Health Benefits Status Quo Horrible Compared to Health Rosetta


Let's face it, your health benefits stink. Given the massive amount of money spent by employers on health benefits, it's brutal to look at just how bad the status quo is for health benefits -- it's created a 20-year-long economic depression for the middle class. Great people are operating inside of a horribly designed system as this NY Times doctor/columnist/patient painfully describes. I've gone so far as to say that we've gone to war for less than what the status quo healthcare system has delivered.

Far more resources have been directed towards administrative overhead designed to optimize revenues than to optimize the Quadruple Aim. Fortunately, smart employers such as a small manufacturer and a small hotel chain have proven how you can spend 30-50% less per capita AND provide great benefits.

The fact is that most payroll increases for companies have gone to pay for healthcare's hyperinflation, rather than wages. Forward-looking organizations recognize that we can expect much more from this large of investment. For those who haven't read some of my prior pieces, a bit of background may help. Those who have read those pieces may want to scroll down to the comparison of status quo versus the Health Rosetta.

As you get Open Enrollment information from your employer and consider that they are likely paying $10,000 or more on your behalf, reconsider whether you are okay with the status quo. This is all the more important as most employers are going to high deductible plans and thus what comes out of your paycheck covers less and less. This make healthcare and health plans one of the few industries where the value proposition gets worse every year.

No industry has lower Net Promoter Scores (a measure of customer satisfaction) than Health Plans. Tweaks on the margins won't get the job done. If you work for an employer over a few hundred employees, the company is self-insured unless they love burning dollar bills. If so, they have to adhere to ERISA regulations that make them a fiduciary of your money. Some lawyers are suggesting to me that many employers are failing in that fiduciary duty and thus have legal exposure. It's your money and they have a duty so you should expect more. The Health Rosetta is meant to provide a roadmap to a dramatically improved value equation.

Background

The Health Rosetta is the model health benefits package that wildly outperforms the status quo. The positive impact for employees and their community are breathtaking when they are employed. In contrast, we see teacher strikes with health benefits being a core issue of contention. The cost of healthcare's hyperinflation on a typical American family's nest egg has been $1M. Most people haven't made these connections, nor do they know how much better things are when the health benefits are optimized. This is a core reason behind the documentary I'm working on -- i.e., to catalyze a movement that is a partnership between increasingly dissatisfied clinicians and individual citizens (aka patients, consumers, people).

For those in the healthtech arena, I am 100% convinced that nothing would accelerate the adoption of modern, effective digital health tools than buyers of health benefits getting smarter. Unfortunately, I came to the conclusion that much of the technology in healthcare is just re-arranging deck chairs on the Titanic. Until we fix how dollars flow, digital health innovators will continue to get table scraps relative to incumbents selling 1980's-based systems for hundreds of millions.

In the video below, Aneesh Chopra (former CTO of the U.S.) outlines how if new payments models demonstrate they lead to a better healthcare experience for our seniors, Medicare has legal authority to scale reimbursement throughout the system. In other words, innovation that may start with employers that can be proven to also work with seniors would scale to the entire gamut of private and public payers. Go to the CMS Innovation Center to learn more.

Status Quo Versus Health Rosetta Comparison

The list of items will grow over time but gives an employer or union a good punch list of what to work on. They are ordered roughly by the level of effort and disruption to the relative payback -- i.e., low effort and high ROI bubbles to the top. Since proposing this open source initiative, feedback from a wide variety of people has shaped the Health Rosetta. That includes benefits leaders at medium and large companies and especially benefits consultants representing firms such as Aon Hewitt, HUB International, Mercer, USI and various independent consultants -- some have or are drafting or reviewing the expanded version of the items in this piece. If you have expertise in any of the areas, we'd benefit from your expertise. Where the item has been outlined in more detail, there is a link to that item. Listed below is just a summary.

Transparent Medical Market

Status Quo

Wildly variant, opaque pricing for items such as scans, surgeries and other medical services. If there is any price/quality correlation, it’s inversely correlated. Sometimes “transparency” solutions are available giving the best, bad deal while still having co-pays, deductibles, the oxymoronic "Explanation of Benefits", etc. and all the other things that make for a horrible consumer experience.

Health Rosetta

The good news is there is a solution to the most vexing problem healthcare has had -- pricing failure.

  • Fair, fully transparent price to employer/individual at high quality centers who readily accept quality reporting such as Leapfrog.
  • Providers able to set a price that works for them while avoiding claims/collections hassles and accompanying receivables.
  • No charge for individual going to these providers. No EOBs, bills, etc. -- just a thank you note.

 

Concierge style employee customer service

Status Quo

Employees left to navigate an extremely silo’ed and uncoordinated healthcare system receiving conflicting and often non-evidence based recommendations

Health Rosetta

Having resources to help you navigate the system that can draw on expertise for quality and cost including understanding benefits plans, best provider options, etc.

 

Value-Based Primary Care

Status Quo

  • Flawed reimbursement incentives have turned primary care into “loss leaders” that are like milk in the back of the grocery store (i.e., low margin designed to get people to high margin items)
  • Short appointments due to not investing properly in primary care
  • Primary care shortage due to making primary care discipline unappealing
  • Long wait times to get in can lead to small “fires” blowing up
  • Medically unnecessary face-to-face appointments clog the waiting room and delay care for people who truly need face-to-face encounters
  • Record levels of dissatisfaction & burnout amongst PCPs

Health Rosetta

  • High Net Promoter Scores
  • Quadruple Aim leading organizations
  • Ounce of prevention is worth a pound of cure
  • Same or next day appointments for issues not addressed via email/phone
  • Extensivist (for the sickest patients) has smaller panel allowing proactive care management & coordination.
  • Can reduce issues 40-90% and spending 20-50%

 

Access to world class acute care hospitals for complex, expensive procedures 

Note: 6% of employees at large org typically account for 80% of medical costs. 

Status Quo

  • Quality and prices vary widely
  • Studies find 40% of transplants are medically unnecessary
  • High rates of complications at community hospitals who don’t do high volumes of complex procedures 

Health Rosetta

Due to the infrequency of these procedures (transplants, neurological procedures, cardiac, spine and other six-figure or more procedures), the Transparent Medical Network is a good tool to pair with this since those procedures happen more frequently. It raises the visibility and understanding how there is wide variance in value between different provider options.

  • Second opinions at no charge for employee at world class Centers of Excellence facilities (e.g., Mayo & Cleveland clinics)
  • Unit cost often higher but lower complication rates & avoidance of unnecessary procedures makes it have a strong ROI.

 

Aging & end-of-life

Status Quo

  • Individuals and families left to fend for themselves at the most stressful moment in their lives.
  • Healthcare delivery systems and community goals not in sync

Health Rosetta

 

Retirement healthcare costs

Status Quo

With pensions mostly gone, a very low percentage of Americans have healthcare savings for living or healthcare costs (estimated at $300k per household not covered by Medicare)

Health Rosetta

By avoiding wasted costs, companies are able to fund HSAs (triple tax benefit) and more broadly fund 401k matching funds

 

Quality/safety embedded in provider network

Status Quo

  • Varied participation in 3rd party safety reporting such as Leapfrog
  • Culture of shame/secrecy when errors are made

Health Rosetta

 

ERISA

Status Quo

  • Many ERISA plans have “holes” that expose employers unnecessarily
  • Pay for high cost ASO networks

Health Rosetta

  • Fully-compliant ERISA plans that protect companies from abuse
  • ERISA fiduciary oversight and review at least as strong as 401k oversight and management
  • Use TPA networks focused on high quality providers and geographic coverage

 

Actionable Analytics

Status Quo

Everybody produces data but very few produce actionable information

Health Rosetta

Focus on data ==> information ==> knowledge ==> wisdom Example: MyHealth Access Network (an HIE in Oklahoma) can provide analytics offering advanced decision-support tools such as Archimedes IndiGO. This tool integrates dozens of health/disease determinants to provide previously unavailable treatment guidance based on medical evidence.

 

Value Based Plan Design

Status Quo

Blunt-instrument High-deductible Health Plans  that lead to unmanaged chronic disease that leads to expensive medical blow-ups

Health Rosetta

  • Designed to encourage appropriate health-seeking behavior and avoid over treatment & lower value providers.
  • Strategic use of copay reductions or waivers, premium reductions, and health saving contributions.
  • Leading employers recognize not all incentives are financial — e.g., convenient, no cost primary care

 

Direct resources to evidence based tools

Status Quo

  • Minimum of 30% of care not evidence based
  • Only about half of that care for which good medical evidence based guidelines exists is actually rendered according to guidelines
  • Massive overuse of imaging (e.g., 80M CT scans/yr in US)

Health Rosetta

  • Codifying Choosing Wisely & Consumer Reports recommendations
  • Designing EHR systems to provide point-of-care evidence-based decision support: important information must find the physician at decision time rather than the physician needing to find that information.

 

In depth pharmacy management woven into primary care

Status Quo

  • Pharmacists represent another medical silo frequently uncoordinated from rest of system
  • Frequent duplicative & conflicting prescriptions
  • Adherence issues due to cost, complexity and lack of understanding

Health Rosetta

  • Pharmacy woven tightly into primary care
  • Patients and caregivers educated on need for particularly drugs and reasoning behind prescription regimens

 

Disease specific care pathways

Status Quo

Disease-specific pathways not codified into many EHRs and responsibility for execution not always assigned

Health Rosetta

Creation of specific roles assigned to flight control over patients on pathways (care guidance nurses, health coaches, practice enhancement personnel)

 

EHR technology

Status Quo

  • Most EHRs are designed around the need for documentation & billing accuracy, and are obtrusive to the clinical visit. Perverse payment incentives trump clinical efficacy.
  • More personal health records have been accessed by hackers than have been made easily available to patients themselves.

Health Rosetta

  • Modern EHRs provide physicians with robust real-time decision support and deliver the interoperability to deliver the value of health information exchanges.
  • Secure, easy and open access to one’s own health records will be made as available as other sensitive data such as financial records.

 

Community based health initiatives

Status Quo

Despite being major cost drivers for the corporation, they have little to no involvement in these initiatives. (Note: Only 20% of health outcomes are determined by clinical care)

Health Rosetta

Employer/union coalitions leverage their reach & spending impact. Coalitions support programs such as Blue Zones to make it easier to have strong well-being in the community.

 

Health Information Exchanges

Status Quo

  • Currently an aggregator of clinical, hospital, imaging and laboratory data including admission, discharge and transfer
  • Users generally must actively fetch data
  • Sequestration of health information at provider or system level may inhibit consumers from seeking care from independent providers providing higher quality and service at lower cost

Health Rosetta

  • HIE data tightly integrated into individual EHRs to present a global view of patient.
  • Actionable and critical data in HIE must be pushed to those providers able to act on those data. HIE data on diagnosis and medications pushed to first-responders in the field.
  • Analytics capabilities sit atop data repository to provide unique Big Data reports
  • Employers and public health have access to de-identified Big Data to guide planning, regulatory and purchase decisions.
  • Availability of information through HIE allows consumers to seek care based on value without fear of missing information or care coordination failure

 

Coordinated Care

Status Quo

Care may be fragmented in two situations leading to preventable errors:

  1. When a person is receiving care from two providers, especially when that care exists in different places at different times and
  2. During transitions of care when one provider takes over from another.

Examples include a patient seeing several specialists as well as a primary care physician; A patient transitioning from hospital to home, hospital to skilled nursing facility or to a hospital offering a higher level of care.

Health Rosetta

  • Providers coordinate care by asynchronous communication facilitated by electronic health record systems, either by sharing the same system or through a health information exchange.
  • Providers utilize HIE for direct, secure communications between primary care and specialty care, such as Doc2Doc, which can reduce unnecessary in-person consultations.
  • Provider provide warm handoffs during transition of care, up to and including POTS dialog when appropriate.  Providers commit to thorough and timely documentation, especially for discharge and transfer summaries.
  • Providers and specialists develop treatment compacts that avoid duplicative testing and treatment or conflict.

 

Wellness Initiatives

Status Quo

Wellness often purveyed by independent entities not aligned with primary care and rarely focusing on at-risk populations

Health Rosetta

An intermediate level of care between ordinary wellness and conventional preventive care: Alignment between wellness and primary care to focus on that portion of population that is well but at increased risk for common diseases such as diabetes. With many specious ROI claims in the Wellness field, independent and credible third-party validation should be part of their program (e.g., Validation Institute).

 

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