Site moved to, redirecting in 1 second...

26 posts categorized "Health Savings Accounts"

March 14, 2011

David Harlow quoted in AMA American Medical News story on daily deal websites

Groupon, LivingSocial and other daily deal websites are being used by health care providers -- though thus far mostly by those that are not covered by traditional commercial or governmental health insurance (e.g., dental, chiropractic, acupuncture services).  Read the American Medical News story on Groupon, where I was quoted, and please take a look at my blog post on the subject as well -- at the Mayo Clinic Center for Social Media blog -- entitled: Groupons for Health Care Services: No-Brainer or Legal Minefield?  In that post, I observed:

There are a number of legal issues, and their resolution will depend, in part, on where you are situated, since many of the relevant rules are state laws, which vary.  For example:

Groupon collects 50% of the price of the groupon as its fee; is that illegal fee-splitting under applicable state law?

Is the 50% fee an illegal kickback in exchange for a referral?  Are you subject to federal laws in this area in addition to any state laws?

Do provider agreements with third party payors prohibit the offering of discounts to plan subscribers?  (If you can get over the first two issues, you may need to screen out folks who are insured by carriers who limit your ability to discount or risk being in default under an agreement with your biggest customer.)

There is at least one more issue to consider, as well:  State laws on gift certificates and their requirements touching on expiration dates.  Two lawsuits filed in the last week or so -- one against Groupon, and one against LivingSocial -- allege that the relatively short life of the daily deal violates state gift certificate laws.  The plaintiffs' lawyers would like to see these cases certified as class actions.

Bottom line: With the proliferation of high-deductible health plans, and FSAs, HSAs and the like, the general public is becoming more price sensitive in paying for health care services; while health care providers need to become more creative in order to address this issue, they must also remember that they are subject to a tangled web of regulations above and beyond other consumer-facing businesses.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

June 02, 2009

Grand Rounds Vol. 5, No. 37: The June Is Bustin' Out All Over Edition

June is bustin' out all over . . . .  Lord knows my nose knows it, thanks to all the pollen in the air these days.  Check out the classic movie rendition of this set piece (well worth the eight-minute investment), let your coffee and/or antihistamines kick in, and then let's dive into the past week's medblogging, loosely categorized into insights of patient bloggers, provider bloggers, bloggers I've met in real life (the number keeps growing), bloggers following the money trail through the health care thicket, and bloggers who are or should be dancing and/or shirtless (watch the whole movie clip . . . on second thought, let's leave it at dancing).


Last time I hosted Grand Rounds, we delved into the origins of Valentine's Day, so even though we're a couple weeks shy of the vernal equinox, since June is bustin' out all over, the historian in me feels the need to touch on an ur-Spring nugget or two before we get going.  Where do these celebrations of Spring come from?

Attis was a Phrygian god, whose annual death and resurrection were mourned and celebrated at a Spring festival.  (On the other hand, the death and rebirth of the Sumerian Tammuz was a summer solstice thing rather than a vernal equinox thing.)  James Fraser, in The Golden Bough, wrote:

The annual death and revival of vegetation is a conception which readily presents itself to men in every stage of savagery and civilisation: and the vastness of the scale on which this ever-recurring decay and regeneration takes place, together with man's most intimate dependence on it for subsistence, combine to render it the most impressive annual occurrence in nature, at least within the temperate zones. It is no wonder that a phenomenon so important, so striking, and so universal should, by suggesting similar ideas, have given rise to similar rites in many lands.

What I best remember from The Golden Bough, though, is the tale of the king-for-a-year, who ascends the throne as a result of a cultic regicide, and ends his term the same way.  Great stuff.

For further reading linking The Golden Bough, The Holy Grail, Wagner's Parsifal, and T.S. Eliot's The Waste Land, check out Derrick Everett's article on The Waste Land.

I'm not certain that Rogers and Hammerstein had these themes in mind when writing Carousel.  Heck, who knows what they had in mind; they threw in a happy ending that wasn't in their source material (but hey, that's show business).  You, dear reader, certainly didn't have these themes in mind when you tuned in to today's edition of Grand Rounds.  Nevertheless, on with today's show.

Provider Bloggers

At Musings of a Distractible Mind, Dr. Rob discusses Atul Gawande's recent New Yorker piece on health care cost variations across the country (a good read, well worth the time), which focuses on McAllen, TX, a small border town that consumes far more than the average annual per capita amount of health care services.  Gawande loops in the Dartmouth Health Atlas folks, asks the hard questions about physician-owned facilities and financial incentives, and concludes that outfits like Geisinger, Intermountain, Kaiser Permanente and Mayo -- not-for-profit integrated delivery systems with salaried docs -- have the model we should strive to emulate systemwide.  Dr. Rob recounts his own experience with physician-owned facilities.  His conclusion is a folksy twist on Gawande's:

How do we fix it?  There are lots of good answers, and lots of dumb ones as well.  The bottom line is the bottom line, though.  How you pay docs will determine what happens.  It’s America, after all.  It’s what makes us great.  Right?

Right.  The thing is, guys, we've known this for at least forty years.

ACP Hospitalist reports on Sid Wolfe's new Public Citizen campaign to get hospitals to step up reporting of physician wrongdoing.  Bob Wachter, at Wachter's World, delves deeper into the problem, and says:

I’m proud to say that over the past five years, my hospital (UCSF Medical Center) has taken Leape’s challenge to heart, withdrawing clinical privileges (and filing accompanying NPDB reports) in several cases for behavior that, I’m quite confident, would have been tolerated a decade ago. This is progress. As Kissinger once said, “weakness is provocative.” As more hospitals take this tougher stance, I think we’ll see the boundaries of acceptable behavior shift everywhere. And patients will be safer for it.

Bongi, at other things amanzi, recalls a suboptimal experience in his training, when the "see one, do one, teach one" approach was reduced to "read an article about one, do one immediately afterwards."

At Providentia, Romeo Vitelli looks at the historical precursors to Jenny McCarthy and the current crop of anti-vaccinationists. 

Ken Cohn, a physician and consultant
(who I know in real life [IRL]), recounts a (positive) experience in asking health care administrators to consider ethics in physician-hospital relationships.

I take a baby aspirin a day, and Doc Gurley says I should keep on doing so, because I'm better off puking up blood than having a heart attack.

Seizures and how they have been misunderstood (epilepsy vs. demonic possession) is the subject of this week's selection from Mind, Soul and Body.

Suddenly becoming a first responder at 35,000 feet? On Your Meds' Barbara Olson takes you there.  (The blog is part of Medscape, so free registration is required).

NurseAusmed recounts difficulties in handling patient communications and managing patient expectations at Nursing Handover.

How to Cope With Pain takes a page from a book offering guidance to those who have lost their spiritual way and turns the advice to use for those facing physical, rather than spiritual, pain.

Web 2.0 meets the health care establishment, and KevinMD [IRL] observes that since health care is largely a business, this should not be surprising.  For a window into social media use by health care provider organizations, check out healthsocmed.

The anonymous author of Notes of an Anesthesoboist says it's hard for women doctors to make friends . . . perhaps they should introduce themselves as drug pushers instead?

John Crippen wants to, but the NHS Blog Doctor just can't look away from the kids pushed onto TV talent shows by 21st century stage mothers.

Paul Levy [IRL] goes another round with SEIU Local 1199 at Running a Hospital.

At UDM Solutions, David Siwicki provides a clinical perspective on deciding whether to prescribe opioids for chronic pain patients who use marijuana.

Nancy Brown offers sound advice on talking to teens about alcohol at Healthline's Teen Health 411.

Follow the Money

DrRich, at the Covert Rationing Blog, always follows the money, and this week the trail leads to the following unlikely destination: the American College of Surgeons encouraging malpractice suits -- against overseas surgeons offering services to medical tourists.

Big Pharma also always follows the money, and David Williams, at the Health Business Blog, remains perplexed over Pharma's failure to engage with the public via twitter.  (GSK has already responded to David's post, but in a way that doesn't exactly undercut his point.)  For a window into Pharma's engagement with social media, look no further than Shwen Gwee, who organized the Social Pharmer unconference in conjunction with the HealthCamp Boston unconference I co-organized in late April.  Speaking of social media, feel free to follow me on twitter: @healthblawg.  

Last week, I took a look at the proposed Medicare Inpatient Prospective Payment System (IPPS) updates for FFY 2010.  Among other things in the rule (including payments cut to the bone), I was surprised to see tucked away in there a tacit acknowledgement that the whole "no pay for never events" thing isn't really saving anybody that much money.

Lots of hospitals are touting new private rooms these days.  Seems to help patient care (lower infection rates, better sleep, more privacy), but despite the benefits, Jeffrey Seguritan at nuts for healthcare observes that the private room is being pushed by the AIA, and wonders whether health care dollars really ought to be spent these days on capital projects such as these.  (My brief response: these days, they really aren't, given the tight financial markets).

In a medblogosphere first, The Happy Hospitalist has publicly described an entry in the $10 million X Prize competition:

How do you [reduce health care costs dramatically]?  Here's my theory.  You can do more to affect health care costs by getting 10,000 people to change their lifestyle habits than you can by getting a few hundred docs to change how they document and collect data and prescribe some pills.

So here's what you do.  You bribe the public.  People are inherently lazy, but they respond well to piles of money.

For a fuller introduction to the X Prize competition: Scott Shreve [IRL] posted his twitterview on the X Prize with Bertalan Mesko (@berci) at Crossover Health Learn more about it there.

The big HITECH Act pot of money that everyone in health IT is itching to get their hands on is going to have some strings attached: chief among them are going to be definitions of "meaningful use" and "certified EHR."  Them that are likely to be certifying -- CCHIT -- have been the target of some possibly well-deserved pot-shots, and the gloves have come off.  See Gilles Frydman's [almost met IRL at the Health 2.0 conference in Boston a month or so ago] framing of the debate at and John Moore's [IRL] take at Chilmark Research.  

Health technology research and development yielded two bits of news this week: FDA approval of a handheld ultrasound unit, via Vijay Sadasivam's scan man's notes, and Ves Dimov's post at Clinical Cases and Images on the Rovio - a WiFi-enabled mobile webcam, which may be more attractive to medical users given the recent study that found patient satisfaction, physician satisfaction and diagnostic agreement (measured both between face-to-face and virtual vists, and between two face-to-face visits) to be similar for face-to-face and virtual visits.  (Yesterday's Boston Globe took a closer look at this study, virtual visits in general, and American Well in particular.)    

The health IT crowd is working on interoperability and portability of health information.  Google Health is one of the platforms that may enable folks to reach this holy grail.  Brian Dolan at mobihealthnews says that Google Wave, an open-source tool for communication and collaboration, looks like a killer tool for enabling Google Health to do more in terms of provider-provider and patient-provider collaboration.

Evan Falchuk's observation at See First on prevention: it ain't cheap; treatment of preventable disease is more expensive than the savings from avoided disease and complications, so we need to be talking about more than cost-effectiveness.  [Supposed to meet IRL soon.]

Patient Bloggers

For some reason, diabetics are very well-represented among Grand Rounds' usual suspects.  This week, they're turning into media critics as well, following President Obama's nomination of Sonia Sotomayor to the Supremes.  Amy Tenderich [who I also almost met IRL at Health 2.0] touched on the media frenzy regarding the nominee's Type 1 diabetes at The Diabetes Mine, as did Six Until Me's Kerri Morrone Sparling.  Not to leave Type 2 diabetes unattended, Rachel Baumgartel offers tips for the newly diagnosed Type 2 diabetic at Diabetes Daily.  (For those who care to immerse themselves in The Politics of the Sotomayor Nomination, the good folks at SCOTUSblog say come on in, the water is fine.)  For a taste of the difficulties faced by some diabetics traveling through airports with needles and curious liquids, head on over to Tim Brown's post at Shoot Up or Put Up

At Getting Closer to Myself, Leslie offers her reflections as a twentysomething with auto-immune disease, specifically a feeling of how she can't go home again to an idealized summer retreat.

Barbara Kivowitz describes a good day at In Sickness and In Health, and invites all of us to do the same.

Bloggers Who Are or Should Be Dancing

Val Jones [IRL] is pretty pleased with her high-deductible health plan (HDHP) - cash-only PCP combo.  I hope her husband is dancing after the office procedure scheduled on a dime last weekend . . . and I hope Dr. Val has all the releases for those photos stashed away somewhere.  It's a good solution for those with no chronic conditions, young kids, or other sources of regular interactions with the medical-industrial complex.  And no less a luminary than Clay Christensen says we're 5-6 years away from the tipping point (to mix metaphors) on HSA/HDHP combos, at which time we're likely to see a significant change in the economics of healthcare (with or without significant movement in DC).  For one example of where this may play out, see my recent post on retail health clinics.

No dancing for you if you're susceptible to one of the side effects of Cipro and its relatives (fluoroquinolones): tendon rupture.  There's a black-box warning regarding this, but many clinicians and patients are unaware, says Paul Auerbach at Healthline's Medicine for the Outdoors.

InsureBlog's Bob Vineyard shares good news for Cuba's pre-op transsexual population: coverage is here.  Surely cause for someone (patients, if not bloggers) to dance.

Well, that's the last dance . . . for this week.  See you around the medblogosphere, and next week at the next edition of Grand Rounds

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

May 28, 2009

Retail Health Clinic Summit: Can we get there from here?

At one of the pre-summit workshops yesterday, Tom Charland (ex-MinuteClinic exec and now consultant) channeled Clay Christensen (Mr. Disruptive Innovation) for a while and laid it on the line: unless retail clinics find a way to beef up off-season volume for at least 5-6 years, they may be dead in the water.  In that time, if Christiansen is right, HSA/HDHPs will become much more prevalent than they are today -- prevalent enough so that retail clinics could safely opt out of health insurance plan provider networks and have a sufficient patient base to draw from.

In the interim, Tom and I agree that retail health clinics need to break out of current operating modes, particularly into chronic care / disease management.  In fact, I was quoted on this point towards the end of a thoughtful piece on retail health clinics in BNA's Health Care Policy Report last month.  Retail clinic providers (including one from Spain), other consultants, payor representatives, drug and device reps, urgent care center operators, and even the US Armed Forces (planning a pilot project foray into retail health clinics) all showed up for the Summit, which provided a mix of perspectives on challenges and opportunities facing this nascent industry.

Slides from my talk at the summit on the Massachusetts experience, and lessons for the future  -- especially the need to move into chronic care and to partner more effectively with health care systems -- are provided here for your viewing pleasure.  My work with all components of health care systems -- including physicians -- makes clear that these combinations have the potential to be very powerful, and makes equally clear that the groundwork must be laid carefully with physician partners and champions in order to ensure the success of such an undertaking.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

March 04, 2009

Dan Greden, head of eHealth Product Management at Aetna, speaks with David Harlow about PHRs and patient engagement

Dan Greden, Head of eHealth Product Management at Aetna, spoke with HealthBlawg last week about Aetna's PHR system, its above-average rate of adoption by members, and the benefits that it provides to members, clinicians and ultimate payors.

The audio file of my interview with Dan Greden (about 30 minutes long) is available for download/podcast. A full transcript is at the end of this post (and in the linked transcript).

About 11% of Aetna's subscribers are active users of the Aetna PHR system (vs. well under 5% PHR adoption by the population at large).  The PHR is automatically populated with data from providers' clinical systems, including prescription information and lab results.  As Greden explains in greater detail, the PHR system is bolstered by an evidence-based medicine expert system that generates patient-specific alerts to patient and/or clinician (depending on the urgency of the alert), and allows for members to be more fully engaged in active management of their own health care.  This increased level of engagement is beneficial both to the management of members' health and to the management of the cost of care.  As more employer health plans steer members into HDHP/HSA combinations, members are becoming more cost-conscious, and have become more interested in learning about quality and cost-effectiveness when it comes to managing their own health care.

Aetna's system allows members to delegate access to their PHRs to clinicians and family members in a variety of controlled ways, limiting access where the member so desires (or where the right to impose limits is required by law -- e.g., for records relating to minors' reproductive health issues).

Greden stressed that the records belong to the individual members, and that in case of a change in insurance coverage a departing member may arrange for his or her PHR to be ported to HealthVault.

As the entire country has become focused on EHRs and PHRs thanks to the HITECH Act (which, by the way, brings PHRs into the big HIPAA tent), it is instructive to look at successful implementations of PHRs such as Aetna's, which has been in place in one form or another for over two years, in order to consider how the HITECH Act's billions might best be spent.  For example, the architects of the new system should consider in very concrete terms the improvements to patient care that are enabled by PHR systems such as Aetna's and the accompanying EBM expert systems and logic, and the minimum infrastructure necessary to enable such improved coordination of care and better outcomes, both on the patient side and on the provider side. 

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Interview of Dan Greden, Head of eHealth Product Management at Aetna

February 26, 2009

David Harlow:  This is David Harlow on HealthBlawg and I am speaking today with Dan Greden who is the head of eHealth Product Management at Aetna.  Good morning, Dan.

Dan Greden:  Hey, good morning.

David Harlow:  Well, thank you for taking the time to be with us this morning, Dan. I had the pleasure of hearing you speak at a recent conference on Health 3.0 and while we may debate the definition of Health 3.0, what I heard from you about what you are doing at Aetna was fascinating. I would like to ask you to speak a bit about your work in connection with the personal health records online access tools for Aetna members and how that allows them to be engaged with their physicians managing their own healthcare.

Dan Greden:  Great.

David Harlow:  So I wonder if just for starters if you could describe what the tool is and how patients are accessing it?

Dan Greden:  Sure, David.  We built our PHR as part of our Aetna Navigator secure website and that was a deliberate decision from the beginning that it should be part of the rest of our members’ online experience. You know, it’s not a separate tool, it’s highly integrated into all their other interactions, and what we focused on was building a tool that helps them be better consumers of healthcare and providing them a resource to make decisions, to be more engaged with health care providers, and so our approach was really beyond just putting the data on a secure site.  What we chose to do is really marry the data that we all really have through our normal healthcare plan operations with our care engine, the analytical engine that our Active Health Management subsidiary provides us, so we could really guide our members by continually analyzing their records and reaching out to them and/or their physicians when we find an opportunity to improve their care or be more engaged to better manage their care through that analysis of their records.  So even though we call it a PHR, it’s really much more than just a record online, it’s really a tool and resource that our members can use to be more engaged and better consumers of their healthcare resources.

David Harlow:  And what about their clinicians?  What access or inputs to the PHR do the clinicians have, and how do they use that information?

Dan Greden:  Well, the first and the primary way that a member shares their information with their physicians is by printing it out; we had that ability in the product the day we launched, which was just over two years ago, February 14th of 2007.  Since then we have added additional capabilities to have the physician access the record when the member provides that to the clinician. So the member is always in control of who sees their records; they have to formally delegate the access to someone else, whether it be a physician, whether it be a family member.  The way it works electronically is that a member can go online, choose the physician that they want to access their records and then when, if the physician is using our Aetna provider portal which is part of a larger package of resources that Navimedix provides -- it’s a company that provides tools for physicians to automate their practices -- when the physician staff or office is going on and doing something like an eligibility verification prior to the visit or even perhaps submitting a prior claim, if the member has delegated access to the PHR it will show up as part of that activity and there will be a prompt that asks the office: hey, your patient, your member has asked to share this with you, click here to print it.  We also can send care alerts -- or what we call care considerations -- that the care engine identifies to the physician in that way.  So if there is an opportunity to improve care we deliver it via that channel as well.

David Harlow:  That’s a very interesting additional tool.  Now, how are those care alerts generated and what are they based on?

Dan Greden:  Well, what the care engine does is it takes the claims-derived data from a multitude of sources. It’s not just medical claims but also pharmacy claims.  We look at lab claims, often we have lab results as well, and it goes through and does several types of analysis.  The first is it will go through and try and identify a potential presence of certain medical conditions and so it’s not just taking the way the claims are coded as the basis for the presence of the medical condition, you have to look for more evidence beyond that so if we use the example of a diabetic, we’ll see whether the claim coding, the ICD-9, or the CPT-4, or whatever, suggest the presence of diabetes, but those are often rule-out diagnoses the way the physicians code the claims so we’ll also look to see, all right, do I see prescriptions that would be consistent with someone managing diabetes, do I see lab results that would be consistent with someone  managing diabetes and based on what that analysis provides, the care engine may say you know I have reasonable cause to suspect this member has diabetes.  I am going to go through and do an additional set of analyses to make sure that all the best practices of care related to a patient with diabetes are being followed. So, for example, is this patient taking a low dose of an ACE inhibitor?  There have been recent studies that have proven that a very low dose of lisinopril, for example, five milligrams for example, can in the long run significantly prevent complications with kidney function, and if the member has taken a scrip that’s great, no action will be taken.  But if we see that the member has not taken it we will send a note to the physician as well as to the member, just informing them of this potential opportunity. You know, we are not drawing any conclusions; we are just introducing the topics for further discussion and further exploration between the member and their physician.  So that’s an example of how diabetes would work.  There are literally hundreds of different opportunities to improve care that are analyzed and dozens more medical conditions that have care management protocols or alert potentials in place.

David Harlow:  I’m wondering whether you have the potential to overload physicians with information about these various alerts, alerts that go to physicians or that go to patients as well.

Dan Greden:  The potential is there to overload physicians with the result of this analysis.

David Harlow:  Yeah, there is a potential, it seems to me, to provide so much information that the physicians could potentially be overloaded with information on a variety of conditions for a large number of patients.

Dan Greden:  First of all that’s a great question, and the way that that’s been managed is two-fold.  One, I mentioned how the analysis for the presence of the condition is fairly rigorous, it doesn’t just look for the claim coding, it looks for other data that would corroborate the presence of the condition, so it reduces errors that way, but I think the primary way that that’s mitigated is through what we call the alert urgency; we don’t send physicians just routine and preventive care, and the way that the alerts are communicated to the physicians  is also a function of the criticality.  So level one urgency is a life-threatening situation that we may have identified, whether it’s a drug-to-drug interaction risk or a drug-to-medical-condition interaction risk, or in rare cases, a drug-to-family-history interaction risk, the type of thing a physician may not have recognized on their own but it is potentially life-threatening, that will typically be made through a phone call with follow-up fax.  But less urgent ones are typically sent by mail or fax, and the ones that really involve the member being proactive, or engaging in preventive care, are not sent to the physician. So through the urgency of the alert and the means through which the alert is delivered we have been able to manage that pretty well I think. Active Health has been running the care engine for, boy, a little over five years now, I think about five years, and so it’s a staff of physicians who run this part of that business so it’s been pretty sensitive to what warrants an outreach and what a proper form of outreach is based on the content. 

David Harlow:  And the care guidelines that they use are based on peer review journals or data from your network or a combination of both or how does that work?

Dan Greden:  They are really more expert than I am on this but I know that they continually review peer-reviewed journals and include that.  There is analysis going on of informatics work within our databases but it’s really -- a lot of the feedback that they get suggests that this is a means for physicians to learn about new findings in various fields, and the ACE inhibitor one is a good one. That’s a couple of years old, still being understood throughout the physician community that treats people with diabetes, and so they often get the feedback on care consideration from the physicians, like: thanks, I didn’t know the study, your note prompted me to look into it and I am going to start changing my treatment approach.

David Harlow:  This system has been in place for two years now, and I am wondering whether you have done any sort of systematic review of quality of care improvements, cost of care reductions, any sort of tracking that’s been done to date?

Dan Greden:  We track that extensively, but because we started our pilot two years ago we’ve really only had a meaningful user base for about a year.  We are just now starting to see some early indicators of the improvements in care and so we are really at, we think, the tip of the iceberg on that but what we are seeing is a few things.  People who use our PHR generate significantly more of those care considerations, those care alerts that I talked about.  That’s a good thing for medical costs, because we have seen through other work in the care engine, Connected Health Management, which has been up and running about five years, that the more alerts that are generated, the more opportunities we have to improve care and lower costs. So the PHR makes that care engine program and its ROI more effective.  We have also found that the compliance with those alerts is higher for people who use our PHR. We think it’s for a few reasons, but one of them is that we are sending the notice to both the physician and the member in some cases so there is better follow-through. That improvement is over four percent so early indicators are that the users of our PHR are much more likely to have a medical condition and the PHR helps them be more engaged with their care, so we do expect, as we have had more of a experience base to do our informatics work on, that will continue to see very specific cost savings.

David Harlow:  I see, now you say this is now this was done as a pilot for a year and it’s been out of pilot so how many patients or what proportion of your membership is using this actively and how do you measure that?

David Harlow:  Yeah that’s still changing pretty rapidly because, like I said, so many of these deployments have happened recently.  I mean, to give you a specific number, about eighty-five percent of the membership who has our PHR have had it for seven or eight months or less, so it’s relatively new to most of these people.  In terms of how we measure this, we don’t just measure what percent of the people who have the PHR have used it.  Now obviously we’d do that too but what's more relevant to us is who are they, what is the value delivered to these members through the PHR and then really focusing on making sure that we continue to build out the right capabilities to help them be better consumers of their healthcare.  As an example, we have much higher than normal usage among people with a medical condition.  Also we see higher usage among mothers with children.  They are doing things like accessing immunization records or other health data across multiple kids or even a single kid, and we also see the pre-retirees use it more.  Now what's important to note there is that while there are similarities there is different value delivered to each of these members based on how they are using the tools.  So our measurements around adoption really tend to focus more on who is using it and what they are using it for and what the value delivered from that is.

David Harlow:  Sure, now do you have a sense of what proportion of your membership is using this in some regular fashion?

Dan Greden:  Again,  it continues to grow significantly every month and we do measure this regularly, right now over ten percent of our subscribing members -- these are the ones who you know subscribe directly to the health plan  --  have accessed  their PHR,  and that’s higher than the industry average, and we expect that to continue growing.  A little clarifying point is that those are the members who are easier for us to communicate to, those are the ones who through their employer subscribe to the plan and you know their dependants for example, their minor dependants have a PHR but the parent accesses it for them, but we have to count those.

David Harlow:  You are not counting those other family members in your percent?

Dan Greden:  That’s right I mean we do when we look at that as well, but I think the more relevant measure is the one that I gave you.

David Harlow:  Subscriber rather than the member, I guess. Okay.  Have you thought about additional bits and pieces of functionality that could be added on?  You said a moment ago that different people access this and use it in different ways depending on their personal situations. Has looking at that given rise to thoughts about expanding the functionality of the tool?

Dan Greden:  Oh yeah, we have a very long list of enhancements on our product plan in the forward years.  I think the best way to describe it is our plan, which is based on an assumed evolution of this because it’s a new tool right now, is just simply building awareness of the tool and what it can do for people.  So a lot of more recent enhancements have been to help people delegate access to a record or bring other people to access their record.   You know, we just talked about how there is a tool for a member to delegate access to their physicians but we haven’t talked about a new capability we launched where a member can delegate access to their family members.  So, for example, I went on when we shipped this enhancement a few months ago, and all right, now my wife can access my record.  I don’t know whether she has done the same for me, and I have to check, but what's interesting about that is if a member does that and their spouse or other adult dependent for whatever reason isn’t registered on our websites yet, we built it in such a way that they can invite that member by sending an e-mail to any e-mail address that’s from the member themselves and it’s an invitation to come online with Aetna and access their PHR.  We borrowed from a lot of other social networking sites, such as Facebook, in designing that so our focus has really been on how do we just create awareness in that initial experience with the PHR and then down the road we’ll be building a lot more integration of the PHR to other activities within the health plan.

David Harlow:  I see.  The other area that I was interested in thinking about here is plans for the future in the context of new legislation.  Now I know it may be too soon to be planning this out since I don’t think the legislators who voted on this have even read it yet – let alone the rest of us.

Dan Greden:  It’s my sense that it’s very directional at this point but more detail to come.

David Harlow:  Right.  There are a couple of areas that I did want to sort of explore with you a little bit. The first of those has to do with security, the online security of this information, which I imagine has been a big part of the design upfront.  The HIPAA regulations in the future look like they will have more technology-specific direction in there whereas up until now it’s really been technology-agnostic, if you will, and HHS is being directed to come up with more specific requirements that will be updated on an annual basis in conjunctions with industry stakeholders.  So as an industry stakeholder, I am wondering if there is a particular architecture that you are more comfortable with, or security architecture and systems, and whether you have some cause for concern where this could be changing on an annual basis.

Dan Greden:  Again, it’s really too early to have concern but I know that in our case we have invested heavily in security not just in the technology framework but also in operational protocols and protections and processes, long before we even had our PHR, so what we found is that this is a logical extension to our security environments already.  I know that in the case of the data-sharing work that we have done is part of the AHIP working group, the America's Health Insurance Plans working group, I think that was a very good approach in defining an industry standard that works well amongst the larger community of stakeholders and so if we see something like that evolve out of this I expect that would be constructive.

David Harlow:  Yes, and hopefully that will evolve.  As you said, it is very early.

Dan Greden:  One thing I also see is that something like a PHR – obviously not limited to that --  this is very new to everybody and so it’s an opportunity for the whole healthcare community to really raise awareness among the rest of the population that doesn’t think about this stuff all day long, to explain the benefits and so on.

David Harlow:  Right.  Now one of the other issues that jumped out of me was a section of the new law that addresses the ability of an individual to restrict access to information in his or her medical record, and that is a patient can ask an individual provider not to share information with insurance companies if it’s not for purposes of treatment or payment, and I imagine that currently the PHR that you describe, that you are using, captures a lot of such information and I am wondering whether you have had any pushback or feedback from members about what information should or should not be in this PHR?

Dan Greden:  In the way we approach that is, once again, we make it clear over and over again that the patient or our member owns their record.  They are in control of it.  They are in control of what’s in it.  They are in control of who sees it.

David Harlow:  Yeah.  You are much clearer about that than many others.

Dan Greden:  Yeah, that’s true, and I think there are a few reasons for that.  I mean, we are not a hospital, so I think potential confusion about the ownership of data that others might have doesn’t exist for us.  In terms of the details of the language, we already support the idea that a member can choose to not share parts of the record or does not just share the record at all.  We even have built the capabilities, say for whatever reason the member wanted to exclude parts of the record from a specific delegation, a specific sharing, they can do that.  So I think generally it’s consistent.  I would add that we encourage sharing the whole record.  A lot of what we are doing here is trying to encourage more open and constructive dialogue about members’ health but -.

David Harlow:  It’s hard to connect the dots if you don’t have access to all of them.

Dan Greden:  Yeah.  I will also give you a very specific example of how we really pushed for some of that. You know, state privacy laws are such that there is a lot of information about minors that can’t be disclosed to anyone by us, including their parents.  So we built, instead of taking the choice and saying all right, well we just, parents can’t access their minor child’s PHR, which obviously isn’t the right thing for a lot of people, we started to build some additional capabilities in order to comply with state privacy laws where types of information that are specifically addressed in the law are filtered out of the view, and the parent is still seeing ninety-eight or ninety-nine percent of most records but specific content about whether it would be reproductive help or substance abuse treatment that state law, state privacy law explicitly addresses, that’s filtered out; so we get the benefit for the vast majority of the people by still having parents be able to access minor child’s PHR and still complying with state privacy law.  To build that capability, we had to spend some of our resources, but we felt it was the right thing.

David Harlow:  Sure.  So that can be applied to any of these other situations where disclosure will be limited or information can be customized to different providers or different folks that would access the information?

Dan Greden:  That’s right and from my perspective the fact that the legislation doesn’t even have  -- fostering the discussion of this is a great thing.

David Harlow:  Yeah, is it your sense or do you just say that you know it would make sense for people to share information more clearly, do you have a handle on whether that is in fact what's being done or whether people are keeping some information close to the vest, if you will?

Dan Greden:  Yeah, in our case a lot of the sharing features are fairly new so it’s hard for me to know.  I don’t have enough data to really draw any conclusions yet but what I can tell you is that when it’s shared, sharing it by paper is still the most common.  It’s an interesting thing, but when we did research not long ago, the vast majority of physicians, even those that practice in an environment that have an EMR, use paper so you know -.

David Harlow:  I am familiar with that in my own paperless office here -.

Dan Greden:  Yeah exactly I have piles everywhere in mine -.

David Harlow:  So that’s the mode of communication.  It’s interesting.  There is a physician module for this, is there not?

Dan Greden:  Well, the way it works is, through Aetna’s provider or physician portal,  we’ve added the delivery of the PHR onto existing workflow that was already built there, so in other words our assumption, our view on this is that we don’t want to ask our providers to take an additional step so when they are -.

David Harlow:  You don’t need to log in somewhere else?

Dan Greden:  Oh gosh, no, they log in the same place and when they are doing other work that they already need to do with us such as verifying eligibility of one of their patients for coverage, in some cases submitting the claim, as they do those other steps we can layer delivery of a personal health record onto that activity without them really having to do any additional work.  You know, classic scenario is, a member of the staff goes in the morning of the appointment, the night before, verifies that there is coverage in place and they verify the eligibility and if the member has delegated the PHR to that physician it’s delivered via that same activity.

David Harlow:  Right.

Dan Greden:  And just to close the loop, what we find is they told us: Yup, and we print it out and we stick it in the folder along with everything else so -.

David Harlow:  I understand  it’s a work in progress and I guess I have asked this another way before, but do you see sort of a particular growth curve in terms of additional functionality or additional utilization by patients and physicians?  This has sort of taken off in the past year and do you see it continuing to grow, or sort of leveling off in the next year or so?

Dan Greden:  No.  I think we are really just getting started in terms of the people who can really benefit from a PHR becoming aware of these tools and what they do.  I’m not one who believes that a PHR is valuable to everyone though, I think -.

David Harlow:  I was just going to ask that, is it the goal to have a hundred percent adoption?

Dan Greden:  No I would think there are better ways that we can engage those -- we call them young and invincibles -- but realistically some are at a point in their life where for whatever reason they are not even generating medical claims -- obviously we would like if they were doing their preventive care but you know there is a lot of our population who just don’t use their clinician resources and medical resources at all.  We have different ways to engage them that are more effective and more relevant than the PHR, but I think we are really still at the beginning of getting the part of the population that would benefit from the PHR to understand what they are, understand that they have one and then try it and see how it delivers value for them.  In our case, we are continuing to deploy this tool pretty rapidly, but last year -- you know, I think we touched on these numbers earlier --  we went from around a million at the very beginning of ’08 to over seven at the beginning of the year.  We were just deploying it aggressively. We are getting past the mid point so that’s going to slow down then we will start to see a lot of these people who have gotten it recently, have it for some time, have the marketing that we have in place to make them aware would start kick in but we are already seeing a pretty nice growth in the awareness and the adoption.

David Harlow:  Yes, well, very interesting.  It sounds like a very valuable program as it’s being rolled out.  Well thank you.  I have been speaking with Dan Greden, head of eHealth at Aetna.  This is David Harlow on HealthBlawg, and once again, thank you, Dan.

Dan Greden:  Oh, you’re welcome. Thank you.

December 15, 2008

Massachusetts Health Care Quality and Cost Council: Quality and cost transparency or veils?

One of the much-ballyhooed (and predictably delayed and diluted) innovations of the 2006 Massachusetts health care reform and universal access law is the development of an online resource providing cost and quality data in a consumer-friendly format.  MyHealthCareOptions debuted last week (see HCQCC press release).  After taking it for a spin, I must express my disappointment with the current state of affairs.

The site does not provide very much meaningful data.  For example, hospitals' differing rankings on quality of care are mostly undercut by notes saying that the differences are not statistically significant.  In other cases, both cost and quality data are unavailable.  In any event, cost data are not given in dollars but in ranges ($, $$, $$$, etc.), and quality data is given in the form of star ratings, as a result of the long negotiations among payors, providers and the state agency, as is par for the course in this sort of cost and quality disclosure exercise.

Many of the categories of data described on the site are empty -- I hope they are placeholders for data to be provided in the near future, but I am concerned that the data will not be forthcoming.

Even if the site were more fully realized, how would it affect health care purchasing behavior?

Except for the tiny minority of patients with truly consumer-directed health care (e.g., gold-plated indemnity plans or high deductible health plans combined with health savings accounts and no network restrictions) patients go to health care providers based on referrals from their primary care providers, within networks defined by their health care insurers.  The health care insurers that had the tiny bit of data on the new website coaxed out of them have much more data available in-house, and they have been using this information for years on developing provider networks and encouraging utilization of an appropriate mix of highest-possible-quality, lowest-possible-cost providers, consistent with the demands of patients and premium payers for world-class health care in teaching hospitals and at their affiliated providers.

In sum, cost and quality transparency won't change health care purchasing behavior unless the data provided is much more robust and employers and other premium payors are in a position to demand that health care insurers change their contracting practices.  Unfortunately, I do not think that the data will be much more robust in the near term, and I do not think that any employer or health plan will be prepared to engage in development of tiered health plans, restricting access to certain groups of providers.

Cost and quality transparency will change behavior only if there is a sea change both in the quality of this data and in the impact of the health care purchasing decision on the patient's pocketbook. 

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

August 02, 2007

CMS releases final 2008 IPPS (Medicare inpatient prospective payment system) rule for hospitals

CMS released its final rule on the 2008 Medicare hospital inpatient prospective payment system yesterday.  It will be published in the Federal Register August 22.  The CMS press release says:

The IPPS payment reforms would restructure the inpatient diagnosis-related groups (DRGs) to account more fully for the severity of each patient’s condition. In addition, the rule includes important provisions to ensure that Medicare no longer pays for the additional costs of certain preventable conditions (including certain infections) acquired in the hospital. The rule also expands the list of publicly reported quality measures and reduces Medicare’s payment when a hospital replaces a device that is supplied to the hospital at no or reduced cost.

Highlights (quoted or adapted from the press release) include:

  • Payment increase.  Payments to all hospitals will increase by an estimated average of 3.5 percent for FY 2008 when all provisions of the rule are taken into account, primarily as a result of the 3.3 percent market basket increase.
  • MS-DRGs.  745 new severity-adjusted diagnosis-related groups (Medicare Severity DRGs or MS-DRGs) to replace the current 538 DRGs. Projected aggregate spending will not change as a result of the reforms. However, payments will increase for hospitals serving more severely ill patients and decrease for those serving patients who are less severely ill. (This is intended to remove incentives for "cherry-picking.")
  • Outliers; capital cost reimbursement.  New methodologies for calculating outlier payments and capital cost reimbursement, which are intended to be more accurate.
  • No pay for "never" events.  The rule implements a provision of the Deficit Reduction Act of 2005 (DRA) that takes the first steps toward preventing Medicare from giving hospitals higher payment for the additional costs of treating a patient who acquires a condition (including an infection) during a hospital stay. Already the feature of many state health care programs, the DRA requires hospitals to begin reporting secondary diagnoses that are present on the admission of patients, beginning with discharges on or after October 1, 2007. Beginning in FY 2009, cases with these conditions would not be paid at a higher rate unless they were present on admission. In order to improve the reliability of care in the nation’s hospitals, the rule identifies eight conditions, including three serious preventable events (sometimes called “never events”) that meet the statutory criteria. CMS will work to add an additional 3 conditions to the list next year.
  • Quality measures and reporting.  New quality measures that hospitals would need to report in calendar year (CY) 2008 in order to qualify for the full market basket update in FY 2009.  Failure to report will result in a 2% penalty.  CMS will measure 30-day mortality for Medicare patients with pneumonia and plans to adopt two measures relating to surgical care improvement in the CY 2008 outpatient prospective payment system final rule. In addition, CMS will finalize two additional surgical care improvement measures by program notice after they receive NQF endorsement.
  • Replacement medical device reimbursement.  Payments for replaced medical devices which were recalled and replaced by manufacturers below cost will be reduced.
  • Specialty hospitals.  In keeping with the plan contained in CMS’s August 2006 final Report to Congress on specialty hospitals, the rule creates new disclosure requirements for these hospitals. The rule requires physician-owned hospitals to disclose such ownership to patients and provide the names of the physician owners upon request. The rule also requires physician-owned hospitals to require physician owners who are members of the hospital’s medical staff to disclose their ownership to the patients they refer to the hospital. Disclosure would be required at the time of referral. In addition, the rule requires a hospital to notify all patients in writing if a doctor of medicine or doctor of osteopathy is not present in the hospital 24/7, and describe how the hospital will meet the medical needs of a patient who develops an emergency condition while no doctor is on site. CMS now has the authority to terminate a provider agreement for noncompliance with these disclosure requirements.

-- David Harlow

May 16, 2007

Health Wonk Review is up at Health Care Policy and Marketplace Review

Bob Laszewski has posted the latest edition of Health Wonk Review at his blog, Health Care Policy and Marketplace Review (yes, that's a mouthful).  As usual, HWR covers a broad range of issues (and acronyms); this week, the selection includes HSAs, SEIU, an RWJF review of proposals to establish health courts, fleecing the uninsured, the obligatory post on Massachusetts health care reform, and even a couple of HealthBlawg posts -- on CVS's Minute Clinics and an IRS about-face on friendly PCs.

-- David Harlow

April 25, 2007

Consumers could use some guidance more than choice

In our society, we value choice very highly.  Sometimes, however, choice is not a universal good.

A tip of the hat to Joe Paduda at Managed Care Matters for linking to the California Health Care Foundation report on consumer choice in health care (both benefits side and services side), which concludes that the clutter of information and the dizzying array of choices are more harmful than helpful to consumers.

David Williams, at Health Business Blog, muses about the parallels between the shift from defined benefit retirement plans to 401(k) plans and the shift from employment-based health insurance to employment-related HSAs and HDHPs.  He writes:

I heard several times this week at the World Health Care Congress that if they’re given the tools to do so, consumers will take responsibility for their health care as they’ve taken responsibility for their retirement savings.

His conclusion: it hasn't really happened with retirement planning, and it ain't about to happen in health insurance and health care planning either.

A single payor system would certainly limit choices and reduce confusion, but that's just as certainly not on the horizon.  To torture the analogy a bit further, that would be like moving from 401(k) plan dominance back to a defined benefit plan or, hey, even a fully-funded Social Security system -- in other words, away from consumer-directedness and back to paternalism.

Back on planet Earth . . . we're moving in the direction of consumer-directed health care because self-determination and choice are fundamentally good, right?  Far be it from me to invoke paternalism as a social good, but it seems clear that as consumers we, collectively, do not have the wisdom or data at our fingertips necessary to make the best decisions about health care benefits or services.  Despite the protestations or promises of the Revolution Healths of the world to the contrary (see related post here), this market has a long way to go before it can be considered mature.

-- David Harlow 

April 23, 2007

Survey says: physicians do not consider patients' out-of-pocket costs when ordering care

Interesting survey results released earlier this month tend to show that no matter how consumer-directed health care may become, consumers may not be able to keep their out-of-pocket expenses in check on their own, because the physicians ordering diagnostic and therapeutic services are often ignorant of or indifferent to the out-of-pocket expenditure implications of their orders. 

Excerpted from the news release:

Increased patient cost sharing is likely to miss the mark in safely reducing health care spending because many physicians do not routinely consider insured patients' out-of-pocket costs when recommending expensive medical care, according to a study by researchers at the Center for Studying Health System Change (HSC) and the University of Chicago Hospitals in the April 9 Archives of Internal Medicine.

While almost 80 percent of physicians consider patient costs when prescribing a generic over a brand-name drug, far fewer consider patient costs when deciding what diagnostic tests to recommend (40.2%) or deciding whether to hospitalize a patient when outpatient treatment is an option (51.2%), the study found.  [Emphasis supplied.]

"Most physicians reported routinely considering insured patients' out-of-pocket costs in clinically straightforward prescribing decisions, but only half or fewer do so in more complex situations that allow greater clinical discretion," said Hoangmai H. Pham, M.D., M.P.H., the study's lead author and a senior health researcher at HSC, a nonpartisan policy research organization funded principally by the Robert Wood Johnson Foundation, which solely supported the study.

"Because physicians consider patient costs less frequently in making decisions about more expensive services, it's likely that increased patient cost sharing will be limited as an effective cost-control tool," said Pham, who coauthored the article with G. Caleb Alexander, M.D., M.S., of the University of Chicago Hospitals; and Ann O'Malley, M.D., M.P.H., an HSC senior researcher.

The study, "Physician Consideration of Patients' Out-of-Pocket Costs in Making Common Clinical Decisions" is based on HSC's 2004-05 nationally representative Community Tracking Study Physician Survey, which collected information from 6,628 practicing physicians. The survey response rate was 53 percent.

Noting that previous research has shown physician decisions affect how 90 percent of every health care dollar is spent, the authors point out that "whether increased cost sharing can effectively control health care spending depends on whether patients and physicians can together consider costs during clinical decision making."

Here's hoping that physician communication with patients on such issues can find its way into provider report cards.  Perhaps we take a step in the right direction by tracking and reporting time spent providing charity care; another finding of the survey is that

[p]hysicians providing at least 10 hours of charity care a month were more likely than those not providing any charity care to consider out-of-pocket costs in both diagnostic testing (40.7% vs. 35.8%) and care setting decisions (51.4% vs. 47.6%).

-- David Harlow

April 19, 2007

Health Wonk Review is up at Healthcare Economist

Jason Shafrin covers the waterfront in the latest edition of Health Wonk Review, up at Healthcare EconomistMassachusetts' continuing experiment figures prominently in the current Review.

-- David Harlow