Next Things First

An Early Morning Reality Check by Rob Coppedge
September 30, 2008, 5:42 am
Filed under: consumer engagement, health it | Tags: ,

The New York Times published an essay this morning by Dr. Abigail Zuger which does a great job of reminding us that – despite our best efforts – “health” is extremely difficult to quantify, measure and control:

This is your health we’re talking about, the intangible that you probably think people like me can help you achieve and maintain. Why do we all persist in treating health like a bankable asset? Is it the solidity of our flesh and bone? The lab reports that look like bank statements? Either way, the operant fiction is that with diligent adherence to expert advice, pretty much anyone can sock away a nice little stash of health for the future.

In fact, though, health is the opposite of a commodity. It flits around… defying all the best intentions and predictions. No one can really articulate what the word means; no two people understand the concept in exactly the same way. And that includes you and your doctor.

This advice is especially important to those of us in the business who are comfortable talking about insured populations in terms of “lives”, health care facilities in terms of “beds” and to whom everything comes back to “data”. Certainly, more and better metrics are needed and I believe strongly that data driven analytics and predictive modeling will revolutionize the delivery of care. However, we have to be careful not to forget that individuals interact with the health care system in very personal ways (what is more personal than sickness).

To this end, successful health care services business models going forward have to be a mix of the technical and the personal. Technology driven solutions are needed, but only the ones that appreciate the intricacies of translating their service for the realities of the population they are serving will be successful.

In other words, now as ever in health care services, the best technology alone won’t win. And that’s not a bad reminder for guys like me who never tire of talking about “innovation” and”disruption”…

Clearly, there is health, and there is health, and sometimes the twain just will not meet.

Posted by RobC


The Office on a Diet by charlottegee
September 28, 2008, 4:18 pm
Filed under: wellness | Tags:

The season premiere of “The Office” (9/25/08) entered the world of employer-sponsored wellness initiatives*, with the main office in New York announcing a “Biggest Loser”-type contest: The branch that loses the most weight earns extra vacation days. Let the games begin!

Every week over the summer, “The Office” employees are weighed on a freight scale in the warehouse. Things soon get a bit out of hand, of course. Some employees take the challenge too far by forcing coworkers to walk five miles or purposely ingest tapeworms to lose weight (not a tapeworm). They–very sadly–eat fruit at birthday parties (but soon sneak some cake), one goes on a Master Cleanse diet and passes out, they turn up the heat in the office to create their own sweat lodge. You get the idea.

Eventually HR steps in, sending a memo saying this kind of behavior is not supported, and Michael the Branch Boss winds up in a fat suit, telling the employees that big is beautiful.

All of this is funny, but raises some interesting questions. With team-based competitions and employee wellness programs popping up all over the place now, how do organizations ensure that they don’t let things go too far? For example, Shape Up The Nation is a workplace team-based competition, where employees track and post various things online such as weight loss and pedometer steps. What’s to keep someone from getting a bit out of control? From walking miles and miles a day (instead of working) just to win the competition?

And, what about (gasp!) cheating? Sally said she walked 200,000 steps, but how can we be sure?

Taking a step back, BusinessWeek’s The Debate Room recently featured a pro and con argument about wellness programs in general: Employee Wellness Is Ill-Conceived / Businesses should stop trying to meddle in their workers’ health and fitness habits. Pro or con? As expected, interesting points on both sides.

No matter where you come down on this issue, two things seem pretty clear. First, a program’s incentive structure must be appropriately constructed with the organization’s (and the employees’) unique needs and wants in mind. And, secondly, there must be some ground rules set from the beginning to avoid participants going to extremes, which are never healthy anyway.

*Note: Employer-sponsored wellness initiatives are based on the idea that healthier employees are more productive and cost less in terms of health care claims costs. Obesity, smoking and lack of activity are all usual suspects targeted with these programs.

Posted by CharlotteGee

But, But, It’s Recession-Resistant, Right? by charlottegee
September 26, 2008, 9:24 am
Filed under: economy, pharmaceuticals, wellness | Tags: , ,

From WSJ

From WSJ

We’ve all declared it and/or heard it and/or believed it: Health care is a recession-resistant industry. If people need care, and have the means to get it, well, they’ll get it, right? Surgeries will go on; prescriptions will keep being written and filled; patients will go see their doctors when something is wrong or they need a check-up. But, according to the Wall Street Journal:

As the credit crunch threatens to throw the economy into a deep slump, Americans are already cutting back on health care, a sector once thought to be invulnerable to recession. Spending on everything from doctors’ appointments to preventive tests to prescription drugs is under pressure.

The number of prescriptions filled in the U.S. fell 0.5% in the first quarter and a steeper 1.97% in the second, compared with the same periods in 2007 — the first negative quarters in at least a decade, according to data from market researcher IMS Health. Despite an aging and growing U.S. population, the number of physician office visits also has been declining since the end of 2006. Between July 2007 and 2008, the most recent month for which data are available, visits fell 1.2%, according to IMS.

This is scary stuff. And the article notes some scary anecdotes to go along with the stats: women not going to the OB/GYN as often for preventive care; a woman delaying surgery for a cataract, which will only get worse with time; people not following up with the bloodwork or treatments that their doctors ordered; a schoolteacher skipping her asthma medication to save on prescription costs.

In sum:

“That says to me that people are just deferring care if it’s not acute,” says Laboratory Corp.’s chief executive, David King.

As noted time and again when discussing the uninsured, lack of preventive care and lack of primary care services to take care of health problems from the get-go only result in sicker patients with more acute issues, which are, of course, more costly to treat. (Not to mention the effects this decrease in utilization will have on the health care companies/organizations providing all these services.)

What can health care players — doctors, hospitals, payors, pharma companies, drug stores, organizations with wellness companies, etc. — do to help ensure people continue to receive the care they need? Ideas?

Here’s one, from the article:

Speaking at an investor conference this month, Walgreens Co. Chief Executive Jeffrey Rein said the U.S. is experiencing the “tightest prescription market” in his 27-year career, as more cash-strapped patients skip their pills or take half doses. He said the company has looked at different ways to get people to fill prescriptions. For example, pharmacists are reaching out to patients through phone calls and emotional appeals such as, “Do they want to be around when their kids grow up, or their grandkids?” Mr. Rein said.

Posted by CharlotteGee

So What If? by charlottegee
September 24, 2008, 3:55 pm
Filed under: uninsured/underinsured, wellness | Tags: ,

HealthLeaders Media recently compiled 10 mini-articles dealing with various scenarios: What if safety-net hospitals start to fail? What if the uninsured hit 75 million? What if people actually start taking care of themselves? And the like.

An interesting editorial concept, because, really, who knows what will happen next? All 10 scenarios are based on current (actual) trends, and the authors just take them to their extremes. And while doing so, shed some light on potential innovations that could help a system that seems to be cracking more and more every day.

Consider: What if primary care physicians become extinct? The writer covering this scenario summarizes the important role primary care physicians play, after telling us that they might disappear because of, guess what, money (or “the growing compensation disparities between specialists and primary-care doctors”):

… Sure, nurse practitioners and physician assistants can handle some of the preventive care if that [the disappearance of PCPs] happens. Primary-care doctors often cite routine cancer screenings and immunizations among their irreplaceable preventive services, but those can and will be handled by nonphysicians. It’s when a patient has multiple severe medical problems that the primary-care doctor’s coordination will be missed. Specialists can individually treat hypertension, diabetes, arthritis, and depression, but when one patient has all four conditions, how will they be managed? They won’t.

The piece also provides an interesting perspective on wellness:

What if Americans listened to their doctors and exercised, ate healthier, and stopped smoking? The trend of chronically ill Americans-more than 130 million people-would be reversed. The country’s healthcare system could actually change its focus from sickness to health. …

“We have to be very careful how we analyze this, because one person’s benefit will be another person’s detriment,” says David B. Nash, MD, MBA, chair of the department of health policy at Jefferson Medical College of Thomas Jefferson University in Philadelphia.

The biggest winners in a healthier society would be patients and employers. Healthier Americans would live longer lives. Employers would not have to pay an increasing percentage of their budgets on healthcare, but could allocate the money into salaries, products, and infrastructure. …

But what about providers? Nash says only 3% of the American population follow four basic wellness goals: Don’t smoke, stay close to your ideal body weight, exercise three times a week for at least 20 minutes, and eat fruits and vegetables regularly. If that percentage increased to a mere 9% of the population, Nash says, hospitals would see a large drop in admissions for bronchitis and upper respiratory problems, heart attacks and strokes, and diabetes. In short, healthier Americans would force physicians and hospitals to make changes.

Want one more? What if universal health care happens?

… who would provide care for all the newly insured patients? Massachusetts, which has one of the highest rates of physicians per capita, doesn’t have enough primary-care docs to meet the demand. So imagine what might happen in Texas, a state with one of the lowest rates of docs per capita and more than 5.5 million uninsured, or 25% of the population.

“It may push providers, hospitals, and the government to start thinking more about efficiency, cost effectiveness, and controlling costs,” says [Michael] Doonan.

Read 10 Events That Could Change Healthcare.

Not Sure Which Game Inside Baseball Is Watching by Rob Coppedge
September 23, 2008, 1:36 pm
Filed under: economy, health it, nashville market | Tags: , ,

Nashville-based PR firm, Jarrard, Phillips, Cate and Hancock, released the results of a recent survey of health care “players'” views on the recent economic turmoil. Like Jarrard’s regular publication, Inside Baseball, the survey had a slightly humorous tone – but reading the results hammered home that the traditional, for-profit health care services establishment in Nashville might be so focused on their own inside baseball that they are actually watching the wrong game.

Reading these results – and, for that matter, any issue from the Inside Baseball archive – I worry that the Frist family might need to get a restraining order. The adoration for HCA and the wisdom of the Frists isn’t misguided: They have certainly built a strong and iconic company that in its repeated private to public to private transactions and the convection current of M&A around its hospital assets has made the Frist family, and oftentimes their shareholders, a considerable fortune. And the Inside Baseball team captures the sentiments of many in Nashville:

…the financial world is upside down; Cressey [Senator Bill Frist’s firm] has more money than just about anybody in town – and now the Frist Family has been named by our readers as the most likely survivor of one of the most dramatic financial fallouts … ever. (That China expansion thing is making more sense every day.)… Just who will benefit from the fall out? You said hospital giant HCA (shocker) and the city’s endless crop of country music songwriters.

However, it is uncertain that the business model that HCA has ridden for all these years is going to be a winner this time. Thriving through superlative lobbying efforts to optimize reimbursement levels and underinvesting in technology, it is questionable how this legacy player will compete as demographic and economic necessity shifts care out of the facility. Burdened by a significant debt load and leadership that doesn’t waste money on newfangled innovations, the company has its sights set firmly on doing business as usual.

And as we learn from Inside Baseball: As HCA goes, so goes everyone else in town.

What a frustration to the real entrepreneurs in Nashville who can’t raise money for new business models and innovative health care-focused technologies. The lack of capital and support has driven many of these young management teams out of the city and into new markets.

This is Nashville’s loss, but also theirs – as the strong ecosystem of “legacy” health care companies – which among other things own and manage hospitals, clinics, surgery centers, etc. – is the target client base for this next generation of health care services companiea with business models focused on making the big guys faster, smarter and more agile (really correcting for years of under, or incorrect, investment in information technologies).

As the financial crisis ripples through Wall Street and Washington, perhaps an unintended consequence will be an increased focus on administrative and clinical efficiency driving solutions from a new wave of innovative health care companies. Perhaps our nation’s fiscal crisis and both political parties’ commitment to health care reform will refocus our attention.

Or, maybe as more than a third of Nashville’s health care elite said:

…drinking is the best course of action right now.

The Vultures Are Circling: Thousands Will Die by Rob Coppedge
September 19, 2008, 3:18 pm
Filed under: economy | Tags:

Here’s some sunshine from expert distressed investor Wilbur Ross:

Wilbur Ross, founder of private equity firm WL Ross & Co LLC, expects as many as a thousand U.S. bank closures in the coming months, CNBC said on its website on Monday.

The billionaire investor, who made his fortune making investments on distressed industries, said the closures will create opportunities for investors, CNBC said, adding that he is looking at picking up smaller distressed institutions.

“I do think a lot of the regional ones will (close), just as they did in the last savings and loan crisis in the 1990s,” the website quoted Ross saying.

Ross said there will be too many people willing to provide capital to the large financial companies, making them less of a bargain than smaller banks, according to the website.

It does make you wonder how much comments like these are designed to be self-fulfilling… Say it, stoke the panic a bit and start buying…

More Perspective on Cutting Medicare Health Support (yes, this came out last month…) by Rob Coppedge
September 18, 2008, 7:48 pm
Filed under: chronic care, medicaid/medicare | Tags: ,
Before we launched the blog, Jonathan Burkland, an investment banker at Stanford Group who has followed the Medicare Health Support issue closely and knows a bit about the disease management industry, had an opinion piece in Modern Healthcare on the subject.

Chronic-disease patients unquestionably are a heavy drain on the healthcare system. The Centers for Disease Control and Prevention estimates that chronic-disease patients account for 75% of America’s healthcare bill.

The CMS seems to have ignored those facts, and earlier this year said it intends to terminate the project with the last of the pilots shutting down in December…

…how can the CMS presumably believe that the interim results of phase one did not justify continued exploration into phase two? Are there other elements that could have contributed? Did patient enrollment, for example, take longer than planned? Did the program run long enough for the initial investment in areas such as patient recruitment and compliance to be offset by the long-term reduction in expensive care, such as emergency room visits?

We agree that Congress and CMS has “cut the cord” on this program too quickly. Plagued by bad data feeds and should-have-been-expected difficulties in identifying, reaching out to and managing the health of Medicare members in ways that hadn’t been attempted before, these efforts deserve a second-life. As Burklund points out:
There is some good news on this front. The recently passed Medicare bill, which survived a presidential veto, calls for a study on the feasibility of establishing a Medicare Chronic Care Practice Research Network of providers who would test new models of care coordination and other care approaches for chronically ill beneficiaries, and expand those models to the larger Medicare patient population, if appropriate. Also, the bill calls for a thorough study of the methods of analysis and the program design of Medicare Health Support. Maybe this can get things back on track.