NOTE:  Also published by MCOL

I’m thinking this evening of the amazing journey we’ve begun together, and I’m thinking about the conversation I had with Dr. Joycelyn Elders, former US Surgeon General, who will open our Annual Meeting and Innovation Summit on Nov 14.  Each of our phone calls is such a delight.  Imagine being able to call the woman who “explained” to Congress how teenagers need more guidance, and to ask her some of the hard questions on national health policy!

I’ve been very lucky in this career of mine.  I’ve been blessed to work with some of the most amazing folks at every turn.  What’s remarkable is that so many of us know the real gold in health care is not the care itself, but in making HEALTH the goal of our endeavors.  What’s exciting now is that many of us “passionate idealists” are working hard to make sure that the improvement in health is the #1 priority, and that health care becomes one of the tools to get there.

Each of us approaches this in different ways.  For instance, Brian Klepper, whom you often read about when you read my writings, is passionately moving the needle on Primary Care Providers, blogging on Health Affairs and causing a ruckus with the RUC (the panel that sets clinician reimbursement rates, the panel that is so very much under-represented by primary care physicians).  Brian’s efforts are getting bolder and growing stronger, and I am an ardent supporter of the efforts to be sure that Primary Care gets equivalent pay that shows their importance in the health engagement and promotion that keeps people well, working, and building healthier, prosperous communities.

Another good friend is Ron Loeppke, MD MPH, whom I’ve know for far too many years to remember.  Ron’s passion is now directed to his new job, as Vice Chairman of the Board, U.S. Preventive Medicine, Inc. (traansparency: I have the honor of serving on the board with Ron and so many of our mutual friends).  Ron is also the past Chair of the American College of Occupational and Environmental Medicine (ACOEM), and has chaired the Health and Productivity section for as long as I can remember.  Recently, Ron wrote an op-ed piece on the need for preventionists, and it’s posted on the ACOEM site.  Ron has been a driving force for linking worksite health to worksite performance, and we’ve had the joy of sharing many conferences, slides and ideas together.  As he says in the article:

The clinical science of preventive medicine focuses on wellness and health promotion and health risk assessment to keep people healthy (primary prevention); and early identification/diagnosis of illness through age/gender/risk appropriate screening and biometric testing (secondary prevention); as well as earlier evidence-based intervention/treatment to deter complications and the disabling impact of conditions (tertiary prevention). The preventive health care movement reaches well beyond the four walls of medical facilities to include workplace health and community health initiatives. 

I quote this as others in the space of value-based designs do not see the ROI of prevention and wellness.  But think about it:  if we can prevent the high cost interventions, if we can build intrinsic desire for health and accountability to save our health, the saved dollars will go far to build healthier communities.  The companies that tell me that they cannot focus on health, that they only want to get the costs down, are doing themselves, their families, and their communities a disservice.  Simply stated, if the company gets 80% or more of its workforce from the geographic community, then there is an 80% chance that the next person coming to get a job will have the same risk factors as the person who just left.  Want more proof?  Google Ron and start reading.

And on the topic of value-based designs, another friend I’ve been very much in contact with lately is Mike Critelli, the former CEO of Pitney Bowes who is now the Chair and CEO of Dossia, which is so very much more than a Personal Health Record.  Under Mike’s direction, Dossia is quickly growing into the family and community health management tool that I have been hoping for, building the capacity of families to “gather” into one record that the head of the family health improvement plan (usually the mom, folks, that’s been my story all along!), can manage.  With the strong support of a very talented group of programmers, community health improvement experts, international IT experts, and more that are too many to name, the group at Dossia is getting grand traction around the country, and I am, of course, delighted to have them on the CHVI board.  We share many strong ideas of accessibility and accountability, and then we work with our different constituencies to influence change as far and as fast as possible.

It’s stunning, isn’t it, that we expect an “engaged, accountable patient,” yet the patient gets no records, has virtually no decision-making authority except how much he/she is willing to spend out of his/her own pocket for care.  Yet, that’s not the accountable consumer we want.  We want a consumer who protects the health of herself, her family, her community.  We know, from research published by another renowned colleague, Dee Edington (of Univ of Michigan fame), that an engaged consumer of health has costs 30% lower than one who is unengaged.  We know that reducing risks from hi to moderate lowers costs 33%–that’s what happens when people are engaged, not entitled and waiting for the system to cure them.

Yes, I’m quite lucky, indeed.  Yes, I’ve used this opportunity to highlight the amazing work of my friends and colleagues AND to link to our upcoming summit, because I’m excited about our mission, and I’m excited that they will all be there with us.

Maybe, too,  as I watch the sun set over the beautiful SW Florida sky this evening, the stars really are aligning.  Perhaps we’ve squeezed as much value out of the delivery system as we can–and remember, most of the dollars, all $2.6 Trillion of them, are focused on the 10-20% of folks who are not so committed to health promotion or prevention.  Maybe now that the economics of health is so very important to understand, the stars are ready to assist.  Perhaps the stars, whose light has to travel so very far to be seen, have finally arrived in sight–and those of us who have spent so very many years promoting health, are finally being seen as well.  Perhaps the focus on outcomes allows all of us to ask the question, “How do we short-circuit the path to achieving these outcomes?”  and we can, finally, all get quiet while the stars’ universe responds, “It’s in the path to health promotion.”

It’s a wonderful night to dream of what could be, to imagine that there is a growing focus on health, outcomes, and healthy communities.  Tonight I’m not going to focus on this paradise’s need for jobs, affordable care, and primary care clinicians.  Tonight I’m going to hope and pray and dream of the US as healthy, prosperous, and job-wealthy.  I believe that’s what the stars are showing us.  If we’ll only look up, they will tell us that nothing is impossible.

It’s been a long few weeks, and temperatures have not subsided.  The AC needed–the cooling off that would come with accountability throughout the stakeholders of consumers, patients, physicians, health plans, health services, pharma-device-biospecialties, etc.– is not on the horizon.    Today, the heated up consumers have shown they have lost confidence in our economy, and the stockmarket dropped 350 points already today. The Congress is worn out from its weary negotiations, and members have recessed for 5 weeks, leaving less than 90 days for negotiations by the SuperCommittee, who will, in turn, “solve” the money crisis, we hope.  But, the money counting has begun. Does this matter to health care, employee engagement, and accountable care?  It sure does, as it reflects the impact that loss of revenue and loss of taxes will have on our ability to get health care coverage for more citizens.

Then, another stunning blow:  In an overlooked clause in the PPACA legislation, Massachusetts hospitals will recoup $275M in Medicare reimbursements, and 7 other states will also be receiving new Medicare dollars, while the rest of the states get hit for these dollar transfers.  The article, in the Associated Press, explains it this way:

Hospitals in Massachusetts will reap an annual windfall of $275 million through a loophole enshrined in the new health care law. Hospitals in most other states will get less money as a result.

Hospital association executives in other states are up in arms over the news, buried in a Medicare regulation issued Monday. It comes at a time when hospitals face more cuts under the newly signed federal debt deal.

“If I could think of a better word than outrageous, I would come up with it,” said Steve Brenton, president of the Wisconsin Hospital Association.

Even Medicare says it is concerned about “manipulation” of its inpatient payment rules to create big rewards for one state at the expense of others.

Hospitals in 41 states will lose money as result of the change. The biggest loser: New York, which is out $47.5 million.

Seven states come out ahead, though none do as well as Massachusetts. Runner-up New Jersey stands to gain $54 million, or about 20 percent of the Massachusetts windfall.

President Barack Obama’s health care overhaul was supposed to lead to reforms in Medicare’s byzantine payment system. Critics say this latest twist will encourage hospitals and other big players to game the system in a scramble for increasingly scarce taxpayer dollars.

Hospitals are paid under a complex set of formulas for their services for Medicare recipients.  When these kinds of shifts are made, the hospitals, of course, must take the hit–unless they are in the “lucky” states.  But, as you may imagine, these less-fortunate hospitals have bills to pay, too.  So, they often raise pricing on the other national payers of health care:  the employers.  This means we can expect to see the employer-provided costs of health insurance to go up, which means employers have one of 3 alternatives:

1/ pay the increase.  But their sales are down (witness the plunging consumer spends) and their insured population (workers, families) have already absorbed 100%+ increases in insurance costs over the past 10 years;

2/ pass the increase to their covered lives.  See #1 above, and note that recently Kaiser Family Foundation published research that showed that 61% of the uninsured in America are part of a family with a fulltime employee who is offered affordable health care and chooses to not take it. Passing costs to employees who choose not to take it does not make a healthier employee nor a healthier corporation.

3/ do not offer insurance.  Well, it will sure save dollars for America’s employers (up to $13,700 per family in 2010).  But it certainly will not increase employee engagement in their health or performance, and it will not add to the total health improvement for employers, who are experiencing the aging and sicker workforces that have been documented over and over again.

So, Turning on the AC, as noted in my previous blog, hasn’t quite worked so well in the past few weeks.  Accountable Care may well have become AcCOUNTable care, emphasis on the count.  I hope that those that received the reimbursed dollars will be able to support the only reasonable outcome:  send people to those states for the coverage they will not find in their own. Another reason for Medical Travel, but, alas, it’s not about improved health.  It’s about improved reimbursement, just as many have feared.

Allow me, then, to tie this to my passion for improved health.  To do this, I’m using some quotes from the Founding Fathers as well as some from more modern efforts.

We hold these truths to be self-evident: that all men are created equal; that they are endowed by their Creator with certain unalienable rights; that among these are life, liberty, and the pursuit of happiness. This line from our Declaration of Independence, penned by Thomas Jefferson, captures the intent of the Founding Fathers (note: I’m choosing to translate “men” as the placeholder for both genders).  People are born with certain rights that must be protected and promoted.  Jefferson also linked the pursuit of happiness to the health of body and mind, writing,  “Happiness is not being pained in body or troubled in mind.”  He wrote, too, of purpose, education, and walking fast—all items that would enhance our life, liberty and the pursuit of happiness.  If one respects Jefferson, one respects health and understands that health grows as we acknowledge its importance in our pursuit of happiness, building wisdom and proficiency in managing our health.

Let us not proclaim infallibility. Benjamin Franklin thoughtfully considered every word and passage in our Constitution.  Writing that he could not proclaim that all evils were addressed in its words, he cautioned humility and the opportunity to let time judge the words—and then he signed the Constitution.  He was quite sure that it was better than any other guarantee of freedoms that existed: it was a game-changer.  He also knew that healthy living was a game-changer (“healthy, wealthy and wise…”), and he wrote of value in words that ring true today: “When the well’s dry, we know the worth of water.”  Today, the wells of both health and wealth are running low, with obesity on the rise, inactivity robbing our children of their future, and wealth stolen from them as we argue over “who pays.”  Our communities are paying, our businesses are paying, our government is paying, and all of those mean that we, individually, are paying.   Yet we behave as though our declining health is worth the lack of attention we personally give to it.  Unhealthy, un-wealthy, and unavoidably unwise? The fallacy of ignoring our personal health is the mounting debt that poor health leaves on all of us. That’s not the test of time Franklin, Jefferson, nor any of the Patriots envisioned. Young men, lean and often hungry and cold, fought for the freedom to pursue better lives, and their wives and sisters kept the spirit alive in every home.   The spirit of America demands we do better, that we are not infallible and can recognize our poor behaviors and change them.

The question isn’t who’s going to let me; the question is who’s going to stop me. Ayn Rand wrote these words.  For those of you too young to know her, she’s not a Founding Father but an insightful author.   Her words ring true on this day of Independence:  Each of us has, within us, something that causes us pride, rouses us in the morning, proclaims devotion to a significant other, perhaps a child, a spouse, or a higher purpose.  We support that flame of purpose by building a machine that can withstand the trials of both success and failure: a healthy body and mind.

I hope that this July 4^th, we each pause for a moment to declare our independence from poor health, poor wealth, and lack of wisdom to acknowledge the implications of both.  In America, we have the opportunity to do better for ourselves:  take a walk.  In America, we have the responsibility to do better for our families:  teach them healthful eating.  In America, we have the spirit to lift our communities to be the healthiest in the world, shining a new level of hope as a beacon for the world.  We have the tools, we have the model, and we have the obligation to those who came before us and those who will come after us to embody the freedoms we passionately defend.  On this July 4^th, I wish America well.

Dividends in value-based benefit design, embedded in health care reform, are accelerated with an Outcomes-Based Contract™ that improves population health and employee health care benefits, as evidenced in recent results from the CIGNA and Merck contract for diabetes control. This adds to the remarkable evidence cited in the latest Health Affairs November, 2010 issue on VBID, which contains articles highlighting Pitney Bowes, the work of our co-founder, Dr. Jack Mahoney and close allies Niteesh Choudhry and Mark Fendrick.

You may remember that I was asked to comment on the groundbreaking Outcomes-Based Contract™ that was launched by CIGNA and Merck in 2009. Nayer Commends CI-Merck Yesterday, Oct 28, 2010, the first-year results were announced by CIGNA and they are stellar. To Cut to the Punchline: CIGNA estimates that up to $8000 per patient per year can be saved by instituting a comprehensive VBBD, including reduction in care acquisition costs (lower co-pays) plus enrollment in coaching/counseling. http://tinyurl.com/CI-Merck-OBC

Aligning incentives across all of the stakeholders, the definition of an OBC™, means that both CIGNA and Merck took risks to engage, activate, and create accountability for the diabetes patients in this total health management approach. A long-time colleague, Dr. Jeff Kang, who is the CI Chief Medical Officer, is quoted as follows:

“Because CIGNA is able to coordinate data and resources within our company, we are better able to support the health needs of the whole person,” said Dr. Jeffrey Kang, CIGNA’s chief medical officer. “By integrating medical and pharmacy programs, we can identify people who may need extra support early in the diagnosis and progression of their diabetes, which means customers can potentially stay healthier longer.”

Kang said CIGNA is uniquely positioned in the industry to successfully complete an outcome-based contract, and that this is the first of what the company expects will be many more such contracts with pharmaceutical manufacturers. “It’s a key aspect of the future of pharmacy contracting,” added Kang.

Early results showed : improved blood sugar levels of more than 5 percent for those continuously enrolled in the program regardless of which diabetes drug they were taking. Customers who actively participated in CIGNA’s diabetes support program were 3 percent more likely to have their blood sugar under control than those who were not in the program. There was also a 4.5 percent increase in blood sugar lab testing during the period.

• Blood sugar levels improved by more than 5 percent
• Individuals who participated actively in CIGNA’s diabetes support program were more likely to control their blood sugar than those not in the program
• 87 percent of people taking Merck’s Januvia® and Janumet® took their medications correctly
• Savings could be as much as $8,000 per person when medications are taken properly

“Merck is pleased to partner with CIGNA on this program,” said Sethu Reddy, M.D., MBA, vice president medical affairs, Merck. “As the number of people with diabetes continues to increase in the United States and globally, achieving blood sugar control and increasing adherence to diabetes treatment regimens are important goals for patients with type 2 diabetes and their doctors.”

I’ve had the great good fortune to work closely with colleagues at CIGNA and at Merck. You know that I’ve worked for many years with Michael Sokol, MD, who is now the global medical director for Merck; much of our work together was done before he moved to Merck, but we continue to be in close contact and he recently published new analysis of VBBD. Some of you know that I participate as a speaker for Merck events on VBBD, and that I was a co-creator of the toolkit for VBBD for them.

I’ve had long discussions, in various venues, with many of the leaders and innovators in both companies, including Rick Brush, Jeff Doemland and Gary Earl (and Dr. Kang and his team) at CI, Jerry Vuocolo, Pat Counihan, Jeff Niekelski, Rich Patrylak, and Dr. Sokol, among many others at Merck (including some who have moved on to other companies, as well). Real concerns were debated, such as how to measure success, the acquisition of data and measurement of impact, and the bottom-line definitions of value among stakeholders. There was even trepidation as to whether a payer (employer) and a provider group would agree to the intricacies needed to conquer this tipping point.

Yet, when the debates slowed down, and in each instance, when we removed the real and perceived barriers and said, quite simply, “Yes, but what if…What would that new health system look like if we could get this to happen? How can we make this happen?” that’s when the real work ensured. Each time, at each venue, we agreed that focusing on the patient outcomes was not only the right thing to do, it was the only way to change the system and drive accountability all the way to the consumer level, and that’s when the magic began.

This week (11/1/10) is being touted as the “test” of health care reform as the elections draw near. I say, “no,” the real tests are already happening. It takes renegades to be brave enough to test new concepts, to move the dial, and to publish measured results that show directional improvement. I go on record to note, instead, that this week is, in fact important, as Health Affairs publishes a whole volume on Value-Based Insurance Design—and many of the folks on our panel of experts are publishing great work. I go on record to note that it’s not only about the insurance, but it’s about the system-wide accountability that uses data and accountable care to improve outcomes. It’s about the consistent, focused, deliberate efforts of the Experts at the Center for Health Value Innovation that have shown, and continue to show, that value-based benefit designs deliver dividends that matter to individuals, providers, plan sponsors, businesses, and communities—all of which manage a health-wealth-performance© portfolio of their own.

Another tipping point is achieved. Hurray and congratulations to CIGNA and to Merck. Great job! to the patients who enrolled and the care providers who coached them forward.

Look ahead, now: there are more tipping points in the distance, and we will climb every point necessary to improve the health value and economic balance of our country.

In 2008, the National Changing Diabetes Project® (NCDP) introduced the National Diabetes Goal which calls for 45 percent of Americans who are at risk for type 2 diabetes to know their blood glucose level and what actions to take by the year 2015.

Cyndy Nayer, president and CEO of the Center, states, “We are proud to support the NDG and share its emphasis to improve the lives of people affected by diabetes. The Center’s focus on value-based design and its pro-active initiatives for sustainable health and financial improvement align with the NDG mission. Creating a focus on diabetes in America is one that will promote the prevention, early detection, and management of the disease.”

According to the American Diabetes Association, 23.6 million children and adults in the United States, or 7.8 percent of the population, have diabetes. While an estimated 17.9 million have been diagnosed with diabetes, 5.7 million people are unaware that they have the disease. Survey results released by Gallup® and commissioned by the National Changing Diabetes Program show that, while more than 90 percent of Americans consider diabetes a serious health issue, awareness has not yet translated into collective, widespread action.

About the National Diabetes Goal

The National Diabetes Goal was first launched in May 2008 by the National Changing Diabetes Program (NCDP) in conjunction with many healthcare stakeholders, including, among others the American Diabetes Association and the American Association of Diabetes Educators.

About The Center for Health Value Innovation

Information Exchange for Value-Based Design

The Center for Health Value Innovation has grown into the nation’s premier organization dedicated to sharing the evidence of improved health and economic outcomes through value-based designs for sustainable health and financial improvement.

Caterpillar found that even a $5 copay was enough to deter some from taking prescribed statin medication. When the medications were free, the compliance level jumped 14 percent to 80 percent of those prescribed.

The company also uses monetary incentives to encourage employees to buy healthier foods in its cafeterias, and to quit smoking. The article also encouraged smaller companies to look at simple value-based measures such as free flu shots.

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