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Friday
Jul112008

Can decision support consist of more than threats, promises and stiff upper lips?

By Laurie Gelb

Can decision support consist of more than threats, promises and stiff upper
lips?

Here's where domains, measures and thresholds come in.

Here's where the rubber hits the road.

In one study, sufferers, clinicians and payors were asked how they would
measure the value of a drug for a condition for which disease- modifying
therapy did not yet exist. The same methodology works whether options are
plentiful, mediocre, whatever.  But in this case--

Physicians highlighted clinical results in one or more domains, all of which
have a demonstrable impact on quality of life.
Patients focused on being able to experience things they have not been able
to experience recently.
Payors wanted to see statistically significant differences from placebo on
some objective measures, not really caring which -- the FDA's job.

Every stakeholder was able to specify domains (pain being one, just so we're
clear on what a domain is) that were relevant to him, and whether or not an
improvement in that particular domain would in itself justify
prescribing/taking/reimbursing therapy. Obviously, not all domains were
salient to every stakeholder.

Every stakeholder was able to specify how improvements in salient domains
would be measured (numerically and/or categorically) as well as her
threshold for that improvement -- what number or value or outcome would
constitute sufficient reason to act.

But the answers were different for everyone.  (So were the questions, of
course -- computer-assisted interviewing uses previous answers to frame
relevant questions).

So, when you're doing stakeholder research, instead of dragging out a stack
(real or virtual) of static scenario cards for tradeoff analysis and
sorting, instead of asking about abstractions like preference and
satisfaction that aren't used in real life, what if you asked about:

Domains that are salient
Measures that are used to measure change or value in those domains
Thresholds applied to those measures to justify action

Bear in mind, these are studies that run (very) low five figures and a few
weeks, all told -- this is a framework for frequent studies, not once a
decade. So you can track how the findings change as the environment does.

What next? You might design decision support that makes very clear...

What domain(s) are affected by the intervention you recommend or wish
considered What measures show change when the intervention is used, in whom,
and how frequently. how predictably To what extent any particular threshold
of change can be predicted, guaranteed or even hoped for

Of course, you update this as the data come in and time goes on.

Presto! User-centric decision support can be yours.
And it can be theirs.
If you do all this on the Web, kiosk or CD-ROM, you can develop a "wizard"
that enables the user to "buy in" to their choice using their own criteria.

The decision that's owned is the result that's achieved.

We're not just talking about justifying or avoiding therapy -- this is about
staff/physician recruitment/retention, open enrollment and a thousand other
choices.

Effective decision support reduces and supports the burden of choice.
How is yours doing?
Any stories to share?

Sunday
Jun222008

Health Care Is Personal: In Memory of Karen

By Clive Riddle

Just a few months into my first administrative position at a hospital in 1981, just a year out of college, I remember feeling pleased with myself as I edited the Radiation Therapy Center feasibility study I had just spent countless hours and days preparing. It was a thick report full of projections, tables, charts, and narrative. Then in the background, I could year the sobbing outside my office.

My office had been converted from an admissions room, and was situated next to a quiet area for families, off the main lobby. I had never really paid attention my surroundings. I was too into my new job. But the sobbing persisted, and at some point I had to leave my office for a meeting. As I rounded the corner I spied the family, grieving for a loved one that had just passed away upstairs.

In the years to come, as I progressed in my career, becoming CEO of a regional provider owned health plan, I was typically far removed from the actual rendering of health care. Instead I was immersed in the business of it: budgets, monthly reports, department head meetings, actuarial projections, marketing campaigns, contract negotiations, board meetings, personnel issues.

Now and then, but never often enough, I tried to remind myself of that day outside my hospital office, so early in my career, when I first learned that health care is personal, and can not so lightly treated as just another business or commodity.

During my more than dozen years running that health plan, I had the great pleasure of working every day with Karen (Hutcheson) Speziale. She was the Chief Operating Officer of the plan, and she made the plan run, and run well. Karen passed away this past week, after a six and a half year battle with cancer. Karen should have been with us for at least a couple of more decades.

I remember sitting in my health plan office with Karen and our Medical Director, making decisions on proposed benefit and coinsurance levels for the coming plan year. We set a higher coinsurance level and benefit limitation for Total Parenteral Nutrition (TPN), which was at the time increasingly being used in the treatment of Crohn’s Disease. Years later, one of my children would be diagnosed with Crohn’s. We also set various new benefit parameters for several different prescription and treatment options for cancer.

Health care is personal.

After I left that health plan to start MCOL, Karen went on to take a position with Kaiser Permanente, developing and then managing their expansion in our market. Kaiser is now the dominant health plan in our area. Later, Karen moved away to San Diego, and really flourished there.

Karen volunteered significant time in elementary school classrooms. She became the advisor for the local chapter of her Sorority at the university. She spent countless hours on other civic activities. Several of her former department heads from our old health plan remained the closest of friends with her, taking really cool vacations together, and staying in constant touch. She also kept very close ties with her family. When Karen’s illness required that she fully retire from her job, she continued all her contributions to the community.

I very recently took a quick trip to visit with Karen. She had just returned from a visit to the Kindergarten class where she helped the kids learn to read. They had put on a program just for her. On the wall in her office was a plaque recently given to her by her Sorority as the national “Alumna of the Year.” The perpetual annual award will now bear her name.

Karen’s investment in community time should serve as a wake up  call to all of us working on the business side of health care, to put and keep some balance in our lives, as Karen did.

Karen shared with me how recently at the hospital she had an hour long conversation with a nurse on what was wrong with health care. Karen laughed about it, but its hard to argue that there is something significant that needs to be done with health care. We can start by remembering how personal it is.

Anyone reading this who knew Karen Speziale might be interested to know that donations in her memory can be made to San Diego Hospice at www.sdhospice.org

Monday
Jun162008

International Health Care Data and Comparisons

By Clive Riddle

With this election year, health care is a central topic of discussion for Presidential and Congressional candidates. Inevitably, references are made inferring either superior or inferior performance of the U.S. health care system compared to various other countries.
So just what kind of current data is out there reflecting various attributes of international health care? Below is collection of selected international health care factoids, compiled by Global Health Resources this year:

Health Spending And Insurance Systems in Seven Countries, 2007

Australia

Canada

Germany

Netherlands

New Zealand

United Kingdom

United States

National health spending

Per capita (U.S. $PPP)*

$3,128

$3,326

$3,287

$3,094

$2,343

$2,724

$6,697

Percent of GDP*

9.5%

9.8%

10.7%

9.2%

9.0%

8.3%

16.0%

Percent of primary care practices with:

Any financial incentive for quality

72%

41%

43%

58%

79%

95%

30%

Electronic medical records

79%

23%

42%

98%

92%

89%

28%

Percent uninsured

0%

0%

<1%

<2%

0%

0%

16%

*PPP is purchasing power parity. GDP is gross domestic product

Source: Toward Higher-Performance Health Systems: Adults’ Health Care Experiences In Seven Countries, 2007
Health Affairs, October 2007
http://content.healthaffairs.org/cgi/content/full/26/6/w717

Cost of Medical Procedures: United States and Abroad (in US dollars)

Procedure

United States

Costa Rica

Mexico

Korea

Heart bypass

$130,000

$24,000

$22,000

$34,150

Heart-valve replacement

$160,000

$15,000

$18,000

$29,500

Angioplasty

$57,000

$9,000

$13,800

$19,600

Hip replacement

$43,000

$12,000

$14,000

$11,400

Hysterectomy

$20,000

$4,000

$6,000

$12,700

Knee replacement

$40,000

$11,000

$12,000

$24,100

Spinal fusion

$62,000

$25,000

N/A

$3,311

Source: Medical Tourism Association, 2007 Survey

Procedure

United States

Costa Rica

Mexico

Korea

Heart bypass

$130,000

$24,000

$22,000

$34,150

Heart-valve replacement

$160,000

$15,000

$18,000

$29,500

Angioplasty

$57,000

$9,000

$13,800

$19,600

Hip replacement

$43,000

$12,000

$14,000

$11,400

Hysterectomy

$20,000

$4,000

$6,000

$12,700

Knee replacement

$40,000

$11,000

$12,000

$24,100

Spinal fusion

$62,000

$25,000

N/A

$3,311

Source: Medical Tourism Association, 2007 Survey

The Cost of Medical Procedures in Selected Countries (in US dollars)

Procedure

US Retail Price*

US Insurers' Cost*

India**

Thailand**

Singapore**

Angioplasty

$98,618

$44,268

$11,000

$13,000

$13,000

Heart bypass

$210,842

$94,277

$10,000

$12,000

$20,000

Heart-valve replacement (single)

$274,395

$122,969

$9,500

$10,500

$13,000

Hip replacement

$75,399

$31,485

$9,000

$12,000

$12,000

Knee replacement

$69,991

$30,358

$8,500

$10,000

$13,000

Gastric bypass

$82,646

$47,735

$11,000

$15,000

$15,000

Spinal fusion

$108,127

$43,576

$5,500

$7,000

$9,000

Mastectomy

$40,832

$16,833

$7,500

$9,000

$12,400

* Retail price and insurers' costs represent the mid-point between low and high ranges
** US rates include at least one day of hospitalization; international rates include airfare, hospital and hotel

Source: Medical Tourism: Global Competition in Health Care, National Center for Policy Analysis, November 2007
http://www.ncpa.org/pub/st/st304/st304.pdf

Wait Time to get an Appointment in Seven Countries

Percent of adults who waited 6+ days for an appointment to see regular medical doctor

Canada

30%

United States

20%

Germany

20%

United Kingdom

12%

Australia

10%

Netherlands

5%

New Zealand

4%

Source: Fixing the Foundation: An Update on Primary Health Care and Home Care Renewal in Canada, January 2008
http://www.healthcouncilcanada.ca/docs/rpts/2008/phc/HCC_PHC_Main_web_E.pdf

Percent of adults who waited 6+ days for an appointment to see regular medical doctor

Canada

30%

United States

20%

Germany

20%

United Kingdom

12%

Australia

10%

Netherlands

5%

New Zealand

4%

Source: Fixing the Foundation: An Update on Primary Health Care and Home Care Renewal in Canada, January 2008
http://www.healthcouncilcanada.ca/docs/rpts/2008/phc/HCC_PHC_Main_web_E.pdf

Access to “Medical home”* Among Adults in Seven Countries, 2007

Australia

Canada

Germany

Netherlands

New Zealand

United Kingdom

US

59%

48%

45%

47%

61%

47%

50%

*Medical Home: Has a regular doctor or place that is very/somewhat easy to contact by phone, always/often knows medical history, and always/often helps coordinate care

Source: Toward Higher-Performance Health Systems: Adults’ Health Care Experiences In Seven Countries, 2007
Health Affairs, October 2007
http://content.healthaffairs.org/cgi/content/full/26/6/w717

Out-of-Pocket Expenses for Medical Bills in the Past Year in Seven Countries

(in U.S. $ equivalent)

Australia

Canada

Germany

Netherlands

New Zealand

United Kingdom

United States

None

13%

21%

9%

38%

12%

52%

10%

$1-$100

11%

17%

17%

15%

17%

12%

9%

More than $1,000

19%

12%

10%

5%

10%

4%

30%

Source: Toward Higher-Performance Health Systems: Adults’ Health Care Experiences In Seven Countries, 2007
Health Affairs, October 2007
http://content.healthaffairs.org/cgi/content/full/26/6/w717

Mortality Amenable to Health Care in Selected Countries*

Deaths per 100,000 population

Country

1997-98

2002-03

France

76

65

Japan

81

71

Spain

84

74

Australia

88

71

Sweden

88

82

Italy

89

74

Canada

89

77

Netherlands

97

82

Greece

97

84

Norway

99

80

Germany

106

90

Austria

109

84

Denmark

113

101

New Zealand

115

96

United States

115

110

Finland

116

93

Portugal

128

104

United Kingdom

130

103

Ireland

134

103

*Deaths from certain causes before age 75 that are potentially preventable with timely and effective health care.
Source: Measuring the Health of Nations: Updating an Earlier Analysis, The Commonwealth Fund, January 2008
http://www.commonwealthfund.org/usr_doc/1090_Nolte_measuring_hlt_of_nations_
HA_01-2008_ITL(web).pdf?section=4039

 

Cost-Related Access Problems in Seven Countries, 2007

 

Australia

Canada

Germany

Netherlands

New Zealand

United Kingdom

United States

Percent in past year due to cost:

Did not fill prescription or skipped doses

13%

8%

11%

2%

10%

5%

23%

Had a medical problem but did not visit doctor

13

4

12

1

19

2

25

Skipped test, treatment or follow-up

17

5

8

2

13

3

23

Percent who said yes to at least one of the above

26

12

21

5

25

8

37

Source: Health Care: Solutions Without Borders, The Commonwealth Fund
http://www.commonwealthfund.org/aboutus/aboutus_show.htm?doc_id=597055

For More Information:

Global Health Resource
www.globalhealthresources.com

 

Monday
Apr282008

“Personal” is more than a word

By Laure Gelb
In my last post, I speculated as to whether 2008 might be the year that disease management communication from MCOs finally got personal. The next one-page MCO piece I saw (an EOB insert) offered the following snippets:  

 

“We think getting personal is a healthy idea.”
“We know that nothing is more personal than your health.”
“Do you take a healthy interest in good health?”
This piece of paper attempts to induce enrollment in the personal health coach program. But where are the benefits offered for this proactive behavior?  

 

“If you qualify…one person to call for answers and advice. It’s confidential and it’s free.”
o      OK, so you want me to transfer the expectation that my physician will offer answers and advice, to a nurse whom I’ll never meet.

o      You want me to believe that it’s confidential, when I’m reading every week about health insurance data privacy breaches.

o      And you want me to celebrate that it’s “free,” when my premiums and copays have never been higher.

 Health coaching should ideally align with the patient’s medical home. Can we more strongly link that proposition to premiums and copays? Talking points could include:
 

 

  • The relationship between OOP costs, medical errors and drug interactions
  • The higher risk of unidentified ME/DI among patients with multiple conditions/polypharmacy
  • The opportunities for improved outcomes that multiple conditions can obscure
  • The importance of a “medical home” in reducing ME/DI
  • What a health coach actually does, and indications that having a coach might help; how the coach and the medical home can support each other
 Although managed care has been “doing” disease management since the 80’s, a patient’s “buy-in” to disease management, with the time, effort and emotional costs it entails, will be short-lived unless it’s obtained through honest discussion of its potential benefits, rather than demanded or condescendingly waved in front of someone with many conflicting priorities. And I haven’t seen an EOB insert yet that addressed questions like:
 

 

  • Why I am on two drugs that are supposedly “contraindicated” in combination?
  • Does anyone at the MCO know or care about all that treatments I’ve had?
  • Isn’t a health coach going to refer me to a doctor for the tough calls anyway?
  • How will a stranger get me to do all the things I already know I should do?
  • Why can’t the health plan just find me a better physician?
There’s a real shortage of health content in member communication, and it’s no wonder that members find it difficult to read, let alone remember (or act on) any of it. The next time you want to change a member’s mind or otherwise influence behavior, you might want to check your communiqué for a few basic points:
 

 

  1. Is it clear what you are asking members to do?
  2. Is a coherent value proposition for them to take this action presented and are potential objections addressed?
  3. If members to whom your request is directed are not appropriate candidates, how will they know?
  4. Is there a high ratio of important content to buzzwords like “personal,” “healthy” and “wellness”?
 All this is no more than Marketing 101, of course. When disease management diverges from marketing exchange theory (equal value achieved by all parties to a transaction), it is less likely that any transaction, change or improved outcome will result. And, at the end of the day, the evidence suggests that clinical outcomes are more durably and significantly improved by self-imposed than externally-imposed change. Yes, the MCO (and the physician, nurse, et.al.) can help present the rationale for change, a means for implementing it and incentives for doing so. But only the patient “pulls the switch” each and every day. Every day brings new health decisions (like self-dosing qd), challenges and opportunities. It takes more than a few clichés to frame and support optimal choices. And there has to be a balance between “happy talk” and the certain knowledge that some “good” decisions and intentions go horribly wrong.
Next month: domains, measures and thresholds -- the keys to behavioral change.
Tuesday
Apr222008

What's the current state of things in the Convenient Care Industry?

By Clive Riddle

After attending two sessions on retail medicine at the World Health Care Congress today, here's what we found out:

John Agwunobi, MD, EVP Professional Services for Wal-Mart shared the following statistics for Convenient Care visits at Wal-Mart locations, through their various contracted providers:

  • adults comprise 79% of visits, 21% of visits are for children
  • 55% of patients have no insurance coverage
  • Patient surveys indicate, had the Wal Mart convenient care location not been available, 40-50% of patients would have seen a primary care physician; 20-35% of patients would have used an urgent care facility; 10-15% would have gone to an ER; 5-10% would have foregone treatment
  • 90+% of patients indicate overall satisfaction
  • 25-40% of visits are for immunizations & screenings; and 60-75% of visits are to treat common illnesses

Doctor Agwunobi also discussed the Wal-Mart $4 Generic Prescription program, which is offered to all Wal-Mart customers and is proactively promoted through the Convenient Care locations. The program involves 361 generic prescriptions covering up to 95 percent of prescriptions written in the majority of therapeutic categories. Nearly 30 percent of $4 prescriptions are filled without insurance. The $4 prescriptions now represent approximately 40 percent of all filled prescriptions at Wal-Mart.

Web Golinkin, President and CEO, of RediClinic discussed RediClinic customer experiences, noting that RediClinic is a partner of Wal-Marts. Mr. Golinkin is also President of the Convenient Care Association and shared the following insights regarding the Association and industry as a whole:

  • There were 150 clinics when the Convenient Care Association founded less than two years ago to more than 950 today nationwide, with 1,500 projected by the end of 2008.
  • Overall, the clinics have treated more than 2.5 million patients in 36 states
  • Surveys indicate 16% of consumers have tried a clinic and between 34 to 41% say they intend to

Golinkin stated the potential obstacles or events that could slow industry growth would be if:

  • The industry suffered future systemic clinical quality issues
  • A shortage and/or increased cost of Nurse Practitioners (NPs) and Physician Assistants (PAs) occurred
  • If various states continue with additional regulatory impediments (clinic licensure requirements, restrictions on NP/PA scope of practice and prescriptive authority, physician oversight requirements, corporate practice of medicine prohibitions, etc.)
  • If increased Operator/business model failures occur. He noted that there have been some failures, commented that this should be expected with any industry having relatively lower barriers to entry but higher ongoing working capital requirements. He felt there will be a shakeout with consolidation.

Michael Howe, CEO of MinuteClinic, states their organization's strengths include:

  • They are "Right Size” engineered for efficiency and high quality
  • Proprietary Electronic medical record system embedded with standardized “best practice” protocols
  • Facilitates measurement of results and continuous quality improvement
  • Interoperability drives continuity of care back to the Medical Home
  • Consumer friendly - with convenient locations in consumer pathway, and “Lifestyle conscious” hours and “walk in” scheduling
  • “High touch” capability of practitioners drives compliance
  • Patient Referral system facilitates the creation of “Medical Homes”when lacking

He cited an independent external research study conducted by Market Strategies in April 2007 indicating a patient satisfaction rate, as well as the percent likely to recommend, of 97%. He noted that MinuteClinic adheres to national standards of practice guidelines, (which have been adopted by their Association) but also is the first retail health care provider to be Joint Commission accredited.

Howe also cited a peer reviewed study from September 2005 through September 2006 of 57,000+ MinuteClinic evaluations of acute pharyngitis, looking for outcome measures to include adherence to best practice treatment guideline in presence of negative or positive RST, use of back up confirmatory strep culture testing in presence of negative RST, and documented rationale when antibiotic was prescribed in presence of negative RST. The study indicated an overall adherence rate of 99.15%.