But Which Half?

By Kim Bellard, January 30, 2013

Advertising lore credits John Wanamaker, the department store magnate and marketing pioneer, with the famous quote: “Half the money I spend on advertising is wasted; the trouble is I don't know which half.”  It turns out he could have been talking about spending on health care.

The British Medical Journal, through their Clinical Evidence initiative, recently reported that they’d analyzed 3,000 medical treatments that had been studied in controlled, randomized studies.  It turns out that for half of those treatments, we have no idea how well they work.  Indeed, only about a third of the treatments were found to actually be beneficial or likely to be beneficial.  The rest are likely to be harmful.

Sadly, this does not come as a surprise.

We know we don’t know enough.  The vast number of medical treatments have never even been studied in a true clinical trial.  Worse yet, sometimes even when there is clear empirical evidence about which treatments are most effective, that information does not always sway physician behavior, or does so only very slowly (for example, see this study on the use of heart stents versus medication therapy).

There is no shortage of reports of unnecessary or even harmful care.  It’s even scarier when that care is associated with high costs.  In no particular order, one could cite recent controversies with spinal fusions, hip replacements, or chemotherapy drugs.   There can be lots of money at stake for manufacturers, drug companies, and health care providers.  That kind of money can distort the question of what is truly in the best interests of the patient.

Many employers, payors, and researchers have been pushing for “evidence-based medicine” for many years now.  EBM focuses on making sure that treatments have appropriate research to support their effectiveness, and in getting the word out about such treatments.  One of the many initiatives from ACA was the Patient-Centered Outcomes Research Institute, which is charged with conducting research to provide such evidence and funded by a $1 head tax on people covered by insurers.  And, of course, AHRQ probably is wondering why we need a new organization to focus on EBM, given their many efforts on effectiveness.

In time, this may all become much easier, as more patient data become electronic and more connected, and we can make more use of computing power to track what truly happens to patients under various courses of treatments.  I mentioned a couple examples of this in my last blog, citing Optum/Mayo’s new initiative and meta-research studies in lieu of clinical trials.  Another example comes from Archimedes Inc., a firm founded by David Eddy, who was one of the early pioneers of evidenced-based medicine.  Archimedes claims to use its advanced mathematics and computing prowess “to run clinically realistic virtual trials on any population and create compelling evidence to make decisions in health and economic outcomes research, policy creation, clinical trial design, and performance improvement.”  Apparently HHS thinks they can, as it hired Archimedes last year.

Most physicians I know are very bright, care very much about their patients, and work hard to stay current on the medical literature.  Unfortunately, the latter is virtually impossible to do, given the sheer volume of that literature.  Even when there are clear results about which treatment is truly the most effective, the research doesn’t usually come with a guide as to how physicians can implement the associated changes to their practice routines.  It’s as much of a question of change management as it is the evidence to make the change.

It would seem that the situation is tailor-made for clinical decision support tools, which seek to provide clinicians with information on treatment options, potential outcomes, and possible contra-indications at point-of-care.  Unfortunately, we may not quite be ready for them.

Last summer The Annals of Internal Medicine published a study on clinical decision support systems by Bright, et. al.  They did a meta-analysis of studies on CDSSs, and found ample evidence of their efficacy in improving process measures, but sparse results on their impact on clinical or economic outcomes.  Whether this is due to the limitations of the underlying studies, the CDSSs themselves, or how they were used by clinicians is unclear. 

Similarly, KLAS Research recently released results of their survey of health care providers on their satisfaction with clinical decision support tools.  The results cited a general level of frustration, especially due to lack of integration with EHRs and “alert fatigue” caused by ineffective targeting of alerts. 

Worst yet, according to new research from the University of Missouri, patients don’t seem to trust treatment recommendations from physicians who use CDSSs, believing them to be less capable than physicians who make decisions unaided.  Patients don’t even like it when physicians consult with other physicians before making a recommendation!  They think their doctor should know everything.  I blame television for this – on medical shows like Grey’s Anatomy or House physicians pull up the most obscure diagnoses and treatments strictly from memory, without ever having to consult any reference materials.  Nobody’s memory is that good. 

Clinical decision support systems aren’t going to replace doctors; they are simply tools to aid health care professionals, much as a stethoscope or a thermometer does.  One can imagine a future where CDSSs -- and EHRs -- fit seamlessly into patient visits, providing real-time, interactive information while with the patient.  The line between evaluation, documentation, and clinical decision support should blur, in order to more accurately diagnosis patients and determine the best course of treatment.  

In the meantime, it’s somewhat of a crapshoot.

A recent study by Deloitte indicates that 62% of Americans believe that, in fact, over 50% of U.S. health spending is wasted, which is up from the already high 51% in 2009.  The message about necessary spending may be getting out, but consumers may be getting the wrong idea – only 18% thought the problem was not using evidence-based treatments, versus 69% who blame fraud and abuse in the payment system.  In other words, the problem can be blamed on greedy crooks, not on well-meaning health care providers.  Defensive medicine and unnecessary paperwork were each also cited by about a third of respondents. 

I agree that fraud, defensive medicine, and inefficient administration contribute cause us to spend money we shouldn’t, and each should be addressed, but I suspect more of unnecessary spending comes from well-intentioned treatments that aren’t really best for the patients.  As professionals, health care providers should be more stringent about basing their treatment recommendations on evidence that truly supports them.  More importantly, as the people whose health is going to be impacted by those treatments, it’s incumbent on us to demand that evidence.

Maybe one day we’ll have Star Trek’s tricorder to non-invasively diagnosis or even Star Trek Voyager’s holographic doctor to treat.  Maybe someday nanobots will fix all our ills without our even being aware of their work.  All that is in the future.  For right now I’d settle for simply being able to know the odds that a recommended treatment will actually benefit me.


Mercer introduces new Mercer Marketplace

By Claire Thayer, January 28, 2013

Mercer now offers employers and their employees’ access to a new private benefits exchange, Mercer Marketplace.  The Mercer Marketplace includes over 20 types of benefits, allowing employees to construct a personalized portfolio with traditional core benefits as well as optional voluntary benefits. The new exchange includes qualified benefit designs available from multiple insurance providers. In addition, Mercer Marketplace can facilitate, but does not require, a move to a defined contribution funding.

Learn more at:


The Health Insurance Exchange Directory 2013

By Claire Thayer, January 24, 2013

Looking for contact information the new public and private health insurance exchanges? HealthQuest Publishers, from MCOL, just released a brand new 120+ page directory and database with contact information on health insurance exchanges throughout the country. This new Health Insurance Exchange Directory provides comprehensive contact information for all state-based public exchanges and public partnership exchanges as of January 2013 as well as a number of private exchanges.

Watch a one minute video about the Health Insurance Exchange Directory:

The Health Insurance Exchange Directory includes a contact database and encompasses:

  • Organizational Directory of 50 selected HIXs.  Contact and summary information along with a listing of 350 key individuals with leadership or operational involvement. Almost half of employees in the directory have email address listed.
  • Executive Profiles providing contact and biographical information for 75 executives and thought leaders involved with Health Insurance Exchanges representing a wide range of organizations including exchanges, health plans, consulting groups, associations and others.
  • Indexes for convenient navigation and reference organized six different ways
  • Contact Database with all the information from the Organizational Directory and the Executive Profiles in an Excel spreadsheet. It includes tabs for Organizational Directory organizations, employees and Executive Profile employees.

Learn more at:


Get Ready…ACA Superbowl

By Lindsay Resnick, January 23, 2013

Bring your A-game to both sides of the ball, it’s time to play game winning offense and defense. As ACA’s October 2013 open enrollment gets closer, winning health plans are focused on honing their direct-to-consumer marketing skills around retaining and acquiring membership.  It means getting into the Affordable Care Act game by protecting your base with tough defense, and preparing to put points on the board (aka new members) with aggressive offense.

DEFENSE: Retain the members you already have. Prioritize those that are the most valuable and create customized engagement strategies to keep them. Take a data-driven approach to understanding your most vulnerable “at risk” population within your Individual and Small Group businesses that can soon make individual choices.

Core objectives for health plan retention:

  1. Maximize retention of existing membership in both on and off Exchange products by minimizing the potential to lose Individual and Small Group customers to competitors.
  2. Leverage membership data and third-party intelligence to improve understanding of current Individual and Small Group customers.
  3. Communicate a timely and relevant message to existing membership, employers, and distributors to support retention by improving member engagement and building brand loyalty.
  4. Emerge as a trusted source for information regarding what health care reform is and what is means to those most impacted…Who’s eligible for what? What’s in it for ME?

OFFENSE: Get your share of the open enrollment “land grab”. Understand needs and attributes of various segments of new market entrants to optimize acquisition campaigns. Create on/off Exchange strategies to generate new leads and sales from individuals most likely to enter the market as a result of ACA’s disruptive events. Switching will be at an all-time high... make sure they switch to you!

Core objectives health plan acquisition:

  1. Increase sales opportunities to enroll a larger percentage of the individuals across all segments likely to purchase through public/private Exchanges and, small businesses SHOP Exchanges (e.g., uninsured, disenfranchised small group employees, subsidy eligibles, new Individual shoppers).
  2. Optimize and increase the use of database management and segmentation tools to improve targeting capabilities and gain a better understanding of the marketplace than your competitors.
  3. Work in tandem with your product development team to identify various product acquisition paths, mapping current portfolio to a post reform products. These product acquisition paths will be the basis for determining messaging and sales strategies.
  4. Deploy a new business direct response marketing tactics that blends push-based education with pull-based entry into your selling cycle. 

The future of health insurance belongs to the prepared.To achieve and sustain profitable growth, marketing strategies need to look very different going forward. They need to move from product-centric…see who buys it; to consumer-centric…understand how they engage.

Tomorrow’s health insurance consumer needs to be at the center of everything marketers do throughout the customer lifecycle.  An engaged consumer means connecting early and often, nurturing them into the sales cycle, keeping them involved through purchase, and delivering a superior customer experience. A balanced approach to customer retention and acquisition, supported by data-based intelligence and strong consumer engagement, will determine ACA winners.


"Faith is taking the first step even when you don’t see the whole staircase" - Martin Luther King

By Cyndy Nayer, January 22, 2013

The day before the 2nd inauguration of the President Obama, I have paused.  I’ve been thinking about the post I wrote last year at this time, with quotes of MLK and how they applied to my work, my vision, and, at the time, to the organization I had founded and built on evidence of health value innovation.  It’s no secret it’s been a tumultuous year for all of us.

This past year has been a year of conflict:  the dis-collaboration of the elected officials, the persistence of debt in the government, the modest recovery of the economy, the continuation of foreclosures, and so on.  Today, Twitter is alive with evidence of low to no health improvement from electronic medical records (EHR), the appearance of lack of remorse by Lance Armstrong, the noise of the NRA video with the Obama daughters, and so much more negativity.

On the opposite end, there was a call for Obama’s face to join Lincoln’s at Mt. Rushmore , the praise of Obamacare (ACA) [despite the unprecedented increases in insurance premiums for the 21-29 year olds], and the return of Hillary Clinton to Capitol Hill for updates on national defense.

This emotional rollercoaster is a ride this recession-weary country could well avoid.  So, today, I search for a hero who can help us refocus, that can help us restore our faith in in positive days ahead, and that will support our call to Capitol Hill and the White House to stop this battling and help us get the country back to work, get the kids healthy, and put our health system to top form and optimal outcomes.

I turn to a story, one more time, about Gabby Giffords, but not the PAC story (though, I’m so glad that she and husband Mark Kelley put their strengths into the efforts to protect our children and communities).  No, this time, it’s a message of facing demons and rebuilding on higher ground.

Gabby and Mark sat, on Nov 8, 2012, in a courtroom in Tuscon, AZ and faced her shooter.  Through her husband, Gabby told the shooter, “Today I am done thinking about you,”  and left the courtroom.  Her message to the press is that this is certainly not forgotten, but a resolution to move on.

Gabby is a true American hero.  We’ve struggled through her fight to live, her fight to walk, her fight to talk.  I’vedocumented the success of the recovery as a testament to all that the American health system does right.  The collaboration between health systems, the teamwork of the proficient care providers throughout the recovery, and her personal and very public messaging that yes, she’s getting better, and yes, she’s frustrated, and yes, it’s hard, and yes, she will persevere.

This is the message I’d like to hear from all of our elected officials.  America is a “do” country, not a “do not,” not even a “try” country.  For many years, when people tell me they are going to try something, I put a grin on my face and remind them of the famous philosopher Yoda, of Star Wars fame, who said “Do or do not, there is no try.”  America is that country, the DO country.

Need proof?  Check out this article  Apollo 40 years on:  how the moon missions changed the world for ever.  You will discover that innovation that supported the missions to the moon included (excerpt from the article):

Apollo 9 astronaut Rusty Schweickart’s ”mind-expanding view and the epiphany that it triggered led him to vividly appreciate the insanity of humans fighting over borders that were invisible to him from up there. ‘Hundreds of people in the Middle East killing each other over some imaginary line that you’re not even aware of, that you can’t see,” he recounted. ‘ And from where you see it, the thing is a whole, and it’s so beautiful,” he remembered of his view of Earth. “You wish you could take one in each hand, one from each side in the various conflicts, and say, ‘Look. Look at it from this perspective. Look at that. What’s important?’”  This later influenced astronomer Schweickart’s speech, later turned into an essay entitled “No Frames, No Boundaries,” was embraced by those at the conference, including Carl Sagan, who borrowed from for his uplifting poem Pale Blue Dot, published in his 1994 book of the same name.

The article goes on to document the increase in education funding that fueled the PhDs who developed the navigation system, the protective coverings, and so much more, all built on the faith that we could actually get a man to the moon, because President John F Kennedy declared it would be so.

Need more proof?  Stan Musial.  I have also paused today because Stan-the-Man has passed away.  I grew up in St. Louis.  I was at Stan’s last game in 1963.  I saw him often at Musial and Biggies, one of the best steak houses ever (it closed many years ago) and he never failed to give a smile, wave his hand, ask my little brothers for a handshake, or sign a napkin (or a Cardinal cap, which he more often than not was wearing).  I saw him 40 years later, still standing tall, still with that cockeyed grin, but a but stooped and a bit unsteady.  I wept today, because Stan Musial is the symbol of the Gateway to the West, of the St. Louis Cardinals, of the hope that St. Louis was in those years.  The years he played baseball were also the years of Dr. King.  I don’t think anyone would say those were collaborative years, no, but we did remarkable things, like missions to the moon, Medicare and Medicaid, and freedom to vote.  Our visions, our passions, while not always in sync, came together in sadness (the assassinations of John and Robert Kennedy, and of Dr. King) and in joy (the retirement celebrations of Stan-the-Man, the 1969 walk on the moon).

We never know how far our vision or our passion will reach.  We don’t know the depths of despair that some go thru during the frustration of reorganizing the vision, reformulating the steps, but never, ever losing hope of achievement.

I hope no one ever goes through what the parents at Newtown nor Gabby Giffords, nor the families of the now 900+ people who have been killed since the Newtown tragedy occurred must live with every day.  I hope I live to see the end of health system errors that cause needless suffering– in poor outcomes, in financial loss, and in family jobs–that we’ve all witnessed over the past years.

I say today that this is where I’m going:  to speed innovation that proves it is a solution to the gaps in care, gets people to better manage their own health, and puts the system into pro-active mode for healthier communities. At my lowest, I reach back to the heros, the Gabbys, the Marks, the Stans, the JFKs, the astronauts, the MLKs, and the many more who envision a bolder, grander, more compassionate America.  I refuse to give up my dream.  I will move forward on the faith that is my core, and I’ll take that first step, that 101st step, and I’ll hold your hand as you join me.

Lonny Dunn (@ProNetworkBuild)

1/12/13, 8:16 AM“The mediocre teacher tells. The good teacher explains. The superior teacher demonstrates. The great teacher inspires.” – William A. Ward

I share with you that tweet above that I think is so profound, and I hope it helps you, and those you love, find your way.  I pray, too, that those who guide our country find the will and the faith to solve for what is holding us back, not for personal interests, but for collective improvement. And, I include one more message below from the Twitter-sphere [apologies, I don't know who tweeted it]:

Don’t tell me the sky is the limit when I know there are footprints on the moon.

Be well, my friends, and travel with your head up and your eyes open and your passion in your hearts. Bless the USA, its leaders and its heroes.