Entries in Riddle, Clive (307)

Friday
Jun222018

A Visit to Planet Gawande

By Clive Riddle, June 22, 2018

We still don’t know much at all about what the heck the Amazon-Berkshire-JPMorgan healthcare triumvirate will be doing. But we do now know who will be running it. The renowned Dr. Atul Gawande has been appointed its Chief Executive Officer, effective July 9th.

https://upload.wikimedia.org/wikipedia/commons/thumb/5/56/Atul-Gawande_%28cropped%29.jpg/220px-Atul-Gawande_%28cropped%29.jpg

 The announcement quotes Atul: “I’m thrilled to be named CEO of this healthcare initiative. I have devoted my public health career to building scalable solutions for better healthcare delivery that are saving lives, reducing suffering, and eliminating wasteful spending both in the US and across the world. Now I have the backing of these remarkable organizations to pursue this mission with even greater impact for more than a million people, and in doing so incubate better models of care for all. This work will take time but must be done. The system is broken, and better is possible.”

Amazon’s Jeff Bezos says “we said at the outset that the degree of difficulty is high and success is going to require an expert’s knowledge, a beginner’s mind, and a long-term orientation. Atul embodies all three, and we’re starting strong as we move forward in this challenging and worthwhile endeavor.”

For those who don’t already know all there is to know about Atul Gawande, let’s take a quick visit to Planet Gawande and check out the man who will be commanding the mystery ship Amazon-Berkshire-JPMorgan.

Atul’s website homepage succinctly provides this description: Atul Gawande is a staff writer for The New Yorker, and author of four books; (2) Atul Gawande practices general and endocrine surgery at Brigham and Women’s Hospital; and (3) Atul Gawande is Executive Director of Ariadne Labs, a joint center for health systems innovation. Of course, item #3 will require editing. As the already updated Ariadne Labs website announces “Atul Gawande transitions to Chairman and becomes CEO of new health care organization.”

What are Atul’s roots? He was born in 1965 in “Brooklyn, New York, to Indian immigrants to the United States, both doctors. His family soon moved to Athens, Ohio, where he and his sister grew up, and he graduated from Athens High School in 1983.”

As an undergraduate and in medical school, he dived into the worlds of politics and healthcare policy. He volunteered for Gary Hart's and Al Gore's presidential campaigns. He served a health-care researcher for Rep. Jim Cooper (D-TN). He became Bill Clinton's healthcare lieutenant during the 1992 campaign. He served as senior HHS advisor after Clinton's inauguration and directed one a committee in the Clinton Health Care Task Force, before returning to medical school, re3ceiving his MD in 1995.

During his residency his career as a writer launched with Slate, and soon he was writing essays for the New Yorker. His June 2009 New Yorker essay, The Cost Conundrum was widely read and influential,  in which he compared the health care of two towns in Texas to show why health care was more expensive in one town compared to the other.. He continues to occasional whip out New Yorker Essays, with these being the titles of his works during the past 18 months:

  • Curiosity and What Equality Really Means, The New Yorker, Jun 2, 2018
  • Is Health Care a Right?, The New Yorker, Oct 2, 2017
  • How the Senate’s Health-Care Bill Threatens the Nation’s Health, The New Yorker, Jun 26, 2017
  • Trumpcare vs. Obamacare, The New Yorker, Mar 6, 2017
  • Trumpcare, The New Yorker, Feb 27, 2017
  • The Heroism of Incremental Care, The New Yorker, Jan 23, 2017

He has also written more technical papers and studies in journals including the New England Journal of Medicine and has authored four books:

Of Gawande’s most recent book, Malcolm Gladwell wrote, “American medicine, Being Mortal reminds us, has prepared itself for life but not for death. This is Atul Gawande’s most powerful – and moving – book.”

Of course, the platforms from which Gawande has drawn the experiences and perspectives that he writes about is from being a clinician, researcher and academian. He practices general and endocrine surgery at Brigham and Women's Hospital in Boston, Massachusetts. He is a professor in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health and the Samuel O. Thier Professor of Surgery at Harvard Medical School.

His outside affiliations have included Ariadne Labs where he has been Executive Director, Lifebox, Safesurg.org, WHO Safe Surgery Saves Lives initiative and the Center for Surgery and Public Health.

Ariadne Labs might be the most instructive, in regard to the approaches Guwande might take in his new gig. Ariadne Labs is a joint center between Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, founded in 2012 by Gawande and others.

Here’s more about Ariadne Labs direct from their website – which says their mission is “to find solutions to some of the most complex problems in health care, including life-threatening errors in surgery, maternal and neonatal mortality, failures in end-of-life care, and fragmented and ineffective primary health care systems. Leveraging a network of expertise across the Harvard-Brigham system, Ariadne Labs’ designs, tests, and spreads simple solutions to address failures in health care delivery worldwide.”

Here’s what Ariadne Labs lists as its more prominent innovations:

  • The Surgical Safety Checklist, developed in collaboration with the World Health Organization, shown to reduce post-surgical deaths and complications by 47 percent worldwide.
  • OR Crisis Checklists, a compendium of 12 checklists to guide surgical teams through critical lifesaving steps when sudden emergencies occur in the OR. In simulation testing, Ariadne Labs demonstrated that when the checklists are not used, clinical teams completed only 77 percent of lifesaving steps in an emergency. When the teams used the checklists, they completed nearly 100 percent of lifesaving steps.
  • The Safe Childbirth Checklist, developed with the World Health Organization to address the major causes of maternal and neonatal mortality. Implemented with Ariadne Labs BetterBirth Program of peer-to-peer coaching, the intervention has demonstrated significant improvement in the quality of care during labor and delivery in low-resource settings.
  • The Delivery Decisions Team Birth Project, a solution package aimed at reducing C-section rates in the U.S. by improving communication between clinicians and laboring women, defining the basic care women in labor should receive and prioritizing women’s preferences for care. The project is being tested with tens of thousands of patients across the United States.
  • The Serious Illness Conversation Guide, a structured tool to help clinicians and patients have meaningful conversations about what matters most to patients. The guide is the centerpiece of the Serious lllness Care Program, a systems-level intervention to ensure that all patients with serious illness receive care that aligns with their goals and values.
  • The Primary Health Care Vital Signs, a global data resource for measuring and monitoring the strength of primary care systems in countries around the world, developed with the World Bank, WHO, and the Bill and Melinda Gates Foundation as part of the global Primary Health Care Performance Initiative.

We’ll all stay tuned to see what happens next on Planet Gawande.

 

Friday
Jun152018

Healthcare Organization Mobile Device Use: Check That Pager

By Clive Riddle, June 15, 2018

The list of benefits derived from mobile device use by clinicians and staff at healthcare organizations is a long one. But the challenges exacted comprise a worrisome list topped by privacy and cybersecurity concerns. Organizations who promote or allow BYOD (Bring your own device) of course have significantly enhanced concerns.

So in this context its worthwhile to take a gander at the eighth annual Spok survey report: Mobile Strategies in Healthcare Results Revealed. The good news is that 57% of healthcare organizations surveyed have developed a documented mobile device strategy. The bad news is 43% have not.

They respondents say these are the challenges they are facing

  • Wifi coverage – 51%
  • Cellular coverage – 40%
  • Data security – 34%
  • Compliance with BYOD policies – 34%
  • IT support – 29%
  • Mobile adoption rates – 28%

For those with a strategy, here’s the top seven components included:

  1. Mobile management and security - 56%
  2. Mobile device selection - 51%
  3. Integration with the EHR - 48%
  4. Infrastructure assessment (wireless and mobile) - 45%
  5. Clinical workflow evaluation - 43%
  6. Device ownership strategy (such as BYOD) - 34%
  7. Mobile app strategy (in-house, third-party, hybrid) - 29%

How well are these policies enforced? 39% said extremely well, 33% said well. 24% weren’t sure and an honest 4% said poorly. With respect to validating compliance, 48% use education, 42% gather data from the devices, 37% seek feedback from the end user, 23% take surveys, and an honest 21% said they aren’t doing any validation.

With respect to devices they organization supports, 74% said smart phones, 69% wifi phones, 56% onsite pagers, 54% tablets, 45% wide area pagers, 22% encrypted pagers, 12% voice badges and 6% wearables.  

Perhaps the biggest surprise I found in the report was this passage: “Pagers are still a mainstay in healthcare. Despite the growth of other communication tools, they remain at a relatively high level of use as other mobile devices complement them (without necessarily replacing them altogether). In fact, onsite pagers are the most popular communication option for non-clinical care team members such as housekeepers, transport techs, and phlebotomists.” For non-clinical staff 54% listed some type of pager as their primary communication device (onsite 40%, wide area 10% or encrypted 4%/) Wifi phones came in at 15% and smartphones at 14%.

Thursday
Jun072018

The 260 Page 2018 Annual Medicare Trustees Report and the Part D Rx Share of the Pie

By Clive Riddle, June 7, 2018

 

This week CMS released the 2018 Annual Medicare Trustees Report, which provides a financial/actuarial analysis of the current state of the Medicare Fund, and projections regarding the Fund solvency going into the future.  The big takeaway always emphasized from the report is at what year in the future will the Fund become insolvent, but there really is a lot of historical information in the report worth a gander.

 

In regard to when the Fund is projected down, we are told the “Trust Fund will be able to pay full benefits until 2026, which is three years earlier than last year’s projections, attributable to adverse changes in program income. The Trustees project that total Medicare costs (including both HI and SMI expenditures) will grow from approximately 3.7 percent of GDP in 2017 to 5.8 percent of GDP by 2038, and then increase gradually thereafter to about 6.2 percent of GDP by 2092.”

 

But in addition to the voluminous portion of the report dedicated to projections taking us to near the end of the century, there’s plenty of history and present tense buried in the 260 page report as well. Here’s a snapshot from the report of Medicare in 2017:

It’s interesting to look out what portion of the expenditures are from Part D. On a gross basis, $100.1 Billion in Prescription Drug expenditures out of $702.1 Billion in benefits represents 14.3% of benefit expenditures.

 

But not all beneficiaries have Part D coverage, so that’s not an apples to apples percentage.

Looking at 2017 benefits for Part A, Part B, Part C and Part D combined, total benefits were $702.1 Billion, of which 29.9% ($209.7 Billion) was spent through Part C, the Medicare Advantage program. Given the analysis doesn’t break down the benefit expenditure categories for the contracting Part C Medicare Advantage plans, here’s a breakdown of the Regular Medicare expenditures including Part D (backing out Part C):

  • Hospital:  43.6% ($197.9 Billion)
  • SNF: 6.2% ($28.3 Billion)
  • Home Health Care: 4.1% ($18.4 Billion )
  • Physician Fees: 15.2% ($69.1 Billion)
  • Prescription Drugs (gross adjusted): 13.5% ($61.6 Billion)
  • Other: 17.4% ($78.8 Billion)

Regarding the Gross Prescription Drugs adjustment: You will note the above Prescription Drugs total $61.6 instead of the $100.1 Billion in the above snapshot. That’s because the Medicare Advantage Part C enrollees with Part D enrollment were backed out, given that the other benefit expenditure categories didn’t include a breakdown from Part C. So the Part C enrollment in Part D plans, as a percentage of total Part D enrollment – taken from the December 2017 Medicare Advantage/Part D Contract and Enrollment Data Summary Report - was extrapolated (61.5% of Part D Enrollees are not enrolled in Part C; 61.5% of $100.1 Billion in total Prescription Drugs expenditures = $61.6 Billion.)

 

But the only problem with stopping there, is not all regular Medicare beneficiaries are enrolled in Part D. There were 43.2 million PDP enrollees at the end of 2107, while there are 58.5 million total Medicare beneficiaries. Of the 15.3 million 2017 beneficiaries with no Part D, 1.9 million were from Part C, leaving 13.4 million regular(non-part C)  Medicare beneficiaries with no Part D, and 26.2 million with Part D, out of a total 39.6 million regular Medicare beneficiaries. Now if we extrapolate 66% (26.2/39.6 million) for regular Medicare with Part D, from the other benefit expenditure categories (reducing the expenditures by one third for the other categories) we can get an apples to apples look.

 

This will reflect the percentage benefit expenditures extrapolated for Regular Medicare beneficiaries with Part D coverage:        

 

  • Hospital:  40.7% ($130.6 Billion)
  • SNF: 5.8%  ($18.7 Billion)
  • Home Health Care: 3.8% ($12.4 Billion )
  • Physician Fees: 14.2% ($45.6 Billion)
  • Prescription Drugs (net adjusted): 19.2% ($61.6 Billion)
  • Other: 16.2% ($52.0 Billion)

 

19.2% of the Medicare benefit pie for prescription drugs, get us a lot closer to the Milliman analysis just conducted for AHIP in the commercial population, which found Rx representing 23.3% of total costs including administration. If we add in the extrapolated portion (66%) of the $8.2 Medicare administrative expenses from the above snapshot, the regular Medicare prescription drug portion represents 18.9% including administration.

Friday
Jun012018

Anthem, IngenioRx and Taking a Total View of the Prescription Drug Trend

Anthem, IngenioRx and Taking a Total View of the Prescription Drug Trend
 

By Clive Riddle, June 1, 2018

 

In the crossover worlds of national pharmacy chains, PNMs and health plans, we have witnessed the emergence of CVS-Aetna , Cigna-Express Scripts, and the UnitedHealthGroup’s OptumRx fueled by its 2015 acquisition of Catamaran, plus the rumored Walmart Humana pairing. Meanwhile, Anthem took a somewhat different approach, starting their own PBM from scratch instead of acquiring or merging with someone on in the Rx aisle. Thus last October Anthem announced the launch of IngenioRx, which will assume Anthem’s PBM business when its current commitments expire in 2020.

 

IngenioRx, thus sidelined for another year and a half – and looking to improve its visibility while gearing up – just released just released a Drug Trends Report in the same style as other national PBM reports, not letting the fact that it not yet operational serve as a roadblock. Instead, they focused reporting on the current Anthem book of business that they will be serving.

 

With that in mind, here’s what they shared for Anthem’s 2017 commercial population, emphasizing they were examining the total drug trend, including medical benefit and prescription benefit utilization, unlike many reports from others that are only positioned to report on the prescription benefit experience:

·         21% of Anthem’s total drug spend was administered via the medical benefit,, and 79% via the pharmacy benefit. For specialty drugs only, the breakdown was 42% medical benefit and 58% pharmacy benefit.

·         Anthem’s total drug trend was 2.0%, comprised of -4.6% non-specialty drug spend and 9.9% specialty drug trend.

·         Anthem’s 2.0% total drug trend drivers included 5.6% inflation, 1.2% new drugs costs, -0.8% reduction in utilization, and -4.0% decrease in costs due to management approaches. For non-specialty drugs, inflation was 4.9%; for specialty drugs inflation was 6.5%.

 

Carving out the prescription benefit to independent PBMs in the health plan world created three inefficiencies: (1) inability to manage the total drug trend due to some drugs administered through the medical benefit, as IngenioRx points out; (2) doesn’t allow for optimal coordination of care between the prescription and medical treatment components; and (3) creates duplication of administrative resources required in administering eligibility and reporting for the two components.

 

If IngenioRx remained just an in-house PBM for Anthem, taking the total drug trend management view will be easier, But Anthem’s IngenioRx will be a stand-alone PBM, pursuing other business as well, and requiring its own separate administrative systems, making taking a total view for the Anthem book of business a little more challenging.

 
Friday
May182018

Six Things To Know From Deloitte Research on Health Plan Government Business

Six Things To Know From Deloitte Research on Health Plan Government Business
 

By Clive Riddle, May 18, 2018

 

This week, Deloitte Center for Health Solutions’ Andreea Balan-Cohen, Ph.D., and Maulesh Shukla gave a presentation on Medicare Advantage and Medicaid Managed Care Trends: Deloitte Research in a live HealthcareWebSummit event.

 

The basis for their discussion was Deloitte Center for Health Solutions analysis of financial performance trends in the US fully insured health plans market between 2011 and 2016. This research series was divided into three chapters: Chapter 1, published in December 2017, provided summary observations on overarching developments in the market. Chapter 2, published in March 2018, focused on trends in health plan government programs, specifically Medicare Advantage and Medicaid managed care. Chapter 3, forthcoming later this month, will focus on trends in the commercial individual and commercial group lines of business.

 

Here’s six key findings they shared on U.S. health plans’ government business:

1.     Government programs accounted for a large and growing share of health plan revenue and underwriting gains.

2.     The Medicare Advantage business experienced significant top-line growth and bottom-line volatility, including a notable decline in underwriting performance in 2014 and 2015.

3.     In Medicaid managed care, aggregate plan revenue increased steadily between 2011 and 2016, and underwriting performance grew impressively before retrenching in 2016.

4.     The largest Medicare and Medicaid plans by national revenue captured a disproportionate and growing share of industry underwriting gains.

5.     Medicare Advantage performance variation widened beginning in 2014; smaller plans and newer entrants experienced substantial headwinds.

6.     Medicaid managed care markets exhibited widening performance variation at the company and state levels beginning in 2014.