Healthcare Town Hall

Workforce Management looks back at the roots of the wellness concept.

Also driving enthusiasm for workplace wellness campaigns in the 1980s was the rising cost of health benefits…

In 1987, StayWell, along with actuarial firm Milliman & Robertson (now called Milliman Inc.), released a study showing for the first time that common health-risk factors such as smoking, obesity and not wearing seat belts were strongly linked to higher health care costs. Subsequent studies backed those findings.

“It got employers very interested in costs,” [David] Anderson [of StayWell Health Management] says.

Just for the sake of nostalgia, check out the prices of various household goods in 1987. The car prices in particular caught our eye–especially with healthcare costs for a family of four in 2012 approximating the cost of a midsize sedan.

Prevention Milliman Medical Index, MMI, Wellness

The Centers for Disease Control and Prevention (CDC) released a new study indicating that half of U.S. adults are receiving preventive care, a number that will be watched as the Patient Protection and Affordable Care Act (PPACA) and its preventive incentives are implemented. The entire report can be read at ModernHealthcare.com.

On the issue of preventive care, Ed Jhu and Jason Nowakowski evaluate the effects the PPACA’s reforms may have on preventive care utilization in their paper “Benchmarking Preventive Care Utilization.” They conclude:

“In general, we have found that current utilization of preventive services is roughly 60% to 70% of what is clinically recommended in PPACA for many services. However, there is fairly significant variation by service, which is due to either variation in actual utilization rates or to measurement difficulties related to some of the factors identified previously in the report. We did see higher utilization for childhood-related services thank for adults, likely for the obvious reasons: parents taking better care of their children than they do of themselves. Children are also often required to have certain vaccinations and procedures in order to attend schools. Additionally, it’s routine for newborns to be administered a certain regimen of preventive services. In general, it seems to be easier for adults to put off the preventive services recommended for them.

There’s little in the pre-PPACA data to indicate where the preventive care trends are going to go next – except, very generally, up. The focus on preventive care in the reform measures, and the publicity surrounding them alone, will presumably push utilization in that direction. There are also certain health plans that don’t presently cover some of the procedures, but will be required to now. That, coupled with the fact that many of the procedures must be offered with no copays, would also tend to suggest greater utilization moving forward. While it’s unlikely that utilization of preventive services will ever reach 100%, it is certainly possible we will see it go up from the current levels.”

Here’s more on prevention.

Prevention Ed Jhu, Jason Nowakowski, Utilization

Bruce Pyenson presented his study on lung cancer screening at Health Affair’s “Value in Cancer Care” briefing on April 12 in Washington DC. Watch his presentation at HealthAffairs.org – scroll down to “The Case For Lung Cancer Screening of High-Risk Patients & Improving Payment And Delivery Of Cancer Care.”

Also, here is the study’s abstract:
Read more…

Actuary, Prevention, Research Bruce Pyenson, Cancer, Prevention

According to a recent article in the Washington Post, early data shows recent upticks in utilization of some preventive services by Medicare patients, presumably triggered by provisions in the healthcare reform law encouraging use of preventive care. Medicare enrollees can now obtain wellness checkups and screening tests for cancer and other serious conditions at no cost, for example.

Interestingly, the article notes that so far only the more general procedures, wellness exams, have seen significant bumps in utilization. At this early stage, it appears that utilization of more invasive screening procedures such as mammograms or colonoscopies is relatively flat even with the removal of cost sharing under health reform.

This could well speak to the heart of the preventive challenge itself, and certainly raises many questions: Will we ultimately see utilization remain stubbornly close to current benchmarks for some procedures? If removing copays is not sufficient, what kinds of incentives are necessary to get people to use the clinically-recommended levels of services? Where does education fit into the larger goal of persuading people to use them? If the right kind of utilization is incented, what will be the long-term cost implications?

Moving forward, it will be more important than ever for providers and carriers to attempt to answer these questions. Our recent report, “Benchmarking Preventive Care Utilization,” points out that there are “numerous problems that actuaries and other analysts may expect to encounter as they attempt to set baselines and benchmarks for preventive services”—not the least of them is agreeing on and communicating a definition of “preventive services” in the first place. Other issues are related to claim coding complexities, billing, medical innovations, considerations for “at-risk” patients, and finding ways to distinguish screening and diagnostic procedures.

The Washington Post article is only an early indicator, and it introduces more questions than answers. The march toward increased use of preventive care will be one of the more interesting aspects of reform to monitor as the American healthcare system goes through this period of evolution.

Prevention Ed Jhu, Jason Nowakowski, Prevention

Under the provisions of the Patient Protection and Affordable Care Act (PPACA), all health plans (other than those that choose to remain grandfathered) will be required to provide preventive services without copays, coinsurance, or other cost sharing. Although there is no way to tell exactly how the PPACA requirements will affect preventive care trends, it is safe to say that use of preventive services overall is likely to increase. This paper discusses existing preventive care utilization rates and compares them to a calculation of the recommended utilization rates.

Prevention, Wellness Ed Jhu, Jason Nowakowski, Prevention

Sometimes the idea that keeping people healthy reduces costs can break down, but sometimes it actually works. A new article by Atul Gawande (subscription required) looks at one such instance. Here is an excerpt from the article, in which a young doctor named Jeffrey Brenner, in Camden, N.J., applies some of the statistical techniques he used as a volunteer police reform commissioner to identifying healthcare “hot spots” in his hometown:

[Brenner] made block-by-block maps of the city, color-coded by the hospital costs of its residents, and looked for the hot spots. The two most expensive city blocks were in north Camden, one that had a large nursing home called Abigail House and one that had a low-income housing tower called Northgate II. He found that between January of 2002 and June of 2008 some nine hundred people in the two buildings accounted for more than four thousand hospital visits and about two hundred million dollars in health-care bills. One patient had three hundred and twenty-four admissions in five years. The most expensive patient cost insurers $3.5 million.

We’ve blogged before about geographic cost disparity in healthcare, though never at so granular a level. Given the hope attached to reducing admissions and readmissions as a way of controlling healthcare costs, it seems reasonable that a formula that identified “super utilizers” as they are called and focused on improving their care (and minimizing unnecessary utilization) would help to reduce costs.

Cost, Prevention Atul Gawande, Utilization

We have talked before about diabetes. Today, the Task Force for the National Conference on Diabetes issued a diabetes-related call to action:

The Call to Action seeks to address diabetes prevention, diagnosis, treatment and management, as well as to identify the practices and resources required to meet the needs of people with, and at risk for, diabetes,” said Steve Edelman, M.D., a practicing endocrinologist and Founder and Director of Taking Control of Your Diabetes, one of the members of the Task Force.

Diabetes currently affects nearly 24 million people in the U.S.(1) and is expected to reach 32 million by 2031.(2) (p.2,l.81-2) Modeling by Milliman, an actuarial firm, indicates that diabetes-related costs could increase from 10 percent of U.S. health expenditures in 2011 ($340 billion) to 15 percent by 2031 ($1.6 trillion).(2) (p.2,l.90-2)

Read more here.

Prevention, Wellness Diabetes

Some of you may remember this interview from last May, which explained the results of a 2009 study for the Lung Cancer Alliance that used actuarial methods to clarify the opportunity posed by lung cancer screening.

The case for increased lung cancer screening gained more momentum last week when the Los Angeles Times reported on the results of an analysis by the National Cancer Institute. Here is an excerpt from the Times article:

Advanced CT imaging can reduce deaths from lung cancer by 20% among heavy smokers by detecting tumors at an earlier stage when they are more treatable, according to results released Thursday from the first study to compare the value of CT scans and regular chest X-rays for lung cancer screening.

The long-awaited results of the trial involving more than 53,000 former and current heavy smokers were so conclusive that the study was terminated ahead of schedule last week and letters were sent to all the participants advising them of the results.

The findings are considered a major step forward in fighting the most deadly form of cancer — which is expected to kill an estimated 157,000 Americans this year — because chest X-rays have never been proven to be an effective tool for identifying tumors. CT scans are more powerful and provide a much clearer picture of the lungs.

Cancer, Prevention Bruce Pyenson, Cancer, Sara Goldberg

The Disease Management Care Blog looks at the question of hypertension, blood-pressure treatment, and the medical home model:

Long ago, the Disease Management Care Blog was a co-investigator in a multi-center high blood pressure (hypertension) research program. Everyone was treated with a precisely defined script and, compared to it’s regular patients, the blood pressure of all the DMCB’s research participants dropped. The DMCB concluded that that was thanks to two features of the research trial: 1) free drugs, and 2) a nurse devoted to making sure people took their free drugs.

That nurse helped convince the physician-DMCB that disease management could work.

“Could work,” with the emphasis on could, is also the context of this report by the expert health insurance actuaries over at Milliman, who examine the same potential of the patient centered medical home (PCMH) in the management of hypertension. In this handy and thoroughly researched review (63 references), authors Kathryn Fitch, Kosuke Iwasaki and Bruce Pyenson discuss how the PCMH could improve the treatment of hypertension thanks to its a) ongoing patient monitoring and treatment plans, b) use of telephonic and email outreach, c) concurrent co-morbidity management, d) efficient medication adjustments, e) liberal use of non-physicians for low-risk patients, f) increased patient-provider communication, g) coordination of specialist access and g) an ability to measure population-based outcomes.

All well and good, says the DMCB, but the reason why policymakers and other stakeholders may want to download the report is because it contains some key caveats…

Prevention, Wellness Bruce Pyenson, hypertension, Kate Fitch, Medical home

We have talked before about the newfound ability to gather community health data and mine if for new insight. A recent project for the Robert Wood Johnson Foundation and King County in Washington state looked to do just that by seeking information on health disparities in different ethnic groups. Here is a summary of their findings:

The pilot project revealed that King County employees generally experienced high quality of care on most  performance measures.  This made it difficult to observe relationships between quality of care and absenteeism and productivity.  The analysis did, however, reveal significant disparities in asthma medication use, with African-American patients less likely than other groups to receive adequate medication.

Indeed only 70.4% of African-American patients received appropriate medications for asthma, compared to 87% of Asians, 89.8% of whites, and 100% of Hispanics. See the full results here and in particular note Table 2 in the appendix.

Prevention, Quality of Care data pooling, disparities in care