The Truven Health Blog

The latest healthcare topics from a trusted, proven, and unbiased source.

An Educated Patient With Financial Accountability

By Anita Nair Hartman/Wednesday, November 27, 2013
Anita-Nair-Hartman imageA recent Wall Street Journal article highlights a strategy employers are using to manage rising healthcare costs: sharing more of the cost burden with employees. Benefit plans with higher out-of-pocket costs for consumers have been rising in popularity over the past few years in the employer-sponsored healthcare sector. Consumers considering new products on the state and federal insurance marketplaces will also find that their choices include plans with higher out-of-pocket costs. It is clear that American consumers will be taking on more of the cost burdens for their health care. The hope is that an educated consumer with financial accountability will take care of their health and make sound financial choices to manage it.

The question is: How do we get consumers to that state? Health plans and employers are looking at tools and services that will create more educated consumers. We need to support consumers as they navigate the healthcare maze and help them become engaged participants. Rather than our traditional point approach, where we engage at enrollment or when a treatment is needed, our industry needs to take a holistic view of the consumer and engage in ongoing and constant communication. We need to turn consumer health management into an everyday occurrence. New innovations in technology, consumer analytics learned from other industries, richer healthcare data, and improved analytics have put us in a better position to create more engaging consumer tools. Our next generation of tools must make healthcare a routine, easy, and intuitive part of every consumer’s day. 

Anita Nair-Hartman
Vice President Market Planning and Strategy

The Time is Now

By Michael R. Udwin/Friday, November 22, 2013
Michael R Udwin imageMany hospital executives around the country are cautiously communicating with their boards, medical staff, patients and community; attempting to explain why they are facing reimbursement penalties from processes or outcomes which failed to meet established benchmarks.  Beyond these somewhat awkward conversations, what are these leaders expected to do next?

Of course, a natural response might be to find someone to blame, whether it be subordinates, physicians, payers or even government.  Beyond perhaps feeling better having done so, it is not likely this will reduce the likelihood of facing similar penalties next year.  Since credit is afforded to those institutions that make great improvement, many executives view a “low” starting point as an opportunity to recognize significant gains.

So where do you begin?  Data.  Not just any data.  Validated, risk-adjusted and trusted data is the cornerstone upon which to build a strong yet flexible structure, anchored by transparency, accountability and empowerment. This information can be used to construct a pipeline of opportunities, at the procedural or diagnosis level, representing the greatest gap from best practice and impacting the largest number of patients.  With a clear appreciation of organizational bandwidth, it is then possible to strategically launch, implement, and sustain initiatives that recognize inherent strengths while addressing barriers to best practice.

Given the uncertainty within the healthcare community, it is easy to become reflexive or even despondent. Yet, it is in these times of flux that innovation, courage and true leadership emerges.  The data are there. The talent is there. The commitment to excellence is there. So now is the time to take charge on behalf of board members, medical staff, patients, and most importantly community!  

Michael R. Udwin, MD, FACOG
National Medical Director

Recent NCQA Report Highlights Need for More Use of Evidence-Based Guidelines

By Michael L. Taylor/Tuesday, November 19, 2013
Mike Taylor imageMost upper respiratory illnesses (colds, sinus infections and acute bronchitis) are caused by viruses. Typical antibiotics will not be helpful in curing these infections. In fact, overuse of antibiotics leads to bacterial resistance, a situation in which antibiotics lose their ability to kill bacteria. Antibiotic resistant infections have been estimated to cause 23,000 deaths annually.

To improve this situation, guidelines have been published around inappropriate antibiotic use. But as a nation, the US is not complying with these guidelines. A recent report from the NCQA showed that compliance with these guidelines has decreased, falling from 29% in 2009 to 24% in 2012. The report did show improvement in levels of compliance with guidelines for childhood obesity screening and pediatric immunizations.

Why do physicians follow guidelines at such a low level? There are several reasons:

  • Some guidelines are overly complex – LDL cholesterol -lowering guidelines come to mind.
  • In the example of antibiotics, some physicians don’t have the time to ‘negotiate’ with patients about the advisability of antibiotics in certain situations.
  • Physicians have an incentive to keep patient satisfaction scores high, which may lead to ordering tests or treatments because patients want them, even if not needed.
  • Clinical situations exist where guidelines do not apply.

As a nation, are we doing any better with other screening recommendations?  Nation-wide, breast cancer screening rates (as of 2010) are 72%, cervical cancer screening rates are 83% and colon cancer screening rates are only 59% of those who are eligible.

It is hoped that changes in the Affordable Care Act (ACA) to cover these screening procedures with no out of pocket charges will improve compliance with the guidelines. But we cannot expect 100% coverage to solve the problem. Many employers have offered these services at 100% coverage for some time, and yet their employees’ screening rates are often quite low.

There are several reasons for non-compliance with screening recommendations: 
 Fear of learning one has cancer
  •  Lack of knowledge about the test.
  • Fear of the test causing pain or discomfort.
  • Perception of cost.
  • Not wanting to take the time to have the test.
  • No personal  primary care physician.
  • Personal physician neglected to recommend the test.
  • Perception that guidelines change often and may not be correct, as has been the case with breast and cervical cancer screening.

To improve compliance with guidelines, each of these factors should be considered.  Educational materials need to be personalized and as specific as possible, and information about price transparency is a must.
Guidelines and templates for clinical care have the potential to improve the quality of medical care delivered, and better implementation of guidelines requires both patient and physician education and acceptance.

Michael L. Taylor, MD FACP
Chief Medical Officer

When Patients Become Consumers, Price Matters

By Michael L. Taylor/Tuesday, November 19, 2013
Mike Taylor image“How much is that x-ray?”

I read a recent commentary in which the author was struggling to understand the cost of a standard back x-ray. In the scenario described, the author had ‘pulled’ her back, so she went to the doctor who recommended a set of x-rays. The author went on to describe efforts to discover where the x-ray could be obtained and the price.

The result? Price information was nearly impossible to gather. Hospitals and imaging centers needed to know the insurance information and many other data points before determining the price.  Unfortunately this is an all too common scenario. Why does this happen, and how can this situation be resolved?  The “whys” are another topic, but I’d like to address the “hows”.

There is a definite trend toward developing tools to address this inability to learn about price of medical services. This trend is called “transparency,” and doctors, health plans and hospitals are facing more pressure to provide transparency tools to consumers.  With new insurance markets and exchanges using consumer driven health plans, patients are paying higher out of pocket costs for medical services, and are rightly asking questions about the costs of services.  In the past, patients paid very little of the healthcare bill and didn’t really care (or understand) the costs of the services they were receiving. In the post reform era, consumers are spending more of their own dollars and so are demanding price transparency. I think this is an important and timely trend. 

But consumers need to ask more than the cost of the service.  In our author’s situation, what are the questions she needs to ask about her diagnostic and treatment plan?  (All aspects of the plan, including radiology, lab tests, treatments and procedures, are subjected to similar questions.)  Here are the questions she needs to ask the doctor:

1.       What is the benefit of the test you are recommending?
2.       What is the cost, and what are the risks? For an x-ray, how much radiation exposure will I receive?  For a medication, what are possible side effects?
3.       Is this test or procedure even recommended for my situation? (In our back pain example, routine x-rays for this condition are not recommended, and shouldn’t be done in most cases.)
4.       How will the test results change my treatment?  If the results do not change the treatment, why do the test?
5.       If a procedure is recommended, what information is available to determine the quality of the procedure?
6.       Where is the best location for the test or procedure?

This seems like a lot of information, and will be less or more important depending on the cost or risk of a procedure. How can we expect the average consumer to be able to get these answers? To get back to the specific question of cost, however, at Truven Health Analytics, we understand consumers need this information and have developed a tool to provide answers. Our Treatment Cost Calculator uses our MarketScan® database, one of the largest of its kind, to provide the answers. Our research shows significant cost variation for the same test or procedure in different parts of the country, but surprisingly, also shows considerable price variation within a given market.  For example, the same test may vary in price by several-fold in the same city.  Our Treatment Cost Calculator allows the user to input the name of the test and the city where the test is offered; using MarketScan data, the tool shows the user all the locations for the test (including directions) and the range of prices for the test.  Our tool also includes quality information when available. 

Our intent is to arm the user with data about the necessity of the test, the range of prices being charged in the user’s location and data measuring the quality of the test.  We don’t expect patients to make clinical decisions, but we want the patient to be able to ask intelligent questions about their treatment plan.  We believe this level of transparency is necessary for a patient to be an active partner in their healthcare, not a passive recipient. This is the heart of patient centered care.

Michael L. Taylor, MD FACP
Chief Medical Officer

Shifting the Data-Sharing Mindset for the At-Risk Healthcare Environment

By Larry Yuhasz/Thursday, November 14, 2013
Larry Yuhasz imageThe shift from fee-for-service (FFS) to at-risk reimbursement also represents a shift from siloed data sources and facilities to physician-driven networks that need to be connected with patient-centric decision support and work flow applications. In the FFS world, health systems and health plans often thought of patient data as a strategic asset to help recruit and retain both physicians and patients to their networks and services. Yet, in the at-risk world, the more data available about the patient, the better the ability to manage risk and coordinate care. The change in mindset from controlling patient data to allowing it to flow freely (albeit, securely) across networks is a radical transformation in the U.S. healthcare system. The three key barriers to overcome are business model, proprietary data formats and governance.

At the business model level, as health systems, providers, and payers form new at-risk arrangements, they need to under gird those arrangements with the relevant flow of administrative and clinical data to manage performance and risk. Health plans that have been reticent to share claims data need to shift gears both culturally and operationally to help the new provider-driven networks understand costs.

In terms of format, the Federal government has been trying to stimulate interoperability standards through the ARRA HITECH roll out, but many vendors (particularly EMR vendors) have been fighting back to defend their proprietary data formats. As the volume of at-risk contracts grows, new at-risk entities will not be able to function without some form of interoperable gateway to share and receive patient data. So that means that EMR customers will be the ones to request and implement interoperable gateways from their vendors. And if they continue to resist, there is a new generation of interoperability platform vendors that will fill the need.

Finally, from a legal perspective, no one entity actually “owns” the patient data. The patient owns his/her own data. Yet this creates a quagmire of governance models that is bogged down in consent management policy and privacy mechanisms. If patients do not allow an at-risk network to see their data, the network cannot optimize performance. So we may see a new market dynamic whereby network participation requires upfront patient consent to data sharing (an opt-out consent model).

Larry Yuhasz
Director for Strategy and Business Development