The Inconvenient Truth about Health Care Behavior
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8/13/2010
The Inconvenient Truth about
Health Care Behavior
Presented by:
Kara J. Trott, CEO
ASHHRA Annual Conference & Exposition
Tampa, FL September 27, 2010
1
The Inconvenient Truth about
ASHHRA Annual Conference &
Healthcare Behavior Exposition
September 27, 2010
Why don’t people . . . . . . . .
• Use all the great tools and services we’ve added to our
health plan?
• Respond to disease managers or wellness coaches?
• Do what they need to do to make themselves healthier?
And the list goes on and on and on . . . .
The answers are evident if you get inside their [your] heads !!!
Proprietary and Confidential 2
18/13/2010
What do healthcare consumers
ASHHRA Annual Conference &
think? Exposition
September 27, 2010
82%
The % of employees who believe they are effective healthcare
consumers
(Employer perception: 36%
36%)
Proprietary and Confidential 3
Source: Making Health Care Consumerism Work – Aligning Employer and Employee Interests, Towers Perrin, 2007
What do healthcare consumers
ASHHRA Annual Conference &
think? Exposition
September 27, 2010
49%
Think too many patients are getting medical tests and treatments
that they don’t really need . . .
BUT
Only 16%
Think they had a medical test or treatment that was probably not
necessary
Proprietary and Confidential 4
Source: The Public and the Health Care Delivery System, NPR/Kaiser Family Foundation/Harvard School of Public Health, 4/09
28/13/2010
Consumer vs. Expert Perceptions ASHHRA Annual Conference &
Exposition
September 27, 2010
Proprietary and Confidential 5
Source: The Public and the Health Care Delivery System, NPR/Kaiser Family Foundation/Harvard School of Public Health, 4/09
Hospital employees and
ASHHRA Annual Conference &
environment compound challenge Exposition
September 27, 2010
• Higher than average users of health care services
Category % above norm*
Bed days +17%
Out‐patient procedures +15%
In‐patient admissions +12%
Emergency room visits +8%
* Based on Quantum Health 2009 book of business analysis
• Environment makes healthy lifestyle difficult
– High stress
– Cafeteria food – “Eating on the run”
– Shift work
Proprietary and Confidential 6
38/13/2010
The healthcare environment ASHHRA Annual Conference &
Exposition
September 27, 2010
Unnecessary Care
“We spend between one‐fifth and one‐
third of our healthcare dollars – $500‐
700 billion – on care that does nothing
to improve our health.
health.”
Proprietary and Confidential 7
The healthcare environment ASHHRA Annual Conference &
Exposition
September 27, 2010
Underlying problem facing all healthcare users: Fragmentation
“…health care delivery is complicated, comprising layers
of processes and handoffs that patients and families find
bewildering and clinicians view as wasteful…the
healthcare system is a
‘nightmare to navigate’
. . .it
it feels less like a system than a confusing,
confusing expensive,
expensive
unreliable and often impersonal disarray.”
Institute of Medicine 2001
Proprietary and Confidential 8
48/13/2010
The healthcare environment ASHHRA Annual Conference &
Exposition
September 27, 2010
Fragmented healthcare delivery causes pervasive confusion, excess utilization,
missed connections and lack of follow‐up
p
Third ‐Party
• 50% of patients leaving physician
Employer
Administrators Stop Loss office report not understanding
Policy
what they’ve just been told
PPO • 24% of all services are duplicate if
Network
seeing one physician; 44% when
seeing 4+ physicians
Providers Employees
Tertiary
PCP • 33% of patients not given post‐
Other Care
Physicians
Specialists Settings discharge instructions
Home Health
• 41% of patients self‐refer to a
Outside Out ‐ of‐ Network
Care Agency specialist, and 61% of such referrals
Specialists Hospital
Physicians are to the wrong physician resulting
in an average 11 month delay and
33% higher cost
Proprietary and Confidential 9
The healthcare environment ASHHRA Annual Conference &
Exposition
September 27, 2010
Delivery system is a cottage industry
788,000 physicians in the U.S.:
Physician office
size
% of offices
1 39.4%
51.1%
2 11.7% 76.3%
3‐5 25.2%
6‐10 14.1%
11+ 9.6%
Source: CDC 2009 Proprietary and Confidential 10
58/13/2010
The healthcare environment ASHHRA Annual Conference &
Exposition
September 27, 2010
Not only is healthcare wildly confusing, but the delivery system structure is
one where
h utilization
tili ti iis d
driven
i by
b supply‐induced
l i d dd demand d rather
th ththan efficacy
ffi
• Providers are paid for procedures
• Technology is more readily available in the US than in other OECD countries
and is distributed to communities much faster
• Physicians make more use of diagnostics and procedures in the US
• Specialist use is higher and primary care use is lower
Proprietary and Confidential 11
Source: Annals of Internal Medicine, 2005; *“It’s the Price, Stupid,” Anderson, Reinhardt et al, 2003.
The healthcare environment ASHHRA Annual Conference &
Exposition
September 27, 2010
¾Expansion of new technology
• Baker et al studied availability and use of MRI
MRI, CT
CT,CABG,
CABG angioplasty
angioplasty, cardiac ICU
ICU, PET
• Greater availability = greater per capita use
• Ï Cardiac facilities = Ï interventions
• Ï angioplasty = Ï CABGs
• Ï MRI = Ï CT scans
¾Supply‐induced demand
• John Wennberg MD (Dartmouth Atlas) – Medicare Regions with highest per‐
beneficiary cost tend to have:
• lower number of PCPs
• Higher number of sub‐specialists
• Higher use of procedures/diagnostics
• Worse outcomes
• “Regions with greater care intensity had higher mortality”
Proprietary and Confidential 12
Source: Annals of Internal Medicine, 2005; Variations in Use of Medicare Services, Wennberg, Commonwealth Fund, 2005
68/13/2010
The healthcare environment Health & Welfare Plan
Management Conference
June 17, 2010
¾ More healthcare better health.
¾ In fact, evidence increasing suggests overuse leads to worse
outcomes.
High
Health
outcomes
Low
Low High
Expenditures
13
The healthcare environment ASHHRA
Health
Annual
& Welfare
Conference
Plan &
Management
Exposition
Conference
September
June 17, 27,
20102010
Leading Causes of Death in the U.S.
1. Cancer
2. Heart Disease
3. Medical Intervention
Proprietary and Confidential 14
78/13/2010
But . . . We’ve given some solutions
ASHHRA Annual Conference &
a try Exposition
September 27, 2010
Common tools in health plan benefit structure to help consumers:
• Nurselines
N li
• Advocacy services
• Cost/quality tools
• Disease management coaching
• Wellness coaching
Proprietary and Confidential 15
But the results are disappointing ASHHRA Annual Conference &
Exposition
September 27, 2010
Use and impact:
• Nurselines – less than 5% use
use, no impact on total claim spend
• Advocacy services – 2‐5% use, helpful for those who use it
• Cost/quality tools –8/13/2010
Problem with the way services are
ASHHRA Annual Conference &
delivered in health plan Exposition
September 27, 2010
Fragmented, “siloed” functions (even if under same name) – forces members to seek
services out or reach out to members too late
Hospital resources
¾ Services rely on MEMBERS
to seek them out or reach
out to members after the
HR
fact (i.e., 105 days for DM)
¾ All operate on different
TPA system specific to function
with only information
necessary to that function
• Benefits
• Eligibility ¾ Slivers of answers ≠
• Claims Disease Mgt
Solutions
Wellness Med Mgt
PPO ¾ IF shared, data is
PBM
“interfaced” after the fact
to isolated functions – does
• Lifestyle
•Pre
Pre--cert not change processes
• Coaching
••Concurrent
• Case Mgt
Proprietary and Confidential 17
Underlying assumption of service
ASHHRA Annual Conference &
structure Exposition
September 27, 2010
Information
Attitude
Behavior
Proprietary and Confidential 18
98/13/2010
Underlying assumption of service
ASHHRA Annual Conference &
structure Exposition
September 27, 2010
Information
Attitude
Behavior
Proprietary and Confidential 19
Real impact of information ASHHRA Annual Conference &
Exposition
September 27, 2010
Information
Intentions
(life)
Behavior
108/13/2010
The human reality ASHHRA Annual Conference &
Exposition
September 27, 2010
B gift
Buy ift ffor wife’s
if ’ Pick
Pi k up d
dry
Birthday! cleaning.
Pick up kids at Take care of my
soccer practice. patients.
Work on taxes. What’s for dinner
tonight?
Get new tires for Healthcare mindshare…
the car.
Proprietary and Confidential 21
The human reality ASHHRA Annual Conference &
Exposition
September 27, 2010
Decision making is rarely rational – emotions, habits and social forces drive decisions
Shop
Need Trigger
Point
Recognition
Use Active
and Emotions, Info
Evaluation Habits,, Gathering
Social
forces
Buy
Trigger
Point
Transaction Decision
Making
Source: Retail Marketing,
Proprietary and Confidential 22
Lusch, Dunne & Gebhardt, 1993
118/13/2010
Who do we need to focus on? ASHHRA Annual Conference &
Exposition
September 27, 2010
One inconvenient truth:
80% of cost comes from 20% of members
BUT 60% of the 20% are new each year
SO . . .
over 5 years,
80% of cost comes from 60‐70% of members
Proprietary and Confidential 23
Organization of benefit services go
ASHHRA Annual Conference &
against human behavior Exposition
September 27, 2010
The inconvenient truths
• You can
can’tt break the patient or the process down into discreet components and
address them separately
• You can’t expect patients to seek out support when they don’t even know they need
it
• Services that could help patients while they are going through healthcare have
become administrative and narrow
• You can’t expect patients to trust strangers or the plan when customer service hasn’t
been helpful
• Reaching out 3‐4 months later isn’t very helpful
• To change behavior and impact costs the your services must:
– Be accessible to members
– Be designed to “intercept” members in their normal path since they won’t ask or recognize what they
need
– Build a relationship of trust with the member
Proprietary and Confidential 24
128/13/2010
The strategic role of customer
ASHHRA Annual Conference &
service Exposition
September 27, 2010
How does the question
“who are some in‐network cardiologists?”
get answered?
Proprietary and Confidential 25
Solution: Reorganize benefit delivery to
ASHHRA Annual Conference &
maximize contact, minimize confusion Exposition
September 27, 2010
Implement a new benefit delivery structure with a
specialized approach designed to intercept and
coordinate care real‐time:
• All customer service for all functions flows through
specially trained care coordinators who identify
opportunities to intercept members while they are
making decisions
• Members are intercepted when they want to talk
• Intercept is real time (not after the fact)
Proprietary and Confidential 26
138/13/2010
This approach creates a “Virtual”
ASHHRA Annual Conference &
Medical Home for each member Exposition
September 27, 2010
Members work with Care Coordinators who operate on a single data platform
that p
provide the coordination and support
pp of a “Virtual” Medical Home
executed through the benefit plan – benefits drive behavior:
• Promoting primary care through incentives
• Supporting physicians’ need for coordination
support and information
• Specially trained Care Coordinators in a team
including customer service/advocates and
nurses (UR/pre‐cert/CM and DM)
• Operating on the same system that
aggregates all health activity and
benefits information in an expert
system with real‐time alerts
Proprietary and Confidential 27
Reorganization of benefit delivery
ASHHRA Annual Conference &
services Exposition
September 27, 2010
• All patient touch points (highlighted) are pulled out of an administrative structure and
handled in a new horizontally integrated structure
– Single point customer service not just for information but advocacy and interception
– Integrated with care management which was used for coordination and interception in addition to
normal UR/pre‐cert ‐‐ replaces traditional UR, CM, DM
Care Management
Health Plan & PBM Enrollment & Eligibility
& Wellness
Claims Administration Decision Support Case Management
Customer Service Customer Service Complex Case Management
g
‐ Coverage Enrollment Administration Care Coordination
‐ Claims Eligibility
Pre‐Certification & UR
‐ Provider Selection
Disease Management
Provider Network
Health Coaching
Wellness
148/13/2010
Change in strategic functions ASHHRA Annual Conference &
Exposition
September 27, 2010
Function Old Model New Model
Customer service Fragmented; problem resolution; Strategic intercept; build trust;
minimize contact maximize contact; triage
Enrollment process Plan election Educate, create relationship, capture
health activity information
Incentives Participation Primary care use, behavioral
Data system Functionalized, siloed, interfaced All health activity information,
after the fact single operating system, real‐time
alerts
Pre‐Certs, Referrals Cost management Intercept & coordination
Disease management Outbound, 105 days later,8/13/2010
How it works: Coordination and
ASHHRA Annual Conference &
interception for CM Exposition
September 27, 2010
•Referring PCP ordered a CT scan and MRI in transfer
of an oncology patient
•While it met criteria for approval, Care Coordinator
contacted oncologist to confirm these were the tests
needed
•Answer: Only needed $200 CT Scan, not $1500 MRI
•Why was it ordered? PCP couldn’t remember from
passing hallway
h ll conversation what
h was needed
d d and
d
no staff to follow‐up
•PLUS: Patient engaged in case management at point
of diagnosis
Proprietary and Confidential 31
Structure drives more contact and
ASHHRA Annual Conference &
interception Exposition
September 27, 2010
Type of Interaction Results
Households/Members with a Care Coordinator contact 84%/61%
Members with Large Cases:
Patients in the top 10% of cost with a Care Coordinator 87%
Patients with ≥$10,000 in claims with a Nurse Care Coordinator 97%
Targeted Conditions with a Pre‐Admission Contact 60%
Inpatient Discharges with Post‐Discharge Contact 78%
Members with Chronic Conditions:
Members with chronic conditions in total population 18%
Chronic condition members with a Nurse Care Coordinator 47%
Targeted Chronic condition members with a DM Care Coordinator 21%
Source: validated study of 55 employer groups 2009
Proprietary and Confidential 32
168/13/2010
Trust increased and “conscious”
ASHHRA Annual Conference &
changes in behavior Exposition
September 27, 2010
92 % member
b satisfaction
ti f ti vs. IIndustry
d t
average of 51‐65%:
• 52% report they are more aware of
health risks and options
• 26% report they changed a healthcare
decision
94% of providers would recommend:
• “Helps them help their patients”
• Makes office staff’s job easy
HR workload reduced by at least 25%
Source: satisfaction surveys for 55 groups, 2009
Proprietary and Confidential 33
Extensive contact drives changes in
ASHHRA Annual Conference &
utilization Exposition
September 27, 2010
Type of Service Actual vs. Expected
PCP Use Up 5%
Preventive Screenings‡ Up 5%
Specialist Use Down 7%
ER use Down 6%
Outpatient Surgery Down 1%
Diagnostics Down 1%
Readmissions Down 20%
Inpatient Admissions Down 3‐8%*
Inpatient LOS Down 22‐27%*
Inpatient Days Down 24‐33%*
Average cost of cases >$50,000 Down 13%
Source : Validated study completed March 2010 of pre‐post data for 25 groups, incurred basis comparing actual versus expected utilization based on
actuarially expected utilization for year 1
‡No “expected” comparison so preventive screenings reflects actual change
Proprietary and Confidential 34
*Inpatient with and without maternity admissions
178/13/2010
Change isn’t easy, but was it worth
ASHHRA Annual Conference &
it? Exposition
September 27, 2010
• After 3 years in a data set of 36 groups:
– 89% lowered their trend and had costs below expected
p
– 61% held annual cost increases to below inflation
– 17% had costs that were lower than before
• All achieved results without shifting costs or reducing benefits – all added primary
care incentives and increased benefits
Proprietary and Confidential 35
Source: validated study of 36 groups with 3 completed years of experience
Change isn’t easy, but was it worth it? ASHHRA Annual Conference &
Exposition
September 27, 2010
Starting year 1:
Translate your cost curve
DOWN by eliminating
unnecessary utilization
0 1 2 3 4
Year of program
Proprietary and Confidential 36
188/13/2010
Change isn’t easy, but was it worth it? ASHHRA Annual Conference &
Exposition
September 27, 2010
Year 2+ and beyond:
Reduce the rate of increase
by getting people healthier
over time
0 1 2 3 4
Year of program
Proprietary and Confidential 37
What you can do ASHHRA Annual Conference &
Exposition
September 27, 2010
Think about:
• What is the reality for your hospital’s
hospital s employees – think about your own
personal experience and how you would respond to your own benefit
structure
• How can you reorganize benefit delivery to:
– Build trust with your members
– Give them help even though they aren’t asking for it (intercept)
– Use customer service more strategically
– Use care management to help, not just be administrative
– Ch
Change utilization
tili ti and d save you and
d your members
b unnecessary costt and
d services
i
• Consider creative and innovative approaches – are the results worth it for
your organization and your members
Proprietary and Confidential 38
198/13/2010
The Inconvenient Truth
about Healthcare Behavior
Presented by:
Kara J. Trott, CEO
ASHHRA Annual Conference & Exposition
Tampa, FL September 27, 2010
39
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