Monday, January 26, 2015

A Courageous First Step


First posted 1/26/15 on The Health Care Blog

Note from Brian: Important story. Promising that Medicare is finally taking this step. Self-funded purchasers should demand that their plans take similar steps.

Earlier today, Health and Human Services (HHS) Secretary Sylvia Mathews Burwell announced that HHS is doubling down on the historic shift taking place across the health care industry towards value-based care, and is setting a target of having 50 percent of Medicare payments under value-based care arrangements by 2018.

This would mean that in less than three years, around a quarter of a trillion dollars of health care spending would be made to providers who are being compensated not for ordering more tests and more procedures, but for delivering better outcomes – keeping patients healthier, keeping them out of the hospital, and keeping their chronic conditions in check.

This shift will address a central problem of the US health care system, one that lawmakers and policy experts on all sides of the issue agree is a key contributor to runaway medical inflation.

The logic is straightforward: by simply paying for the volume of services delivered, every provider has a strong incentive to do more — more tests, more procedures, more surgeries. And under this system, there is no financial incentive to maintain a comprehensive overview of patient care – to succeed by keeping the patient healthy, and health care costs down.

Tuesday, January 20, 2015

Getting A Return on Electronic Health Record Investments

Note from Brian. A fundamental health care infrastructure problem is the continuing inability of Electronic Health Records (EHR) to seamlessly share data, despite a 4 year program that taxpayers poured $30 billion into. 

This failure in interoperability is a barrier to care coordination, forcing poorer outcomes at much greater cost. Not having complete or consistent patient information also seriously degrades the capacity of any health care provider to perform under risk-based reimbursement arrangements.

Perhaps the best solution to this issue is Direct exchange, which has created a framework, that would be integrated into every EHR, for secure exchange using a national network of accredited email providers. Some 160 communications and provider organizations now support this fledgling effort, on more than 10 million patient encounters have been updated using it.

No group should be more invested in interoperability and complete patient information than purchasers. These attributes are clearly in the interests of better care and cost.

On Thursday at Noon ET, David Kibbe, MD, the Founder and CEO of Direct Trust, will host a Webinar that lays out the business case for an interoperability platform, and why purchasers should support it. Hope you'll join us.

In the meantime, here's an article that lays out the basics of the issue.

Friday, January 9, 2015

House Approves Legislation Marking 40 Hours as 'Full Time' for PPACA Purposes

NBCH thanks the American Benefits Council for the information provided in this post.

The U.S. House of Representatives approved a measure on January 8 that would establish 40 hours as the benchmark for "full time" work under the Patient Protection and Affordable Care Act (PPACA). The 252-172 vote included 12 Democrats.

The Save American Workers Act (H.R. 30), introduced by House Ways and Means Committee member Todd C. Young (R-IN), would replace the number 30 (hours per week) with the number 40 (hours per week) for purposes of identifying full-time employees and satisfying the PPACA employer mandate under Internal Revenue Code Section 4980H. H.R. 30 would also modify the calculation of full-time equivalent workers by requiring employers to divide the aggregate number of hours of service of employees who are not full-time employees by 174 rather than 120.

President Obama has issued a Statement of Administration Policy asserting that he would veto H.R. 30 if it reached his desk, noting that the measure would increase the federal budget deficit, reduce the number of people receiving employer-based health insurance coverage and increase the number of individuals who are uninsured. The latest Congressional Budget Office budget score estimates that H.R. 30 would increase the deficit by $53.2 billion over the next ten years. House Minority Leader Nancy Pelosi (D-CA) stated in a January 8 news conference that the measure would add half a million people to the ranks of the uninsured.

Senators Susan Collins (R-ME) and Joe Donnelly (D-IN) have introduced a companion bill in the U.S. Senate, the Forty Hours is Full Time Act (S. 30), but legislative text remains unavailable at this time.

Thursday, January 8, 2015

Two Coalition Job Opportunities

The National Business Coalition on Health is seeking a dedicated and enthusiastic Director of Membership to support the organization's mission "to help member coalitions lead in improving health and the value of health care services in their communities." The Director of Membership Services serves as the coalition's primary contact for member support; provides strategic leadership for the association's membership program; cultivates relationships with member coalitions; maintains a working knowledge and understanding of coalition activities, interests, and needs; and subsequently strengthens networking and capacity building opportunities to ensure that coalitions are efficiently and effectively sharing best practices and learning from one another.

To read more about the job opportunity at NBCH, click here. To apply, please submit the requested materials to

The Maine Health Management Coalition is hiring a Director of Data Systems and Analytics. The Director will lead the Data Systems and Analytic Department at MHMC, develop and execute on a sustainable strategic plan, and to achieve excellence in a changing competitive landscape. The Director is also expected to play a leadership role integrating the Department with national efforts striving to achieve similar objectives.

To read more about the job opportunity at MHMC, click here. To apply, please submit the requested materials to

House Passes Bill Exempting Veterans When Determining Employer Mandate Applicability

NBCH thanks the American Benefits Council for the information provided in this post.

On January 6, the U.S. House of Representatives passed the Hire More Heroes Act (H.R. 22) by unanimous, bipartisan vote of 412-0.

The measure, sponsored by Representative Rodney Davis (R-IL), would exempt veterans already enrolled in coverage under TRICARE or the U.S. Department of Veterans Affairs (VA) from being taken into account for the purposes of determining if an employer is subject to the employer mandate under the Patient Protection and Affordable Care Act (PPACA).

The PPACA "shared responsibility" employer mandate under Internal Revenue Code Section 4980H, which took effect on January 1, requires employers with 100 or more full-time (or equivalent) employees to offer health coverage that satisfies affordability and minimum value requirements to their full-time employees or pay a penalty if even one full-time employee receives a premium tax credit for health coverage obtained through a health insurance exchange. (The 100 employee threshold is applicable only under transition relief for 2015; after 2015, the threshold is 50 employees.)

The bill would allow businesses to hire veterans covered by TRICARE or the VA without counting them as full-time employees. Supporters of the measure point out that it will help some small businesses stay below the mandate threshold as well as encourage the hiring of veterans.

The bill was previously introduced in the House in the 113th Congress and approved by a vote of 406-1. The measure was not considered by the Senate.

Sunday, December 21, 2014

An Early Look At Changes In Employer-Sponsored Insurance Under The Affordable Care Act

Note from Brian. Health Affairs has published an interesting article by four researchers at the Urban Institute. The abstract is below. Access the article here.

Critics frequently characterize the Affordable Care Act (ACA) as a threat to the survival of employer-sponsored insurance. The Medicaid expansion and Marketplace subsidies could adversely affect employers’ incentives to offer health insurance and workers’ incentives to take up such offers. This article takes advantage of timely data from the Health Reform Monitoring Survey for June 2013 through September 2014 to examine, from the perspective of workers, early changes in offer, take-up, and coverage rates for employer-sponsored insurance under the ACA. We found no evidence that any of these rates have declined under the ACA. They have, in fact, remained constant: around 82 percent, 86 percent, and 71 percent, respectively, for all workers and around 63 percent, 71 percent, and 45 percent, respectively, for low-income workers. To date, the ACA has had no effect on employer coverage. Economic incentives for workers to obtain coverage from employers remain strong.

Friday, December 19, 2014

New NBCH Action Brief: Prostate Cancer

Among American men, prostate cancer is the most common non-skin cancer and the second leading cause of cancer death, exceeded only by lung cancer. In 2010, medical costs associated with prostate cancer were estimated at $12 billion - the fifth highest cost for any cancer site - with total cancer costs in the United States amounting to nearly $125 billion. The significant financial burden of cancer, compounded with the emotional strain of diagnosis and treatment, can create a complex situation for employers. This Action Brief outlines the scope of prostate cancer as well as how health plans are addressing the issues based on data from eValue8. Lastly, the brief highlights actions employers can take to educate its workforce about screening options and improve quality of life while reducing treatment costs for those facing a prostate cancer diagnosis.

Access the latest in NBCH's series of Action Briefs here.

Tuesday, December 16, 2014

Good News From CMS At Last? Maybe Not.

Note from Brian. Over at The Health Care Blog, veteran analyst Roger Collier explicates the recently released CMS data showing a 4th straight year of nominal health care cost growth. Is this the result of the ACA implementation or an artifact of a sluggish economy? Mr. Collier believes that as the economy picks up steam the health care industry will want to press its advantage and make up for lost time.

A worthwhile read to anyone who tracks health care cost dynamics.

LA Times - Seattle: Where Employers Use Quality Control To Shape Health Care

Note from Brian. Yesterday's LA Times ran this article, which describes how major Seattle employers - e.g., Boeing, Costco, Starbucks and Nordstroms - have worked with local health systems, like Virginia Mason Medical Center, on quality assurance systems, including standardized processes and precise scheduling, to achieve better health outcomes at lower cost.

There is much to be learned here. One lesson is that is that nearly all health systems have room for significant improvement. Another is that successful community templates, like the one in Seattle, are available to guide quality assurance efforts elsewhere. A third is that, with sufficient market pressure from purchasers, most health systems will be receptive to demands for better, more cost-effective care.

While the article focused on large employers, regional business health coalitions can achieve the same leverage by aggregating the collective purchasing heft of their members employers, unions and local governments.

No doubt several of our own coalitions are already headed down this path. We'd welcome updates from them on this blog so we can share your experiences with the larger coalition community.

NYTs - Forbidden Topic in Health Care Policy: Cost-Effectiveness

Aaron Carroll, MD, a pediatrician, health services researcher and prominent blogger (at The Incidental Economist) has an article in the New York Times that addresses head-on the taboo against research on health care cost effectiveness. While some claim that a focus on cost will lead to rationing and death panels, the harsh truth is that the US health care industry has leveraged this perspective to advantage, which is why our per capita health care costs are double those of other developed nations. Dr. Carroll writes a strongly sensible argument on why cost effectiveness matters and needs to be a core part of any funding plan.

Monday, December 8, 2014

Devicemakers explore risk contracts with hospitals

Tiptoeing into the broader accountability movement, some of the largest medical-device manufacturers are negotiating experimental deals with hospitals to take on performance-based financial risk for their implants.

While drugmakers have been testing risk-based contracts for several years,devicemakers are just beginning to explore taking on risk for products such as pacemakers and other implantable devices. Experts say cardiac devices are a primary focus of new risk-sharing agreements under discussion, likely because hospitals face potentially lower payment rates for congestive heart failure patients. “They're aligning risk to the kind of risk that matters to providers,” said Brandi Greenberg, a managing director at the Advisory Board Company.

Experts say each risk-based contract between a hospital and devicemaker is structured differently. Some agreements may stipulate that the manufacturer return a percentage of the device's price if it doesn't meet certain performance goals or fails within a set period of time. Under other agreements, a hospital pays more for a device that fulfills a manufacturer's quality and economic claims.

Read the full story via Modern Healthcare.

Friday, December 5, 2014

New Report from Northeast Business Group on Health: Employers Frustrated by Ineffectiveness of Traditional Diabetes Management Programs

Most employers have diabetes prevention or management programs in place but point to lack of employee engagement as a key factor in the ineffectiveness of such programs, says a new report from Northeast Business Group on Health (NEBGH). Traditional disease management techniques – primarily telephone outreach and information distribution – are not working to stem the diabetes epidemic, according to the report, based on a NEBGH Solutions Center research project that included an employer survey and roundtable discussion with 26 executives from employers, health plans, providers, consulting organizations and pharmaceutical firms.

“Employers are aware of the toll diabetes takes on their employees, as well as the impact to their organizations in terms of direct healthcare costs and indirect costs associated with diabetes-related absenteeism, presenteeism, disability and early retirement,” said Laurel Pickering, MPH, President and CEO of NEBGH. “But we need to look beyond what is currently in place in most organizations and actively pursue innovative new models of care delivery, new ways of engaging employees and new business models that reward high value care, if we are serious about making a dent in this American epidemic.”

Read more about the report's release here and access the full report here.

Featured Partner Event: How can we use data to improve health?

Join the Robert Wood Johnson Foundation for a discussion on how best to collect, share, and protect health information; and how to use it to build a Culture of Health. The December 11th life-stream will feature Lisa Wear-Ellington, CEO of the South Carolina Business Coalition on Health - a NBCH coalition member.

What: Data for Health: Learning What Works for Charleston
When: Thursday, December 11; 9:00-10:30 a.m. ET
Register online today

Tuesday, December 2, 2014

NBCH's Opportunity Knocks - December 2014

Note: NBCH publishes the Opportunity Knocks eNewsletter to assist NBCH members and their employer members in learning about opportunities, supporting our goals of improving health, transforming health care, community by community. Please note that publication in an Opportunity Knocks eNewsletter is not meant to be construed as an endorsement of any company, product, or service by NBCH. To find out how your company can submit an opportunity for Opportunity Knocks contact Susan Dorsey.

Expanding Vaccine Coverage for Your Workforce: A Primer for Employers 
In the wake of the initial health care reform legislation, wellness programs are increasingly prevalent, owing in part to the preventive care mandates set forth in the Patient Protection and Affordable Care Act. Specifically, PPACA requires that all recommended immunizations must be covered without patient cost-sharing (ie, no out-of-pocket [OOP] cost to the patient). [1]

In an effort to increase uptake of often-overlooked adult vaccines, managed care organizations and their employer customers can focus on two particular barriers to immunization: cost and access. The National Vaccine Advisory Committee and the Infectious Diseases Society of America recognize these barriers among the leading impediments to optimal immunization rates among adults, and likewise support initiatives to minimize patient OOP cost and expand access to adult vaccines in settings beyond the physician’s office. [2-4] 

Promoting Immunizations Through Broad Coverage
According to an interview with Charity Rausch, PharmD, Director of Analytics and Clinical Initiatives at Employers Health (December 2011), immunizations are usually covered exclusively under the medical benefit. An alternative arrangement, dual coverage under both the medical and pharmacy benefit allows for vaccines to be administered and paid under either benefit at the patient’s discretion. Arranging dual coverage for adult immunizations with your insurance carrier and/or pharmacy benefits manager (PBM) minimizes the detrimental effect of OOP cost and limited access on vaccine uptake.

Attaining dual coverage for immunizations begins with you expressing your vaccine access and coverage needs to the account manager/account executive at the health plan or PBM. Specifically, you should communicate your desire for all immunizations to be covered under both the medical and pharmacy benefits with no cash outlay for beneficiaries. Both of these elements are crucial for removing the leading barriers to optimal immunization, such as limited administration settings and OOP patient expense. As such, you should ensure that coverage for immunizations is provided in the majority of medical locations in the plan network, including physicians’ offices, urgent care facilities, county health departments, community pharmacies and in on-site or near-site workplace clinics.Many insurance carriers and PBMs already have such vaccine coverage programs available for their employer customers. On the health care delivery side, trained and licensed pharmacists in all 50 states are now authorized to administer the influenza and pneumococcal vaccines, and the majority of states allow for the pharmacy administration of multiple vaccines. [5]

As of December 2011, 37 states allowed pharmacists to administer any vaccine through various processes and 46 allowed the administration of the herpes zoster vaccine in the pharmacy. [5] The allowable age of the patient that pharmacists are authorized to vaccinate varies by state, with 13 states allowing vaccinations for patients of any age, 16 states allowing vaccinations for patients aged 18 years and older, and 1 state defining the age parameter as “adult.”[5] 

Case Study: Pfizer Inc
Following the open access blueprint outlined previously, Pfizer Inc recently sought to broaden access to adult immunizations for its workforce. As company pharmacy benefits are managed through a PBM, discussions took place between the Pfizer employee benefits team and representatives from the PBM to determine options to make vaccines available in alternative settings.

Prior to these discussions, Pfizer employees were able to be immunized through network physicians under their carrier’s medical benefit as well as through a special pharmacy benefit exclusive to the seasonal flu vaccine at one national pharmacy chain. Through dialogue with the PBM, the Pfizer employee benefits team learned that a second available option was the PBM’s Broader Vaccine Program. The Broader Vaccine Program includes seasonal influenza but goes beyond flu to include the 2 pneumococcal vaccines.

Included as immunizing providers in the vaccine network are 49,000 participating pharmacies in which beneficiaries may receive their immunizations for zero OOP cost via cashless transaction. All vaccinating pharmacies are offered the opportunity to participate, assuming they follow state laws and are certified to immunize per the standard client language in the contract. The PBM offers a flat rate price point for immunizations within the Broader Vaccine Program that includes ingredient cost and administration fee. The network for administration of these vaccines is annual but follows flu season for initiation, running from August 1 of one year to July 31 of the subsequent year.

Pfizer’s benefits team opted for the Broader Vaccine Program, which offered greater coverage through an expanded immunization menu. As a result, Pfizer employees are able to receive flu and pneumococcal immunizations in network retail pharmacies, as well as in their physicians’ offices, with no OOP expense.

Wellness benefits are attractive to employers as a means of reducing health care costs in the long term, and immunizations are no exception. In an effort to increase workforce immunization rates and minimize absenteeism, employers frequently offer onsite seasonal flu vaccination to employees at no or low cost to their employees. [6]With all 50 states now authorizing trained and licensed pharmacists to administer the influenza and pneumococcal vaccines, vaccine delivery in the pharmacy is virtually ubiquitous.[5]

By achieving expanded immunization coverage for the workforce through the processes outlined here, employers have an opportunity to increase vaccine uptake. Improved vaccine uptake and subsequent associated health benefits may result in sizeable savings for employers. Immunizing healthy, working adults against influenza alone has the potential advantage of reducing morbidity and mortality, lost workdays, and physician visits, in addition to generating savings through the reduction of lost productivity. [7]Overall, including additional vaccines in your benefits package and providing them at zero OOP cost for your employees in multiple settings represents a positive intervention supporting the health of your workforce.

1. Kaiser Family Foundation. Summary of New Health Reform Law. Last modified April 15, 2011. Accessed Sept. 17, 2012.
2. National Vaccine Advisory Committee. A pathway to leadership for adult immunization: recommendations of the National Vaccine Advisory Committee. Public Health Rep.2012;127(suppl 1):1-42.
3. Infectious Diseases Society of America. Actions to strengthen adult and adolescent immunization coverage in the United States: policy principles of the Infectious Diseases Society of America. Clin Infect Dis. 2007;44:e104-e108.
4. Pickering LK, Baker CJ, Freed GL, et al. Immunization programs for infants, children, adolescents, and adults: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2009;49:817-840.
5. American Pharmacists Association and Academy of Managed Care Pharmacy. Pharmacist-provided immunization compensation and recognition: white paper summarizing APhA/AMCP stakeholder meeting. J Am Pharm Assoc. 2011;51:704-712.
6. Centers for Disease Control and Prevention. Make it your business to fight the flu. pdf. Accessed September 17, 2012.
7. National Foundation for Infectious Diseases. Top reasons to get vaccinated. NFID Web site. Accessed June 26, 2012.


Tuesday, November 25, 2014

Cost of Diabetes Care Keeps Climbing, Report Shows

The cost of diabetes care in the United States has increased 48 percent in recent years, climbing to more than $322 billion annually, a new report shows.

Even greater increases in cost were seen with prediabetes care, which have risen 74 percent, and undiagnosed diabetes, which have jumped 82 percent, the researchers added.

In 2012, excess medical costs and lost productivity associated with diabetes totaled more than $1,000 for every American. That total includes $244 billion in medical costs -- including doctor's office and hospital visits, prescription drugs and other health conditions such as high blood pressureand kidney complications -- and $78 billion in lost work productivity.

Read the full story via HealthDay.