivering affordable, high quality products and services for providers and patients. This session will discuss keys to winning the healthcare triple crown including a baseline model, synthesizing the global clinical and business literature, and testing this model against panelist and audience experience and expertise. Participants will leave with a framework within which to test concepts presented throughout the Summit against the real opportunities and constraints of the business of healthcare.

– Description

General Session: Emerging (and Decaying) Models

8:00 am – 9:00 am
Salons III & IV

The CMS Perspective: Where Do We Go From Here?

Interviewer:
Bruce Bodaken, Visiting Scholar, Brookings Institution and former Chairman and CEO, Blue Shield of California, Summit Chair

Speaker:
Andy Slavitt, Acting Administrator, Centers for Medicare & Medicaid

9:00 am – 10:00 am
Salons III & IV

The Real Deal: Taking on High-Cost, Complex Patients at Scale

Despite challenges, we are seeing an incredible wave of new solutions in caring for populations with multiple chronic diseases, more significant behavioral health issues and complex social situations. Many suspect these solutions will have even more opportunities ahead as they transform individual care. Hear payer, investor and innovator perspectives on what can really be achieved and what new opportunities have yet to be tackled.

Introducer:
Guy Eiferman, Senior Vice President, Strategic Planning and Managing Director, Healthcare Services and Solutions, Merck

Moderator:
Mark D. Smith, MD, MBA, Founding President, California HealthCare Foundation, Summit Chair

Speakers:
Adam Boehler, CEO, Landmark Health
Jay M. Gellert, President and CEO, Health Net, Inc.
Leeba Lessin, President and CEO, CareMore Health System
Thomas A. Scully, General Partner, Welsh, Carson, Anderson & Stowe

10:00 am – 10:30 am
The Monarch Bay Courtyard

Morning Break

10:30 am – 11:20 am
Salons III & IV

Size Matters: New Approaches to National Provider Brands

Even the most notable regional systems face a growth dilemma, causing some to explore innovative approaches to national expansion, unburdened by brick-and-mortar models.  Cleveland Clinic and DaVita HealthCare Partners are on the forefront of these efforts, and others are not far behind.  How are best-of-breed providers thinking about scale, how are they ensuring quality and how will they avoid obstacles seen in past waves?

Introducer:
Kris Joshi, PhD, Executive VP, Products, Emdeon

Moderator:
Michael E. Chernew, PhD, Leonard D. Schaeffer Professor of Health Care Policy and Director, Healthcare Markets and Regulation Lab, Harvard Medical School

Speakers:
Toby Cosgrove, MD, President and CEO, Cleveland Clinic
Kent Thiry, Co-Chairman and CEO, DaVita HealthCare Partners

11:30 am – 12:30 pm

Deep Dive Sessions

Salons II
What the Consumer Really Wants: Data Insights into Purchasing Behavior
Hosted by Aon

Facilitated by Matt Levin, EVP and Head of Global Strategy, Aon and Janet Faircloth, SVP, Strategy and Solutions, Aon

+ Description

Pavilion I
Big Brains on the Internet of Things (IoT)
Hosted by Box

Facilitated by Aneesh Chopra, former CTO, White House, President Obama with panelists: Aaron Levie, CEO, Box; Lee Shapiro, former President, Allscripts and Bill Russell, CIO, St. Joseph Health System

+ Description

Salon I
Transparency of Cost and Quality: Changing Consumer Behavior at Scale?
Hosted by Emdeon

Facilitated by Doug Ghertner, President, Change Healthcare and Jason Gorevic, CEO, Teladoc

+ Description

The Plaza
The Next Holy Grail: Strategic Cost Control
Hosted by Healthagen

Facilitated by Charles Kennedy, MD, Chief Population Health Officer, Healthagen

+ Description

12:30 pm – 2:00 pm
The Monarch Bay Courtyard

Lunch

Topic Tables

+ Description

2:00 pm – 2:50 pm
Salons III & IV

Harnessing the Reality of End-of-Life

End-of-life care accounted for over 28% of Medicare’s budget—or $170B spent in the last six months of life for Medicare beneficiaries alone. According to the Institute of Medicine, enhancing the quality of medical and social services at the end of life would create substantial progress toward a sustainable U.S. health care system. Now more than ever, end-of-life services are becoming a strategic industry priority. Two prominent payers and a health system leader will discuss the most critical issues, where best economics are emerging and potential models for advancing management of end-of-life care.

Moderator:
Alexandra Drane, Co-Founder and Chair of the Board, Eliza Corporation; Co-Founder, Engage with Grace

Speakers:
Mark B. Ganz, President and CEO, Cambia Health Solutions, Summit Chair
Wright R. Lassiter, III, President, Henry Ford Health System
Harold L. Paz, MD, MS, EVP and Chief Medical Officer, Aetna

3:00 pm – 4:00 pm

Deep Dive Sessions

Pavilion I

Busting Myths about the 50+: Tracking that Works
Hosted by AARP

Facilitated by Jody Holtzman, SVP Thought Leadership, AARP, with presenter Brad Fain, Principal Research Scientist, Head of the Human Systems Engineering Branch, Georgia Tech Research Institute and panelist Julio Corredor, Director, Worldwide Innovation

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Salon I

The Complexities of Patient Financial Responsibility
Hosted by Availity

Facilitated by Russ Thomas, CEO, Availity with panelists; Alan Levine, CEO, Mountain States Health Alliance, Rob Coppedge, SVP Strategic Investment and Corporate Development, Cambia Health Solutions, and Sam Khashman, President and CEO, Imagine Software

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The Plaza
Agile Health – New Models of Care Need New Models of IT
Hosted by CSC

Facilitated by Robert Wah, MD, Chief Medical Officer, CSC, and President of the AMA and Lisa Pettigrew, Industry General Manager, Global Healthcare, CSC

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Salon II
Zip Code-Driven Health Insights…More Informative than Genetic Code?
Hosted by Optum

Facilitated by Paul Bleicher, MD, PhD, CEO, Optum Labs, and Dave Dickinson, Chief Innovation Officer, Optum Labs

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4:00 pm – 6:00 pm
The Monarch Bay Courtyard

Afternoon Break

4:15 pm – 5:15 pm
The Terrace Salon

Confab of Women Building Impactful Companies

Join an unmoderated discussion among female healthcare leaders focused on what it takes to build strong teams, how to bring out the best “male” and “female” traits, what “female” traits provide distinct advantages, and what women are getting it done and why.

Speakers:
Gail Boudreaux, Former CEO, UnitedHealthcare
Alexandra Drane, Co-Founder and Chair of the Board, Eliza Corporation; Co-Founder, Engage with Grace
Ann H. Lamont, Managing Partner, Oak HC/FT Partners, Summit Innovation Chair
Lisa Suennen, Managing Partner, Venture Valkyr

6:00 pm – 7:00 pm
Pacific Promenade Lawn

Global Health Reception

7:00 pm – 9:00 pm
The Pacific Promenade

The Big Dinner
Global Disease: How New Investment Priorities Are Changing the Landscape

As the Bill & Melinda Gates Foundation works with its partners to transform lives in developing countries, they are acutely focused on tapping into the talent and resources of the private sector. If Ebola taught us anything, low-cost, sustainable solutions need to be created and delivered to ensure not only local and global health, but also economic viability for all. Enter stage left…opportunity. Sue Desmond-Hellmann will share the business case for the global frontier.

Introducer:
Robert Margolis, MD, CEO Emeritus, HealthCare Partners, Summit Chair

Interviewer:
David Brailer, MD, PhD, Managing Partner and CEO, Health Evolution Partners; Chairman, Health Evolution Summit

Speaker:
Sue Desmond-Hellmann, MD, CEO, Bill & Melinda Gates Foundation

9:00 pm – 11:00 pm
The Plaza

Après

Blackjack and poker overlooking the Pacific.

 

MAY
01
FRIDAY
Print Full Agenda
6:00 am – 7:00 am
The Gazebo

Morning Fitness Boost

Summit Boot Camp

7:00 am – 12:00 pm
Salon Foyer

Registration Open

7:00 am – 8:00 am
The Monarch Bay Courtyard

Breakfast

General Session: Disruptive Models

Disruption is happening in pockets, at varying paces and in a variety of ways. In 2015, the Summit explores where new innovations are seeing landfall and the army of others just behind.

8:00 am – 9:00 am
Salons III & IV

Moon Shots on Health

Moon Shots – big thinking and aiming for breakthroughs instead of incremental improvements – this is the Google[x] mandate. Google has disrupted just about everything we can think of, so what are they up to in health? Will they be the creator or a potential competitor? The former head of the largest health plan in the country shares her perspectives on moon shots…potential profiles, obstacles and how the practical realities of the past may be shifting. Together, this session will raise the stakes and foreshadow areas where we see breakthroughs instead of barriers.

Moderator:
Peter Neupert, Operating Partner, Health Evolution Partners and Former Corporate VP, Microsoft Health Solutions Group, Summit Chair

Speakers:
Gail Boudreaux, Former CEO, UnitedHealthcare
Andy Conrad, PhD, Head of Life Sciences, Google

9:00 am – 9:30 am
Salons III & IV

Consumer On Ramps – Disruptive Models Creating Value

As health care endeavors to engage consumers in their health, some companies are also beginning to create efficiencies, support evolving reimbursement streams and position for value creation. From searching for health information to being monitored remotely; from the healthy consumer to those managing chronic disease or facing acute conditions—the early adopters are contributing to the new health economy. This session will highlight a few innovators disrupting information flow and creating value through the holy grail of the consumer engagement.

Moderator:
Brandon H. Hull, Managing General Partner, Cardinal Partners, Summit Innovation Chair

Speakers:
Eric Rock, CEO, Vivify Health
Ben Wolin, CEO and Co-Founder, Everyday Health

9:30 am – 10:25 am
Salons III & IV

Corporate Venture Takes Hold of Health Care

Creating a corporate venture group is certainly one of the hippest strategies to hit the health industry in years. And while these ventures all hope to capitalize on the next biggest disruption to hit the market, they will not all look the same in their pursuits. Hear what disruptive models are on the horizon, what factors are being considered and what you can expect.

Introducer:
Mark Speers, Partner and Managing Director, Health Advances, LLC

Moderator:
Lisa Suennen, Managing Partner, Venture Valkyrie

Speakers:
Rob Coppedge, SVP Strategic Investment and Corporate Development, Cambia Health Solutions
Dave Schulte, Managing Director, Kaiser Permanente Ventures
David Stevenson, Managing Director, Global Health Innovation Fund, Merck
Rafael Torres, Head of Healthcare, GE Ventures

10:25 am – 10:30 am
Salons III & IV

Comments and Transition to Innovation Activities

Julie Murchinson, CEO, Health Evolution Summit

10:45 am – 1:00 pm
The Plaza

Corporate Venture Action Group

Innovation Activities (concurrent)

Innovators and health leaders roll up their sleeves in an intimate and interactive setting to explore opportunities.

10:40 am – 11:40 am
Salon I

Innovations with Traction: Straight Talk from Customer CEOs

Patient retention and new patient acquisition have always been strategic imperatives, but their importance has risen to mission critical in the transition from fee-for-service to fee-for-value. While these areas may have great impact on both risk of lost revenue and new growth opportunities, they have not been easy problems to solve—and several innovative solutions have stalled. A leading health system CEO talks with innovators about the range of challenges health systems are facing, the approach that different companies are taking and the successes that organizations are experiencing to ensure true value is realized.

Facilitator:
Roy Smythe, MD, Chief Medical Officer, AVIA

Speaker:
Rodney F. Hochman, MD, President and CEO, Providence Health & Services

Innovators:
Mark Hefner, CEO, Infina Connect Healthcare Systems
Oran Muduroglu, CEO, Medicalis

10:40 am – 11:40 am
Pavilion II

Disruption in Progress: Designing for the Consumer

Innovators and health care leaders on the consumer front lines retreat to the boardroom to explore how best to design for the consumer. Innovators are encouraged to roll up their sleeves in this intimate discussion exploring critical needs, while potential payer, provider and retailer customers help to inform design and their approach.

Facilitator:
Joshua Riff, SVP, Consumer Products, Optum

Contributors:
Rushika Fernandopulle, MD, MPP, CEO and Co-Founder, Iora Health
Jeffrey Kang, SVP, Health and Wellness, Services and Solutions, Walgreens Boots Alliance
Tej Shah, SVP, Business Development, Blue Cross Blue Shield of Louisiana

10:40 am – 11:40 am
Pavilion III

Disruption in Progress: Where Life Science Is Headed:
Opportunities Beyond the Pill

Innovators and life science leaders retreat to the boardroom to explore new opportunities beyond the pill. Innovators are encouraged to roll up their sleeves in this intimate discussion exploring critical needs, while potential pharma, biotech and medical device customers inform their solutions and their approach.

Facilitator:
Naomi Fried, PhD, VP of Innovation, Medical Information and External Partnerships, Biogenidec

Contributors:
Guy Eiferman, SVP, Strategic Planning and Managing Director, Healthcare Services and Solutions, Merck
Diego Miralles, MD, Global Head of Innovation, Janssen Pharmaceuticals, Johnson & Johnson
Pascale Witz, EVP, Global Divisions and Strategic Development, Sanofi

11:45 am – 12:45 pm
Pavilion IV

Disruption in Progress: Care Delivery Innovation

Innovators and health care leaders on the front lines of care delivery retreat to the boardroom to explore how to best to design solutions to improve care and reduce cost of delivery. Innovators are encouraged to roll up their sleeves in this intimate discussion exploring critical needs, while provider executives share the value they are seeking and how potential solutions are vetted behind closed doors.

Facilitator:
Molly Coye, MD, Chief Innovation Officer, UCLA Health System

Contributors:
Lyle Berkowitz, MD, FACP, FHIMSS, Associate Chief Medical Officer of Innovation, Northwestern Memorial Hospital
Chip Blaufuss, Assistant VP Strategic Innovation, Hospital Corporation of America
Birthe Dinesen, Professor, Department of Health Science and Technology, Aalborg University (Denmark)
Chuck Dowling, CEO, DiabetesAmerica

11:45 am – 12:45 pm
Pavilion V

Disruption in Progress: Connecting with Capital

Innovators and seasoned investors retreat to the boardroom to connect on the capital landscape: opportunities on the horizon, what investors are seeking, and what they may require in the coming years. Innovators are encouraged to roll up their sleeves in this intimate discussion to ask their burning questions and to hear from the veterans.

Facilitator:
Jodie Emery, Partner Healthcare and Private Equity, Caldwell Partners

Contributors:
Thomas Carella, Managing Director, Merchant Banking Division, Goldman Sachs
Brandon H. Hull, Managing General Partner, Cardinal Partners, Summit Innovation Chair
Noah Knauf, Managing Director, Warburg Pincus
Ravi Sachdev, Partner, Clayton, Dubilier & Rice

Jeffrey: On millimorts and microlives…

Very good, very interesting piece on risk measurement and reporting…

http://www.jeffreybraithwaite.com/new-blog/2014/11/20/youll-be-dying-to-hear-about-this

You’ll be dying to hear about this

There’s lots of death in the world. Transport is risky, for instance—planes, automobiles, trains and ships can crash, maiming or killing passengers. You don’t have to go much further than seeing the road toll, or hearing about Malaysian Airlines Flight MH17 shot down over the Ukraine, or watching the TV scenes of the Costa Concordia, run aground just off Isola del Giglio near the coast of Italy, to appreciate that death is never far away.

Then there’s infectious diseases. You can all-too-readily catch a cold, or the flu, or TB, or lately, the Ebola virus. And there seem to be never-ending wars and skirmishes in the Middle East; and terror, spread by fundamentalists.

Each of these, depending on fate, can hasten someone’s demise. Wrong place, wrong time, wrong circumstances.

Lifestyle issues can cause problems for your risk profile too—but these are slower, and more stealthy. Think of smoking, drinking too much, eating yourself into a coma or just gross obesity, or the more insidious dangers of sitting at a computer for years on end with little exercise. These can translate over time into heart or lung disease, diabetes, and cancer.

Whether you are active or passive, things you do or don’t do can shorten your lifespan, or kill you a little or a lot faster than you would otherwise last. So what levels of risk do you actually, quantitatively, face in your own life?

*****

Stanford University decision scientist Ron Howard in the 1970s presented a novel way to calculate this risk. He introduced the idea of the micromort, defined as a one-in-a-million likelihood of death.  This is such an evocative unit of measurement that it deserves a little further attention.

If you live in the US or another relatively rich, OECD-style country, with good law and order, legislation that keeps society relatively risk free (such as with environmental and public health issues sorted out, effective building codes, and so forth), a well-educated population, access to health care, and a buoyant GDP, you can expect a micromort of one on any particular day. Another way of saying this is that’s the standard expected death rate for any individual today in any one 24 hour period: a microprobability of one in a million is your index of baseline risk.

These are great odds for you, today, as you read this; you are very likely to get through it. Congratulations if you do.

What circumstances lead to an elevated risk? Say if you do dangerous things or even just live life to the full? How does your micromort level get upgraded?

In the United States, you accumulate an extra 16 micromorts each time you ride a motorcycle 100 miles, for instance. Or 0.7 micromorts are added for each day you go skiing; so go for a week and you’ve added five more.

Or you might decide to do something a little more strenuous. With hangliding, the additional risk of dying equates to eight micromorts per flight; or skydiving, nine per freefall.

They are relatively benign compared to moving up to base-jumping. Do so, and you rapidly earn many more risk points: 430 micromorts per jump, in fact.

Marathon running, anyone? That will be seven micromorts to your debit account for each run. Even walking 17 miles adds one micromort, as does a 230 mile car trip, and add another one for every 6,000 mile train trip. But the puzzle is, it’s not always clear how to treat these: the walking introduces an element of risk (you could be out and about and get run over, or be struck by lightning) but it’s also beneficial (it contributes to improved health).

Perhaps even more interesting, there are microprobabilities associated with accumulated chronic risks in contrast to these other single-shot event risks. These are lifestyle choices and behaviors that incrementally add a little more risk through exposure. They won’t kill you if you have bad luck on a given day, but will slowly have an effect—and may claim you in the end.

Every half a liter of wine exposes you to a micromort because it can accrue into cirrhosis of the liver. Each one and a half cigarettes does the same, but the menace here is cancer or heart disease. Even eating 100 char-broiled steaks, 40 tablespoons of peanut butter or 1,000 bananas sneaks up on you in the form, respectively, of cancer risk from benzopyrene, liver cancer risk from aflatoxin B or cancer risk from radioactive potassium-40.

*****

Hang on though. I doubt I’ve done much to help anyone.

Because a clear problem is that people aren’t very good at doing these kinds of statistics, or applying them to their own lives—and are even less capable of acting on them. We can readily appreciate that skiing or motorcycling add some risk for the time you are doing them compared to the everyday activities of being at work or hanging out at home, yet many people are undeterred. People even cheerfully find ways of taking on more risk, such as by climbing Everest, driving fast cars, or having unsafe sex.

Everyone knows about that steadily accumulated risk, too: not too many of us are blind to the fact that drinking too much alcohol can lead to liver disease or smoking to lung cancer over time. And although both have been falling for decades, this hasn’t stopped millions of people indulging. There’s 42.1 million US smokers at last count, or 18.1% of the population, and on average each adult US citizen consumes 8.6 liters of alcohol annually.

This is not the best performance internationally but is by no means high by international standards, and Eastern Europeans smoke more heavily, and really give hard booze like vodka a nudge.  Nevertheless, both activities contribute to what public health people quaintly call excess deaths and the rest of us know by “their drinking or smoking (or both) killed them eventually.”

But what does it actually mean that you expose yourself to increased risk if you go out walking regularly or eat bananas?  We need another way of looking at this, because it’s too hard to do the sums.

*****

Enter the University of Cambridge medical statistician David Spiegelhalter and his colleague Alejandro Leiva who invented the idea of a microlife. This is another unit of risk which has the calculation built in for you. It is half an hour of your life.

If you increase your risk by one micromort, then this shortens your life by half an hour. These calculations apply to people on average, and work out for entire populations, but any one of us might be lucky or unlucky, depending on our individual characteristics. Any particular risk doesn’t convert exactly to the specific individual. But with enough people in the US (beyond 316 million now) and on the planet (7 billion and rising), there’s a relentlessness accuracy about the statistics.

So now let’s do some life expectancy math with Spiegelhalter. Smoke a pack a day? You lose up to five hours a day. Accumulated, that’s up to eight years off your life. Have six drinks a day and that binge costs you one half hour allocation—a shortened life by ten months or so. Stay eleven pounds overweight and you sacrifice half an hour every day you do so (another ten months across your lifespan), as you do if you watch TV for two hours. Your coffee habit at 2-3 cups daily takes away another half hour lot. So does every portion of red meat each day. Another ten months each time.

It’s not all negative. There’s good news. Eat five serves of fruit and vegetables every day and you gain up to a couple of hours each time. You get three years back. Exercise and the first 20 minutes per day earns you a surprising hour (there’s a good investment—a year and a half), and each subsequent 40 minutes adds up to one more half hour bonus to your credit (a bit more work but that seems a pretty good deal, too, to get a ten month return).

If you have a hobby, activity or diet and it’s not been dealt with so far, you can fill in some of the gaps with some good guesstimates. Do you have passive pursuits, akin to watching TV? This is a net deficit. Do you do active, exercise-oriented activities, such as weekly amateur netball, soccer, bowling or basketball—or just walking regularly? Add some lifespan.

These half hour allocations alter somewhat depending on your genetics of course (you can have lucky or unlucky genes) or your socioeconomic status (wealthy people typically live longer than poorer folks) or your gender (women on the whole live longer than men). That said, with this idea you are now able to alter your risk profile by changing your behavior with a tangible, calculable return.

*****

There’s a punchline to this, and it may be already occurring to you as you reflect on your own lifestyle and lifespan. There are a million microlives in fifty seven years of existence. That, for many of us, is roughly the adult allocation.

Let’s call that your life expectancy baseline. We can assume that you have had a reasonably healthy childhood (not so for everyone, of course, but true for many US children, and true for most readers). Then, from that point on, a large part of your healthy adult life is now measureable.

So: come out of your teens, reach your 21st birthday, and as the “jolly good fellow” and “happy birthday to you” songs subside, imagine you then have 57 years to go. That is, you have an allocation of 78 years in total, maybe a little longer, maybe a little shorter.

Yes, all sorts of unexpected things might happen along the way, but to some degree your lifespan is now no longer vague, but quantifiable. The actual life expectancy in the US indeed hovers around this: it’s 79.8 years overall, 77.4 for males and 82.2 for females. (It’s higher in some northern European countries and Japan, but that’s a story for another day).

However, you might be reading this thinking: Yikes. I’m not 21: I’m a bit older than that. In this case, you’ve already used up a proportion of your time left. Console yourself. At least you got through the riskiest stage of all: being a baby, up to one year of age, and childhood, up to six or so, when many things can go wrong.

But have you used what you were given so far, well? Or do you have a fair bit of regret?

To make an obvious point, however, this isn’t Doctor Who. You don’t have a Tardis to go back in time and fix the past. So stop any lamentations. Look forward.

By now, if you’ve come to value more readily each half hour and especially the cumulative effect of your lifestyle choices to date, don’t listen to me preaching. Feel completely empowered. You know what to do and how to alter your own numbers.

Now, all that’s left is to do the math. You’ll have a much clearer picture of your life and potential death than ever before. It’s your move: what’s next?

Further reading

Blastland, Michael and Spiegelhalter, David (2014). The Norm Chronicles: Stories and Numbers About Danger and Death. New York: Basic Books.

Howard, Ronald (1984). On fates comparable to death. Management Science 30 (4): 407–422.

Spiegelhalter, David (2012). Using speed of ageing and “microlives” to communicate the effects of lifetime habits and environment. British Medical Journal 345: e8223.

Spiegelhalter, David (2014). The power of the MicroMort. BJOG: An International Journal of Obstetrics & Gynaecology 121 (6): 662–663.

NextGen Managed Care Priorities

 

http://www.ajmc.com/publications/issue/2015/2015-vol21-n4/Redefining-and-Reaffirming-Managed-Care-for-the-21st-Century

Redefining and Reaffirming Managed Care for the 21st Century

Published Online: April 15, 2015
David Blumenthal, MD, MPP; and David Squires, MA
T he term “managed care” is dangerously close to meaninglessness, and unlike pornography, as famously stated by United States Supreme Court Justice Potter Stewart, we may not even recognize it when we see it. Group Health Cooperative of Puget Sound, Kaiser Permanente, and Geisinger are managed care organizations (MCOs). But so are Medicaid plans that—after taking a cut—pay the clinicians’ fee for service and call it a day. The MCO alphabet soup has come to include HMOs, PPOs, ACOs (MSSP and Pioneer), MA plans, PCMHs, IDNs, IPAs, and who knows what else. The very concept of managed care, with its somewhat paternalistic implication of organizational and/or clinician direction of care, seems to run crosswise of the emergent trend toward patient engagement in and control over the care experience.1

Still, few consumers want care that is completely unmanaged, and clinicians talk every day about the management of their patients’ problems: the management of chronic illness and acute illness, of diabetes and appendicitis, of schizophrenia and depression. The optimal management of care, and the creation of policy and organizational environments that facilitate it, continue to have deep intuitive resonance. It is time to retool the term managed care for the 21st century.

That process should start with a review of the major domains of service that can and should be managed for the benefit of patients, and by addressing the seeming—but not inherent—contradiction between care management and patient engagement and empowerment. These are the tasks we set out to do here.

Benefits Management

Certain types of MCOs serve as both insurer and provider. These organizations have to manage benefits as part of the managed care experience.

Clinical benefits management in this setting covers services whose value is supported by evidence. Based on insights from comparative effectiveness research, benefits management should exclude or discourage the use of services shown to be unsafe, ineffective, inferior to alternatives, or not cost-effective. Financial or nonfinancial incentives can also be developed to help shape patients’ choices, such as cost-sharing schemes to nudge patients toward highly effective services. The area of behavioral economics offers useful insights into how to manage proven benefits most effectively.

Clinical Management

Proper care management involves the application by clinicians and MCOs of a series of clinical strategies and techniques that are likely to result in better-coordinated, cost-effective, patient-responsive, and high-value services. These approaches include:

• proactive management of conditions between visits;

• good information systems with clinical decision support;

• predictive analytics to identify patients most likely to benefit from intervention;

• use of patient registries;

• care teams that include a variety of clinicians;

• strategies to address the nonmedical determinants of health;

• management of patient experience, informed by patient surveys; and

• an emphasis on shared decision making.

Clinical management techniques can be employed in any setting, but are likely to be easier and more successful when supported by an infrastructure that enables collaboration and information-sharing across providers, between patients and providers, and even among patients where appropriate. This infrastructure can be provided by external organizations or developed in-house, but will always need to be tailored to the local contexts.

Patient Engagement

Finally, it is important to broaden the concept of care management to include patients as managers of their care experience. For patients with health problems, self-management (or co-management with a clinician) is a powerful tool. For this reason, patient engagement is the third domain of managed care.

As with clinical management, patient engagement can occur anywhere, but is most likely to succeed when supported by an underlying infrastructure. One area where this infrastructure is rapidly developing is the growing market of consumer-directed health information technology products. Patient portals, for example, allow patients to remotely connect with their clinicians or access their medical records, and OpenNotes developers are experimenting with enabling patients to add to provider records. Important new opportunities are arising for patients to voluntarily augment their health information through apps, smart watches, biosensors, and other innovations coming down the tech pipeline.

Another strategy for empowering patients is to improve transparency—in other words, give them reliable information on quality and cost. Such information is currently mostly unavailable or shielded behind proprietary contracts. Having it available when patients need it and in a form that they can understand is necessary for them to make treatment choices and fully participate in shared decision making.

These and other methods for elevating patients’ agency and decision making are increasingly demanded by patients, and they should be part of the managed care concept for the 21st century.

Author Affiliation: The Commonwealth Fund (DB, DS), New York, NY.

Source of Funding: None.

Author Disclosures: The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff.

Author Information: Concept and design (DB, DS); drafting of the manuscript (DB, DS); critical revision of the manuscript for important intellectual content (DB, DS).

Address correspondence to: David Blumenthal, MD, MPP, The Commonwealth Fund, 1 E 75th St, New York, NY 10021. E-mail: db@cmwf.org.

REFERENCES

1. Binder L. Value-based purchasing versus consumerism: navigating the riptide. American Journal of Accountable Care. 2015;3(1):11-14.

– See more at: http://www.ajmc.com/publications/issue/2015/2015-vol21-n4/Redefining-and-Reaffirming-Managed-Care-for-the-21st-Century#sthash.701lslWB.dpuf

The Life Insurance Model kick starts in the US

http://www.nytimes.com/2015/04/08/your-money/giving-out-private-data-for-discount-in-insurance.html

Giving Out Private Data for Discount in Insurance

By

Michael Doughty, president of John Hancock Insurance, stretches in Boston. Hancock will offer a program that tracks policyholders’ medical data and offers discounts for healthful behavior. Charlie Mahoney for The New York Times

Andrew Thomas’s life insurer knows exactly when he arrives at his local gym. The company is notified when he swipes his membership card, and 30 minutes later, it checks that he is still there, tracking his location through his smartphone.

The insurance company has a vested interest in keeping Mr. Thomas alive and well. In return for sharing his exercise habits, his cholesterol level and other medical information, Mr. Thomas, a 51-year-old medical publisher who lives in Johannesburg, earns points, which translate into premium savings and other perks. By staying in good shape, it is less likely that Discovery, his insurer, will have to pay out his life and disability policies.

“Every Saturday morning, just for playing golf, I get points,” said Mr. Thomas, who said he received about 9 percent back on his life insurance premiums for each of the last five years. “It is trying to make people live a health y lifestyle.”

Now John Hancock will become the first life insurance company to introduce a similar program for American consumers. The program, being announced Wednesday, will apply to both term and universal life insurance policies and is being operated through a partnership with Vitality, a global wellness company that already works with employers and health insurers in the United States.

The concept — which has been used in South Africa, where Vitality is based, Europe, Singapore and Australia — has the potential to transform the way life insurance is priced, at least for consumers who are willing to continually share their health data. But it also raises questions about how that information will be protected — and whether it could be used in ways that ultimately work against a consumer’s best interests.

People who sign up will receive a free Fitbit monitor, which can be set to automatically upload activity levels to the insurer. The most active customers may earn a discount of up to 15 percent on their premiums, in addition to Amazon gift cards, half-price stays at Hyatt hotels and other perks.

John Hancock, a division of Canadian insurer Manulife Financial, says it hopes the program will help reinvigorate life insurance sales, which have stagnated industrywide for decades. Just 44 percent of households in the United States own individual policies, according to Limra, a trade group, a 50-year low. Any product that reminds consumers of their mortality is hard to get excited about, but industry analysts said that financially strained households, changing demographics and increasingly complex and expensive products have led to the decline in sales.

“It has been a slow to no-growth industry for a long time,” said Michael Doughty, president of John Hancock Insurance, based in Boston. “It is crying out for innovation and for someone to try to reinvent the product to make it more relevant.”

The new program also upends the traditional approach to life insurance underwriting, which typically bases its pricing on a detailed but static snapshot of a person’s medical status. Now, John Hancock’s term and universal policies will be priced continuously, at least for consumers who choose the Vitality program.

John Hancock and Vitality, which is owned by Discovery, said the information would not be sold and would be shared only with entities that help with the program’s administration, though the aggregate data could be used to inform the development of new insurance products.

Nonetheless, some specialists expressed privacy concerns.

“All of a sudden, everything you do and everything you eat, depending on which bits of the information they collect, is sitting in someone’s database,” said Anna Slomovic, lead research scientist at the Cyber Security Policy andResearch Institute at George Washington University and a former chief privacy officer at Equifax and Revolution Health.

Of course, buying any life insurance policy requires customers to share detailed medical histories upfront. But consumers participating in the Vitality program must be comfortable providing enough information continuously to meet certain thresholds that will convert into worthwhile savings. That might include the frequency of workouts, reporting a physical exam or answering sensitive personal questions: During the last 30 days, how often did you feel so nervous that nothing could calm you down? Hopeless? Depressed?

“You do not have to send us any data you are not comfortable with,” Mr. Doughty said. “The trade-off is you won’t get points for that.”

Participants need to amass 3,500 points to achieve silver status, 7,000 to reach gold and 10,000 for platinum. Nonsmokers automatically earn 1,000 points, and people with in-range cholesterol, glucose and blood pressurewill receive 1,000 points for each. A “verified” standard workout three times a week, or an advanced workout twice a week, provides another 3,120 points over the course of a year. Flu shots, 400 points. The clock is reset each year, though 10 percent of points may carry over.

All customers participating in the program will start by paying a premium priced at the gold level. That is a discount of about 9 percent for a 45-year-old man who bought a $500,000 term insurance policy that covered a 20-year period: He would pay $750 annually, compared with the $825 it would cost outside of the Vitality program.

So what if he does everything right, but breaks his leg? Or worse, gets a serious disease like cancer? While those conditions would not directly affect his rate, if he could not maintain gold status for any reason, he could see premium increases of 1.1 to 1.6 percent each year. But if he reached platinum status, his premiums would fall by about 0.30 percent each year.

The program may attract healthier people who have already engaged in these activities on their own. The strategy also tries to tap into the way humans are naturally wired: There is generally no immediate tangible benefit to life insurance, but this program is structured to try to change that.

“People respond far more to immediate gratification than delayed gratification,” said Dr. Kevin Volpp, director of the Center for Health Incentives and Behavioral Economics at the Leonard Davis Institute. (He has performed research sponsored by Vitality.)

The number of points assigned to a particular activity is determined by how it will influence a person’s longevity, based on Vitality’s internal findings — and its level of difficulty. “Stopping smoking is more valuable than one session of activity,” explained Alan Pollard, chief executive of Vitality. “If something is a complex behavioral change, it will attract more points.”

Vitality’s research has found that Americans are generally five years older than their actual age, after taking into account various health and wellness factors. All participating policyholders will be given a “Vitality age,” which will help the program set personal guideposts.

“The people who have the time to devote to jumping through all the hoops are likely to be better off than average, and those healthy enough to do wellness activities may be unrepresentative of the chronically ill,” saidFrank Pasquale, a professor at University of Maryland Carey School of Law. “I believe that is one reason why there is empirical research severely questioning the value of wellness programs.”

John Hancock, which operates in all 50 states, said the universal life program had been approved by insurance regulators in 30 states, while the term program is available in 20 states; more states are expected to be announced throughout the year. It said no regulators had declined to approve it yet.

“It changes the paradigm of life insurance,” Dr. Volpp said. “In some sense, it tries to change your insurance into less of a passive vehicle that pays the bills if something happens, into a more active vehicle to get people to lower their risk.”

Harvard Business School/Harvard Medical School – Healthcare Innovation

 

Peter Orzack (citi) on the economics and financing of health. Gave interesting insights into potential unintended consequences of transparency (aside from reduced variation), could get collusion.

Drugs and devices require RCT level evidence to be enacted, but health financing policy can be done from the hip.

Risk adjustment will be improved by clinical (EMR) level data. At present, claims-based risk adjustment can predict only 10% of future spending whereas clinical data + SES data can predict 40%

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Note “Micro Kale” on the menu:WP_20150415_013

Mark T. Bertolini, CEO of Aetna, presenting one of the most powerful speeches on health care reform and renewal of corporate america I’ve every heard.

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WP_20150415_015Also had an extended conversation over dinner with Ceci Connolly (MD, PWC Health) spoke with Halle Tecco (CEO, Rock Health) and Luc Sirois (Hacking Health, coming to HISA’s HIC 2015), Dr Paul Tang (Paolo Alto Medical Foundation) and Kaiser Permanente (polypill work).