The Great Debate

In November at the PHA Annual Forum, Al Lewis, CEO of Quizzify, and Ron Goetzel, Senior Scientist, Johns Hopkins Bloomberg School of Public Health engaged in “The Great Debate” on whether employee wellness programs demonstrate a return on investment. Download the recording here.

Don’t miss the chance to learn real strategies and tools to improve population health

The 16th Annual Population Health Forum is just one week away and here at the Population Health Alliance we are thrilled about the speaker line-up and incredible learning opportunities we have in store. Our goal is for every participant to come away with actionable strategies and tools to improve population health.

We can’t wait for our attendees to hear from our keynote speakers, including noted journalist Eleanor Clift, about what the elections mean for health care, along with Oliver Wyman partner Sam Glick who will share his thoughts on how to safely navigate the consumer health care revolution.

Providers should be sure to take advantage of CEU available for nurses and physicians and can attend several education sessions focused on everything from scaling programs to population health strategies for aging populations. Henry Chueh, MD, MS, Chief of Biomedical Informatics and Director of the Lab of Computer Science, Massachusetts General Hospital’s Lab of Computer Science is just one of the excellent educational presenters sharing insights. There is so much to learn and understand in population health related to the dizzying maze of  new models of payment.

Those who attend the Executive Leadership session on November 2nd will be treated to a debate to remember as expert Al Lewis squares off against expert Ron Goetzel.  Al Lewis has already said wellness industry defenders have “got some ‘splaining to do.” It will surely be a fun and educational session!

Our Convening Leaders workshops offer participants the chance to delve deeper into specific topics like how to deliver the right message to patients at the right time. Our sponsors including Health Dialog, Healthy Roads, Interactive Health, Healthwise, Silverlink, and Intel-GE Care Innovations have vast expertise to share.

Employers have a keen interest in population health and there will be plenty for them to learn about including wellness programs and how to structure health challenges to get the most engagement from employees. A special Innovators Learning Lab will also focus on how we help individuals and employers take data and create an actionable plan for behavior change and improved whole health. Those interested in incentives can learn from Welltok’s Michael Dermer and other industry experts about the latest science and strategies.

As a reminder, thanks to our sponsor Healthy Roads, all attendees will receive a complimentary copy of the updated Population Health Alliance Outcomes Guideline Report, the “official playbook” of population health program measurement.

We hope to see everyone in Washington next week!

Guest Post: Implementation matters. Particularly if it relates to what matters to the purchaser

Paul Terry formal photoBy Paul E. Terry, Ph.D., Chief Science Officer, StayWell Health Management

I picked up an undercurrent during this year’s Care Continuum Alliance – CCA Forum 2013 that I tested often in break-time conversations. “Do you think there is a connection between the return on investment (ROI) and value on investment (VOI) discussions?” I asked. While the answers I got ranged from technical to philosophical, the general tenor from consultants and purchasers alike was a genuine appetite for broadening the criteria we use to judge success in population health management.

I think three things explain a great vibe at the conference that spoke to a readiness to take population health from what has been an inordinate focus on ROI to a preference for advancing VOI. Many view VOI as richer, if not more meaningful to purchasers, first, because of opportunities that accountable care organization (ACO) and regional exchanges could present; second, because of extant limitations in ROI methodology; and, probably most important, because VOI represents the next level of maturation and opportunity for the field.

Regional exchanges and the VOI of wellness

Most presenters who ventured into whether and how the exchanges could influence population health management acknowledged it’s too early to tell. I found Medical Director for Employers Health Coalition Bruce Sherman’s rendition especially edifying given his postulate that small employers may finally have enough critical mass to reconcile the VOI of prevention. Sherman, a medical director for Ohio’s Employer’s Health Coalition, is able to see more clearly than most how the lack of investment by one employer ultimately disadvantages the collective competitiveness of a region.

A scenario I posed to Sherman that he agreed was viable was one where exchanges and population health management providers become more focused. Businesses generally are adjusting to an era of hyper-specialization, and winning or losing in population health will relate to a VOI that is different from one employer to the next.

What I found telling about the VOI propositions offered by those who discussed exchanges or ACOs was the continued preoccupation with the employer as purchaser. It’s more than ironic that “patient centered” homes and value-based purchasing are watchwords, but that the consumer’s values and needs still get short shrift. When a conference has panels of patients replace experts, I’ll be convinced we are fully embracing patient-centered concepts.

At long last: positive proof that wellness works for everyone all of the time

Would the CCA Forum, or any science-oriented group, organize sessions to support this headline? Of course not, but it’s attention-getting isn’t it? That’s undoubtedly a goal behind the hyperbolic harbingers of the notion that wellness doesn’t work.  Nevertheless, the CCA Forum made room for a “great debate” on ROI so presenters could posit that piece meal programs tested using quasi-experimental methods will yield unimpressive or inconclusive results. Not much grist for disagreement but, ever the optimist, I’m predicting those bent on scaring up controversy will inadvertently help to advance VOI metrics.

Short of more randomized controlled trials for comprehensive, long-term population health programs that balance individual interventions with culture change, today’s ROI methods are about as good as they’re going to get. My Dad taught me that you don’t dignify some criticisms with an answer. If CCA is looking for debate questions, here are some that I’d find interesting: Do wellness programs over-measure and under-intervene? The ratio of incentives to educational program spending is nearing 4:1; could this do more harm than good? The Affordable Care Act (ACA) rules could lead to annual health screening for many who would otherwise not be due for screenings according to clinical consensus guidelines; how should this be reconciled? Qualified debaters would be credible scientists who don’t have a financial interest in proving or disproving the questions.

Taking PHM to the next level

Conferences are at their best when they offer healthy doses of both education and inspiration. That the behavioral economics principles advanced in the book “Nudge” are being successfully applied in a clever product like “StickK” is a grand testament to how research can drive innovation. Seeing how an icon to consumer-based health education such as Weight Watchers is mobilizing its formidable peer-support infrastructure as a population health strategy is also remarkable. Learning how the Joslin Diabetes Center is translating its exemplary results in diabetes management into the diabetes prevention sphere was another example of how champions for change build on their own success.

This year’s CCA Forum was, as usual, masterful at enabling networking. It was during an informal lunch debate I had with three of population health’s most prolific researchers — Ron Goetzel, Ph.D., vice president, Truven Health Analytics, Seth Serxner, Ph.D., MPH, chief health officer, OptumHealth and Dee Edington, Ph.D., Edington Associates — that I was reminded of a fourth tenet for why implementation matters. Thought leaders don’t bemoan the failings of others because looking for bad apples is precious time away from creating ever more effective systems that support implementation excellence. Leaders are problem solvers, not problem describers. What’s more, they have an abiding message advancing what they are for, not merely polemics about what they’re against. On this count, this year’s CCA Forum convinced me that when it comes to implementation matters, the value of population health management is in very capable, and constructive, hands.

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Guest Blog Post Disclaimer CCA invites guest bloggers to post on Voice on Population Health Blog as a benefit for our members and the industry and to allow for exchange of ideas and information regarding population health. The views, opinions and positions expressed within these guest posts are those of the author alone and/or of the company the author represents and do not represent those of the Care Continuum Alliance (CCA), its members, or the industry as a whole. CCA is not responsible for the accuracy, completeness and validity of any statements made within this guest post article. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author(s) and any liability with regards to infringement of intellectual property rights remains with them.

CCA Letter to Congressman Ryan on behalf of Medicare Advantage Beneficiaries

October 4, 2013

The Honorable Paul Ryan

Chair, Committee on Budget

United States House of Representatives

1233 Longworth House Office Building

Washington DC 20515

Dear Representative Ryan:

As the Congressional discussion of budget priorities continues, we are writing on behalf of the Care Continuum Alliance (CCA) to seek your support in assuring that the more than 14 million Medicare beneficiaries enrolled in a Medicare Advantage (MA) plan will not experience any additional cuts to the MA program, and will continue to have access to the quality care delivery, care coordination and wellness and prevention services offered by MA plans.

CCA convenes a broad range of stakeholders dedicated to enhancing the health of populations. Through advocacy, research, and education, CCA advances evidence-based population health management strategies. The CCA aims to improve care quality and health outcomes while reducing preventable costs for the healthy and those at risk of or suffering from chronic conditions. Our diverse membership of more than 200 organizations and individuals includes physician groups, nurses, other health care professionals, hospital systems, wellness and prevention providers, population health management organizations, pharmaceutical manufacturers, pharmacies and pharmacy benefit managers, health information technology innovators, employers, researchers, and academics.

Our member organizations serve Medicare beneficiaries across the country, including a large majority of beneficiaries enrolled in MA plans across the country. MA enrollees receive high quality care and enhanced services at lower costs. Of particular importance, MA enrollees often receive enhanced, evidence-based wellness and prevention services and chronic care management. These programs directly benefit America’s seniors and help reduce health care spending overall.

For example:

Medicare seniors with diabetes in a MA Special Needs Plan had 7% more primary care physician office visits and 19% fewer days in the hospital compared to seniors in Medicare fee for- service (FFS). [i]

Seniors in an MA plan had a 14.5% 30-day readmission rate from 2006-2008, which was 22% lower than FFS readmission rates.[ii]

Seniors in MA plans are less likely to report trouble in receiving care, more likely to have a usual source of care, and more likely to receive necessary preventive services compared to seniors in FFS.[iii]

Despite the measurable success of MA, the program faces challenges in 2014, 2015 and beyond. The Patient Protection and Affordable Care Act (PPACA) mandated $200 Billion in cuts to the MA program. In addition, the 2012 Fiscal Cliff deal cut $2.5 Billion from Medicare Advantage through a coding intensity provision. The Congressional Budget Office has outlined projected cuts to these programs in the coming years:

Even though only a small portion of PPACA cuts have taken effect so far (only ten percent of the cuts will have gone into effect by the end of 2013), the reduction in beneficiary choices has begun.[iv]  The number of MA plans is projected to drop in 2014.[v] Although we understand that Congress faces many difficult choices in the budget debate, we are concerned that any further cuts to the MA program will undermine the ability of the program to sustain its impressive track record in improving care and reducing costs for Medicare beneficiaries.

We would be pleased to provide additional information on the program, highlight examples of the program’s success, and further detail the positive impact it is having on the lives of America’s seniors.  If we can be of assistance, please feel free to contact Vicki Shepard at 202-525-9588 Vicki.shepard@healthways.gov.

Sincerely,

/signed/

Fred Goldstein

Acting Executive Director

Care Continuum Alliance

Vicki Shepard

Chair, Government Affairs Committee

Care Continuum Alliance


[i] “Medicare Advantage Chronic Special Needs Plan Boosted Primary Care, Reduced Hospital Use Among Diabetes Patients.” Health Affairs 31.1 (2012).

[ii] Lemieux, J., Sennett, C., Wang, R., et al., “Hospital Readmission Rates in Medicare Advantage Plans.” American Journal of Managed Care 18(2):96-104 (2012).

[iii] Centers for Medicare and Medicaid Services, Medicare Advantage, Hill Notification Document, 11 (2007).

[iv] Congressional Budget Office, Letter to the Honorable Nancy Pelosi (March 20, 2010).

[v]Avalere Health analysis of CMS Landscape File, September 23, 2013 accessed at http://www.avalerehealth.net

 

Rand Report on Workplace Wellness: What Employers Must Know (Part I)

Q&A about the Rand Report on Workplace Wellness (Part I)

What Employers Must Know

The RAND Corp Workplace Wellness Programs Study, presented to Congress, brought about much needed discussion and questions about the state of workplace wellness programs, their outcomes, and their long term role in the transformation of our health care system and the attainment of a better health status for all in our Nation. Questions abound on the report, its methodology and its findings. CCA received and studied many of those questions and, on Wednesday June 19, convened a group of researchers and experts to go over the methodology, data and conclusions of the RAND Workplace Wellness Programs Study with the authors.

Soeren Mattke and Hangsheng Liu, senior scientists at RAND, answered the questions received and the follow up clarifications posed by those on the call. The following is a summary of that long and in depth conversation.

Read Q&A about the Rand Report on Workplace Wellness (Part II)

The RAND Corp Workplace Wellness Programs Study, presented to Congress, brought about much needed discussion and questions about the state of workplace wellness programs, their outcomes, and their long term role on the transformation of health care and the attainment of a better health status for all in our Nation.

Did anything surprise you?

I was surprised that the cost curve did not reach statistical significance, due to random noise in the model. Another surprise…high-powered incentives tied to health outcomes are much less common than the literature would have us think. Nine percent of employers use health contingent incentives and use them in modest amounts. Public debate is ahead of the actual state of the field.

Did the study look at all at components – online, in-person counseling, content, classes, support, communications, etc.?

No. The limited time and funding prohibited that level of granularity. Our wish list for future research includes amount of exposure, level of interventions, and level of exposure.

Among the nonparticipants who also receive the benefits of health promotion, a. Is there a motivation selection bias or in fact could the nonparticipants be receiving benefits? b. Could savings, therefore, be underestimated?

a. Yes, there is still the possibility of some bias because it was not a randomized, controlled trial. The difference-in-difference method is powerful in observing those, but we can’t rule out unobservable differences between participants and nonparticipants. It is possible that some nonparticipants were exposed to health promotion activities (e.g., better food offerings, exercise messaging) at the worksite but didn’t participate in personalized counseling program and would not be picked up by the analysis.

b. These estimates, given the research design used, reflect the marginal impact of a lifestyle management component. Changes in environment would impact both participants and nonparticipants, and we would have no way of comparing to other employers to get to that effect.

How does the report affect the current position of wellness in the market? For example, do you feel it does anything to temper the “rosy” expectations that came from earlier meta-analyses?  Will the current data in the report help us to better manage more realistic expectations around workplace wellness?

Some past numbers were too rosy. Look at what wellness programs are doing. It is not unrealistic that cost neutrality is a positive result because these programs are intervening in a workforce population that is not sick. These programs are a preventive effort to avoid future healthcare costs, so if we can get to cost neutrality and better health this is a good result for the industry and the programs.

Given the fact that some of these presentations are somewhat old now, a. What’s your thought about some of the newer strategies/approaches to wellness program engagement, including outcomes-based interventions? b. Were there sufficient data to look specifically at the outcomes-based programs for their impact on healthcare costs?

a. These types of programs remain rare, so there is not enough good data for meaningful statistical assessment.

b. No, there was not enough data and no employers tied to outcomes. A fine line exists between shifting risk and cost to more vulnerable employees and dependents and making employees feel compelled to take advantage of the programs offered. More research and more data are needed to find the right balance between appropriate risk sharing and inappropriate cost shifting.

a. What value do you think there’d be in formulating a clearly established list of wellness-sensitive conditions, so that outcomes can be more specifically studied? b. What about process measures – the outcomes of wellness on use of preventive care services, disease-specific preventive care, and medication adherence?

a. Hard question. In essence, we know many conditions are sensitive to health behaviors. The former surgeon general attributes 75% of healthcare costs to behavior. Many cancers, and potentially asthma and COPD, can be tied to obesity. We must find a way to quantify the strength of relationship in order to call it “wellness sensitive.” To begin to unpack the “black box,” we should define conditions and look more closely at what can be done for a quicker response versus what can be expected to happen later in the process.

b. The more clinical outcomes are better tied to disease management, the better, because that is the intervention strongly tied to medication adherence. There would be value in looking at the use of preventive services, either through employer screenings or healthcare providers, but really only those recommended by USPSTF.

I saw a tweet that approximately says, “…see? Wellness doesn’t work.” I would assume, seeing your presentations, that you would not make such a strong statement. Comment?

Workplace wellness involves complex interventions, and success will always depend on the particular intervention within the particular context and the particular measures of outcomes used. From what we see here, there is clear evidence for a qualitative and meaningful effect on health risks, but no strong evidence for savings of healthcare costs. Here we see a roughly cost neutral intervention that achieves a gain in health risk reduction.

a. What costs were or were not included in the cost analysis?  b. Were there any assessments of costs directly related to the interventions versus costs unrelated to interventions?

a. We included medical and prescription drug costs. We did not have data on work loss, workers comp, disability, etc.

b. We did not analyze whether changes in healthcare utilization were for wellness sensitive conditions. Rather, this was a high level look at overall costs without attempting to attribute at a more granular level. We did, however, take out years in which an employee was pregnant or participating in a case management program for high cost, high-risk conditions.

Can you comment on suggestions for future research?

Future research should seek to get more granular with related versus unrelated costs. Another area to consider is different type of outcomes, like productivity and other work-related impacts. A larger sample size may show significant effect on cost, so more employers in the database and a longer time series may indicate at what difference the curves converge and reach statistical significance. Also, we need to begin to unpack the black box. We can’t assume that all programs are effective or all programs are ineffective, and we need to understand the distinctions, i.e. how do employer (e.g., culture, support) and employee (e.g., health literacy, age, gender, ethnicity) characteristics drive changes so that targeting interventions becomes more effective.

Read Q&A about the Rand Report on Workplace Wellness (Part II)

Guest Post: Healthcare Choices, Patient Voices

A critically important goal of healthcare reform is to deliver patient-centric care.  However, in today’s busy practice of medicine, patients are too often asked to decide on care without fully understanding their options and without the opportunity to think about their preferences.  We make few decisions as important or personal as those affecting our health, yet too often our voice as a patient is not heard.

Healthcare decisions, particularly those regarding care for which there are multiple evidence-based options, (preference sensitive) are common.  82% of adults over the age of 40 have made a decision about a surgery, test, or new medication in the past two years.[i]  Too often physicians lack the training, resources, or time to educate patients on the risks and benefits of their various care options. Doctors do even less well with exploring patients’ personal preferences.  Because patients don’t know what they don’t know, it’s simply not possible to obtain truly informed consent from a patient who is not informed.  Risks and benefit discussions aren’t really meaningful without a full explanation of options and a full exploration of personal preferences.

A Shared Decision Making approach to care educates patients about any and all medically sound treatment options and helps them sort through the confusing clutter of medical terms and acronyms.  Patients are informed on the risks, benefits, trade-offs, and side effects of each viable choice. This approach puts the patient at the center of the decision, ensuring that the selection is not only clinically appropriate, but also the right course for them.   Thus prepared, patients can then have a better quality discussion about their treatment options with their physicians, which is the goal of Shared Decision Making.

As we continue to debate ways to improve quality and reduce costs, Shared Decision Making emerges as one such way.  Patients who go through a Shared Decision Making process tend to choose less invasive procedures[ii], which in turn leads to better outcomes and reduced spend. The patients are happier too, reporting a better care experience and improved doctor-patient communication.[iii]  This approach to care is both effective and practical. It has been successfully adopted in busy medical practices across the country resulting in more loyal patients and more satisfied clinicians.

Healthcare choices are hard. Knowing you even have a choice is paramount. Shared Decision Making will draw out patient voices where they so critically need to be heard.

Dr. Peter Goldbach brings more than 30 years of experience to Health Dialog’s management team, including 15 years of experience in medical administration and 17 years maintaining a primary care and pulmonary disease practice. Prior to joining Health Dialog, Dr. Goldbach served as President and Chief Executive Officer of Med-Vantage Inc., a healthcare informatics and engagement company. Before that, Dr. Goldbach was Medical Director for Blue Cross Blue Shield of Massachusetts, where he provided medical direction for the company’s “Pay for Performance” and eHealth programs. In other previous roles, Dr. Goldbach has held CEO, trustee, and medical staff president positions with two Boston-area community hospitals.

Dr. Goldbach received an undergraduate and master’s degree from UCLA and his medical degree from SUNY Downstate Medical Center College of Medicine. He completed his Internal Medicine internship and residency at George Washington University Hospital, and his Pulmonary Disease fellowship at Cedars-Sinai Medical Center / UCLA School of Medicine.

[i] Zikmund-Fisher., et al. The DECISIONS Study. Medical Decision Making. Sep-Oct 2010.

[ii] Decision Aids for People Facing Health Treatment or Screening Decisions. Cochrane Database of Systematic Reviews. 2011 October 5;(10).

[iii] Ibid.

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CCA invites guest bloggers to post on Voice on Population Health Blog as a benefit for our members and the industry and to allow for exchange of ideas and information regarding population health.

The views, opinions and positions expressed within these guest posts are those of the author alone and/or of the company the author represents and do not represent those of the Care Continuum Alliance (CCA), its members, or the industry as a whole. CCA is not responsible for the accuracy, completeness and validity of any statements made within this guest post article. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author(s) and any liability with regards to infringement of intellectual property rights remains with them.

 

A Voice for Population Health Management in a New Year of Opportunities

Tracey Moorhead, President & CEO

Tracey Moorhead, Care Continuum Alliance President & CEO

Welcome! We’re thrilled to launch this blog as another important step in the evolution of Care Continuum Alliance (CCA). Our members, along with other industry leaders and observers, know that CCA has long served as the convening voice for care management strategies, first for disease management and, since 2007, for the full continuum of population health interventions – wellness, prevention and other approaches to improving health, reducing disease risk and raising productivity. Today, we add the industry’s voice to the vibrant online community of social media commentary.

Since early in the debate over health care reform, there’s been much talk about the Triple Aim of better care quality, outcomes and value – and nearly as much head scratching over just how to achieve it. That’s a perplexing sight from the perspective of population health management (PHM), which has long offered tools and resources to reach all three goals (and a growing body of work to support its view). PHM also has an indispensable role in the drive toward greater accountability in care delivery, a point that came through clearly in the comments of industry leaders in a recently published CCA white paper on key industry issues for 2012.

We reached out, through a survey, to high-level thought leaders within and outside our membership to develop the paper and found strong optimism about opportunities in accountable care and other new delivery models; expanding government and societal recognition of the value of wellness and prevention; and increasing consumer acceptance of mobile health and other technology-enabled care common in PHM programs. “Key Issues in Population Health Management – Key Industry Issues for 2012,” available freely as a download from the CCA website (www.carecontinuum.org), illustrates the many avenues available to population health management for making meaningful differences in care quality and value.

There may be those who say the white paper’s resolutely positive tone comes filtered through rose-colored glasses. But the industry isn’t alone in its optimism. From policymakers to patient advocates to employers and others at ground zero of the chronic disease fight, the precepts of population health management – care coordination, patient self-management, physician collaboration, outcomes assessment and others – are increasingly part of the arsenal. Also, population health management isn’t shy about looking in the mirror: Survey respondents tempered their upbeat outlook with admonishments that the industry must do more to build the evidence base for and to promote its work.

We intend to meet that challenge with robust research in 2012, vigorous advocacy in support of PHM strategies and promotion through education, including at our annual meeting, The Forum 12, online learning and new events (more on that soon). CCA members and the broader community of stakeholders in wellness, prevention and health management must do the same to broaden the reach of these essential programs.

— Tracey Moorhead, President & CEO

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