1 PubH 7564 Private Purchasers of Health Care: Roles of Employers and Health Plans in the U.S. Health Care System January 2015 Credits: 2 Meeting Days: Sunday-Wednesday, January 11-14, 2015 Meeting Time: January 11, 9:00 AM - 1:30PM; January 12, 8:00 AM - Noon; January 13, 8:00 AM - Noon; January 14, 8:00 AM - Noon Meeting Place: Sunday (1/11/15) – Room 1-450 Moos Tower Monday-Wednesday (1/12-14/15) – Room 2-260R, Executive Center, Carlson School of Management Instructor: Jon B. Christianson Office Address: 15-225 Phillips Wangensteen Building Office Phone: 612-625-3849 Fax: 612-624-2196 E-mail: [email protected]Office Hours: By Appointment I. Course Description Payments received from private insurance companies, with these funds coming for the most part from employer contributions towards employee health care expenses (considered to be part of employee compensation) are critical to the financial survival of most health care providers. The purpose of this course is to help health care managers understand the goals of their “best customers” and how health plans and employers pursue these goals. The course examines the role of employers and health plans in the health care system and, specifically, how the “payers of the bills” for health care develop and implement strategies to achieve their organizational and health care system goals. Topics covered include measurement of provider performance, health benefit design, provider network management, utilization management, payment strategies, and efforts directed at supporting consumers in their health care decisions. II. Course Prerequisites Students must be admitted to the University of Minnesota’s Executive Master in Healthcare Administration Program or have consent of the instructor.
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PubH 7564 Private Purchasers of Health Care: Roles of Employers and Health Plans in the U.S. Health Care System January 2015
Credits: 2
Meeting Days: Sunday-Wednesday, January 11-14, 2015
Meeting Time: January 11, 9:00 AM - 1:30PM; January 12, 8:00 AM - Noon; January 13, 8:00 AM - Noon; January 14, 8:00 AM - Noon
Payments received from private insurance companies, with these funds coming for the most part from employer contributions towards employee health care expenses (considered to be part of employee compensation) are critical to the financial survival of most health care providers. The purpose of this course is to help health care managers understand the goals of their “best customers” and how health plans and employers pursue these goals. The course examines the role of employers and health plans in the health care system and, specifically, how the “payers of the bills” for health care develop and implement strategies to achieve their organizational and health care system goals. Topics covered include measurement of provider performance, health benefit design, provider network management, utilization management, payment strategies, and efforts directed at supporting consumers in their health care decisions.
II. Course Prerequisites Students must be admitted to the University of Minnesota’s Executive Master in Healthcare Administration Program or have consent of the instructor.
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III. Course Goals and Objectives Specific goals and learning objectives are listed in for each class period. IV. Methods of Instruction and Work Expectations
Each class will include a didactic presentation on the part of the instructor; significant issues will be identified and discussed, referencing the readings for the class period. There are no “required” readings for the course. The “starred” readings are a good starting point for students to begin exploring each topic. The amount that students learn in this course, and their performance on assignments, will depend to a large degree on the time and effort they devote to the readings for each topic. During class, students will present or discuss results from individual or group assignments. Students will be expected to prepare for each class by engaging with the readings prior to class, participating in the discussion during class, and completing group and individual assignments as scheduled. “Further” readings are provided as starting points for students who wish to explore specific topics in greater depth and to assist in the completion of individual and group assignments.
V. Course Text and Readings
1. To access readings click on links after each cite. (NOTE: When accessing journal articles, you must be logged into the University of Minnesota using your X500 ID and password as the cites come from E-Journals. If you have any problems accessing assigned readings online, contact Jane Raasch at [email protected]). If you do not have a University of Minnesota Internet ID and password, call 301-HELP and support staff will help you set up an account (or set up your own account at www.umn.edu/initiate and follow the directions.)
2. Optional background reading for this course: PowerPoint lecture on the basics of health insurance posted on Moodle. 3. For each class session, overheads/PowerPoint slides and/or audio will be posted on the Moodle website for
downloading and viewing. To learn more about Moodle, watch Moodle: Online Orientation for Students and/or visit the Moodle support website at http://www1.umn.edu/moodle/, which has a link for “Student support” with user guides, help and FAQs.
VI. Course Outline/Schedule
Date
Module / Topics
January 11 9:00 – 10:00 AM 10:00 AM – Noon Noon – 1:30 PM
Employer Goals for the Health Care System and Their Strategies for Achieving Them Presentation of Group Assignment 1 (15 pts.) Present State of America’s Health Insurance Industry
January 12 8:00 – 9:00 AM 9:00 – 10:30 AM 10:30 – Noon
Measuring Provider Performance: The Foundation of Purchaser Strategies to Reform America’s Health Care System Provider Contracting and Network Management
Discussion of Individual Assignment 1 (20 pts.)
Fundamentals of Provider Payment : Incentives and Rewards
January 13 8:00 – 9:30 AM 9:30 – 10:45 AM 10:45 – Noon
New Payment Arrangements:
Bundled/Episode-based Payments Global Contracts Presentation of Group Assignment 2 (20 pts.)
Utilization Management and Cost Control
Discussion of Individual Assignment 2 (20 pts.) Supporting Employees/Enrollees in Choosing Treatment Options
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Date
Module / Topics
January 14 8:00 – 9:15 AM 9:15 – 10:30 AM 10:30 AM – Noon
Supporting Employees/Enrollees in Maintaining and Improving Their Health Supporting Employees/Enrollees in Managing Chronic Illness Supporting Employees/Enrollees in Choosing Providers: Reporting Provider Performance
Discussion of Individual Assignment 3 (25 pts.)
JANUARY 11, 2015 9:00 – 10:00 AM – Employer Goals for the Health Care System and Their Strategies for Achieving Them The two-decade period from the mid-1970s through the mid-1990s encompassed the ascendancy of a particular type of health plan – the managed care organization in the private health care marketplace and also as a contractor to Medicare and Medicaid. Responding to pressures from employers and government to control health care costs, these organizations (in collaboration with risk-bearing provider systems) instituted a variety of "supply-side" mechanisms, financial and non-financial, to influence provider behavior. Accompanying steps were taken to manage access to care on the part of plan enrollees. The result, eventually, was "managed care backlash" on the part of consumers and providers, precipitated in part by a redefinition by employers of their health benefits’ objectives. Since then, payers and health plans have initiated a variety of new approaches directed at restraining cost growth and improving quality. In this first session, we will describe the transition over the past decade towards a new paradigm of “managed” or “facilitated” consumerism, one that has much broader support among significant actors in the health care arena than traditional managed care. We will discuss the challenges faced by this new approach and the tools at the disposal of health plans. Learning Objectives Students should be able to:
1. Describe the origins and evolution of managed care organizations. 2. Explain the origins and nature of the "managed care backlash" of the 1990s, and its influence on the ongoing
development of the new facilitated consumerism. 3. Explain the factors influencing present employer demands on the health care system, and the role these demands have
played in changing America’s health care system. Suggested Readings Employer Involvement in Health Care
1.* Christianson, J.B. “Managed care.” Encyclopedia of Health Economics, Elsevier, United Kingdom, 2014. (posted on Moodle).
2.* Galvin, R., Milstein, A. “Large employers’ new strategies in health care.” The New England Journal of Medicine 347(12):939-942, 2002. http://www.nejm.org/toc/nejm/347/12
3.* Reinhardt, U.E. “The illogic of employer-sponsored health insurance.” The New York Times, July 1, 2014. http://www.nytimes.com/2014/07/03/upshot/the-illogic-of-employer-sponsored-health-insurance.html?_r=0
4. Galvin, R.S. “Still in the game — Harnessing employer inventiveness in U.S. health care reform.” The New England Journal of Medicine 359(14):1421-1423, 2008. http://www.nejm.org/doi/pdf/10.1056/NEJMp0805021
5. McArdle, M. “Don’t worry about losing your health care … yet.” BloombergView, August 21, 2014. http://www.bloombergview.com/articles/2014-08-21/don-t-worry-about-losing-your-health-care-yet
Employer Strategies for the Health Care System 1.* Christianson, J.B., Ginsburg, P.B., Draper D.A. “The transition from managed care to consumerism: a community-level
status report.” Health Affairs 2008;27(5):1362-1370. http://content.healthaffairs.org/content/27/5/1362.full.pdf+html 2.* Millenson, M.L. “Paradigm, not pill: The new role of patient-centered care.” NIHCM Foundation, February 2014.
http://www.nihcm.org/expert-voices-paradigm-not-pill-the-new-role-of-patient-centered-care 3.* Bernard, T.S. “High health plan deductibles weigh down more employees.” NewYork Times, September 1, 2014. http://www.nytimes.com/2014/09/02/business/increasingly-high-deductible-health-plans-weigh-down-employees.html 4.* Warshawsky, M.J., Biggs, A.G. “Income inequality and rising health-care costs: A worker who today makes $30,000 has had to forsake a 26% salary increase since 1999 as employer costs rise.” The Wall Street Journal, October 6,
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2014. http://search.proquest.com/docview/1586060731/fulltext/512E499D1B5F480BPQ/3?accountid=14586 5. Robert Wood Johnson Foundation and Aligning Forces for Quality. “How employers can improve value and quality in
health care.” January 2013. http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/01/how-employers-can-improve-value-and-quality-in-health-care.html
6. Cheney, C. “Large employers trimming healthcare spending.” HealthLeaders Media, August 15, 2014. http://www.healthleadersmedia.com/page-1/HEP-307443/Large-Employers-Trimming-Healthcare-Spending Applications:
1) Murphy, T. “Humana CEO preaches power of health care consumer.” Seattle News online, February 24, 2011. http://seattletimes.nwsource.com/html/businesstechnology/2014319626_apusceointerviewhumana.html
2) Los Angeles Times. “CalPERS picks four new HMO plans for 5-year contracts” Los Angeles Times, April 17, 2013. http://articles.latimes.com/2013/apr/17/business/la-fi-calpers-hmo-changes-20130418
3) The New York Times. “Health care where you work.” September 2, 2012. http://www.nytimes.com/2012/09/03/opinion/health-care-where-you-work.html?_r=0
4) Banjo, S., Calia, M. “Health costs, weak store traffic hinder Wal-Mart.” The Wall Street Journal, August 14, 2014. http://search.proquest.com/docview/1553110309/fulltext/8D06A0527DF844C7PQ/1?accountid=14586
The Role of Self-Insurance 1.* Weaver, C., Methews, A.W. “One strategy for health-law costs: self insure.” The Wall Street Journal, May 27, 2013.
http://online.wsj.com/article/SB10001424127887323336104578503130037072460.html 2. Lucia, K., Monahan, C., Corlette, S. “Cross-cutting issues: Factors affecting self-funding by small employers: Views
from the market.” Princeton, NJ: Robert Wood Johnson Foundation, April 2013. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf405372
3. Viebeck, E. Study: Self-insured health plans on the rise for private-sector employers. The Hill, November 28, 2012. http://thehill.com/blogs/healthwatch/health-insurance/269827-self-insured-health-plans-on-the-rise-study-finds
Employer Perspectives on Health Care Reform 1.* Sanger-Katz, M. “Why more, not fewer, people might start getting health insurance through work.” The New York
Times, August 20, 2014. http://www.nytimes.com/2014/08/21/upshot/why-more-not-fewer-people-might-start-getting-health-insurance-through-work.html
2.* Tribble S.J. “Temporary fee on big businesses funds Obamacare.” Kaiser Health News, May 22, 2014. http://www.kaiserhealthnews.org/Stories/2014/May/22/fee-on-big-business-funds-Obamacare.aspx
3. Kliff, S. “Obamacare requires employers to offer insurance. What if it’s too expensive?” The Washington Post, March 4, 2013. http://www.washingtonpost.com/blogs/wonkblog/wp/2013/03/04/obamacare-requires-employers-to-offer-insurance-what-if-its-too-expensive/
4. Irwin, N. “Envisioning the end of employer-provided health plans.” The New York Times, May 1, 2014. http://www.nytimes.com/2014/05/01/upshot/employer-sponsored-health-insurance-may-be-on-the-way-out.html
5. Japsen, B. “Obamacare less threatening to private employer hiring.” Forbes, May 30, 2014. http://www.forbes.com/sites/brucejapsen/2014/05/30/obamacare-less-threatening-to-private-employer-hiring/
6. Hancock, J. “Employers eye moving sickest workers to insurance exchanges.” Kaiser Health News, May 7, 2014. http://www.kaiserhealthnews.org/stories/2014/may/07/shifting-employees-to-exchanges.aspx
Further Readings
1. Blumenthal, D. “Employer-sponsored health insurance in the United States – Origins and implications,” New England Journal of Medicine 355(1):82-88, 2006. http://www.nejm.org/doi/pdf/10.1056/NEJMhpr060703
2. Blumenthal, D. “Employer-sponsored insurance – riding the health care tiger.” New England Journal of Medicine 355(2):195-202, 2006. http://www.nejm.org/doi/pdf/10.1056/NEJMhpr060704
3. Robinson, J.C., Ginsburg, P.B. “Consumer-driven health care: promise and performance.” Health Affairs 28(2):w272-w281 (published online 27 January 2009). http://content.healthaffairs.org/content/28/2/w272.full.pdf+html
4. Thomas, S., O’Kane, M. “Value-based purchasing.” American Journal of Managed Care 18(11):750-752, 2012. http://web.b.ebscohost.com/ehost/results?sid=1da13801-2137-4624-a77e-4215ebf746de%40sessionmgr112&vid=2&hid=128&bquery=JN+%22American+Journal+of+Managed+Care%22+AND+DT+20121101&bdata=JmRiPWFwaCZ0eXBlPTEmc2l0ZT1laG9zdC1saXZl
5. Goodell, S., Swartz, K. “Cost-sharing: Effects on spending and outcomes.” Policy Brief No. 20. Robert Wood Johnson Foundation Synthesis Project, December 2010. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2010/rwjf402103
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10:00 AM – Noon – Presentation of Group Assignment 1 Noon – 1:30 PM – Present State of America’s Health Insurance Industry Health plans represent employer interests in the health care system, competing for contracts with employers. They structure their products and actions to gain and retain the business of employer clients, which is critical to their own financial success. In doing so, they provide a wide range of products and services in addition to traditional health insurance. In this session, we trace the development of the health insurance industry and describe its current state. We discuss market concentration, premium setting, and differences among health plan products; describe how plans are evaluated by employers and consumers; and discuss public perceptions of the health insurance industry. Learning Objectives Students should be able to:
1. Describe the structure of the health insurance industry 2. Distinguish among different types of health plans and health plan products. 3. Explain how employers assess health plan performance and choose among health plans. 4. Identify major current issues relating to health plan performance from the perspective of employers and the public.
Suggested Readings Overview of the Private Health Insurance Market
1.* Terhune, C. “Large employers see health costs rising 5% next year.” Los Angeles Times, August 13, 2014. http://www.latimes.com/business/money/la-fi-employer-health-costs-20140812-story.html
2.* American Medical Association. “New AMA study finds lack of competition among health insurers.” February 1, 2011. http://www.ama-assn.org/ama/pub/news/news/competition-health-insurers.page
3.* Calia, M., Mathews, A.W. “UnitedHealth’s profit boosted by lower medical costs: Health insurer raises outlook as medical utilization rates remain restrained.” Wall Street Journal, October 16, 2014. http://search.proquest.com/docview/1612218164/fulltext/3EC081A6BFDA4426PQ/1?accountid=14586
4. Archer, D. “Private insurance is bankrupting Americans: Is Congress paying attention?” Health Affairs Blog, June 26, 2012. http://healthaffairs.org/blog/2012/06/26/private-insurance-is-bankrupting-americans-is-congress-paying-attention/
5. America’s Health Insurance Plans. “Medical loss ratio – What you need to know.” December 5, 2012. http://www.ahipcoverage.com/2012/12/05/medical-loss-ratio-what-you-need-to-know-2/
6. Editorial. “Mixed signals on employee health insurance.” The New York Times, August 25, 2013. http://search.proquest.com/docview/1427733086/fulltext/E96531C3A8F14A87PQ/1?accountid=14586
Applications: 1) Manos, D. “Humana ranked top payer in 2013.” Healthcare IT News, June 26, 2013.
http://www.healthcareitnews.com/news/humana-ranked-top-payer-2013 2) Fellows, J. “Providers grade health plans. Guess who still stinks.” HealthLeaders Media, May 1, 2013.
3) Wisenberg Brin, D. Blue Cross plans feeling pressure to consolidate; competition, high costs lead more to weigh for-profit conversions.” The Wall Street Journal, August 25, 2008, p.B.7. http://online.wsj.com/article/SB121963099177268101.html
4) Rabin, R.C., Some hospital networks also become insurers. The Washington Post, August 25, 2012. http://articles.washingtonpost.com/2012-08-25/business/35491800_1_private-insurers-insurance-product-hospital-systems
Products Offered by Health Plans 1.* Kulkarni, S.S. “FAQ on HSAs: The basics of health savings accounts.” Kaiser Health News, November 9, 2011.
2. Evans, M. “Reform update: Patients’ cost sensitivity worries some doctors.” Modern Healthcare, August 13, 2014. http://www.modernhealthcare.com/article/20140813/NEWS/308139965
3. RAND Corporation. “Expanding consumer-directed health plans could help cut overall health care spending.” May 7, 2012. http://www.rand.org/news/press/2012/05/07/index1.html
4. Warner, J.P. “High deductible health plans with HSAs or HRAs.” August 25, 2010. http://www.warnerbenefits.com/file/forms/High_Deductible_Health_Plans_Explained.pdf
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5. Sood, N., Wagner, Z., Huckfeldt, P., Haviland, A.M. “Price shopping in consumer-directed health plans.” Forum for Health Economics and Policy 16(1):35-53, 2013. http://www.degruyter.com/view/j/fhep.2013.16.issue-1/issue-files/fhep.2013.16.issue-1.xml
Applications: 1) Andrews, M. “Some individual policies offer a way to shrink deductibles.” Kaiser Health News, May 21, 2013.
2) Blue Cross Blue Shield Minnesota. “No more one size fits all in choosing health care coverage.” March 22, 2012. http://www.bluecrossmn.com/bc/wcs/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=Latest&dDocName=POST71A_170724
Competitive Strategies of Health Plans 1.* Johnson, A. “Reforms prod insurers to diversify.” Wall Street Journal, May 12, 2011, p. B.1.
http://online.wsj.com/article/SB10001424052748703643104576291022457851278.html 2. Weaver, C. “Health insurers opening their own clinics to trim costs.” Kaiser Health News, May 4, 2011.
http://www.kaiserhealthnews.org/stories/2011/may/04/insurers-turn-to-clinics-for-cost-control.aspx?referrer=search 3. French, M. “More doctors are a click away, but some say it’s not a healthy trend.” The Seattle Times, July 14, 2014.
1) Miliard, M. “Aetna to cite Leapfrog safety scores.” Aetna News Hub, June 5, 2013. http://newshub.aetna.com/press-release/health-care-professionals-and-networks/aetna-highlight-leapfrog-groups-hospital-safety
2) Health Care Service Corporation. “Health care consumers realize significant cost savings through benefits value advisor program.” The Wall Street Journal, April 18, 2013. http://online.wsj.com/article/PR-CO-20130418-906054.html
3) UCare Media Release. “UCare honors high-performing health care providers at June 18 salute to excellence! event.” June 19, 2013. http://www.ucare.org/SiteCollectionDocuments/Media/20130618_UCare-P4P-event.pdf
4) Von Bergen, J.M. “Independence Blue Cross and Michigan insurer to expand into Medicaid market.” Philly.com, August 10, 2011. http://articles.philly.com/2011-08-10/business/29872468_1_medicaid-market-medicaid-business-independence-blue-cross
5) Weaver, C. “Managed care enters the exam room as insurers buy doctor groups.” Kaiser Health News, July 1, 2011. http://www.kaiserhealthnews.org/daily-reports/2011/july/05/1khn-story.aspx?referrer=search
6) Daily Finance. Cigna’s gains on health plan quality report card reflect improved health and well-being of customers. October 30, 2012. http://www.dailyfinance.com/2012/10/30/cignas-gains-on-health-plan-quality-report-card-re/
7) Wall, J.K. WellPoint spends $50M to burnish brand. Indianapolis Business News, September 17, 2012. http://www.ibj.com/wellpoint-spends--50m-to-burnish-brand/PARAMS/article/36730
8) Nussbaum, A. “WellPoint to acquire Amerigroup for $4.9 billion. Bloomberg, July 9, 2012. http://www.bloomberg.com/news/2012-07-09/wellpoint-to-buy-amerigroup-for-4-9-billion-in-cash.html
9) De La Merced, M.J. “Aetna agrees to buy Coventry in $5.7 billion deal.” New York Times online, August 20, 2012. http://dealbook.nytimes.com/2012/08/20/aetna-is-said-to-strike-deal-for-coventry-health-for-5-7-billion/
10) Business Wire. “Priority Health opens one-stop insurance shops throughout Michigan to better serve residents.” October 11, 2013. http://www.priorityhealth.com/about-us/press-room/releases/2013/information-centers-open
11) BusinessWire. “Anthem Blue Cross and Blue Shield in Indiana committed more than $8 million to health improvement causes in 2013.” March 10, 2014. http://www.businesswire.com/news/home/20140310006246/en/Anthem-Blue-Cross-Blue-Shield-Indiana-Committed
12) BusinessWire. “Humana announces new corporate social responsibility goals and issues report on recent progress.” April 17, 2014. http://humana.newshq.businesswire.com/press-release/current-releases/humana-announces-new-corporate-social-responsibility-goals-and-issues
13) Aetna. “Aetna to acquire the InterGlobal Group.” November 25, 2013. http://www.aetnainternational.com/ai/en/news/2013/11-2013-interglobal
14) Abelson, R. “UnitedHealth, an insurer switching roles, helps hospitals on Medicare billing.” The New York
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Times, June 30, 2014. http://search.proquest.com/docview/1541595410/fulltext/2FB1BB299321491CPQ/1?accountid=14586
15) Business Wire. “Cigna and the Cigna Foundation provide weekend meals to Hamilton Elementary School students as part of Blessings in a Backpack program.” March 12, 2014. http://newsroom.cigna.com/NewsReleases/cigna-and-the-cigna-foundation-provide-weekend-meals-to-hamilton-elementary-school-students-as-part-of-blessings-in-a-backpack-program.htm
Issues Relating to Health Plan Behavior and Performance 1.* Cohn, J. “How Blue Cross became part of a dysfunctional health care system.” Kaiser Health News, March 8, 2010.
http://www.kaiserhealthnews.org/columns/2010/march/030810cohn.aspx?referrer=search 2.* Drew, L.W. “Finding a path through the health insurance market ‘gobbledygook’” Kaiser Health News, April 21, 2011.
http://www.kaiserhealthnews.org/Stories/2011/April/22/insurance-black-hole.aspx 3.* United Press International. “Consumers give healthcare plans low marks.” February 20, 2012.
http://www.upi.com/Health_News/2012/02/20/Consumers-give-healthcare-plans-low-marks/UPI-17301329785602/ 4. Andrews, M. “Some plans skew drug benefits to drive away patients, advocates warn.” Kaiser Health News, July 8,
5. Appleby, J. “Lawsuit accuses Anthem Blue Cross of ‘fraudulent’ enrollment practices.” Kaiser Health News, July 9, 2014. http://www.kaiserhealthnews.org/stories/2014/july/09/anthem-lawsuit-over-enrollment-practices.aspx?referrer=search
6. J.D. Power. “Concerns about not having enough health coverage drive down member satisfaction.” March 10, 2014. http://www.jdpower.com/press-releases/2014-member-health-plan-study
7. Ornstein, C. “How insurers are finding ways to shift costs to the sick.” New York Times, September 17, 2014. http://www.nytimes.com/2014/09/18/upshot/how-insurers-are-finding-ways-to-shift-costs-to-the-sick.html Applications:
1)* Terhune, C. “Kaiser’s rising premiums spark employer backlash.” Los Angeles Times, July 25, 2013. http://articles.latimes.com/2013/jul/25/business/la-fi-kaiser-cost-backlash-20130725
2)* Appleby, J. “Analyst: Nonprofit Blues have huge reserves.” Kaiser Health News, June 29, 2011. http://capsules.kaiserhealthnews.org/index.php/2011/06/analyst-nonprofit-blues-have-huge-reserves/?referrer=search
3) Mathews, A.W. “Insurer sets earnings cap” Wall Street Journal, June 8, 2011, p. B.1. http://online.wsj.com/article/SB10001424052702304906004576371902333544990.html
4) Snowbeck, C. “HMO cash cushions at issue in Minnesota legislature.” TwinCities.com, March 10, 2012. http://www.twincities.com/localnews/ci_20141316/minnesota-health-care-hmo-cash-cushions-at-issue
5) Lee, D. “Worries grow as healthcare firms send jobs overseas.” Los Angeles Times online, July 25, 2012, http://articles.latimes.com/2012/jul/25/business/la-fi-healthcare-offshore-20120725
6) Murphy, T. “Aetna chairman, CEO compensation climbs 26 pct.” The Big Story, April 8, 2013. http://bigstory.ap.org/article/aetna-chairman-ceo-compensation-climbs-26-pct
7) Terhune, C. BlueShield of California will return $50 million to customers. Los Angeles Times, October 31, 2012. http://articles.latimes.com/2012/oct/31/business/la-fi-blue-shield-credits-20121031
8) Reuters. LA doctors, patients sue Health Net for denying claims. September 13, 2012. http://www.reuters.com/article/2012/09/13/us-healthnet-lawsuit-idUSBRE88C19T20120913
9) Lazarus, D. “When health insurers play games, patients lose.” Los Angeles Times, April 17, 2014. http://www.latimes.com/business/la-fi-lazarus-20140418-column.html
The Health Insurance Industry and Health Reform 1.* Emanuel E.J., Liebman, J.F. “The end of health insurance companies.” New York Times online, January 30, 2012.
http://opinionator.blogs.nytimes.com/2012/01/30/the-end-of-health-insurance-companies/ 2.* Cohn, J. “Obamacare is working, but some insurers are behaving badly.” New Republic, July 10, 2014.
http://www.newrepublic.com/article/118638/obamacare-reduces-uninsured-some-insurers-behaving-badly 3.* Cunningham, P.W., Cheney, K. “Why liberals are abandoning the Obamacare employer mandate.” Politico, July 6,
2014. http://www.politico.com/story/2014/07/obamacare-employer-mandate-108578.html 4. Pear, T. “Obama and insurers join to cut health care fraud.” New York Times online, July 25, 2012.
http://www.nytimes.com/2012/07/26/us/politics/obama-and-insurers-join-to-cut-health-care-fraud.html 5. Zamosky, L. Healthcare reform law to usher in new age of consumerism. Los Angeles Times, September 8, 2012.
http://articles.latimes.com/2012/sep/08/business/la-fi-future-of-health-insurance-20120908 6. Cunningham, P.W. “Mandate delay a ‘full-time’ headache for employers.” Politico, July 15, 2013.
7. Weaver, C. “Health insurers respond to reform by snapping up less-regulated businesses.” Kaiser Health News, March 19, 2011. http://www.kaiserhealthnews.org/stories/2011/march/20/health-insurers-reform-business.aspx
8. Harrington, S.E., Weiner, J. “Deciphering the data: Health insurance rates and rate review.” Robert Wood Johnson Foundation, June 2014. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2014/rwjf414107
9. Abelson, R. “Insurers once on the fence plan to join health exchanges in ’15.” The New York Times, May 25, 2014. http://search.proquest.com/docview/1528455998/fulltext/5BC44DD634994309PQ/1?accountid=14586 ‘
10. Hancock, J. “Can employers dump workers to health exchanges? Yes, for a price.” Kaiser Health News Blog, May 28, 2014. http://capsules.kaiserhealthnews.org/index.php/2014/05/can-employers-dump-workers-to-health-exchange-yes-for-a-price/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+Capsules-TheKhnBlog+(Capsules+-+The+KHN+Blog)
11. Khimm, S. “The bigger question behind Hobby Lobby.” msnbc.com, July 7, 2014. http://www.msnbc.com/msnbc/the-bigger-question-behind-hobby-lobby
12. Abelson, R. “High-end health plans scale back to avoid “cadillac tax.” The New York Times, May 27, 2013. http://www.nytimes.com/2013/05/28/business/cadillac-tax-health-insurance.html?pagewanted=all&_r=0 Applications:
1) Hancock, J. “Blue Cross-Blue Shield bets big on Obamacare exchanges.” Kaiser Health News, June 21, 2013. http://www.kaiserhealthnews.org/stories/2013/june/21/obama-administration-blue-cross-blue-shield-insurance-exchanges-marketplaces.aspx
2) Terhune, C. “Blue Shield and Aetna to raise healthcare rates over state objections.” Los Angeles Times, March 6, 2013. http://articles.latimes.com/2013/mar/06/business/la-fi-health-insure-rates-20130307
Further Readings
1. Andrews, M. “Appealing an insurer’s denial is often a good strategy.” Kaiser Health News, June 20, 2011. http://www.kaiserhealthnews.org/Features/Insuring-Your-Health/Michelle-Andrews-on-appealing-insurers-denial.aspx
3. Girion, L. “Health insurer tied bonuses to dropping sick policyholders.” The Los Angeles Times, November 9, 2007, p.A.1. http://www.latimes.com/business/la-fi-insure9nov09,0,3065397,full.story?coll=la-home-center
4. Haviland, A.M., Marquis, M.S., McDevitt, R.D., Sood, N. “Growth of consumer-directed health plans to one-half of all employer-sponsored insurance could save $57 billion annually.” Health Affairs 31(5):1009-1015, 2012. http://content.healthaffairs.org/content/31/5/1009.full.pdf+html
5. Overland, D. “Excellus defends proposed rate hikes despite big case reserves.” FierceHealthPayer, July 22, 2012. http://www.fiercehealthpayer.com/story/excellus-defends-proposed-rate-hikes-despite-big-cash-reserves/2012-07-22
6. Shannon, M. Turning consumers into shoppers: Using high-deductible plans wisely. Health Affairs Blog, October 18, 2012. http://healthaffairs.org/blog/2012/10/18/turning-consumers-into-shoppers-using-high-deductible-plans-wisely/
7. Mattke, S., VanBusum, K.R., Martsolf, G. “Final report: Evaluation of tools and metrics to support employer selection of health plans.” Santa Monica, CA: The RAND Corporation, 2014. http://www.rand.org/pubs/research_reports/RR327.html
8. Appleby, J. “Health insurance from both sides: KHN interview of Aetna CEO Bertolini.” Kaiser Health News, April 7, 2011. http://www.kaiserhealthnews.org/Stories/2011/April/08/bertolini-aetna-q-and-a.aspx
9. Brugh II, V,M., McCarthy, M. “Employer-sponsored medical clinics: much more than convenience care.” BenefitsLink.com, February 28, 2014. http://benefitslink.com/links/20140228-112098.html
10. Reuters. Health insurers begin to provide user-friendly plan guides. September 24, 2012. http://www.reuters.com/article/2012/09/24/us-usa-healthcare-insurance-idUSBRE88N0Y620120924
11. Blue Cross Blue Shield of Michigan. “Blue Cross Blue Shield of Michigan saves an estimated $155 million over three years from patient-centered medical home program.” Press Release, July 8, 2013. http://www.bcbsm.com/content/microsites/blue-cross-blue-shield-of-michigan-news/en/index/news-releases/2013/july-2013/bcbsm-saves-155-million-pcmh.html
12. Cantlupe, J. “More employers unhappy with health insurers, says PWC study.” HealthLeaders Media, January 19, 2010. http://healthplans.hcpro.com/content.cfm?topic=HEP&content_id=245127
13. Hancock, J. “Who really pays for health care might surprise you.” Kaiser Health News, April 30, 2014. http://www.kaiserhealthnews.org/stories/2014/april/30/five-misconceptions.aspx?referrer=search
14. Terhune, C. “Blue Shield, Anthem owe small firms millions of dollars in rebates.” Los Angeles Times, June 4, 2013. Overland, D. “Blue Cross $991M surplus draws criticism, fear of monopoly. FierceHealthPayer, August 10, 2012. http://www.fiercehealthpayer.com/story/blue-cross-991m-surplus-draws-criticism-fear-monopoly/2012-08-10
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15. Scolforo. M. “Pa. regulators probe health insurers’ practices.” The Associated Press, 2010. http://www.boston.com/business/healthcare/articles/2010/06/09/pa_regulators_probe_health_insurers_practices/
16. Wharam, J.F., Ross-Degnan, D., Rosenthal, M.B. “The ACA and high-deductible insurance — Strategies for sharpening a blunt instrument.” New England Journal of Medicine 2013;369(16):1481-1484 . http://www.nejm.org/toc/nejm/369/16
17. Reuters. LA doctors, patients sue Health Net for denying claims. September 13, 2012. http://www.reuters.com/article/2012/09/13/us-healthnet-lawsuit-idUSBRE88C19T20120913
18. Bernard-Kuhn, L. “Businesses tackle the Obamacare equation.” USA Today, June 30, 2014. http://www.usatoday.com/story/money/business/2014/06/30/businesses-obamacare-costs/11822841/
19. Austin, D.A., Hungerford, T.L. “The market structure of the health insurance industry.” Congressional Research Service Report #R40834, April 8, 2010. http://www.fas.org/sgp/crs/misc/R40834.pdf
JANUARY 12, 2015 8:00 – 9:00 AM – Measuring Provider Performance: The Foundation of Purchaser Strategies to Reform America’s Health Care System Efforts on the part of health plans and employers to measure provider performance have intensified over the past decade, with performance measurement assuming a key role in almost all private sector health care strategies. Health plans construct or employ measures of performance to: select providers for inclusion in networks; create tiered networks; structure provider incentive payments; and produce provider performance reports for their members. These measures also can be used in disease management and wellness programs. The way in which performance measures are constructed and used has been a point of contention between employers/health plans and providers. Consumers also have criticized these measures as lacking in relevance for their decision making. In this session, we describe attempts by employers and health plans to measure provider performance, common issues in measure construction, the use of “risk-adjustment” techniques, and alternatives for attributing patients to providers. Learning Objectives Students should be able to:
1. Describe and contrast different approaches to performance measurement. 2. Discuss strengths and weaknesses of these approaches. 3. Discuss the role of risk adjustment techniques in measure construction and how they are applied. 4. Discuss different alternatives for attributing patients to providers for measurement purposes. 5. Contrast how measurement challenges differ for quality vs. cost/efficiency measures.
Suggested Readings The Basics of Provider Performance Measurement
1.* Berenson, R.A., Pronovost, P.J., Krumholz, H.M. “Achieving the potential of health care performance measures. Timely analysis of immediate health policy issues.” Robert Wood Johnson Foundation, May 30, 2013. http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/05/achieving-the-potential-of-health-care-performance-measures.html
2.* Berenson, R. “Seven policy recommendations to improve quality measurement.” Health Affairs Blog, May 22, 2013. http://healthaffairs.org/blog/2013/05/22/seven-policy-recommendations-to-improve-quality-measurement/
3.* National Quality Forum. “The ABCs of measurement.” http://www.qualityforum.org/Measuring_Performance/ABCs_of_Measurement.aspx
4. Pronovost, P.J., Lilford, R. “A road map for improving the performance of performance measures.” Health Affairs 2011;30(4):569-573. http://content.healthaffairs.org/content/30/4/569.full.pdf+html
5. National Quality Forum. Mission and vision. http://www.qualityforum.org/About_NQF/Mission_and_Vision.aspx Importance of Risk Adjustment in Performance Measurement
1.* Schone, E., Brown, R.W., Goodell, S. “Risk adjustment: What is the current state of the art, and how can it be improved.” Policy Brief No. 25, Robert Wood Johnson Foundation Synthesis Project, July 2013. http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/07/risk-adjustment---what-is-the-current-state-of-the-art-and-how-c.html
2. Draaghtel, K. “Concurrent risk adjustment.” Milliman, January, 2012. http://publications.milliman.com/periodicals/rsa/pdfs/rsa-01-2012.pdf
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3. Martin, K., Rogal, D.L., Arnold, S.B. Health-based risk assessment: Risk-adjusted payments and beyond. AcademyHealth. http://www.hcfo.org/pdf/riskadjustment.pdf
4. DuGoff, E., Bishop, S., Rawal, P. “Hospital readmission reduction program reignites debate over risk adjusting quality measures.” Health Affairs Blog, August 14, 2014. http://healthaffairs.org/blog/2014/08/14/hospital-readmission-reduction-program-reignites-debate-over-risk-adjusting-quality-measures/ Applications:
1) Draaghtel, K. “Milliman advanced risk adjuster, MARA.” Milliman, February 2010. http://publications.milliman.com/periodicals/rsa/pdfs/coming-soon-milliman-advanced.pdf
Challenges in Measuring Provider Quality 1.* Mathias, J.S., Baker, D.W. “Developing quality measures to address overuse.” Journal of the American Medical
Association 309(18):1897-1898, 2013. http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=926917&direction=P
2.* Berenson, R. A. “Moving payment from volume to value: What role for performance measurement?” Washington, DC: Urban Institute, December 2010. http://www.rwjf.org/files/research/71568full.pdf
3. Conway, P.H. Mostashari, F., Clancy, C. “The future of quality measurement for improvement and accountability.” Journal of the American Medical Association 309(21):2215-2216, 2013. http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=927065&direction=P
4. Kupfer, J.M. “The morality of using mortality as a financial incentive. Unintended consequences and implications for acute hospital care.” Journal of the American Medical Association 309(21):2213-2214, 2013. http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=927065&direction=P
5. Stefan, M.S., Pekow, P.S., Nsa, W., et al. “Hospital performance measures and 30-day readmission rates.” Journal of General Internal Medicine 28(3):377-385, 2013. http://link.springer.com/content/pdf/10.1007%2Fs11606-012-2229-8.pdf
6. Nyweide, D.J., Weeks, W.B., Gottlieb, D.J. “Relationship of primary care physicians’ patient caseload with measurement of quality and cost performance.” Journal of the American Medical Association 2009;302(22)2444-2450. http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=4491&direction=P
7. Rosof, B. The importance of accurate data in quality –of-care measurement (Editorial). Annals of Internal Medicine 2012;157(5):379-380. http://annals.org/issue.aspx?journalid=90&issueID=24808&direction=P
8. McGinnis, T., Newman, J. “Advances in multi-payer alignment: State approaches to aligning performance metrics across public and private payers.” Milbank Memorial Fund, July 2014. http://www.milbank.org/uploads/documents/MultiPayerHealthCare_WhitePaper_071014.pdf Applications:
1) Cheung, K. “AHA report: Not all readmissions avoidable, ‘ill-suited’ quality indicator.” Fierce Healthcare, September 15, 2011. http://www.fiercehealthcare.com/story/aha-report-not-all-readmissions-avoidable-ill-suited-quality-indicator/2011-09-15
2) Overland, D. Minnesota health plan releases doctor ratings despite opposition. FierceHealthPayer, January 20, 2011. http://www.fiercehealthpayer.com/story/minnesota-health-plan-releases-doctor-ratings-despite-opposition/2011-01-20
Challenges in Measuring Provider Prices, Costs and Efficiency 1.* Robinson, R.C., Williams, T., Yanagihara, D. “Measurement of and reward for efficiency in California’s pay-for-
performance program.” Health Affairs 2009;28(5):1438-1447. http://content.healthaffairs.org/content/28/5/1438.full.pdf+html
2.* Painter, M.W., Chernew, M.E. “Counting change: Measuring health care prices, costs, and spending.” Robert Wood Johnson Foundation, March 2012. http://www.rwjf.org/qualityequality/product.jsp?id=74078
3. McIntyre, A. “Solving the mystery of health-care prices could save $100 billion.” Vox, May 21, 2014. http://www.vox.com/2014/5/21/5723452/could-more-price-transparency-in-health-care-really-save-100-billion
4. Berk, M., Schur, C. “Having a baby: Media confusion over charges, costs, and the benefits of insurance.” Health Affairs Blog, August 6, 2014. http://healthaffairs.org/blog/2014/08/06/having-a-baby-media-confusion-over-charges-costs-and-the-benefits-of-insurance/
5. Japsen, B. “Health care’s measurement pioneers tackle cost.” Princeton, NJ: Robert Wood Johnson Foundation, August 2014. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2014/rwjf414952
Applications: 1) Alltucker, K. “Auction website lets patients suggest prices.” azcentral.com, June 16, 2012.
Challenges in Measuring Patient Experience 1.* Browne, K., Roseman, D., Shaller, D., Edgman-Levitan, S. “Analysis and Commentary. Measuring patient experience
as a strategy for improving primary care.” Health Affairs 2010;29(5):921-925. http://content.healthaffairs.org/content/29/5.toc
Further Readings
1. Higgins, A., Zeddies, T., Pearson, S.D. “Measuring the performance of individual physicians by collecting data from multiple health plans: The results of a two-state test.” Health Affairs 2011;30(4):673-681. http://content.healthaffairs.org/content/30/4/673.full.pdf+html
2. Hoefer, T.P., Hayward, R.A., Greenfield, S., Wagner, E.H., Kaplan, S.H., Manning, W.G. “The unreliability of individual physician ‘report cards’ for assessing the costs and quality of care of a chronic disease.” Journal of the American Medical Association 1999;281(22):2098-2105. http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=4646&direction=P
3. Mehrotra, A., Adams, J.L., Thomas, J.W., McGlynn, E.A. “Is physician cost profiling ready for prime time?” RAND Research Brief, 2010. http://www.rand.org/pubs/research_briefs/RB9523/
4. Nelson, E.C., Gentry, M.A., Mook, K.H., Spritzer, K.L., Higgins, J.H., Hays, R.D. “How many patients are needed to provide reliable evaluations of individual clinicians?” Medical Care 2004;42(3):259-266. http://www.jstor.org/stable/pdfplus/4640735.pdf?acceptTC=true
5. Romano, P., Hussey, P., Ritley, D. “Selecting quality and resource use measures: A decision guide for community quality collaboratives.” AHRQ Publication No. 09(10)-0073, May 2010. http://www.ahrq.gov/qual/perfmeasguide/
6. Scholle, S.H., Roski, J., Adams, J.L., Dunn, D.L., Kerr, E.A., Dugan, D.P., Jensen, R.E. “Benchmarking physician performance: reliability of individual and composite measures.” American Journal of Managed Care 2008;14(12):829-838. http://www.ajmc.com/publications/issue/2008/2008-12-vol14-n12/Dec08-3781p833-838/
7. Miller, T.P., Brennan, T.A., Milstein A. “How can we make more progress in measuring physicians’ performance to improve the value of care?” Health Affairs 28(5):1429-1437, 2009. http://content.healthaffairs.org/content/28/5/1429.full.pdf+html
8. National Committee on Quality Assurance. “HEDIS measure development process. Desirable attributes of HEDIS. HEDIS life cycle.” http://www.ncqa.org/tabid/414/Default.aspx
9. Dimick, J.B., Birkmeyer, N.J., Finks, J.F., et al. “Composite measures for profiling hospitals on bariatric surgery performance.” JAMA Surgery 149(1):10-16, 2014. http://archsurg.jamanetwork.com/issue.aspx?journalid=76&issueid=929681&direction=P
10. Clark, C. “’Kafkaesque’ value system unfairly penalizes doctor pay.” HealthLeaders Media, August 25, 2014. http://www.healthleadersmedia.com/page-1/FIN-307757/Kafkaesque-Value-System-Unfairly-Penalizes-Doctor-Pay
11. Damberg, C.L., Sorbero, M.E., Lovejoy, S.L., et al. An Evaluation of the Use of Performance Measures In Health Care. Santa Monica, CA: RAND Corporation, 2011. http://www.rand.org/pubs/technical_reports/TR1148.html
12. Milliman. Milliman Advanced Risk Adjuster (MARA): Predictive value of inpatient risk score. November 2011. http://publications.milliman.com/periodicals/rsa/pdfs/milliman-advanced-risk-adjuster.pdf
13. Wood, D.L. “Measure health, not care.” Minnesota Medicine, April 2012. http://www.minnesotamedicine.com/PastIssues/April2012.aspx
14. Higgins, A., Veselovskiy, G., McKown, L. “Provider performance measures in private and public programs: Achieving meaningful alignment with flexibility to innovate.” Health Affairs 2013;32(8):1453-1461. http://content.healthaffairs.org/content/32/8/1453.full.pdf+html
15. Neuman, H.B., Michelassi, F., Turner, J.W., Bass, B.L. “Surrounded by quality metrics: what do surgeons think of ACS-NSQIP?” Surgery 2009;149(1):27-33. https://www.clinicalkey.com/#!/BrowserCtrl/doBrowseTo/journalIssue/{"facet":["1-s2.0-S0039606008X00133"],"issn":"00396060","contentType":"Journals"}
16. Romley, J.A., Hussey, P.S., de Vries, H., Wang, M.C., Shekelle, P.G., McGlynn, E.A. “Efficiency and its measurement: what practitioners need to know.” American Journal of Managed Care 2009;15(11):842-845. http://www.ajmc.com/publications/issue/2009/2009-11-vol15-n11/AJMC_09Nov_Romley_842to845/
9:00 – 10:30 AM – Provider Contracting and Network Management Discussion of Individual Assignment 1 A major factor in health plans’ success in securing employer contracts is their ability to negotiate favorable terms when contracting with providers and to effectively “manage” provider networks. In this session, we will discuss the basics of provider contracting, including the way in which health plans and providers attempt to exert leverage in the contracting process. We also
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describe steps that health plans are taking to develop products based on subsets of “high performing” providers, and the reasons why this strategy has been controversial. Learning Objectives Students should be able to:
1. Discuss the nature of the contracting process from the health plan and provider perspectives. 2. Describe how provider reimbursement levels are determined. 3. Discuss issues pertaining to tiered provider networks.
Suggested Readings Contents of Contracts Between Providers and Health Plans
1. CIGNA (posted on Moodle) Health Plan/Provider Leverage in the Contracting Process 1.* Berenson, R.A., Ginsburg, P.B., Christianson, J.B., Yee, T. “The growing power of some providers to win steep
payment increases from insurers suggests policy remedies may be needed.” Health Affairs 2012;31(5):973-981. http://content.healthaffairs.org/content/31/5/973.full.pdf+html
2.* Kocher, B., Emanuel E.J. Overcoming the pricing power of hospitals. Journal of the American Medical Association 2012;308(12):1213-1214. http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=24967&direction=P
3.* Ginsburg, P.B., Pawlson, L.G. “Seeking lower prices where providers are consolidated: An examination of market and policy strategies.” Health Affairs 33(6):1067-1075, 2014. http://content.healthaffairs.org/content/33/6.toc
4. Ginsburg, P.B. “Wide variation in hospital and physician payment rates evidence of provider market power.” Research Brief No. 16, November 2010. Washington, DC: Center for Studying Health System Change. http://www.hschange.com/CONTENT/1162/1162.pdf
5. Melnick, G.A., Shen, Y-C., Wu, V.Y. “The increased concentration of health plan markets can benefit consumers through lower hospital prices.” Health Affairs 2011;30(9):1728-1733. http://content.healthaffairs.org/content/30/9/1728.full.pdf+html
6. Baker, L., Bundorf, M.K., Royalty, A. “Private insurers’ payments for routine physician office visits vary substantially across the United States.” Health Affairs 2013;32(9):1583-1590. http://content.healthaffairs.org/content/32/9/1583.full.pdf+html
7. Vladeck, B.C. “Paradigm lost: Provider concentration and the failure of market theory.” Health Affairs 33(6):1083-1087, 2014. http://content.healthaffairs.org/content/33/6.toc
8. Seipel, T. “California doctors, insurers face off over reimbursement rates.” San Jose Mercury News, February 24, 2014. http://www.mercurynews.com/health/ci_25212839/doctors-insurers-face-off-over-reimbursement-rates
9. Frakt, A. “The future of health care costs: Hospital-insurer balance of power.” NIHCM Foundation, November 2010. http://www.nihcm.org/component/content/article/407
10. Rau, J. “A Tennessee insurer uses its monopoly to deliver bargain premiums.” Kaiser Health News, August 6, 2014. http://kaiserhealthnews.org/news/tennessee-blues-bargaining-power-means-lower-premiums/
11. Terhune, C. “Medical costs up to 20% higher at hospital-owned physician groups, study finds.” Los Angeles Times, October 21, 2014. http://www.latimes.com/business/la-fi-hospital-doctor-deals-20141022-story.html
Applications: 1) Terhune, C. “Small surgeries, huge markups.” Los Angeles Times, January 31, 2013.
http://articles.latimes.com/2013/jan/31/business/la-fi-high-price-knee-20130131 2) Hancock, J. “Expert: Hospitals’ ‘humongous monopoly’ drives prices high.” Kaiser Health News, March 4,
2013. http://capsules.kaiserhealthnews.org/?p=17379 3) Merritt, G. “Children’s Hospital, Anthem reach agreement after two-month standoff.” The CT mirror, June
12, 2012. http://www.ctmirror.org/story/16625/childrens-hospital-anthem-reach-multi-year-agreement 4) Terhune, C. “Many hospitals, doctors offer cash discount for medical bills.” Los Angeles Times online, May
27, 2012. http://articles.latimes.com/2012/may/27/business/la-fi-medical-prices-20120527 5) Lund-Muzikant. Providence severs contract with Health Net just as employers consider options for 2013. The
Lund Report, September 20, 2012. http://www.thelundreport.org/resource/providence_severs_contract_with_health_net_just_as_employers_consider_options_for_2013
6) Editorial Board. “The risks of hospital mergers.” The New York Times, July 6, 2014. http://www.nytimes.com/2014/07/07/opinion/the-risks-of-hospital-mergers.html?_r=0
7) UnitedHealth Group Press Release. “UnitedHealthcare and Tenet Healthcare Corp renew network relationship.” July 29, 2014.
8) Aetna New Release. “Aetna and Geisinger Health System reach new agreement.” July 28, 2014. http://news.aetna.com/news-releases/aetna-and-geisinger-health-system-reach-new-agreement/
9) Seipel, T. “California doctors, insurers face off over reimbursement rates.” San Jose Mercury News, February 24, 2014. http://www.mercurynews.com/health/ci_25212839/doctors-insurers-face-off-over-reimbursement-rates
Tiered Networks, High Performance Networks, Narrow Networks, and Centers of Excellence 1.* Rabin, R.C. “Report faults high fees for out-of-network care.” The New York Times, January 31, 2013.
http://www.nytimes.com/2013/02/01/health/insurance-industry-report-faults-high-fees-for-out-of-network-care.html?_r=0 2.* The Incidental Economist. “If plans are only offering narrow networks, blame information asymmetry.” May 29, 2014.
http://theincidentaleconomist.com/wordpress/if-plans-are-only-offering-narrow-networks-blame-information-asymmetry/ 3.* Cheny, C. “Narrow provider networks set to spread.” HealthLeaders Media, July 15, 2014. http://www.healthleadersmedia.com/page-1/HEP-306360/Narrow-Provider-Networks-Set-to-Spread## 4. Andrews, M. “Warning: Opting out of your insurance plan’s provider network is risky.” Kaiser Health News, March 18,
5. Rosenthal, E. “Costs can go up fast when E.R. is in network but the doctors are not.” New York Times, September 28, 2014. http://www.nytimes.com/2014/09/29/us/costs-can-go-up-fast-when-er-is-in-network-but-the-doctors-are-not.html?_r=0
6. Abelson, R. “Hospitals and insurer join forces in California.” New York Times, September 17, 2014. http://search.proquest.com/docview/1562312161/fulltext/B3C17E9C09744CA8PQ/1?accountid=14586
7. Blecker, E. “The impact of tiered physician networks on patient choices.” HFCO Findings Brief, Vol. XLII, No. 3, September 2014. http://www.hcfo.org/files/hcfo/HCFOFindingsBriefSept2014FINAL.pdf
8. Frakt, A. “Limiting choice to control health spending: A caution.” New York Times, September 15, 2014. http://www.nytimes.com/2014/09/16/upshot/limiting-choice-to-control-health-spending-a-caution.html
9. Carey, M.A. “More employers limit health plan networks but seek to preserve quality, says adviser.” Kaiser Health News, August 13, 2014. http://kaiserhealthnews.org/news/more-employers-limit-health-plan-networks-but-seek-to-preserve-quality-2/
10. Bindman, A. “JAMA Forum: Much ado about narrow networks.” Newsatjama.jama.com, August 13, 2014. http://newsatjama.jama.com/2014/08/13/jama-forum-much-ado-about-narrow-networks/
11. Andrews, M. “Warning: Opting out of your insurance plan’s provider network is risky.” Kaiser Health News, March 18, 2014. http://kaiserhealthnews.org/news/michelle-andrews-opting-out-insurer-provider-network-risky/
12. Brino, A. “The trouble with narrow networks.” Healthcare Payer News, May 30, 2014. http://www.healthcarepayernews.com/content/trouble-narrow-networks
13. Pear, R. “To prevent surprise bills, new health law rules could widen insurer networks.” New York Times, July 19, 2014. http://search.proquest.com/docview/1546075553/fulltext/64B943511553496EPQ/1?accountid=14586
14. Cohn, J. “Maybe you don’t need a big doctor network to get good care.” New Republic, September 8, 2014. http://www.newrepublic.com/article/119359/narrow-networks-and-obamacare-consumers-may-be-better Applications:
1)* Kaiser Health News. “Some heart care costs stay outside insurance coverage, Lowe’s does national comparison shopping for employees’ heart surgery.” February 17, 2010. http://www.kaiserhealthnews.org/daily-reports/2010/february/17/cost-of-heart-care.aspx
2)* Appleby, J. “Consumers hit by higher out-of-network medical costs.” Kaiser Health News, February 8, 2012. http://www.kaiserhealthnews.org/stories/2012/february/09/consumers-hit-by-higher-out-of-network-medical-costs.aspx
3) Terhune, C. Companies go surgery shopping. Los Angeles Times, November 17, 2012. http://articles.latimes.com/2012/nov/17/business/la-fi-bargain-surgery-20121117
4) Gonzales, A. “Cigna offering lower co-pays at its own clinics in Phoenix.” Phoenix Business Journal, August 9, 2011. http://www.bizjournals.com/phoenix/news/2011/08/09/cigna-offering-lower-co-pays-at-its.html?page=all
5) Weaver, C. “Aetna, doctors face off over costs.” Wall Street Journal online, July 4, 2012. http://online.wsj.com/article/SB10001424052702303933404577505182228232366.html
6) Crosby, J. “Medica teams with Fairview on new plan.” StarTribune online, March 8, 2012. http://www.startribune.com/business/141693483.html?refer=y
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7) Andrews, M. “Some insurers paying patients who agree to get cheaper care.” Kaiser Health News, March 26, 2012. http://www.kaiserhealthnews.org/features/insuring-your-health/2012/cash-rewards-for-cheaper-care-michelle-andrews-032712.aspx
8) Toland, B. Highmark offers cheaper, UPMC-free plan. Pittsburgh Post-Gazette, September 11, 2012. http://www.post-gazette.com/stories/business/news/highmark-offers-cheaper-upmc-free-plan-652783/
9) Business Wire. “McKesson joins Employers Centers of Excellence Network.” March 31, 2014. http://www.businesswire.com/news/home/20140331005474/en/McKesson-Joins-Employers-Centers-Excellence-Network
10) BlueCross Blue Shield Press Release. “Highmark Blue Cross Blue Shield introduces new tiered-benefit product built on the Community Blue Network.” October 1, 2014. http://www.bcbs.com/healthcare-news/plans/highmark-bcbs-introduces-new-tiered-benefit-product-built-on-the-community-blue-network.html
11) BusinessWite. “Medica and Mayo Clinic introduce lower cost health plan.” October 6, 2014. http://www.businesswire.com/news/home/20141006006073/en/Medica-Mayo-Clinic-Introduce-Cost-Health-Plan
Provider Issues Concerning Contracts with Health Plans 1. Millman, J. “Should you be able to see any doctor you want?” The Washington Post Wonkblog, September 26, 2014.
1)* Cantlupe, J. Physicians, insurers clash over medical necessity in CA. HealthLeaders Media, September 27, 2012. http://www.healthleadersmedia.com/page-1/PHY-284876/Physicians-Insurers-Clash-Over-Medical-Necessity-in-CA
2)* Casalino, L.P., Nicholson, S., Gans, D.N., Hammons, T., Morra, D., Karrison, T., Levinson, W. “What does it cost physician practices to interact with health insurance plans?” Health Affairs 2009;28(4):w533-w543 (published online 14 May 2009). http://content.healthaffairs.org/content/28/4/w533.full.pdf+html?sid=36420c5a-9240-4639-b71c-0cf279227dc4
3) Toland, B. “Medical ethics focus of insurance dispute between UPMC and Highmark.” Pittsburgh Post-Gazette, March 8, 2013. http://www.post-gazette.com/stories/local/state/medical-ethics-focus-of-insurance-dispute-between-upmc-and-highmark-678402/
4) Fuhrmans, V. “Insurers stop paying for care linked to errors; health plans say new rules improve safety and cut costs; hospitals can’t dun patients”. The Wall Street Journal, January 15, 2008, p.D.1. http://online.wsj.com/article/SB120035439914089727.html
5) Associated Press. “AMA, others suing Aetna, Cigna over payments.” February 10, 2009. http://blog.cleveland.com/business/2009/02/ama_others_suing_aetna_cigna_o.html
6) Reuters. “Aetna ranked tops in connection with doctors.” May 25, 2011. http://www.reuters.com/article/2011/05/25/idUS189606+25-May-2011+BW20110525
7) Cheung, K. “AMA blasts insurers for costly 20 percent error rates.” FierceHealthcare, June 20, 2011. http://www.fiercehealthcare.com/story/ama-blasts-insurers-costly-20-percent-error-rate/2011-06-20
8) Pfeifer, S., Terhune, C. “USC hospital sues Kaiser over nonpayment of bill.” Los Angeles Times, May 23, 2014. http://www.latimes.com/business/la-fi-kaiser-usc-patient-fight-20140523-story.html
Further Readings
1. Ellis, P., Sandy, L.G. Larson, A.J., Stevens, S.L. Wide variation in episode costs within a commercially insured population highlights potential to improve the efficiency of care. Health Affairs 2012;31(9):2084-2093. http://content.healthaffairs.org/content/31/9/2084.full.pdf+html
2. Kaiser Health News. “Cigna agrees to end use of database to determine payments for out-of-network medical services.” February 18, 2009. http://www.kaiserhealthnews.org/daily-reports/2009/february/18/dr00057024.aspx?referrer=search
3. News Release. AHIP files amicus brief on impact of hospital consolidation. America’s Health Insurance Plans, November 29, 2012. http://www.ahip.org/News/Press-Room/2012/AHIP-Files-Amicus-Brief-on-Impact-of-Hospital-Consolidation.aspx
4. Terhune, C. Cedars-Sinai and UCLA cut from Los Angeles health plan. Los Angeles Times, September 21, 2012. http://articles.latimes.com/2012/sep/21/business/la-fi-hospital-costs-20120921
5. Jost, T. “Implementing health reform: Reference pricing and network adequacy.” Health Affairs Blog, October 12, 2014. http://healthaffairs.org/blog/2014/10/12/implementing-health-reform-reference-pricing-and-network-adequacy/
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6. Gorn, D. “Narrow networks bill passes floor vote.” California Healthline, August 28, 2014. http://www.californiahealthline.org/capitol-desk/2014/8/narrow-networks-bill-passes-floor-vote
7. Corlette, S., Volk, J., Berenson, R., Feder, J. “Changing provider networks in marketplace health plans: Balancing affordability and access to quality care.” Health Affairs Blog, June 11, 2014. http://healthaffairs.org/blog/2014/06/11/changing-provider-networks-in-marketplace-health-plans-balancing-affordability-and-access-to-quality-care/
8. Andrews, M. “When a plan overpays for a service, is a patient responsible for a refund?” Kaiser Health News, December 10, 2012. http://www.kaiserhealthnews.org/features/insuring-your-health/2012/121112-michelle-andrews-overpayment.aspx
9. White, C., Reschovsky, J.D., Bond, A.M. “Understanding differences between high- and low-price hospitals: Implications for efforts to rein in costs.” Health Affairs 33(2):324-331, 2014. http://content.healthaffairs.org/content/33/2.toc
10. Abelson, R. “More insured, but the choices are narrowing.” The New York Times, May 12, 2014. http://search.proquest.com/docview/1523785309/fulltext/CA07C834B3AA4587PQ/1?accountid=14586
11. Pacific Business Group on Health. Employers Centers of Excellence Network Program Summary. http://www.pbgh.org/storage/documents/ECEN_Program__Summary_314.pdf
12. Brino, A. “The trouble with narrow networks.” Healthcare Payer News, May 30, 2014. http://www.healthcarepayernews.com/content/trouble-narrow-networks
13. Pear, R. “To prevent surprise bills, new health law rules could widen insurer networks.” The New York Times, July 19, 2014. http://search.proquest.com/docview/1546075553/fulltext/1A54B8895F904963PQ/1?accountid=14586
14. Andrews, M. “Insurance trade-off: Reducing premiums by eliminating expensive doctors, hospitals.” Kaiser Health News, March 1, 2011. http://www.kaiserhealthnews.org/features/insuring-your-health/michlle-andrews-on-premiums-and-prices.aspx?referrer=search
15. Boulton, G. Aurora-Anthem plan seeks exclusivity, promises savings. Journal Sentinel, October 24, 2012. http://www.jsonline.com/business/auroraanthem-plan-seeks-exclusivity-promises-savings-0d7av36-175522981.html
16. Appleby, J. “Domestic medical travel is taking off for surgery deals.” USA Today, July 9, 2010. http://www.usatoday.com/money/industries/health/2010-07-07-travelforhealth07_CV_N.htm
10:30 AM – Noon – Fundamentals of Provider Payment: Incentives and Rewards During the 1980s through the mid-1990s, most provider payment arrangements employed by health plans were designed to influence providers to reduce unnecessary service utilization. Then, responding to consumer backlash, plans and employers largely reverted to fee-for-service payment. However, over the past decade, health plans and purchasers have initiated a variety of new payment approaches that have broader behavioral change goals, including improving quality of care, implementing evidence-based medical practices effectively, and supporting the restructuring of care delivery. These approaches could be seen as “blending” traditional fee-for-service with payments related to provider performance. Recently, health reform legislation has encouraged Medicare to institute payment reforms with similar objectives. We will discuss traditional methods of provider payment, as well as new, blended payment arrangements, in this session. We also describe parallel payment initiatives by Medicare that supplement these private sector efforts. Learning Objectives – Fundamentals of Provider Payment Students should be able to:
1. Describe the basic reimbursement approaches used by health plans in contracts with providers, including their strengths and weaknesses.
2. Describe the different types of pay-for-performance initiatives being undertaken by health plans and purchasers. 3. Describe how these approaches differ in their design and the challenges they pose for implementation, in comparison to
previous payment arrangements between health plans and providers. Suggested Readings Basics of Provider Payment
1.* Reinhardt, U.E. “The options for payment reform in U.S. health care.” New York Times online, February 17, 2012. http://economix.blogs.nytimes.com/2012/02/17/the-options-for-payment-reform-in-u-s-health-care/
2.* Painter, M.W. “Improving Incentives.” Issue Brief, August 7, 2013. Princeton: NJ: Robert Wood Johnson Foundation. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf407378
3. Berenson, R.A., Rich, E.C. “US approaches to physician payment: the deconstruction of primary care.” Journal of
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General Internal Medicine 2010;25(6):613-618. http://link.springer.com/content/pdf/10.1007%2Fs11606-010-1295-z.pdf
4. Center for Healthcare Quality & Payment Reform. “The best antidote to provider market power is to change the healthcare payment system.” May 27, 2014. http://chqpr.org/blog/index.php/2014/05/the-best-antidote-to-provider-market-power-is-to-change-the-healthcare-payment-system/
5. Frakt, A. “Are Medicare cuts causing private insurer cuts?” The Incidental Economist, September 29, 2014. http://theincidentaleconomist.com/wordpress/are-medicare-cuts-causing-private-insurer-cuts/
6. Fellows, J. “Doctors feel pressure to accept risk-based reimbursement.” HealthLeaders Media, July 24, 2014. http://www.healthleadersmedia.com/content/PHY-306716/Doctors-Feel-Pressure-to-Accept-Riskbased-Reimbursement.html
Use of Provider Payment to Encourage and Reward Quality Improvement 1.* Delbanco, S. “The payment reform landscape: Pay-for-performance.” Health Affairs Blog, March 4, 2014.
http://healthaffairs.org/blog/2014/03/04/the-payment-reform-landscape-pay-for-performance/ 2.* Goitein, L. “The argument against reimbursing physicians for value.” JAMA Internal Medicine 174(6):845-846, 2014. http://archinte.jamanetwork.com/issue.aspx?journalid=71&issueid=930309&direction=P
3.* McKethan, A., Jha, A.K. “Designing smerter pay-for-performance programs.” Journal of the American Medical Association. Published online November 6, 2014. http://jama.jamanetwork.com/article.aspx?articleid=1934599&resultClick=3
4. Reinhardt, U.E. “Making surgical complications pay.” Journal of the American Medicine Association 309(15):1634-1635, 2013. http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=926822&direction=P
5. Werner, R.M., Dudley, R.A. “Making the ‘pay’ matter in pay-for-performance: implications for payment strategies.” Health Affairs 2009;28(5):1498-1508. http://content.healthaffairs.org/content/28/5/1498.full.pdf+html
6. Rau, J. “Effort to pay hospitals based on quality didn’t cut death rates, study finds.” Kaiser Health News, March 28, 2012. http://www.kaiserhealthnews.org/stories/2012/march/28/nejm-study-hospital-quality-and-death-rates.aspx
7. Frieden, J. “Pay-for-performance gains lack staying power.” MedPage Today, August 6, 2014. http://www.medpagetoday.com/PracticeManagement/Reimbursement/47089
8. Delbanco, S. “The payment reform landscape: Capitation with quality.” Health Affairs Blog, June 6, 2014. http://healthaffairs.org/blog/2014/06/06/the-payment-reform-landscape-capitation-with-quality/ Applications:
1) Mathews, A.W. “WellPoint helps cut employers’ health cost.” The Wall Street Journal, June 26, 2013. http://online.wsj.com/article/SB10001424127887323998604578567982013011300.html
2) Blue Cross Blue Shield Michigan. “Blue Cross Blue Shield of Michigan and Trinity Health-Michigan achieve new approach to reimbursement with landmark contract.” Trinity Health News Release, April 2013. http://www.trinity-health.org/body.cfm?id=186&action=detail&ref=46
3) Metro, L. “Commercial Blues plans adopting the CMS do-not-pay list policy.” Modern Medicine, April 1, 2010. http://license.icopyright.net/user/viewFreeUse.act?fuid=OTIxMDMwMw%3D%3D
4) BusinessWire. Humana’s provider quality rewards program distributes more than $35 million to primary care physicians in Florida. November 14, 2012. http://www.businesswire.com/news/home/20121114005577/en/Humana%E2%80%99s-Provider-Quality-Rewards-Program-Distributes-35
Use of Provider Payment to Encourage and Reward Health Care Homes 1.* Merrell, K., Berenson, R.A. “Structuring payment for medical homes.” Health Affairs 2010;29(5):852-858,
http://content.healthaffairs.org/content/29/5/852.full.pdf+html 2. Dentzer, S. “One payer’s attempt to spur primary care doctors to form new medical homes.” Health Affairs
2012;31(2):341-349. http://content.healthaffairs.org/content/31/2.toc 3. Abelson, R. “Health insurers are trying new payment models, study shows.” The New York Times, July 9, 2014.
1) BusinessWire. Empire announces physician practices to participate in historic public-private partnership to strengthen primary care. August 23, 2012. http://www.businesswire.com/news/home/20120823006208/en/Empire-Announces-Physician-Practices-Participate-Historic-Public-Private
2) Feder, J.L. “A health plan spurs transformation of primary care practices into better-paid medical homes.” Health Affairs 2011;30(3):397-399. http://content.healthaffairs.org/content/30/3/397.full.pdf+html
3) Business Wire. “New payment and care coordination agreement in place between Anthem Blue Cross and Blue Shield and hundreds of primary care physicians in Indiana.” April 16, 2014.
Reference Pricing 1.* Robinson, J.C., MacPherson, K. “Payers test reference pricing and centers of excellence to steer patients to low-price
and high-quality providers.” Health Affairs 31(9):2028-2036, 2012. http://content.healthaffairs.org/content/31/9/2028.full.pdf+html
2.* Robinson, J.C., Brown, T.T. “Increases in consumer cost sharing redirect patient volumes and reduce hospital prices for orthopedic surgery.” Health Affairs 2013;32(8):1392-1397. http://content.healthaffairs.org/content/32/8/1392.full.pdf+html
3. Appleby, J. “Study finds savings low for employers capping their payments for treatments.” Kaiser Health News Blog, October 9, 2014.
4. Kanavos, P., Reinhardt, U. “Reference pricing for drugs: Is it compatible with U.S. Health care?” Health Affairs 2003;22(3):16-30. http://content.healthaffairs.org/content/22/3/16.full.pdf+html Applications:
1) Terhune, C. “Hospitals cut some surgery prices after CalPERS caps reimbursements.” Los Angeles Times, June 23, 2013. http://www.latimes.com/business/money/la-fi-mo-calpers-hospital-surgery-prices-20130623,0,6571991.story
Medicare Payment Reform Initiatives 1.* VanLare, J.M., Conway, P.H. “Value-based purchasing – National programs to move from volume to value.” New
England Journal of Medicine 2012;367(4):292-295. http://www.nejm.org/doi/pdf/10.1056/NEJMp1204939 2. Ryan, A.M., Blustein, J., Casalino, L.P. “Medicare’s flagship test of pay-for-performance did not spur more rapid
quality improvement among low-performing hospitals.” Health Affairs 2012;31(4):797-805. http://content.healthaffairs.org/content/28/2/w238.full.pdf+html
3. Rau, J. “Medicare announces plans to accelerate linking doctor pay to quality.” Kaiser Health News, July 22, 2013. http://www.kaiserhealthnews.org/Stories/2013/July/22/Medicare-value-based-pay-for-doctors.aspx
Applications: 1) Galewitz, P. “Tulsa hospital gives Medicare patients cash back for surgery.” Kaiser Health News, October 26,
2) Rau, J. “Medicare to begin basing hospital payments on patient-satisfaction scores.” Kaiser Health News, April 28, 2011. http://www.kaiserhealthnews.org/Stories/2011/April/28/medicare-hospital-patient-satisfaction.aspx
3) Pecquet, J., Baker, S. “Medicare proposal links surgical center payments to quality.” The Hill, July 1, 2011. http://thehill.com/blogs/healthwatch/medicare/169497-medicare-proposes-linking-surgical-center-payments-to-quality
Further Readings
1. “Humana’s new provider quality program awarding nearly $10 million in quality awards to primary care physicians across the U.S.” BusinessWire, July 20, 2011. http://www.businesswire.com/news/home/20110720006098/en/Humana%E2%80%99s-Provider-Quality-Rewards-Program-Awarding-10
2. Adamy, J. “WellPoint shakes up hospital payments.” Wall Street Journal, online, May 16, 2011. http://online.wsj.com/article/SB10001424052748704281504576325163218629124.html
3. BlueCross BlueShield Association. “Blue Shield of California awards $29.6 million in pay-for-performance programs in 2009.” Press release, October 5 2009. https://www.blueshieldca.com/producer/news/newsletter/shieldspotlight/shieldspotlight_nov09_article.sp#section4
4. Christianson, J.B., Leatherman , S., Sutherland, K. “Paying for quality: understanding and assessing physician pay-for-performance initiatives.” Robert Wood Johnson Foundation Research Synthesis Report No. 13, December 2007. http://www.rwjf.org/pr/product.jsp?id=24373
5. Kurtzman, E.R., O’Leary, D., Sheingold, B.H., Devers, K.J., Dawson, E.M., Johnson, J.E. “Performance-based payment incentives increase burden and blame for hospital nurses.” Health Affairs 2011;30(2):211-218. http://content.healthaffairs.org/content/30/2/211.full.pdf+html
6. Rosenthal, M.B., Dudley, R.A. “Pay-for-performance Will the last payment trend improve care?” Journal of the American Medicine Association 2007;297(7):740-744. http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=5110&direction=P
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7. Robinson, J.C. “Theory and practice in the design of physician payment incentives.” The Milbank Quarterly 2001;79(2):149-177. http://www.jstor.org/stable/pdfplus/3350546.pdf?acceptTC=true
8. Christianson, J.B., Leatherman, S., Sutherland, K. “Lessons from evaluations of purchaser pay-for-performance programs: a review of the evidence.” Medical Care Research and Review 2008;65(6 suppl):5S-35S. http://mcr.sagepub.com/content/65/6_suppl/5S.full.pdf+html
9. Rosenthal, M.E., de Brantes, F.S., Sinaiko, A.D., Frankel, M., Robbins, R.D., Young, S. “Bridges to excellence —recognizing high-quality care: analysis of physician quality and resource use.” American Journal of Managed Care 2008;14(10):670-677. http://www.ajmc.com/publications/issue/2008/2008-10-vol14-n10/Oct08-3648p670-677/
10. Fellows, J. “Difficult patients: It’s not them, it’s you, doctor.” HealthLeaders Media, September 25, 2014. http://www.healthleadersmedia.com/page-1/PHY-308765/Difficult-Patients-Its-Not-Them-Its-You-Doctor
11. Skinner, J., Fisher, E., Weinstein, J. “The 125 percent solution: Fixing variations in health care prices.” Health Affairs Blog, August 26, 2014. http://healthaffairs.org/blog/2014/08/26/the-125-percent-solution-fixing-variations-in-health-care-prices/
12. Werner, R.M., Kolstad, J.T., Stuart, E.A., Polsky, D. “The effect of pay-for-performance in hospitals: Lessons for quality improvement.” Health Affairs 2011;30(4):690-698. http://content.healthaffairs.org/content/30/4/690.full.pdf+html
13. Editorial. “A view from the safety net.” Journal of the American Medical Association 309(21):2221-2222, 2013. http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=927065&direction=P
JANUARY 13, 2015 8:00 – 9:30 AM – New Payment Arrangements: Bundled/Episode-Based Payment and Global Contracts Discussion of Group Assignment 2 Bundled/Episode-Based Payment Private sector plans and Medicare are experimenting with provider payments that “bundle” related care activities, sometimes in conjunction with reference pricing. These payments place more financial risk on providers but also offer the potential for provider gains. While attractive for some services in theory, bundled payments have proven difficult to implement in practice. Nevertheless, momentum behind bundled payments in the private sector (and in Medicare) seems to be growing. Learning Objectives Students should be able to:
1. Understand the basic design features relating to bundled payment. 2. Discuss the obstacles to implementing bundled payment arrangements. 3. Discuss Medicare support for bundled payment.
Suggested Readings Bundled Payment in Concept
1.* Aligning Forces for Quality. “Bundled payment: The quest for simplicity in pricing and tying payment to quality.” Robert Wood Johnson Foundation, June 2013. http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/06/bundled-payment--the-quest-for-simplicity-in-pricing-and-tying-p.html
2.* Painter, M.W. “Bundled payments: This way toward a challenging yet better place.” Health Care Incentives Issue Brief, 2012. http://www.hci3.org/sites/default/files/files/HCI-IssueBrief-4-2012.pdf
3.* Berenson, R.A., DeBrantes, F., Burton, R. Payment reform: Bundled episodes vs. global payments. Urban Institute, September 2012. http://www.urban.org/publications/412655.html
4. Cutler, D.M., Ghosh, K. “The potential for cost savings through bundled episode payments.” New England Journal of Medicine 2012;366(12):1075-1077. http://www.nejm.org/doi/pdf/10.1056/NEJMp1201853
5. Bach, P.B. “Reforming the payment system for medical oncology.” Journal of the American Medical Association 2013;310(3):261-262. http://jama.jamanetwork.com/issue.aspx?journalid=67&issueid=927287&direction=P
6. Ahlquist, G., Javanmardian, M., Saxena, S.B., Spencer, B. Bundled Care. The Opportunities and Challenges for Providers. Strategy& (formerly Booz & Company), 2013. http://www.strategyand.pwc.com/media/file/Strategyand_BundledCare-OppsChallenges-Providers.pdf
7. Delbanco, S. “The payment reform landscape: Value-oriented payment jumps, and yet…” Health Affairs Blog, September 30, 2014. http://healthaffairs.org/blog/2014/09/30/the-payment-reform-landscape-value-oriented-payment-
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jumps-and-yet/ Bundled Payment Implementation
1.* Robinson, J.C. “Comparison shopping for knee surgery.” The Wall Street Journal, October 29, 2013. http://search.proquest.com/docview/1445463790/fulltext/22F8CFEA752541BEPQ/1?accountid=14586
2.* Hussey, P.S., Ridgely, M.S., Rosenthal, M.B. “The PROMETHEUS bundled payment experiment: Slow start shows problems in implementing new payment models.” Health Affairs 2011;30(11):2116-2124. http://content.healthaffairs.org/content/30/11/2116.full.pdf+html
3.* de Brantes, F., Delbanco, S. “Reference pricing and bundled payments. A match to change markets.” Health Care Incentives Improvement Institute and Catalyst for Payment Reform, October 2013. http://www.catalyzepaymentreform.org/images/documents/matchtochangemarkets.pdf
4. Bailit, M., Burns, M., Houy, M. “Bundled payments one year later: An update on the status of implementations and operational findings.” Health Care Incentives Improvement institute, May 30, 2013. http://www.hci3.org/sites/default/files/files/IB.BundledPayment-June2013-L3_0.pdf
5. Herman, B. “Where commercial and employer bundled payments stand in healthcare right now.” Becker’s Hospital Review, June 27, 2013. http://www.beckershospitalreview.com/racs-/-icd-9-/-icd-10/where-commercial-and-employer-bundled-payments-stand-in-healthcare-right-now.html
6. Herman, B. “4 steps hospitals can take to pilot bundled payments.” Becker’s Hospital Review, June 12, 2013. http://www.beckershospitalreview.com/racs-/-icd-9-/-icd-10/4-steps-hospitals-can-take-to-pilot-bundled-payments.html
7. Fronstin, P., Roebuck, M.C. “Reference pricing for health care services: A new twist on the defined contribution concept in employment-based health benefits.” Employee Benefit Research Institute, April 2014. http://www.ebri.org/pdf/briefspdf/EBRI_IB_398_Apr14.RefPrcng.pdf
8. Williams, T., Yegian, J. “Bundled payment: Learning from our failures.” Health Affairs Blog, August 5, 2014. http://healthaffairs.org/blog/2014/08/05/bundled-payment-learning-from-our-failures/
9. Ridgely, M.S., de Vries, D., Bozic, K.J., Hussey, P.S. “Bundled payment fails to gain a foothold in California: The experience of the IHA bundled payment demonstration.” Health Affairs 2014;33(8):1345-1352. http://content.healthaffairs.org/content/33/8.toc
10. Glaudemans, J., Kolber, M., Ario, J. “Reference pricing and network adequacy standards: Conflict or concord?” Health Affairs Blog, September 18, 2014. http://healthaffairs.org/blog/2014/09/18/reference-pricing-and-network-adequacy-standards-conflict-or-concord/
11. Cailloutte, J., Robinson, J.C. “the ‘failure’ of bundled payment: the importance of consumer incentives.” Health Affairs Blog, August 21, 2014. http://healthaffairs.org/blog/2014/08/21/the-failure-of-bundled-payment-the-importance-of-consumer-incentives/ Applications:
1)* Thompson, J., Golden, W., Hill, R., et al. “The Arkansas payment reform laboratory.” Health Affairs Blog, March 18, 2014. http://healthaffairs.org/blog/2014/03/18/the-arkansas-payment-reform-laboratory/
2) Wall Street Journal Market Watch. “BlueCross announces bundled payment agreement with leading orthopedic groups in Tennessee.” Press Release, May 22, 2012. http://www.marketwatch.com/story/bluecross-announces-bundled-payment-agreements-with-leading-orthopedic-groups-in-tennessee-2012-05-22
3) Mitchell, R. “Slow progress on efforts to pay docs, hospitals for ‘value,’ not volume.” Kaiser Health News, March 26, 2013. http://www.kaiserhealthnews.org/stories/2013/march/26/employers-value-volume-purchasing.aspx
Medicare Bundled Payment Initiatives 1.* Walker, E.P. “CMS testing bundled payments for Medicare.” MedPage Today, August 23, 2011.
http://www.medpagetoday.com/PublicHealthPolicy/Medicare/28172 2. Chernew, M., Goldman D. “Proposal 1: Transitioning to bundled payments in Medicare.” Brookings, The Hamilton
3. Feder, J. “Bundled with care — Rethinking Medicare incentives for post-acute care services.” New England Journal of Medicine 2013;369(5):400-401. http://www.nejm.org/toc/nejm/369/5
4. Minich-Pourshadi, K. “CMS bundled payment changes untenable?” HealthLeaders Media, December 10, 2013. http://www.healthleadersmedia.com/page-1/FIN-287297/CMS-Bundled-Payment-Changes-Untenable
5. Evans, M. “Reform update: CMS to expand bundled-payment initiative.” Modern Healthcare, June 30, 2014. http://www.modernhealthcare.com/article/20140630/NEWS/306309964
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Further Readings
1. Abelson, R. “In bid for better hospital care, heart surgery with a warranty; health plans: quality control.” New York Times, May 17, 2007. http://www.nytimes.com/2007/05/17/business/17quality.html?pagewanted=all&_r=0
2. Adamy, J. “WellPoint shakes up hospital payments.” Wall Street Journal (online), May 16, 2011. http://proquest.umi.com/pqdlink?index=6&did=2348036301&SrchMode=2&sid=1&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1314044474&clientId=2256
3. Hussey, P.S., Sorbero, M.E., Mehrotra, A., Liu, H., Damberg, C.L. “Episode-based performance measurement and payment: making it a reality.” Health Affairs 2009;28(5):1406-1417. http://content.healthaffairs.org/content/28/5/1406.full.pdf+html
4. Newcomer, L.N. “Changing physician incentives for cancer care to reward better patient outcomes instead of use of more costly drugs.” Health Affairs 2012;31(4):780-785. http://content.healthaffairs.org/content/28/5/1406.full.pdf+html
5. Struijs, J.N., Baan, C.A. “Integrating care through bundled payments – lessons from the Netherlands.” New England Journal of Medicine 2011;364(11):990-991. http://www.nejm.org/doi/pdf/10.1056/NEJMp1011849
6. Mechanic, R.E. “Opportunities and challenges for episode-based payment.” New England Journal of Medicine 2011;365(9):777-779. http://www.nejm.org/doi/pdf/10.1056/NEJMp1105963
7. Gamble, M. “More than 60% of providers see opportunity in bundled payments.” Becker’s Hospital Review, October 22, 2013. http://www.beckershospitalreview.com/racs-/-icd-9-/-icd-10/more-than-60-of-providers-see-opportunity-in-bundled-payments.html
8. McLaughlin, J. “Bundling without fumbling: How transparency fits in value-based payments.” Becker’s Hospital Review, July 11, 2013. http://www.beckershospitalreview.com/racs-/-icd-9-/-icd-10/bundling-without-fumbling-how-transparency-fits-in-value-based-payments.html
9. de Brantes, F., D’Andrea, G., Rosenthal, M.B. “Should health care come with a warranty?” Health Affairs – Web Exclusive 2009;29(4):w678-w687 (published online 16 June 2009). http://content.healthaffairs.org/content/28/4/w678.full.pdf+html
10. Mechanic, R.E., Altman, S.H. “Payment reform options: episode payment is a good place to start.” Health Affairs – Web Exclusive 2009;28(2):w262-w271 (published online 27 January 2009). http://content.healthaffairs.org/content/28/2/w262.full.pdf+html
11. Herman, B. “The bundled payments for care improvement program: A hospital analysis.” Becker’s Hospital Review, February 14, 2013. http://www.beckershospitalreview.com/racs-/-icd-9-/-icd-10/the-bundled-payments-for-care-improvement-program-a-hospital-analysis.html
12. Pecquet, J. “Medicare to bundle dialysis payments, reward facilities for training patients.” The Hill, July 26, 2010. http://thehill.com/blogs/healthwatch/medicare/110975-medicare-to-reward-dialysis-facilities-for-training-patients?tmpl=component&print=1&page=
13. Komisar, H.L., Feder, J., Ginsburg, P.B. “’Bundling’ payment for episodes of hospital care. Issues and recommendations for the new pilot program in Medicare.” 2011. Washington, DC: Center for American Progress. http://www.americanprogress.org/issues/2011/07/pdf/medicare_bundling.pdf
14. Rosenthal, M.B. “Beyond pay for performance emerging models of provider-payment reform.” New England Journal of Medicine 2008;359(12):1197-1200. http://www.nejm.org/doi/pdf/10.1056/NEJMp0804658
15. Emanuel, E.J. The Arkansas innovation. The New York Times, September 5, 2012. http://opinionator.blogs.nytimes.com/2012/09/05/the-arkansas-innovation/
Global Contracts Global, also called Total Cost of Care or Accountable Care, contracts between health plans and providers are growing in popularity. Under these contracts, providers agree to deliver services to a defined group of individuals for one “global” payment. Under some contracts, providers assume some degree of risk in return for the chance to share in savings. Learning Objectives Students should be able to:
1. Describe the basic features of comprehensive, global contracts between health plans and providers. 2. Discuss the obstacles to implementing global payment arrangements. 3. Discuss Medicare support for global payment as evidenced by Accountable Care Organizations.
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Suggested Readings Payment Approaches
1.* Song, Z. Safran, D.G., Landon, B.E., Landrum, M.B., He, Y., Mechanic, R.E., Day, M.P., Chernew, M.E. “The ‘alternative quality contract,’ based on a global budget, lowered medical spending and improved quality.” Health Affairs 2012;31(8)1885-1894. http://content.healthaffairs.org/content/31/8/1885.full.pdf+html
2. Shields, M.C., Patel, P.H., Manning, M., Sacks, L. “A model for integrating independent physicians into accountable care organizations.” Health Affairs 2011;30(1):161-172. http://content.healthaffairs.org/content/30/1/161.full.pdf+html
3. Mechanic, R.E., Santos, P., Landon, B.E., Chernew, M.E. “Medical group responses to global payment: Early lessons from the ‘alternative quality contract’ in Massachusetts.” Health Affairs 2011;30(9):1734-1742. http://content.healthaffairs.org/content/30/9/1734.full.pdf+html
4. Christensen, C., Flier, J., Vijayaraghavan, V. Opinion: “The coming failure of ‘accountable care’.” The Wall Street Journal, February 18, 2013. http://search.proquest.com/docview/1288605719/fulltext/A9A617B0FB39462FPQ/1?accountid=14586
5. Andrews, J. “ACOs get down to brass tacks.” Healthcare Finance News, May 12, 2014. http://www.healthcarefinancenews.com/news/acos-get-down-brass-tacks
6. Petersen, M., Muhlestein, D. “ACO results: What we know so far.” Health Affairs Blog, May 30, 2014. http://healthaffairs.org/blog/2014/05/30/aco-results-what-we-know-so-far/
7. Gamble, M. “Total number of ACOs tops 520.” Becker’s Hospital Review, April 24, 2014. http://www.beckershospitalreview.com/accountable-care-organizations/total-number-of-acos-tops-520.html Applications:
1)* Melnick, G., Green L. “Four years into a commercial ACO for CalPERS: Substantial savings and lessons learned.” Health Affairs Blog, April 17, 2014. http://healthaffairs.org/blog/2014/04/17/four-years-into-a-commercial-aco-for-calpers-substantial-savings-and-lessons-learned/
2) McCann, E. “Bon Secours, Aetna ink big ACO Deal.” Healthcare IT News, June 25, 2013. http://www.healthcareitnews.com/news/bon-secours-aetna-ink-big-aco-deal
3) Lowrey, A. “A health provider finds success in keeping hospital beds empty.” The New York Times, April 23, 2013. http://www.nytimes.com/2013/04/24/business/accountable-care-helping-hospitals-keep-medical-costs-down.html?pagewanted=all&_r=0
4) Betbeze, P. “ACO or not, Fairview builds shared savings into all payer contracts.” HealthLeaders Media, May 23, 2011. http://www.healthleadersmedia.com/page-1/HEP-266457/ACO-or-Not-Fairview-Builds-Shared-Savings-into-All-Payer-Contracts
5) HealthPartners. “HealthPartners among first to receive accountable care organization accreditation from NCQA.” News Release, February 14, 2013. http://www.healthpartners.com/public/newsroom/newsroom-article-list/2-14-13.html
6) UnitedHealthcare. “UnitedHealthcare expects to more than double industry-leading accountable care contracts to $50 billion by 2017.” July 10, 2013. http://finance.yahoo.com/news/unitedhealthcare-expects-more-double-industry-120000393.html
7) Overland, D. Medica launches private exchange to sell ACO projects. FierceHealthPayer, October 16, 2012. http://www.fiercehealthpayer.com/story/medica-launches-private-exchange-sell-aco-products/2012-10-16
9) Cheney, C. “Highmark execs detail ACO transformation.” HealthLeaders Media, May 13, 2014. http://www.healthleadersmedia.com/page-1/HEP-304400/Highmark-Execs-Detail-ACO-Transformation##
10) Commins, J. “Providence, Swedish Health launch employer-driven ACO.” HealthLeaders Media, July 7, 2014. http://www.healthleadersmedia.com/page-1/HEP-306131/Providence-Swedish-Health-Launch-EmployerDriven-ACO
11) Independence Blue Cross. “Independence Blue Cross announced results of its accountable care organization (ACO) payment model.” July 14, 2014. http://www.bcbs.com/healthcare-news/plans/Ibc-Announces-The-Results-Of-Its-Aco-Payment-Model.html
12) Independence Blue Cross Press Release. “Independence Blue Cross announces results of its accountable care organization (ACO) payment model.” July 14, 2014. http://www.ibx.com/company_info/news/press_releases/2014/07_14_IBC_announces_results_of.html
Medicare Accountable Care Organizations 1.* Ginsburg, P.B. “Spending to save – ACOs and the Medicare shared savings program.” New England Journal of
Medicine 2011;364(22):2085-2086. http://www.nejm.org/doi/pdf/10.1056/NEJMp1103604 2.* Gold, J. “FAQ on ACOs: Accountable care organizations, explained.” Kaiser Health News, October 21, 2011.
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http://www.kaiserhealthnews.org/stories/2011/january/13/aco-accountable-care-organization-faq.aspx 3. Centers of Medicare and Medicaid Services. “Pioneer accountable care organization model.” General Fact Sheet,
September 12, 2012. http://innovation.cms.gov/Files/fact-sheet/Pioneer-ACO-General-Fact-Sheet.pdf 4. Mostashari, F., White, R. “The ACO hypothesis: What we’re learning from the Medicare shared savings programs.”
Brookings, March 10, 2014. http://www.brookings.edu/blogs/up-front/posts/2014/03/10-medicare-aco-health-care-savings-hospital-physician-mostashari
5. Klar, R. “ACO 101: The basics of accountable care.” Health Affairs Blog, August 29, 2011. http://healthaffairs.org/blog/2011/08/29/aco-101-the-basics-of-accountable-care/
6. Binder, J. “Doctors should be rewarded for quality care – not for cutting corners.” Health Affairs Blog, July 19, 2013. http://healthaffairs.org/blog/2013/07/19/doctors-should-be-rewarded-for-quality-care-not-for-cutting-corners/
7. Ginsburg, P.B. “Accountable care organizations 2.0: Linking beneficiaries.” JAMA Internal Medicine 174(6):945-946, 2014. http://archinte.jamanetwork.com/issue.aspx?journalid=71&issueid=930309&direction=P
8. Damore, J., Champion, W. “Key success factors for the Medicare shared savings program.” Health Affairs Blog, August 21, 2014. http://healthaffairs.org/blog/2014/08/21/key-success-factors-for-the-medicare-shared-savings-program/
9. Rau, J. “One-quarter of ACOs save enough money to earn bonuses.” Kaiser Health News Blog, September 16, 2014. http://kaiserhealthnews.org/news/one-quarter-of-acos-save-enough-money-to-earn-bonuses/
10. Paquette, D. “The surprising Obamacare experiment that saved taxpayers $24 million last year.” The Washington Post, Octobere 6, 2014. http://www.washingtonpost.com/news/storyline/wp/2014/10/06/the-surprising-health-care-experiment-that-saved-taxpayers-24-million-last-year/
Further Readings
1. BusinessWire. “Lahey Clinic joins Blue Cross Blue Shield of Massachusetts alternative quality contract.” News Release, May 14, 2012. http://www.businesswire.com/news/home/20120514006575/en/Lahey-Clinic-Joins-Blue-Cross-Blue-Shield
2. Crosby, J. “Feds reward Park Nicollet for healthy patients.” StarTribune, August 8, 2011. http://www.startribune.com/business/127283643.html
3. NCQA Press Release. NCQA releases HEDIS for ACOs. September 11, 2012. http://www.ncqa.org/Newsroom/2012NewsArchive/NewsReleaseSeptember112012.aspx
4. Rosenthal, M.B., Cutler, D.M., Feder, J. “The ACO rules – Striking the balance between participation and transformative potential.” New England Journal of Medicine 2011;365:e6. http://www.nejm.org/doi/pdf/10.1056/NEJMp1106012
5. Weisman, R. Harvard Pilgrim, partners agree on 4-year contract. The Boston Globe, October 25, 2012. http://www.bostonglobe.com/business/2012/10/25/partners-harvard-pilgrim-reach-new-four-year-contract-that-limits-annual-payment-increases/BpoapJk1S48xuiUo4p6QFK/story.html
6. Berenson, R.A. “Shared savings program for accountable care organizations: A bridge to nowhere?” American Journal of Managed Care 2010;16(10):721-726. http://www.ajmc.com/publications/issue/2010/2010-10-vol16-n10/AJMC_10oct_Berenson_721to726/
7. Evans, M. “About 60% of physician practices avoiding ACOs, study finds.” Modern Healthcare, March 17, 2014. http://www.modernhealthcare.com/article/20140317/blog/303179999
8. Japsen, B. “How accountable care is transforming U.S. healthcare.” The Motley Fool, June 27, 2014. http://www.fool.com/investing/general/2014/06/27/how-accountable-care-is-transforming-us-healthcare.aspx
9. Higgins, A., Stewart, K., Dawson, K., Bocchino, C. “Early lessons from accountable care models in the private sector: Partnerships between health plans and providers.” Health Affairs 2011;30(9):1718-1727. http://content.healthaffairs.org/content/30/9/1718.full.pdf+html
10. Berenson, R.A., Burton, R.A. “Accountable care organization in Medicare and the private sector: A status update.” Robert Wood Johnson Foundation/Urban Institute, November 2011. http://www.rwjf.org/files/research/73470.5470.aco.report.pdf
11. Landon, B.E. “Keeping score under a global payment system.” New England Journal of Medicine 366(5):393-395, 2012. http://www.nejm.org/toc/nejm/366/5
12. Betbeze, P. “Incentives, motivations clash under ACOs.” HealthLeaders Media, April 26, 2013. http://www.healthleadersmedia.com/content/LED-291569/Incentives-Motivations-Clash-Under-ACOs##
13. Bailit, M., Hughes, C., Burns, M., Freedman, D.H. “Shared-savings payment arrangement in health care. Six case studies.” Commonwealth Fund, August 2012. http://www.commonwealthfund.org/Publications/Fund-Reports/2012/Aug/Shared-Savings-Payment-Arrangements.aspx
14. Medica. “Medica continues expansion of ACO offerings in Minnesota.” November 14, 2013. http://newscenter.medica.com/press-release/products-services/medica-continues-expansion-aco-offerings-min
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15. Japsen, B. “Leaving fee for service behind.” Robert Wood Johnson Foundation, June 2014. http://www.rwjf.org/en/research-publications/find-rwjf-research/2014/05/leaving-fee-for-service-behind.html
16. MacDonald, I. “Medicare ACOs growing faster than non-Medicare ACOs.” FierceHealthcare, August 21, 2013. http://www.fiercehealthcare.com/story/medicare-acos-growing-faster-non-medicare-acos/2013-08-21
17. Berwick, D.M. “Making good on ACOs’ promise — The final rule for the Medicare shared savings program.” New England Journal of Medicine 2011;365(19):1753-1756. http://www.nejm.org/doi/pdf/10.1056/NEJMp1111671
18. Meyer, H. “Accountable care organization prototypes: Winners and losers?” Health Affairs 2011;30(7):1227-1231. http://content.healthaffairs.org/content/30/7/1227.full.pdf+html
9:30 – 10:45 AM – Utilization Management and Cost Control Discussion of Individual Assignment 2 Reminders, clinical decision-support systems, predictive modeling, guidelines, and rules are all used by health plans to influence the amount and type of care that providers deliver to patients. Reminders prompt physicians about a patient's care needs prior to, or at the time of, the treatment visit. Clinical decision-support systems typically involve software designed to assist the physician's clinical decision-making. Predictive modeling uses large claims databases to identify patients who may be at risk of specific illnesses in the future and alert clinicians prior to the patient visit. Guidelines, or pathways, assist physicians in taking the appropriate treatment steps, given a patient's condition, and often are applied when treating patients with chronic health problems. They can be incorporated in clinical decision support systems. Rules are used by health plans to intervene more directly in the care process. This session will address the different ways that health plans attempt to influence the delivery of care by providers, including the manner in which these techniques are being employed and evidence of their effectiveness. Learning Objectives Students should be able to:
1. Describe the most common practices used by health plans to influence the delivery of care by providers. 2. Explain the barriers to their effective implementation by health plans. 3. Assess the strength of the evidence supporting their effectiveness. 4. Describe recent trends in their use in conjunction with other efforts to influence physician behavior.
Suggested Readings Utilization Management Challenges Faced by Health Plans
1.* The Medical Society of the State of New York. “Survey reveals that doctors feel pressured by health insurers to alter the way they treat patients.” September 10, 2008. http://www.mssny.org/mssnyip.cfm?c=i&nm=Insurance_Carrier_Rules
2.* Whoriskey, P., Keating, D. “Spinal fusions serve as case study for debate over when certain surgeries are necessary.” The Washington Post, October 7, 2013. http://search.proquest.com/docview/1446809447/fulltext/EEDCC92DBB1441E1PQ/1?accountid=14586
3. Beckman, H.B. “Lost in translation: Physicians’ struggle with cost-reduction programs.” Annals of Internal Medicine 2011;154(6):430-433. http://annals.org/issue.aspx?journalid=90&issueID=20228&direction=P
4. Ofri, D. “Doctors’ bad habits.” The New York Times, October 5, 2013. http://search.proquest.com/docview/1439573436/fulltext/668B06E4998D494DPQ/1?accountid=14586
5. Hancock, J. “Biggest insurer shocked with hepatitis C costs.” Medpage Today, April 20, 2014. http://www.medpagetoday.com/InfectiousDisease/Hepatitis/45341
6. Tilbert, J.C., Wynia, M.K., Sheeler, R.D., et al. “Views of US physicians about controlling health care costs.” Journal of the American Medical Association 310(4):380-389, 2013. http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=927337&direction=P
7. Ofri, D. “Adventures in ‘prior authorization’.” The New York Times, August 3, 2014. http://www.nytimes.com/2014/08/04/opinion/adventures-in-prior-authorization.html?_r=0
8. Andrews, M. “Insurers hesitant to cover many proton beam therapy treatments.” Kaiser Health News, September 23, 2014. http://kaiserhealthnews.org/news/insurers-hesitant-to-cover-many-proton-beam-therapy-treatments/
9. Carroll, A.E. “The placebo effect doesn’t apply just to pills.” The New York Times, October 6, 2014. http://www.nytimes.com/2014/10/07/upshot/the-placebo-effect-doesnt-apply-just-to-pills.html
10. Reuters. “U.S. insurer to stop coverage of gynecological procedure.” August 3, 2014. http://www.reuters.com/article/2014/08/02/highmark-procedure-idUSL2N0Q80IY20140802
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11. Rosenbaum, L. “When is a medical treatment unnecessary?” The New Yorker, October 23, 2013. http://www.newyorker.com/tech/elements/when-is-a-medical-treatment-unnecessary Applications:
1)* Winslow, R., Martin, T.W. “Prostate-cancer therapy comes under attack. Some insurers stop covering expensive proton beams to battle prostate cancer.” The Wall Street Journal, August 28, 2013. http://search.proquest.com/docview/1428388610/fulltext/429FC3C59450434APQ/1?accountid=14586
2) Gardner, A. “Day of admission dictates length of stay for heart failure.” ABC News, May 22, 2010. http://abcnews.go.com/Health/Healthday/story?id=4904656&page=1
3) Reinberg, S. “Too many unneeded brain scans for headaches, study suggests.” HealthDay, March 17, 2014. http://consumer.healthday.com/cognitive-health-information-26/brain-health-news-80/too-many-unneeded-brain-scans-for-headaches-study-suggests-685878.html
4) Cheney, C. “Payer backlash may slow unnecessary spinal fusion surgeries.” HealthLeaders Media, May 23, 2014. http://www.healthleadersmedia.com/page-1/HEP-304825/Payer-Backlash-May-Slow-Unnecessary-Spinal-Fusion-Surgeries##
Overview of Health Plan Efforts 1.* Landon, B.E., Rosenthal, M.B., Normand, S-L.T., Frank, R.G., Epstein, A.M. “Quality monitoring and management in
commercial health plans.” American Journal of Managed Care 2008;14(6):377-386. http://www.ajmc.com/publications/issue/2008/2008-06-vol14-n6/Jun08-3301p377-386/ Applications:
1) MedeAnalytics. “Blue Cross Blue Shield of Vermont selects MedeAnalytics’ medical management analytics.” April 30, 2013. http://www.medeanalytics.com/news-events/blue-cross-blue-shield-of-vermont-selects-medeanalytics-medical-management-analytics
2) MedSolutions. “MedSolutions launches comprehensive post-acute care management project.” March 28, 2013. http://www.medsolutions.com/news/3-28-13.html
3) Keim, B. Paging Dr. Watson: Artificial intelligence as a prescription for health care. Wired. October 16, 2012. http://www.wired.com/wiredscience/2012/10/watson-for-medicine/
4) Ravindranath, M. “Reston firm helps health-care providers ID high-risk patients.” The Washington Post, August 23, 2013. http://search.proquest.com/docview/1427681318/fulltext/EDFFC4EB74664A74PQ/1?accountid=14586
5) Terhune, C. “Blue Shield of California to curb coverage of pricey cancer therapy.” Los Angeles Times, August 28, 2013. http://articles.latimes.com/2013/aug/28/business/la-fi-hospital-proton-beam-20130829
6) Millman, J. “One insurer’s answer to the skyrocketing bills for cancer care.” Washington Post, July 8, 2014. http://search.proquest.com/docview/1543865281/fulltext/CD7DDAC2ADB74191PQ/1?accountid=14586
7) Snowbeck C. “Medtronic sued by insurer Humana over infuse spinal product.” St. Paul Pioneer Press, June 1, 2014. http://www.lexisnexis.com/lnacui2api/api/version1/getDocCui?lni=5CBY-BT91-DYT4-V327&csi=313961&hl=t&hv=t&hnsd=f&hns=t&hgn=t&oc=00240&perma=true
Profiling/Feedback of Information on Treatment Patterns 1.* Dimick, J.B., Hendren, S.K. “Hospital report cards: Necessary but not sufficient?” JAMA Surgery 149(2):143-144, 2014.
http://archsurg.jamanetwork.com/issue.aspx?journalid=76&issueid=929755&direction=P 2. Greene, R.A., Beckman, H., Chamberlain, J., Partridge, G., Miller, M., Burden, D., Kerr, J. “Increasing adherence to a
community-based guideline for acute sinusitis through education, physician profiling, and financial incentives.” American Journal of Managed Care 2004;10(10):670-678. http://www.ajmc.com/publications/issue/2004/2004-10-vol10-n10/Oct04-1901p670-678/
3. PR Newswire. “Blue Cross Blue Shield of Michigan launches initiative to compare costs of care at hospitals across Michigan.” October 15, 2013. http://www.prnewswire.com/news-releases/blue-cross-blue-shield-of-michigan-launches-initiative-to-compare-costs-of-care-at-hospitals-across-michigan-227821661.html
4. Glance L.G., Osler, T.M., Mukamel, D.B. “Effectiveness of nonpublic report cards for reducing trauma mortality.” JAMA Surgery 149(2):137-143, 2014. http://archsurg.jamanetwork.com/issue.aspx?journalid=76&issueid=929755&direction=P
Practice Guidelines 1.* Lin, K.W., Slawson, D.C. “Identifying and using good practice guidelines.” American Family Physician 2009;80(1):67-69.
2. Kuehn, B.M. “Guidelines, online training aim to teach physicians to weigh costs of care, become better stewards of medical resources.” Journal of the American Medical Association 311(23):2368-2370, 2014. http://jama.jamanetwork.com/issue.aspx?journalid=67&issueid=930366&direction=P
3. Goldberger, J.J., Buxton, A.E. “Personalized medicine vs. guideline-based medicine.” Journal of the American Medical
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Association 2013;309(24):2559-2560. http://jama.jamanetwork.com/issue.aspx?journalid=67&issueid=927181&direction=P
4. Editorial. “Improving practice guidelines with patient-specific recommendations.” Annals of Internal Medicine 2011;154(9):638-639. http://annals.org/issue.aspx?journalid=90&issueID=20231&direction=P
5. Seaman, A.M. “Many medical guidelines don’t consider costs.” Reuters, May 7, 2013. http://www.reuters.com/article/2013/05/07/us-medical-guidelines-idUSBRE94610V20130507
6. Whalen, J. “Hospitals cut costs by getting doctors to stick to guidelines.” Wall Street Journal, September 22, 2014. http://online.wsj.com/articles/hospitals-cut-costs-by-getting-doctors-to-stick-to-guidelines-1411416051 Applications:
1)* Morin, M. “Back pain: Doctors increasingly ignore clinical guidelines.” Los Angeles Times, July 29, 2013. http://www.latimes.com/news/science/sciencenow/la-sci-sn-back-pain-doctors-increasingly-ignore-clinical-guidelines-20130729,0,185393.story#axzz2jscgny1T
2) Graham, J. “Mammogram guidelines are sparking a firestorm; Critics hit suggestion that women in 40s may not need routine screening.” Chicago Tribune, November 17, 2009, p.1. http://articles.chicagotribune.com/2009-11-17/news/0911160603_1_routine-mammograms-annual-mammograms-breast-cancer
3) Ando, R. “IBM and Aetna tie up to offer clinical support service.” Reuters, August 5, 2010. http://www.reuters.com/article/idUSTRE6740EW20100805
4) Nussbaum, A. “Aetna urges moms to avoid cesareans births to reduce risk.” Bloomberg.com, July 12, 2012. http://www.bloomberg.com/news/2012-07-13/aetna-urges-moms-to-avoid-cesareans-births-to-reduce-risk.html
5) Gordon, S. “Diabetes groups issue new guidelines on blood sugar.” HealthDay, April 19, 2012. http://consumer.healthday.com/Article.asp?AID=663893
Use of Treatment Reminders 1. Derose, S.F., Dudl, J.R., Benson, V.M., Contreras, R., Nakahira, R.K., Ziel, F.H. “Point-of-service reminders for
prescribing cardiovascular medications.” The American Journal of Managed Care 2005;11(5):298-304. http://www.ajmc.com/publications/issue/2005/2005-05-vol11-n5/May05-2027p298-304/
2. Marcus, A.D. “Big data treasure trove from routine medical checkups.” The Wall Street Journal, May 12, 2014. http://search.proquest.com/docview/1523785007/fulltext/27BE5B13AE7A4170PQ/2?accountid=14586
3. Shinal, J. “If ‘clean’ big data can improve U.S. health care.” USA Today, August 28, 2014. http://www.usatoday.com/story/tech/columnist/shinal/2014/05/14/medical-privacy-health/9087873/ Applications:
1) Mathews, A.W. “WellPoint’s new hire. What is Watson?” Wall Street Journal online, September 12, 2011. http://online.wsj.com/article/SB10001424053111903532804576564600781798420.html
Managing Imaging Use and Costs: Combining Utilization Management Tools 1.* Lee, D.W., Levy, F. “The sharp slowdown in growth of medical imaging: An early analysis suggests combination of
policies was the cause.” Health Affairs 2012;31(8):1876-1884. http://content.healthaffairs.org/content/31/8/1876.full.pdf+html
2.* Iglehart, J.K. “Health insurers and medical-imaging policy – a work in progress.” New England Journal of Medicine 2009;360(10):1030-1037. http://www.nejm.org/doi/pdf/10.1056/NEJMhpr0808703
3. Tynan, A., Berenson, R.A., Christianson, J.B. “Health plans target advanced imaging services: cost, quality and safety concerns prompt renewed oversight.” Center for Studying Health System Change Issue Brief No. 118, February 2008. http://www.hschange.com/CONTENT/968/
4. Rao, V.M., Levin, D.C. The overuse of diagnostic imaging and the choosing wisely initiative. Annals of Internal Medicine 2012;157(8):574-576. http://annals.org/article.aspx?articleid=1355170
5. Seaman, A.M. “Many lower back MRI scans may be unnecessary.” Reuters, March 25, 2013. http://www.reuters.com/article/2013/03/25/us-lower-back-mri-idUSBRE92O0XV20130325 Applications:
1) Mathews, A.W. “Insurers hire radiology police to vet scanning; firms make doctors justify costly CTs, MRIs and PETs; patients 'stuck in the middle'.” Wall Street Journal, November 6, 2008. http://online.wsj.com/article/SB122591900516802409.html
2) Kaiser Health News. “Concerns about unnecessary scans and radiation risk prompt reviews by doctors.” March 2, 2010. http://www.kaiserhealthnews.org/daily-reports/2010/march/02/radiation-and-ct-scans.aspx?referrer=search
3) Parashar, A. “In emergency rooms, it’s getting tougher to say ‘no’ to CT scans.” Kaiser Health News, November 29, 2010. http://www.kaiserhealthnews.org/Stories/2010/November/29/CT-scan-study-short-take.aspx
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4) Galewitz, P. “Imaging at the doctor’s: Good thing or transparent ploy?” USAToday, August 23, 2010. http://www.usatoday.com/yourlife/health/healthcare/doctorsnurses/2010-08-23-Imaging23_ST_N.htm
5) Carey, M.A. “Medical imaging advocates fight proposals requiring advance authorization.” Kaiser Health News, October 18, 2011. http://capsules.kaiserhealthnews.org/index.php/2011/10/medical-imaging-advocates-fight-proposals-requiring-advance-authorization/
6) Hancock, J. Pressure from insurers, government cuts radiology use and spending. KHN Blog, September 10, 2012. http://capsules.kaiserhealthnews.org/index.php/2012/09/pressure-from-insurers-government-cuts-radiology-use-and-spending/
7) Bardin, J. “Use of imaging tests soars, raising questions on radiation risk.” Los Angeles Times online, June 20, 2012. http://articles.latimes.com/2012/jun/12/science/la-sci-ct-mri-growth-20120613
Medicare Utilization Initiatives 1.* Pecquet, J. “Bipartisan duo fights proposals to curb medical imaging.” The Hill, March 31, 2011.
http://thehill.com/blogs/healthwatch/medicare/163957-bipartisan-duo-fights-proposals-to-curb-medical-imaging 2. U.S. Government Accountability Office. “Medicare: per capita method can be used to profile physicians and provide
feedback on resource use. Summary.” September 25, 2009. http://www.gao.gov/products/GAO-09-802 3. Carey, M.A., Serafini, M.W. “Doctors balk at proposal to cut Medicare’s use of imaging.” Kaiser Health News, June 14, 2011.
http://www.kaiserhealthnews.org/Daily-Reports/2011/June/15/1khnstory.aspx Further Readings on Imaging
1. Allen, G.P. “Costs escalate, patients suffer when waste, abuse and fraud permeate diagnostic imaging.” May 2007. http://www.imakenews.com/seroper/e_article000814532.cfm?x=b11,0,w
2. Bogdanich, W., McGinty, J.C. “Medicare claims showing overuse of CT scanning.” New York Times, June 18, 2011, p. A.1. http://www.nytimes.com/2011/06/18/health/18radiation.html?pagewanted=all
3. Bogdanich, W., Ruiz, R.R. “F.D.A. to increase oversight of medical radiation.” The New York Times, February 10, 2010. http://www.nytimes.com/2010/02/10/health/policy/10radiation.html
4. Franklin, C. “Before you get that CT scan…” Chicago Tribune, March 17, 2011, p.21. http://articles.chicagotribune.com/2011-03-17/opinion/ct-oped-0317-scanner-20110317_1_future-cancers-ct-scans-ct-colonography
5. Holcombe, D. “Oncology management programs for payers and physicians.” American Journal of Managed Care 2011;17:e182-e186. http://www.ajmc.com/publications/issue/2011/2011-5-vol17-n5/AJMC_11JOPmayHolcombe_e182to6
6. Iglehart, J.K. “The new era of medical imaging progress and pitfalls.” The New England Journal of Medicine 2006;354(26):2822-2828. http://www.nejm.org/doi/pdf/10.1056/NEJMhpr061219
7. Kaiser Health News. “Federal officials focus on radiation practices at Florida clinic; medical scan makers announce new efforts to prevent mistakes.” February 26, 2010. http://www.kaiserhealthnews.org/Daily-Reports/2010/February/26/Radiation.aspx
8. Kaiser Health News. “Los Angeles Times examines growing popularity, concerns regarding CT scans.” September 8, 2008. http://www.kaiserhealthnews.org/daily-reports/2008/september/08/dr00054331.aspx?referrer=search.
9. Landro, L. ”The informed patient: better ways to treat back pain; insurers, employers target excessive scans and surgeries to improve patient outcomes.” Wall Street Journal, May 16, 2007. http://online.wsj.com/article/SB117926943880204067.html
10. Marchione, M. “Be wary of radiation overdose from medical tests, doctors say.” TwinCities.com, June 14, 2010. http://www.twincities.com/alllistings/ci_15296869?source=rss
11. Perrone, M. “Medical scan makers to install radiation controls.” Seattle Times online. February 25, 2010. http://seattletimes.nwsource.com/html/businesstechnology/2011184043_apusradiationscanssafety.html
12. Phelps, D.” Insurers want 2nd opinion before approving scans.” MPR News, January 4, 2007. http://minnesota.publicradio.org/display/web/2007/01/04/scans
13. PR Newswire. “Anthem Blue Cross and Blue Shield of Wisconsin expands transparency of diagnostic imaging.” October 21, 2007. http://www.prnewswire.com/news-releases/anthem-blue-cross-and-blue-shield-expands-cost-disclosure-tool-to-northcentral-wisconsin-65185497.html
15. Sataline, S. “Doctors may risk overuse of CT scans.” Wall Street Journal, November 29, 2007. http://online.wsj.com/article/SB119627836509306828.html
16. Serafini, M.W., Carey, M.G. “Panel urges crackdown on Medicare’s use of imaging.” Kaiser Health News, June 14, 2011.
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http://www.kaiserhealthnews.org/Stories/2011/June/15/Medicare-imaging.aspx 17. Steenhuysen, J. “Doctors work on radiation problem to ease fears.” Reuters, June 7, 2010.
http://www.reuters.com/article/idUSTRE6565Y820100608 18. Steenhuysen, J. “Younger Americans overexposed to radiation risk.” Reuters, August 27, 2009.
http://www.reuters.com/article/idUSTRE57P59Z20090827 19. Szabo, L. Cancer risks prompt doctors to try to lower imaging scan radiation. USA Today.
http://www.usatoday.com/news/health/2010-05-05-radiation05_st_N.htm 20. Tanner, L. “Use of costly scans is climbing in cancer patients.” April 27, 2010.
http://www.msnbc.msn.com/id/36807258/ns/health-cancer/ 21. Bodenheimer, T., Berry-Millet, R. “Care management of patients with complex health care needs.” Research Synthesis
Report No. 19. Robert Wood Johnson Foundation Synthesis Project, December 2009. http://www.rwjf.org/en/research-publications/find-rwjf-research/2009/12/care-management-of-patients-with-complex-health-care-needs.html
Further Readings – General 1. Juster, I.A. et al. “Use of administrative data to identify health plan members with unrecognized bipolar disorder: a
retrospective cohort study.” American Journal of Managed Care 2005;11(9):578-584. http://www.ajmc.com/publications/issue/2005/2005-09-vol11-n9/Sep05-2123p578-584/
2. Neergaard, L. “Overtreated: more medical care isn’t always better.” ABC News, July 7, 2010. http://abcnews.go.com/Health/wireStory?id=10843361
3. O’Connor, P.J., Sperl-Hillen, J., Johnson, P.E. “Customized feedback to patients and providers failed to improve safety or quality of diabetes care. A randomized trial.” Diabetes Care 2009;32(7):1158-1163. http://care.diabetesjournals.org/content/32/7/1158.full.pdf+html
4. Paltrow, S.J. “Insurers’ black box.” Center for American Progress, October 23, 2009. http://www.americanprogress.org/issues/2009/10/black_box.html
5. Reuters. “UPDATE 1-U.S. health insurers say Gilead hepatitis C drug too costly” May 21, 2014. http://www.reuters.com/article/2014/05/20/insurance-gilead-sciences-drugcosts-idUSL1N0O62C920140520
6. Bindman, A. “Can Physician Profiles Be Trusted?” JAMA 1999;281(22):2142-2143. http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=4646&direction=P
7. Boulton, G. “Guidelines met with dose of skepticism. Do they aid doctors or hinder them?” Milwaukee Journal Sentinel, June 27, 2010. http://www.jsonline.com/business/97280724.html
8. Matlock, D.D., Groeneveld, P.W., Sidney, S., et al. “Geographic variation in cardiovascular procedure use among Medicare fee-for-service vs Medicare advantage beneficiaries.” Journal of the American Medical Association 2013;310(2):155-162. http://jama.jamanetwork.com/issue.aspx?journalid=67&issueid=927264&direction=P
9. Hussey, P.S., Schneider, E.C., Rudin, R.S., Fox, D.S., Lai, J., Pollack, C.E. “Continuity and the costs of care for chronic disease.” JAMA Internal Medicine 174(5):742-748, 2014. http://archinte.jamanetwork.com/issue.aspx?journalid=71&issueid=930064&direction=P
10:45 AM – Noon – Supporting Employees/Enrollees in Choosing Treatment Options There is growing support for the need to provide consumers with information necessary to evaluate treatment options and select the option that is the best fit for their individual circumstances and preferences. Consumer decision aids have been developed to address this issue. We discuss how decision aids function, evidence of their effectiveness, and the roles of employers and health plans in encouraging their use. We also discuss the challenges that low health literacy and numeracy poses for the use of “shared decision making” generally, and specifically how it relates to consumer choice of treatment options. We also describe efforts by payers and health plans to address this issue. Learning Objectives Students should be able to:
1. Describe different approaches being used to support consumers in their choice of treatments. 2. Discuss the problems faced by employers and health plans in implementing decision aids. 3. Evaluate the evidence regarding the effectiveness of these decision aids. 4. Assess the challenges that low health literacy and numeracy poses for informed consumer decision making.
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Suggested Readings Shared Decision Making in Concept
1.* RWJF Aligning Forces for Quality. “Shared decision-making and benefit design: Engaging employees and reducing costs for preference-sensitive conditions.” April 2013. http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/04/shared-decision-making-and-benefit-design.html
2.* Robert Wood Johnson Foundation. “The current and future role of consumers in making treatment decisions.” Issue Brief 4 of 6, October 2007. http://www.rwjf.org/pr/product.jsp?id=23074
3. Brown, E. “Patients who helped with medical choices had higher bills: Study.” Los Angeles times, May 27, 2013. http://articles.latimes.com/2013/may/27/science/la-sci-sn-patient-decisions-higher-bills-20130528
4. Brownlee, S., Colucci, J. The cost of assuming doctors know best. The Atlantic, September 28, 2012. http://www.theatlantic.com/health/archive/2012/09/the-cost-of-assuming-doctors-know-best/262993/
5. Rosenbaum, L. “How should doctors share impossible decisions with their patients.” The New Yorker, July 3, 2013. http://www.newyorker.com/tech/elements/how-should-doctors-share-impossible-decisions-with-their-patients
6. Krumholz, H. “Physician assessment and the hidden curriculum.” American Board of Internal Medicine, September 25, 2014. http://assessment2020.abim.org/2014/09/physician-assessment-hidden-curriculum/ Applications:
1) Landro. L. “Weighty choices, in patients' hands.” The Wall Street Journal, August 4, 2009, p. D.2. http://search.proquest.com/docview/399108922/fulltext/55B3B7206755490BPQ/1?accountid=14586
2) Lewis, D. “Survey: Patient engagement important, but loosely defined.” FierceHealthcare, March 20, 2012. http://www.fiercehealthcare.com/story/survey-patient-engagement-important-loosely-defined/2012-03-20
3) Health Dialog. Health dialog makes decision aid available for national hospice and palliative care month. November 15, 2012. http://www.healthdialog.com/Utility/News/PressRelease/12-11-16/Health_Dialog_Makes_Decision_Aid_Available_for_National_Hospice_and_Palliative_Care_Month
4) Kenen, J. ACA boosts ‘shared decision-making.’ Politico, November 29, 2012. http://www.politico.com/story/2012/11/84356.html
5) Weiner, S.J., Schwartz, A., Sharma, G., et al. “Patient-centered decision making and health care outcomes. An observational study.” Annals of Internal Medicine 2013;158(8):573-579. http://annals.org/issue.aspx?journalid=90&issueID=926759&direction=P
6) Rao, A. Study: Decision aids show promise in reducing medical procedures. KHN Blog, September 5 ,2012. http://capsules.kaiserhealthnews.org/index.php/2012/09/study-decision-aids-show-promise-in-reducing-medical-procedures/
7) PR Newswire. “WiserTogether and Truven Health Analytics partner to help consumers make evidence-based, cost-effective treatment Decisions.” March 11, 2014. http://www.prnewswire.com/news-releases/wisertogether-and-truven-health-analytics-partner-to-help-consumers-make-evidence-based-cost-effective-treatment-decisions-249430551.html
Issues in Shared Decision Making and the Use of Decision Aids 1.* Katz, S.J., Hawley, S. “The value of sharing treatment decision making with patients. Expecting too much?” Journal of
the American Medical Association 2013;310(15):1559-1560. http://jama.jamanetwork.com/issue.aspx?journalid=67&issueid=928054&direction=P
2.* Frosch, D.L., May, S.G., Rendle, K.A.S., Tietbohl, C., Elwyn, G. “Authoritarian physicians and patients’ fear of being labeled ‘difficult’ among key obstacles to shared decision making.” Health Affairs 2012;31(5):1030-1038. http://content.healthaffairs.org/content/31/5/1030.full.pdf+html
4. Carman, K.L., Maurer, M., Yegian, J.M., Dardess, P., McGee, J., Evers, M., Mario, K.O. “Evidence that consumers are skeptical about evidence-based health care.” Health Affairs 2010;29(7):1400-1406. http://content.healthaffairs.org/content/29/7/1400.full.pdf+html
5. Krumholz, H.M. “Variations in health care, patient preferences, and high-quality decision making.” Journal of the American Medical Association 2013;310(2):151-152. http://jama.jamanetwork.com/issue.aspx?journalid=67&issueid=927264&direction=P
6. Ubel, P.A., Abernethy, A.P., Zafar, S.Y. “Full disclosure — Out-of-pocket costs as side effects.” New England Journal of Medicine 2013;369(16):1484-1486. http://www.nejm.org/toc/nejm/369/16 Applications:
1) Shaw, G. “Does decision support make docs look dumb?” Health Leader Media, April 14, 2011.
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http://www.healthleadersmedia.com/page-1/MAG-264919/Does-Decision-Support-Make-Docs-Look-Dumb## 2) Veroff, D., Marr, A., Wennberg, D.E. “Enhanced support for shared decision making reduced costs of care for
patients with preference-sensitive conditions.” Health Affairs 32(2):285-293, 2013. http://content.healthaffairs.org/content/32/2.toc
The Importance of Health Literacy, Numeracy, and Language Issues to Informed Choice 1.* Peters, E., Hibbard, J., Slovic, P., Dieckmann, N. “Numeracy skill and the communication, comprehension, and use of
risk-benefit information.” Health Affairs 2007;26(3):741-748. http://content.healthaffairs.org/content/26/3/741.full.pdf+html
2. America’s Health Insurance Plans. “AHIP statement on HHS’s national action plan to improve health literacy.” Press Release, May 27, 2010. http://www.ahip.org/content/pressrelease.aspx?docid=30599
3. Gorman, A. “Say what? Many patients struggling to learn the foreign language of health insurance.” Kaiser Health News, June 16, 2014. http://www.kaiserhealthnews.org/stories/2014/june/16/many-patients-struggling-to-learn-the-foreign-language-of-health-insurance.aspx
4. Kremer, W. “Do doctors understand test results?” BBC News Magazine, July 6, 2014. http://www.bbc.com/news/magazine-28166019
Applications: 1) America’s Health Insurance Plans. “New tool available for health care companies to assess their
organizations’ health literacy programs.” Press Release, March 15, 2010. http://www.ahip.org/content/pressrelease.aspx?bc=174|29744
2) Boodman, S.G. “Helping patients understand their medical treatment.” Kaiser Health News, March 1, 2011. http://www.kaiserhealthnews.org/Stories/2011/March/01/Health-Literacy-Understanding-Medical-Treatment.aspx
3) Crosby, J. “UnitedHealthcare takes initiative to enhance health literacy.” StarTribune, May 17, 2014. http://www.startribune.com/business/259562401.html
Further Readings
1. Barclay, E. “Speaking the same language. Medical providers struggle to communicate with immigrant patients.” The Washington Post, April 21, 2009, p. F.1. http://www.washingtonpost.com/wp-dyn/content/article/2009/04/20/AR2009042002466.html
2. Bavley, A. “Health literacy is touted to improve patient roles.” June 3, 2010. http://www.computerizedscreening.com/about/news/06-07-2010/health-literacy-is-touted-to-improve-patient-roles
3. Brownlee, S. “Giving patients a larger voice; more doctors welcome dialogue about tests and procedures.” The Washington Post, October 23, 2007. http://www.washingtonpost.com/wp-dyn/content/article/2007/10/19/AR2007101902620.html
4. Health Dialog. “Health Dialog releases testimony on health literacy.” Press Release July 7, 2010. http://www.healthdialog.com/Utility/News/PressRelease/10-07-07/Health_Dialog_Releases_Testimony_on_Health_Literacy
5. Katz, S.J., Howley, S.T. “From policy to patients and back: surgical treatment decision making for patients with breast cancer.” Health Affairs 2007;26(3):761-769. http://content.healthaffairs.org/content/26/3/761.full.pdf+html
6. Landro. L. “The informed patient: the importance of trying to be a good patient.” Wall Street Journal, April 29, 2009 7. PR Newswire. “Limited health literacy increased safety risk for patients with diabetes.” May 19, 2012.
8. Robert Wood Johnson Foundation. “Choice in medical care: when should the consumer decide?” Issue Brief 5 of 6, October 2007. http://www.rwjf.org/pr/product.jsp?id=23075
9. Weinstein, J.N., Clay, K., Morgan, T.S. “Informed patient choice: patient-centered valuing of surgical risks and benefits.” Health Affairs 2007;26(3):726-730. http://content.healthaffairs.org/content/26/3/726.full.pdf+html
10. Seaman, A.M. “Patient communication has room to grow: Studies.” Reuters, May 27, 2013. http://www.reuters.com/article/2013/05/27/us-patient-communication-idUSBRE94Q0KN20130527
11. WiserTogether. “Group Health Cooperative of Eau Claire implements WiserTogether’s shared decision support platform.” July 20, 2012. http://www.wisertogether.com/news/2012/07/20/group-health-cooperative-of-eau-claire/
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JANUARY 14, 2014 8:00 – 9:15 AM – Supporting Employees/Enrollees in Maintaining and Improving Their Health Increasingly, employers are instituting programs and financial incentives that support employees in maintaining and improving their health. The expectation is that these efforts will reduce the rate of increase in health care costs over time by reducing or delaying the onset of chronic illnesses. Employers also hope that they will reduce absenteeism and increase worker productivity. Payers use both rewards and negative incentives to encourage healthy behaviors, and depend on both health plans and independent vendors for delivering program content. The employer role in promoting these “wellness” programs has been controversial as it relates to use of positive versus negative incentives and the protection of personal employee information. Learning Objectives Students should be able to:
1. Describe the rationale for employer/health plan support for healthy lifestyle programs. 2. Assess the strengths and weaknesses of different program designs. 3. Evaluate the evidence that these programs have been successful in achieving their goals. 4. Discuss the impediments to the successful implementation of these programs. 5. Discuss the aspects of these programs that can make them controversial.
Suggested Readings Design of Healthy Lifestyle Programs
1.* Volpp, K.G., Asch, D.A., Galvin, R., Loewenstein, G. “Redesigning employee health incentives — Lessons from behavioral economics.” New England Journal of Medicine 2011;365(5):388-390. http://www.nejm.org/doi/pdf/10.1056/NEJMp1107285
2.* Wall Street Journal. “Survey: employers fret over workers’ poor health habits.” February 22, 2010. http://blogs.wsj.com/health/2010/02/22/survey-employers-fret-over-with-workers-poor-health-habits/
3.* Appleby, J. Workers’ poor health costs employers $344 billion, study finds. KHN Blog, September 14, 2012. http://capsules.kaiserhealthnews.org/index.php/2012/09/workers-poor-health-costs-employers-344-billion-study-finds/
4. National Business Group on Health. “Annual wellness study finds significant jump in incentive dollars as employers report improved employee participation.” February 8, 2011. http://www.businessgrouphealth.org/pressrelease.cfm?printPage=1&ID=170
5. UnitedHealthcare Press Release. “UnitedHealthcare recognizes employers for industry-leading worksite wellness programs.” June 5, 2014. http://www.uhc.com/news_room/2014_news_release_archive/worksite_wellness_awards.htm
6. Murphy, T., Lucey, C. “Wellness programs grow more popular with employers.” AP The Big Story, April 23, 2014. http://bigstory.ap.org/article/wellness-programs-grow-more-popular-employers
Applications: 1)* Medica. “Medica introduces group health and wellness coaching program.” Corporate Announcement, April
2) Midwest Business Group on Health. “New employer survey finds growing use of outcomes-based incentives, majority using either carrot or stick to motivate healthy employee behaviors.” PRNewswire, May 7, 2013. http://www.prnewswire.com/news-releases/new-employer-survey-finds-growing-use-of-outcomes-based-incentives-majority-using-either-carrot-or-stick-to-motivate-healthy-employee-behaviors-206394381.html
3) Cigna. “Cigna says health assessment and coaching are key to reducing health risks; extends exclusive license with University of Michigan.” August 16, 2011. http://newsroom.cigna.com/NewsReleases/cigna-says-health-assessment-and-coaching-are-key-to-reducing-health-risks--extends-exclusive-license-with-university-of-michigan.htm
4) Press Release. “Dean Health Plan, Healthways partner to introduce comprehensive, integrated total population health programs.” Reuters, February 21, 2012. http://www.reuters.com/article/2012/02/21/idUS203818+21-Feb-2012+BW20120221
5) HealthPartners. “HealthPartners first in regional market to introduce health and well-being web portal customized to employers.” Press Release, March 19, 2012. http://www.healthpartners.com/public/newsroom/newsroom-article-list/03-19-12.html
6) BusinessWire. “Alere launches comprehensive coaching solution to help employers battle the causes of rising healthcare costs.” September 30, 2014. http://www.businesswire.com/news/home/20140930005133/en/Alere-Launches-Comprehensive-Coaching-
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Solution-Employers-Battle Evidence of Program Effectiveness
1.* Pho, K. “Do corporate wellness programs work?” USA Today, September 9, 2013. http://www.usatoday.com/story/opinion/2013/09/09/corporate-wellness-programs-column/2790107/
2. Mattke, S., Serxner, S.A., Zakowski, S.L., Jain, A.K., Gold, D.B. “Impact of 2 employer-sponsored population health management programs on medical care cost and utilization.” American Journal of Managed Care 2009;15(2):113-120. http://www.ajmc.com/publications/issue/2009/2009-02-vol15-n2/Feb09-3916p113-120/
3. Russell, L.B. “Preventing chronic disease: an important investment, but don’t count on cost savings.” Health Affairs 2009;28(1):42-45. http://content.healthaffairs.org/content/28/1/42.full.pdf+html
4. Goetzel, R.Z. “Do prevention or treatment services save money? The wrong debate.” Health Affairs 2009;28(1):37-41. http://content.healthaffairs.org/content/28/5/1532.full.pdf+html
5. PR Newswire. “Study: Preventive services can save lives, billions of dollars, at little or no cost.” September 7, 2011. http://www.prnewswire.com/news-releases/study-preventive-services-can-saves-lives-billions-of-dollars-at-little-or-no-cost-102351314.html Applications:
1)* Henke, R.M., Goetzel, R.Z., McHugh, J., Isaac, F. “Recent experience in health promotion at Johnson & Johnson: Lower health spending, strong return on investment.” Health Affairs 2011;30(3):490-499. http://content.healthaffairs.org/content/30/3/490.full.pdf+html
2) Thomas, K. “Companies get strict on health of workers.” The New York Times, March 25, 2013. http://www.nytimes.com/2013/03/26/business/companies-offer-workers-more-incentives-for-health-changes.html?_r=0
3) Medica. “Medica health and wellness coaching program improves health, reduces cost.” January 3, 2012. http://newscenter.medica.com/press-release/products-services/medica-health-and-wellness-coaching-program-improves-health-reduces-
4) UnitedHealth Group. “Study: “Join For Me” program effectively treats childhood obesity.” October 22, 2013. http://www.unitedhealthgroup.com/Newsroom/Articles/Feed/UnitedHealth%20Group/2013/1022JoinForMeChildhoodObesity.aspx
5) UnitedHealthcare Press Release. “UnitedHealthcare recognizes employers for industry-leading worksite wellness programs.” June 5, 2014. http://www.uhc.com/news_room/2014_news_release_archive/worksite_wellness_awards.htm
6) Vestal, C. “Washington wellness plan beats the odds.” USA Today, July 22, 2014. http://www.usatoday.com/story/news/nation/2014/07/22/stateline-washington-wellness-health-employees/12987659/
Concerns about Program Incentives 1.* Singer, N. “Rules sought for workplace wellness questionnaires.” The New York Times, September 24, 2013.
http://search.proquest.com/docview/1435728410/fulltext/177CCBF386CA4E9FPQ/1?accountid=14586 2.* Horwitz, J.R., Kelly, B.D., DiNardo, J.E. “Wellness incentives in the workplace: Cost savings through cost shifting to
unhealthy workers.” Health Affairs 2013;32(3):468-476. http://content.healthaffairs.org/content/32/3/468.full.pdf+html 3. Pearson, S.D., Lieber, S.R. “Financial penalties for the unhealthy? Ethical guidelines for holding employees
responsible for their health.” Health Affairs 2009;28(3):845-852. http://content.healthaffairs.org/content/28/3/845.full.pdf+html
4. Rogers, T., Milkman, K.L., Volpp, K.G. “Commitment devices: Using initiatives to change behavior.” Journal of the American Medical Association 311(20):2065-2066, 2014. http://jama.jamanetwork.com/issue.aspx?journalid=67&issueid=930246&direction=P
Applications: 1)* USA Today. “Not hiring smokers crosses privacy line.” Editorial, January 29, 2012.
http://www.usatoday.com/news/opinion/editorials/story/2012-01-29/not-hiring-smokers-privacy/52874348/1 2) Koch, W. “Workplaces ban not only smoking, but smokers.” USA Today, January 6, 2012.
3) Kwoh, L. “When your boss makes you pay for being fat.” The Wall Street Journal, April 5, 2013. http://online.wsj.com/article/SB10001424127887324600704578402784123334550.html
4) Lerner, M. “Medica wants to put health coach between you and your bad habits; but critics say the voluntary, no-cost program is like health care big brother.” Star Tribune, October 1, 2008. http://www.startribune.com/lifestyle/29981699.html
5) Knight, V.E. “Treading carefully with wellness programs.” The Wall Street Journal, July 28, 2009.
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http://online.wsj.com/article/SB124880470938287485.html 6) Tuna, C. “Theory and practice: wellness efforts face hurdle --- asking workers about family health history can
clash with U.S. genetics law.” Wall Street Journal, February 1, 2010, p. B.2. http://online.wsj.com/article/SB10001424052748703822404575019790731232312.html
7) Mincer, J. “Insight: Firms to charge smokers, obese more for healthcare.” Reuters, October 30, 2011. http://www.reuters.com/article/2011/10/30/us-penalties-idUSTRE79T2S220111030
8) Harris, A. “First wellness program firing suit filed by U.S. agency.” Bloomberg, August 20, 2014. http://www.bloomberg.com/news/2014-08-20/first-wellness-program-firing-suit-filed-by-u-s-agency.html
Health Reform and Wellness 1.* Jost, T. “Implementing health reform: Workplace wellness programs.” Health Affairs Blog, May 29, 2013.
http://healthaffairs.org/blog/2013/05/29/implementing-health-reform-workplace-wellness-programs/ 2. Madison, K., Schmidt, H., Volpp, K.G. “Smoking, obesity, health insurance, and health incentives in the Affordable
Care Act.” Journal of the American Medical Association 2013;310(2):143-144. http://jama.jamanetwork.com/issue.aspx?journalid=67&issueid=927264&direction=P
3. Lewis, A., Khanna, V. “The million-dollar workplace wellness heart attack screen.” Health Affairs Blog, April 29, 2013. http://healthaffairs.org/blog/2013/04/29/the-million-dollar-workplace-wellness-heart-attack-screen/
Further Readings 1. Appleby, J. “Firms offer bigger incentives for healthy living.” USA Today, January 20, 2009.
http://www.usatoday.com/news/health/2009-01-19-diabetes_N.htm 2. CIGNA Corporation. “CIGNA Launches Worksite Wellness Program to Help Combat Top Health Risks Facing
Americans.” News Release February 22, 2010. http://newsroom.cigna.com/article_display.cfm?article_id=1175 3. Editors. “Should people be paid to stay healthy?” New York Times, June 14, 2010.
http://roomfordebate.blogs.nytimes.com/2010/06/14/should-people-be-paid-to-stay-healthy/ 4. Gold, J. “Corporate wellness programs: healthier employees, lower costs.” Kaiser Health News, October 30, 2009.
http://www.kaiserhealthnews.org/Checking-In-With/fikry-wellness-q-and-a.aspx 5. National Institute for Health Care Management. “Building a stronger evidence base for employee wellness programs.”
Meeting Brief, May 2011. http://nihcm.org/images/stories/Wellness_FINAL_electonic_version.pdf 6. PR Newswire. “Medical Mutual of Ohio partners with Linkwell Health to bring can-do wellness program to its members.”
May 5, 2011. http://www.prnewswire.com/news-releases/medical-mutual-of-ohio-partners-with-linkwell-health-to-bring-can-do-wellness-program-to-its-members-121340073.html
7. Slitt, M. “CIGNA earns new accreditation for wellness and health promotion programs from the National Committee for Quality Assurance (NCQA).” News Release, November 9, 2009. http://newsroom.cigna.com/article_display.cfm?article_id=1126
8. Sutherland, K., Christianson, J.B., Leatherman, S. “Impact of targeted financial incentives on personal health behavior. A review of the literature.” Medical Care Research and Review 2008;65(Suppl to 6):36S-78S. http://mcr.sagepub.com/content/65/6_suppl/36S.full.pdf+html
9. Draper, D.A., Tynan, A., Christianson, J.B. “Health and wellness: the shift from managing illness to promoting health.” Center for Studying Health System Change Issue Brief No. 121, June 2008. http://www.hschange.com/CONTENT/989/
10. Jauhar, S. “No matter what, we pay for others' bad habits.” New York Times, March 30, 2010. http://www.nytimes.com/2010/03/30/health/30risk.html?_r=0
11. Lewis, A., Khanna, V. “Here comes ObamaCare’s ‘workplace wellness’.” The Wall Street Journal, June 20, 2013. http://online.wsj.com/article/SB10001424127887323501004578389673547444046.html
12. Bernstein, L. “Keeping employees, bottom lines in shape.” The Washington Post, July 5, 2011. http://search.proquest.com/docview/874564811/fulltext/D7A1BF819AB449A7PQ/1?accountid=14586
13. Huskamp, H.A., Rosenthal, M.B. “Health risk appraisals: how much do they influence employees’ health behavior?” Health Affairs 2009;28(5):1532-1540. http://content.healthaffairs.org/content/28/5/1532.full.pdf+html
9:15 – 10:30 AM – Supporting Employees/Enrollees in Managing Chronic Illness Employers are strong supporters of programs that help employees “self-manage” care for chronic illnesses. The general idea is to place the consumer in a much more central role in medical care treatment. By educating consumers in appropriate treatment methods for their illnesses and supporting their efforts to manage their illnesses, payers and health plans hope that the progression of chronic illnesses can be delayed, and the number of acute flare-ups of chronic illnesses can be minimized. This,
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in turn, would improve the quality of life for employees, reduce emergency room and hospital use, and restrain growth in costs. We discuss efforts of payers and health plans to support consumers in chronic care management and the contexts in which they have been successful. Learning Objectives Students should be able to:
1. Explain the concepts of patient self-management and disease management in their different forms. 2. Discuss the various ways in which employers and health plans are supporting employees and plan enrollees in chronic
illness management. 3. Assess the evidence of their effectiveness in various settings. 4. Describe the obstacles to the effective implementation, by payers and health plans, of programs to support chronic
illness management by consumers. Suggested Readings Importance of Developing Effective Approaches to Chronic Illness Management
1.* Steenhuysen, J. “U.S. diabetes cases to double, costs triple by 2034.” Reuters, November 27, 2009. http://www.reuters.com/article/idUSTRE5AQ0C220091127
2.* Sklaroff, S. “On our own. Why we who struggle to live with diabetes could use a helping hand.” Health Affairs 31(1):236-239, 2012. http://content.healthaffairs.org/content/31/1/236.full.pdf+html
3. Terhune, C., Weintraub, A. “Take your meds, exerciseand spend billions.” BusinessWeek, February 4, 2010. http://www.businessweek.com/magazine/content/10_07/b4166046292556.htm
4. Grens, K. “Half of heart patients don’t stick to their meds.” Reuters, July 25, 2012. http://www.reuters.com/article/2012/07/25/us-heart-patients-meds-idUSBRE86O16M20120725
5. Gillespie, L. “The health care system falls apart when you’re a complex patient.” Kaiser Health News, October 1, 2014. http://kaiserhealthnews.org/news/the-health-care-system-falls-apart-when-youre-a-complex-patient/
Self-Management of Illnesses 1.* Health Affairs. Patient engagement. People actively involved in their health and health care tend to have better
outcomes—and, some evidence suggests, lower costs. Health Policy Brief, February 14, 2013. http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_86.pdf
2.* Bodenheimer, T., Lorig, K., Holman, H., Grumbach K., “Patient self-management of chronic disease in primary care.”JAMA 2002;288(19):2469-2475. http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=4856&direction=P
3. Koven, S. “Why patients don’t always follow doctor’s orders.” The Boston Globe, April 22, 2013. http://search.proquest.com/docview/1331048738/fulltext/76CF9D0C2D814754PQ/1?accountid=14586
4. Jerant, A., Moore-Hill, M., Franks, P. “Home-based, peer-led chronic illness self-management training: findings from a 1-year randomized controlled trial.” Annals of Family Medicine 2009;7(4):319-327. https://www.clinicalkey.com/#!/BrowserCtrl/doBrowseTo/journalIssue/{"facet":["1-s2.0-S1544170909X6004X"],"issn":"15441709","contentType":"Journals"}
Disease Management Programs – Structure and Effectiveness 1.* Vojta, D., De Sa, J., Prospect, T., Stevens, S. “Effective interventions for stemming the growing crisis of diabetes and
prediabetes: A national payer’s perspective. Health Affairs 31(1):20-26, 2012. http://content.healthaffairs.org/content/31/1/20.full.pdf+html
2.* Mullainathan, S. “When a co-pay gets in the way of health.” The New York Times, August 10, 2013. http://www.nytimes.com/2013/08/11/business/when-a-co-pay-gets-in-the-way-of-health.html?pagewanted=all&_r=0
3. Bernstein, J., Chollet D., Peterson, G.G. “Disease management: does it work?” Mathematica Policy Research Inc. Issue Brief No. 4, May 2010. http://www.mathematica-mpr.com/publications/PDFs/health/reformhealthcare_IB4.pdf
1)* Independence Blue Cross. “Independence Blue Cross’s nurse coaches are just a phone call away.” Press Release, May 16, 2013. http://www.ibx.com/company_info/news/press_releases/2013/05_16_IBCs_nurse_coaches_are_j.html
2) Joelving, F. Drop in hospital visits seen with lower drug copay. Reuters, October 3, 2012. http://www.reuters.com/article/2012/10/03/us-drop-drug-idUSBRE8921AP20121003
3) Lin, W.C., Chien, H.L., Willis, G., et al. “The effect of a telephone-based health coaching disease
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management program on Medicaid members with chronic conditions.” Medical Care 2012;50(1):91-98. http://ovidsp.tx.ovid.com/sp-3.8.1a/ovidweb.cgi?WebLinkFrameset=1&S=KIAOFPEMJODDDCAANCOKIHJCIEPOAA00&returnUrl=ovidweb.cgi%3f%26TOC%3dS.sh.18.19.23.27%257c12%257c50%26FORMAT%3dtoc%26FIELDS%3dTOC%26S%3dKIAOFPEMJODDDCAANCOKIHJCIEPOAA00&directlink=http%3a%2f%2fgraphics.tx.ovid.com%2fovftpdfs%2fFPDDNCJCIHAAJO00%2ffs047%2fovft%2flive%2fgv031%2f00005650%2f00005650-201201000-00012.pdf&filename=The+Effect+of+a+Telephone-based+Health+Coaching+Disease+Management+Program+on+Medicaid+Members+With+Chronic+Conditions.&link_from=S.sh.18.19.23.27%7c12&pdf_key=B&pdf_index=S.sh.18.19.23.27
4) Tocknell, M.D. “Aetna targets readmissions with pharmacy pilot.” HealthLeaders Media, August 28, 2013. http://www.healthleadersmedia.com/content/HEP-295739/Aetna-Targets-Readmissions-With-Pharmacy-Pilot
5) Andrews, M. “Group appointments with doctors: When three isn’t a crowd.” Kaiser Health News, March 19, 2013. http://www.kaiserhealthnews.org/features/insuring-your-health/2013/031913-michelle-andrews-on-group-patient-appointments.aspx
6) Ramsey, M. “Ford adopts health management program.” The Wall Street Journal, June 24, 2013. http://online.wsj.com/article/SB10001424127887324183204578565503660688878.html
7) Feder, J.L. “Predictive modeling and team care for high-need patients at HealthCare Partners.” Health Affairs 2011;30(3):416-418. http://content.healthaffairs.org/content/30/3/416.full.pdf+html
Further Readings
1. Agency for Healthcare Research and Quality, USDHHS. “Asthma Return-on-Investment Calculator. User’s Guide.” http://statesnapshots.ahrq.gov/asthma/UserGuide.jsp
2. Conklin, A., Nolte, E. “Disease management evaluation. A comprehensive review of current state of the art.” RAND Technical Report, December 2010. http://www.rand.org/content/dam/rand/pubs/technical_reports/2011/RAND_TR894.pdf
3. Draaghtel, K. Hit or miss? Using risk scores to decide. Milliman, March 7, 2011. http://publications.milliman.com/periodicals/rsa/pdfs/hit-or-miss-using-risk.pdf
4. Healthways well-being improvement solution. http://www.healthways.com/solution/default.aspx?id=91 5. Mattke, S. “Is there a disease management backlash?” American Journal of Managed Care 2008;14(6):349-350.
http://www.ajmc.com/publications/issue/2008/2008-06-vol14-n6/Jun08-3297p349-350/ 6. Motheral, B.R. “Telephone-based disease management: Why it does not save money.” American Journal of Managed
Care 2011;17(1):e10-e16. http://www.ajmc.com/publications/issue/2011/2011-1-vol17-n1/AJMC_11jan_Motheral_WebX_e10/
7. Paez, K.A., Zhao, L., Hwang, W. “Rising out-of-pocket spending for chronic conditions: a ten-year trend.” Health Affairs 2009;28(1):15-25. http://content.healthaffairs.org/content/28/1/15.full.pdf+html
8. PR Newswire. “Capital BlueCross receives inaugural national award for developing oncology case management program.” July 12, 2011. http://www.prnewswire.com/news-releases/capital-bluecross-receives-inaugural-national-award-for-developing-oncology-case-management-program-125428503.html
9. Preidt, R. “Simple case management cuts pulmonary disease admissions.” ABC News, May 22, 2008. http://abcnews.go.com/Health/Healthday/story?id=4901415&page=1
10. Reuters. “Incentives and pharmacist coaches lead to improved health and lower health care costs for diabetic patients.” May 7, 2009. http://www.reuters.com/article/2009/05/07/idUS158325+07-May-2009+PRN20090507
11. PR Web. “New study shows coaching to patient activation levels improves disease management outcomes.” June 10, 2009. http://www.prweb.com/releases/Insignia_Health/LifeMasters/prweb2510184.htm
12. Calandra, R. “The doctor will see you now – in a group.” The Inquirer, May 13, 2013. http://articles.philly.com/2013-05-13/news/39231077_1_dietary-fiber-group-appointments-family-physicians
13. Draaghtel, K. Predicting participation and savings. Using predictive modeling to identify patients for disease management. Milliman White Paper. http://publications.milliman.com/periodicals/rsa/pdfs/predicting-participation-and-savings.pdf
10:30 AM – Noon – Supporting Employees/Enrollees in Choosing Providers: Reporting Provider Performance Discussion of Individual Assignment 3 Providing consumers with timely, useful information about the performance of providers is one way that purchasers hope to
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engage consumers. Their intent is that consumers will use this information, in combination with financial incentives, to seek out lower cost, higher quality providers and to inform their conversations with providers. And, it is hoped that providers will improve their quality and reduce their costs when faced with public comparisons with their peers. The present health care system, some argue, does not provide information that is truly useful to consumers in making cost/quality tradeoffs when choosing providers, or that is credible to providers. We will discuss recent efforts to publicly report information comparing providers, as well as the evidence regarding the influence of this information on consumer and provider decisions. Learning Objectives Students should be able to:
1. Describe the recent efforts to increase the amount and quality of information available to health care consumers about providers.
2. Discuss the responses of providers to these efforts. 3. Assess the evidence regarding the impact of comparative provider performance data on consumer decisions, quality of
care, and health care costs. Suggested Readings Entities Producing Public Reports
1.* Christianson, J.B., Volmar, K.M., Alexander, J., Scanlon, D.P. “A report card on provider report cards: Current status of the health care transparency movement.” Journal of General Internal Medicine 2010;25(11):1235-1241. http://link.springer.com/content/pdf/10.1007%2Fs11606-010-1438-2.pdf
2.* Kullgren, J.T., Duey, K.A., Werner, R.M. “A census of state health care price transparency websites.” Journal of the American Medical Association 2013;309(23):2437-2438. http://jama.jamanetwork.com/issue.aspx?journalid=67&issueid=927128&direction=P
3. Robert Wood Johnson Foundation. “Working with Consumer Reports to educate consumers to make informed health care decisions.” June 2014. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2014/rwjf413645
4. Young, G.J. “Multistakeholder regional collaboratives have been key drivers of public reporting but now face challenges.” Health Affairs 2012;31(3):578-584. http://content.healthaffairs.org/content/31/3/578.full.pdf+html
5. Osborne, N.H., Ghaferi, A.A., Nicholas, L.H., Dimick, J.B. “Evaluating popular media and internet-based hospital quality ratings for cancer surgery.” Archives of Surgery 2011;146(5):600-604. http://archsurg.jamanetwork.com/Issue.aspx?journalid=76&issueID=5406&direction=P
6. Galewitz, P. “Hospitals get into doctor rating business.” Kaiser Health News Blog, April 17, 2014. http://capsules.kaiserhealthnews.org/index.php/2014/04/hospitals-get-into-doctor-rating-business
7. AHIP Coverage. “Committed to stability for patients, health plans are empowering consumers with information.” June 30, 2014. http://www.ahipcoverage.com/2014/06/30/committed-to-stability-for-patients-health-plans-are-empowering-consumers-with-information/ Applications
1)* HealthPartners. “HealthPartners goes national with cost transparency.” July 31, 2013. http://www.healthpartners.com/public/newsroom/newsroom-article-list/7-31-13.html
2)* Wayne, A. “UnitedHealth leads plan to reveal health prices to consumers.” Bloomberg, May 14, 2014. http://www.bloomberg.com/news/2014-05-14/unitedhealth-leads-plan-to-reveal-health-prices-to-consumers-1-.html
3) PR Newswire. “Blue Cross and Blue Shield of Minnesota announces the SmartSelect health care shopping tool to help Minnesotans make more informed health care choices.” September 18, 2013. http://www.prnewswire.com/news-releases/blue-cross-and-blue-shield-of-minnesota-announces-the-smartselect-health-care-shopping-tool-to-help-minnesotans-make-more-informed-health-care-choices-224279251.html
4) PriorityHealth. “New health care price comparison tool from Priority Health will save consumers thousands.” August 22, 2013. http://www.priorityhealth.com/about-us/press-room/releases/2013/healthcare-blue-book-launch
5) Rau, J. “N.Y. hospital group turns the tables on hospital graders.” Kaiser Health News Blog, November 4, 2013. http://capsules.kaiserhealthnews.org/index.php/2013/11/n-y-hospital-association-turns-the-tables-on-growing-number-of-hospital-graders/
6) ConsumerReports. “Is your hospital really as safe as you think?” March 2014. http://www.consumerreports.org/cro/2014/03/is-your-hospital-really-as-safe-as-you-think/index.htm
7) Massy, B. “Medical pricing website proposed in New Mexico.” The Washington Times, October 6, 2014. http://www.washingtontimes.com/news/2014/oct/6/medical-pricing-website-proposed-in-new-
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mexico/?page=all#! 8) O’Donnell, J. “New doctors site rates for experience, quality.” USA Today, October 19, 2014.
Concerns about Public Reports 1.* Sinaiko, A.D., Rosenthan, M.B. “Increased price transparency in health care – challenges and potential effects.” New
England Journal of Medicine 2011;364(10):891-894. http://www.nejm.org/doi/pdf/10.1056/NEJMp1100041 2.* Werner, R., Asch, D. “The unintended consequences of publicly reporting quality information.” Journal of the American
Medical Association 2005;293(10):1239-1244. http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=4967&direction=P
3. Williams, D. “The state of online doctor ratings: It’s still early.” KevinMD.com, April 24, 2013. http://www.kevinmd.com/blog/2013/04/state-online-doctor-ratings-early.html
4. Ubel, P. “How price transparency could end up increasing health-care costs.” The Atlantic, April 9, 2013. http://www.theatlantic.com/health/archive/2013/04/how-price-transparency-could-end-up-increasing-health-care-costs/274534/
5. Ginsburg, P. “Most health cost data of little use: Opposing view.” USA Today, March 5, 2013. http://www.usatoday.com/story/opinion/2013/03/05/health-care-price-transparency-center-for-studying-health-system-change/1966039/
6. Reuters. “Hospital ratings miss many high performers: study.” May 18, 2011. http://www.reuters.com/article/2011/05/18/us-hospital-ratings-idUSTRE74H73F20110518
7. Emanuel, E.J., Steinmetz, A. “Those hospital rankings could use a healthy dose of skepticism.” The Wall Street Journal, July 24, 2013.
Applications: 1) BusinessWire. “U.S. news best hospitals rankings may be misleading, according to Comparion.” May 7,
2) Minnesota Medicine. “MMA finds significant errors in Medica’s physician ratings.” February 2011. http://www.minnesotamedicine.com/PastIssues/PastIssues2011/February2011/MMANewsFeb2011.aspx
3) Mitchell, R. “29 states get ‘F’ for price transparency laws.” Kaiser Health News Blog, March 18, 2013. http://capsules.kaiserhealthnews.org/?p=17815
4) Ostrow, N. “Hospitals ranked top based on reputation more than quality, study says.” Bloomberg Businessweek, April 19, 2010. http://www.bloomberg.com/news/2010-04-19/hospitals-ranked-top-based-on-reputation-more-than-quality-study-says.html
5) Lieber, R. “The web is awash in reviews, but not for doctors. Here’s why.” New York Times online, March 9, 2012. http://www.nytimes.com/2012/03/10/your-money/why-the-web-lacks-authoritative-reviews-of-doctors.html?pagewanted=all
Public Reports and Their Use by Consumers 1.* Hibbard, J.H., Greene, J., Shoshanna, S., Firminger, K., Hirsh, J. “An experiment shows that a well-designed report on
costs and quality can help consumers choose high-value health care.” Health Affairs 2012;31(3):560-568. http://content.healthaffairs.org/content/31/3/560.full.pdf+html
2.* Sinaiko, A.D., Eastman, D., Rosenthal, M.B. “How report cards on physicians, physician groups, and hospitals can have greater impact on consumer choices.” Health Affairs 2012:31(3):602-611. http://content.healthaffairs.org/content/31/3/602.full.pdf+html
3.* Friedberg, M.W., Damberg, C.L. “A five-point checklist to help performance reports incentivize improvement and effectively guide patients.” Health Affairs 2012;31(3):612-618. http://content.healthaffairs.org/content/31/3/612.full.pdf+html
4.* Rosenthal, E. “Given choice, parents pick cheaper medical procedure for children.” The New York Times, October 1, 2014. http://www.nytimes.com/2014/10/02/upshot/given-choice-parents-pick-cheaper-medical-procedure-for-children.html
5. Neergaard, L., Agiesta, J. “Before doctors check your vitals, check out theirs.” Associated Press, July 20, 2014. http://bigstory.ap.org/article/doctors-check-your-vitals-check-out-theirs
6. Reinhardt. U.E. “Health care payers push back against costs.” The New York Times, February 3, 2012. http://economix.blogs.nytimes.com/2012/02/03/health-care-payers-push-back-against-costs/
7. Rothberg, M.B., Morsi, E., Benjamin, E.M., Pekow, P.S., Lindenauer, P.K. “Choosing the best hospital: the limitations of public quality reporting.” Health Affairs 2008;27(6):1680-1687. http://content.healthaffairs.org/content/27/6/1680.full.pdf+html
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8. Harris, K.M. and Buntin, M.B. “Choosing a Health Care Provider: The Role of Quality Information,” Research Synthesis Report No. 14. Princeton, NJ: The Synthesis Project, Robert Wood Johnson Foundation, May 2008. http://www.rwjf.org/pr/product.jsp?id=29683
9. The LeapfrogGroup. “Transparency should not be a luxury; it is a matter of life and death: what purchasers and consumers can do.” February 2, 2010. http://www.leapfroggroup.org/news/leapfrog_news/4773661
10. Cutler, D., Dafney, L. “Designing transparency systems for medical care prices.” New England Journal of Medicine 2011;(10):364:894-895. http://www.nejm.org/doi/pdf/10.1056/NEJMp1100540
11. Rosenberg, T. “Revealing a health care secret: The price.” The New York Times, July 31, 2013. http://www.lexisnexis.com/lnacui2api/api/version1/getDocCui?lni=5918-5G51-JBKK-535B&csi=379740&hl=t&hv=t&hnsd=f&hns=t&hgn=t&oc=00240&perma=true
12. Emanuel, E.J., Steinmetz, A. “Those hospital rankings could use a healthy dose of skepticism.” The Wall Street Journal,July 25, 2013. http://search.proquest.com/docview/1412098277/fulltext/666E303BA4F44CDDPQ/1?accountid=14586
13. Roan, S. “How data can boost the value of care.” Princeton, NJ: Robert Wood Johnson Foundation, August 2014. http://www.nrhi.org/uploads/how-data-can-boost-the-value-of-care_af4q_july-2014-1.pdf
14. Milleman, J. “The incredible cost savings that are possible when patients can actually shop around.” Washington Post, October 21, 2014. http://www.washingtonpost.com/blogs/wonkblog/wp/2014/10/21/the-incredible-cost-savings-that-are-possible-when-patients-can-actually-shop-around/
15. Orszag, P.R. “Let people shop for health care.” BloombergView, October 21, 2014. http://www.bloombergview.com/articles/2014-10-21/let-people-shop-for-health-care
16. Wu, S-j, Sylwestrzak, G., Chah, C., DeVries, A. “Price transparency for MRIs increased use of less costly providers and triggered provider competition.” Health Affairs 2014;33(8):1391-1398. http://content.healthaffairs.org/content/33/8.toc Applications:
1) redOrbit. Blue Cross and Blue Shield of Georgia Launches “Zagat health survey tool.” September 23, 2009. http://www.redorbit.com/news/health/1758420/blue_cross_and_blue_shield_of_georgia_launches_zagat_health/index.html
2) McCann, E. “The price transparency argument.” Healthcare Finance News, May 23, 2013. http://www.healthcarepayernews.com/content/price-transparency-argument
3) Soltas, E. “How to make the health-care market work better.” Bloomberg, March 28, 2013. http://www.bloomberg.com/news/2013-03-28/how-to-make-the-health-care-market-work-better.html
4) Mitchell, R. Employers, unions jointly demand health care price transparency. KHN Blog, November 1, 2012. http://capsules.kaiserhealthnews.org/index.php/2012/11/employers-unions-jointly-demand-health-care-price-transparency/
5) Commins, J. “Consumer reports expands hospital ratings list.” HealthLeaders Media, April 19, 2013. http://www.healthleadersmedia.com/page-1/QUA-291310/Consumer-Reports-Expands-Hospital-Ratings-List
6) Rau, J. “Hospital ratings are in the eye of the beholder.” Kaiser Health News, March 18, 2013. http://www.kaiserhealthnews.org/stories/2013/march/18/expanding-number-of-groups-offer-hospital-ratings.aspx
7) Bebinger, M. “How much for an MRI? $500? $5,000? A reporter struggles to find out.” Kaiser Health News, December 9, 2012. http://www.kaiserhealthnews.org/stories/2012/december/09/mri-cost-price-comparison-health-insurance.aspx
8) Betbeze, P. “Get ready for price transparency.” HealthLeaders Media, November 30, 2012. http://www.healthleadersmedia.com/page-1/LED-287017/Get-Ready-for-Price-Transparency
9) Minnesota HealthScores. “Understanding the cost of your care.” http://www.mnhealthscores.org/?p=cost_landing&category=all&sf=group
10) Bebubger, M. “Mass. Patients can ‘shop’ for health care – at least in theory.” Kaiser Health News, February 26, 2014. http://www.kaiserhealthnews.org/Stories/2014/February/26/Massachusetts-price-transparency-part-of-law.aspx
11) Bernstein, J.R.H., Bernstein, J. “Availability of consumer prices from Philadelphia area hospitals for common services: Electrocardiograms vs. parking.” JAMA Internal Medicine 174(2):292-293, 2014. http://archinte.jamanetwork.com/issue.aspx?journalid=71&issueid=929736&direction=P
Provider Responses to Public Reporting 1.* Watts, L.A., de Bocanegra, H.T., Darney, P.D., Hulett, D., Howell, M., Mikanda, J., Zerne, R., Policar, M.S. “In a
California program, quality and utilization reports on reproductive health services spurred providers to change.” Health Affairs 2012;31(4):852-862. http://link.springer.com/content/pdf/10.1007%2Fs11606-010-1498-3.pdf
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2. Frisch, S. “Pricing problem. Hospitals and clinics struggle to tell patients what things cost.” Minnesota Medicine, April 2013. http://www.minnesotamedicine.com/portals/mnmed/april%202013/pricingproblem1304.pdf
3. Woo, H.E. “The crucible of physician performance reports.” Journal of General Internal Medicine 2010;26(2):226-227. http://link.springer.com/content/pdf/10.1007%2Fs11606-010-1498-3.pdf
4. Smith, M.A., Wright, A., Queram, C., Lamb, G.C. “Public reporting helped drive quality improvement in outpatient diabetes care among Wisconsin physician groups.” Health Affairs 2012;31(3):570-577. http://content.healthaffairs.org/content/31/4/843.full.pdf+html
5. Mehrotra, A. Hussey, P.S., Milstein, A., Hibbard, J.H. “Consumers’ and providers’ responses to public cost reports, and how to raise the likelihood of achieving desired results.” Health Affairs 2012;31(4):843-851. http://content.healthaffairs.org/content/31/4/843.full.pdf+html
6. Seabrook, G.R. “Does rigorous quality process reporting guarantee superior-quality health care?” Journal of the American Medical Association 2013;310(3):316-317. http://jama.jamanetwork.com/issue.aspx?journalid=67&issueid=927287&direction=P
7. Reddy, M. “Doctors check online ratings from patients and make change.” Wall Street Journal, May 19, 2014. http://search.proquest.com/docview/1525882682/fulltext/D4358A7B9B2249AEPQ/1?accountid=14586 Applications:
2) Mathews, A.W. “Compare and contrast when doctors are given a public report card, the resulting competition can serve patients well.” Wall Street Journal, October 27, 2009, p. R.4. http://online.wsj.com/article/SB10001424052970204488304574431741881361528.html
3) CBS News. “Doctors can guard reputation on rating site.” March 3, 2011. http://www.cbc.ca/news/health/story/2011/05/03/doctor-rating-websites-reputation.html
4) Chen, P.W. “A report card for doctors.” New York Times, June 16, 2011. http://well.blogs.nytimes.com/2011/06/16/a-report-card-for-doctors/
5) Teleki, S., Shannon, M. “In California, quality reporting at the state level is at a crossroads after hospital group pulls out.” Health Affairs 2012;31(3):642-646. http://content.healthaffairs.org/content/31/3/642.full.pdf+html
6) Millman, J. “A reminder that not everyone loves more transparency for health-care prices.” Washington Post, June 23, 2014. http://www.washingtonpost.com/blogs/wonkblog/wp/2014/06/23/a-reminder-that-not-everyone-loves-more-transparency-for-health-care-prices/
7) Tu, H., Gourevitch, R. “Moving markets: Lessons from New Hampshire’s heath care price transparency experiment.” California HealthCare Foundation and Robert Wood Johnson Foundation, April 2014. http://www.chcf.org/publications/2014/04/moving-markets-new-hampshire
8) Associated Press. “ACPE survey finds most physician leaders skeptical of online ratings.” January 16, 2013. http://www.ereleases.com/pr/acpe-survey-finds-physician-leaders-skeptical-online-ratings-97316
Medicare Reporting 1. Hostetter, M., Klein, S. “Quality matters. In focus: Medicare data helps fill in picture of health care performance.” The
2. Klein, S. “Quality matters. Q&A: Building an all-payer claims database—The Wisconsin model.” The Commonwealth Fund, April/May 2013. http://www.commonwealthfund.org/Newsletters/Quality-Matters/2013/April-May/QA.aspx
3. O’Donnell, J. “Federal doctor ratings face accuracy, value questions,” USA Today, September 29, 2014. http://www.usatoday.com/story/news/nation/2014/09/29/obamacare-doctor-quality-ratings-accuracy-delay-affordable-care-act/16278733/
4. Lazar, K. “Federal websites updated with data on hospital imaging, use of antipsychotics in nursing homes.” Boston Globe online, July 19, 2012. http://www.boston.com/dailydose/2012/07/19/federal-websites-updated-with-data-hospital-imaging-use-antipsychotics-nursing-homes/TtjhhiM8tt0HdP16Q0XQ1M/story.html
5. Ryan, A.M., Nallamothu, B.K., Dimick, J.B. “Medicare’s public reporting initiative on hospital quality had modest or no impact on mortality from three key conditions.” Health Affairs 2012;31(3):585-592. http://content.healthaffairs.org/content/31/3/585.full.pdf+html
Further Readings
1. Auerbach, A.D., Hilton, J.F., Maselli, J., Pekow, P.S., Rothberg, M.B., Lindenauer, P.K. “Shop for quality or volume? Volume, quality, and outcomes of coronary artery bypass surgery.” Annals of Internal Medicine 2009;150(10):696-704. http://annals.org/issue.aspx?journalid=90&issueID=20182&direction=P
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2. Barr, S. “Dream of a medical ‘price list’ dies in Florida legislature.” KHN Blog, January 30, 2012. http://capsules.kaiserhealthnews.org/index.php/2012/01/dream-of-a-medical-price-list-dies-in-florida-legislature/
3. Ferraro, M. “Medicine’s big mystery, what does treatment cost?” Bloomberg, July 12, 2011. http://www.bloomberg.com/news/2011-07-12/medicine-s-big-mystery-what-does-treatment-cost-mimi-ferraro.html
4. Fox, M. “People like expensive health care, study finds.” NationalJournal, March 5, 2012. http://www.nationaljournal.com/healthcare/people-like-expensive-health-care-study-finds-20120305
5. Hibbard, J., Stockard, Tusler, M. “Does publicizing hospital performance stimulate quality improvement efforts?” Health Affairs 2003;22(2):84-94. http://content.healthaffairs.org/content/22/2/84.full.pdf+html
6. Hibbard, J.H., Stockard, J., Tusler, M. “Hospital performance reports: impact on quality, market share, and reputation.” Health Affairs 2005;24(4):1150-1160. http://content.healthaffairs.org/content/24/4/1150.full.pdf+html
7. Kaiser Health News. “N.Y. AG, Cigna reach agreement on physician ranking system.” October 30, 2007. http://www.kaiserhealthnews.org/daily-reports/2007/october/30/dr00048525.aspx?referrer=search
8. Lansky, D., Findlay, S. “Physician compare site could be ‘game changer,’ but challenges remain.” iHealthBeat, January 12, 2011. http://www.ihealthbeat.org/perspectives/2011/physician-compare-site-could-be-game-changer-but-challenges-remain.aspx
9. Levey, N. “New website to help patients compare doctors, hospitals.” Los Angeles Times, June 27, 2011. http://articles.latimes.com/2011/jun/27/news/la-heb-health-quality-20110628
10. Rau, J. “Lots of ‘C’s as hospitals get graded for patient safety.” KHN Blog, June 6, 2012. http://capsules.kaiserhealthnews.org/index.php/2012/06/lots-of-cs-as-hospitals-get-graded-for-patient-safety/
11. Sun, L.H. Johns Hopkins, other major area hospitals left off top-performer list. The Washington Post, September 20, 2012. http://articles.washingtonpost.com/2012-09-20/national/35497303_1_stroke-patients-hospitals-joint-commission
12. Weaver, C. “Want to know what a hospital charges? Good luck.” Kaiser Health News, June 29, 2010. http://www.kaiserhealthnews.org/stories/2010/june/29/hospital-prices.aspx?referrer=search
13. Whitney, E. “Attention health care shoppers: Colorado’s new price list for procedures.” Kaiser Health News, May 16, 2012. http://www.kaiserhealthnews.org/Stories/2012/May/16/colorado-health-care-price-list-database.aspx
14. Glance, L.G.,Dick, A.W., Osler, T.M., Kellermann, A.L. “Hospital quality: Does past performance predict future performance?” JAMA Surgery 149(1):16-17, 2014. http://archsurg.jamanetwork.com/issue.aspx?journalid=76&issueid=929681&direction=P
15. MN Community Measurement. The Measurement Minute, February 2013. http://mncm.org/wp-content/uploads/2013/05/February-2013-MNCM-Measurement-Minute.pdf
VII. Evaluation and Grading
Grades will be determined based on two group assignments (total of 25 points) and five individual assignments (total 75 points) The student will receive a grade of zero if an assignment is not submitted as scheduled, unless prior arrangements have been made for late submission.
Grading Scale The University utilizes plus and minus grading on a 4.000 cumulative grade point scale in accordance with the following:
A 4.000 - Represents achievement that is outstanding relative to the level necessary to meet course requirements
A- 3.667
B+ 3.333
B 3.000 - Represents achievement that is significantly above the level necessary to meet course requirements
B- 2.667
C+ 2.333
C 2.000 - Represents achievement that meets the course requirements in every respect
C- 1.667
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D+ 1.333
D 1.000 - Represents achievement that is worthy of credit even though it fails to meet fully the course requirements
S Represents achievement that is satisfactory, which is equivalent to a C- or better.
In this course, the percentage score on assignments will be converted to a letter grade as follows:
A=93-100% Represents outstanding achievement relative to the level necessary to meet course requirements
A- = 90-92.99%
B+ = 87-89.99%
B = 83-86.99% Represents achievement that is significantly above the level necessary to meet course requirements
B- = 80-82.99%
C+ = 77-79.99%
C = 73-76.99% Represents achievement that meets the minimum course requirements
C- = 70-72.99%
D+ = 65-69.99%
D = 60-64.99%
F = < 59.99% No credit. Signifies work was below level of achievement that represents minimum threshold to obtain credit or work was not completed and there was no agreement between instructor and student that the student would be awarded an I.
The instructor reserves the right to adjust final grades “upward” based on the overall distribution of points for the class. That is, students may receive a higher grade than expected based on their overall point total, but not a lower grade.
Course Evaluation The SPH will collect student course evaluations electronically using a software system called CoursEval: www.sph.umn.edu/courseval. The system will send email notifications to students when they can access and complete their course evaluations. Students who complete their course evaluations promptly will be able to access their final grades just as soon as the faculty member renders the grade in SPHGrades: www.sph.umn.edu/grades. All students will have access to their final grades through OneStop two weeks after the last day of the semester regardless of whether they completed their course evaluation or not. Student feedback on course content and faculty teaching skills are an important means for improving our work. Please take the time to complete a course evaluation for each of the courses for which you are registered. Incomplete Contracts A grade of incomplete “I” shall be assigned at the discretion of the instructor when, due to extraordinary circumstances (e.g., documented illness or hospitalization, death in family, etc.), the student was prevented from completing the work of the course on time. The assignment of an “I” requires that a contract be initiated and completed by the student before the last official day of class, and signed by both the student and instructor. If an incomplete is deemed appropriate by the instructor, the student in consultation with the instructor, will specify the time and manner in which the student will complete course requirements. Extension for completion of the work will not exceed one year (or earlier if designated by the
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student’s college). For more information and to initiate an incomplete contract, students should go to SPHGrades at: www.sph.umn.edu/grades. University of Minnesota Uniform Grading and Transcript Policy A link to the policy can be found at onestop.umn.edu.
VIII. Other Course Information and Policies
Grade Option Change (if applicable) For full-semester courses, students may change their grade option, if applicable, through the second week of the semester. Grade option change deadlines for other terms (i.e. summer and half-semester courses) can be found at onestop.umn.edu. Course Withdrawal Students should refer to the Refund and Drop/Add Deadlines for the particular term at onestop.umn.edu for information and deadlines for withdrawing from a course. As a courtesy, students should notify their instructor and, if applicable, advisor of their intent to withdraw. Students wishing to withdraw from a course after the noted final deadline for a particular term must contact the School of Public Health Office of Admissions and Student Resources at [email protected] for further information. Student Conduct Code: The University seeks an environment that promotes academic achievement and integrity, that is protective of free inquiry, and that serves the educational mission of the University. Similarly, the University seeks a community that is free from violence, threats, and intimidation; that is respectful of the rights, opportunities, and welfare of students, faculty, staff, and guests of the University; and that does not threaten the physical or mental health or safety of members of the University community. As a student at the University you are expected adhere to Board of Regents Policy: Student Conduct Code. To review the Student Conduct Code, please see: http://regents.umn.edu/sites/default/files/policies/Student_Conduct_Code.pdf. Note that the conduct code specifically addresses disruptive classroom conduct, which means "engaging in behavior that substantially or repeatedly interrupts either the instructor's ability to teach or student learning. The classroom extends to any setting where a student is engaged in work toward academic credit or satisfaction of program-based requirements or related activities." Use of Personal Electronic Devices in the Classroom: Using personal electronic devices in the classroom setting can hinder instruction and learning, not only for the student using the device but also for other students in the class. To this end, the University establishes the right of each faculty member to determine if and how personal electronic devices are allowed to be used in the classroom. For complete information, please reference: http://policy.umn.edu/Policies/Education/Education/STUDENTRESP.html. Scholastic Dishonesty Students are responsible for knowing the University of Minnesota, Board of Regents' policy on Student Conduct and Sexual Harassment found at www.umn.edu/regents/polindex.html. Students are responsible for maintaining scholastic honesty in their work at all times. Students engaged in scholastic dishonesty will be penalized, and offenses will be reported to the SPH Associate Dean for Academic Affairs who may file a report with the University’s Academic Integrity Officer. The University’s Student Conduct Code defines scholastic dishonesty as “plagiarizing; cheating on assignments or examinations; engaging in unauthorized collaboration on academic work; taking, acquiring, or using test materials without faculty permission; submitting false or incomplete records of academic achievement; acting alone or in cooperation with another to falsify records or to obtain dishonestly grades, honors, awards, or professional endorsement; or altering, forging, or misusing a University academic record; or fabricating or falsifying of data, research procedures, or data analysis.” Reference: “a mention or citation of a source of information in a book or article” (Compact Oxford English Dictionary, 2012)
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Citation: “a quotation from or reference to a book, paper, or author, especially in scholarly work” (Compact Oxford English Dictionary, 2012) Quotation: “a group of words taken from a text or speech and reported by someone other than the original author or speaker” (Compact Oxford English Dictionary, 2012) Plagiarism: “the process of taking another person’s work, ideas, or words, and using them as if they were your own” (Macmillan Dictionary, 2012) You will be asked to review a variety of sources of information when completing assignments for this course. It is important that you acknowledge these sources of information appropriately in your written assignments and verbal presentations. If you are quoting a source directly (using the words in the source, not your words) you must indicate this by using quotation marks, as in the definitions above, and by including a citation to the reference from which the quote was extracted. There is nothing wrong with including quotes in your assignments, but you are expected to put them in quotation marks and cite them appropriately. If you use the words of someone else, but do not put them in quotation marks, this is called plagiarism (even if you include a citation), and it violates the University’s academic code. Essentially, you are saying that you wrote these words, when that isn’t true, so you are lying to your instructor and classmates. In addition to using citations for quotations, you should use citations in the text to indicate instances where you have drawn on specific works of others in framing your answer or arguments. In using citations for this purpose, you acknowledge that the thoughts are not entirely yours, even though you may have expressed them in your own words. You should include a reference list at the end of your assignment. This list should include a complete description of all citations included in the text. References 1. Compact Oxford English Dictionary, Oxford University Press, 2012, http://oxforddictionary.com/definition/english
(accessed on August 21, 2012). 2. MacMillan Dictionary, 2012, http://www.macmillandictionary.com/dictionary/american (accessed on August 21, 2012). Plagiarism is an important element of this policy. It is defined as the presentation of another's writing or ideas as your own. Serious, intentional plagiarism will result in a grade of "F" or "N" for the entire course. For more information on this policy and for a helpful discussion of preventing plagiarism, please consult University policies and procedures regarding academic integrity: http://writing.umn.edu/tww/plagiarism/. Students are urged to be careful that they properly attribute and cite others' work in their own writing. For guidelines for correctly citing sources, go to http://tutorial.lib.umn.edu/ and click on “Citing Sources”. In addition, original work is expected in this course. Unless the instructor has specified otherwise, all assignments, papers, reports, etc. should be the work of the individual student. It is unacceptable to hand in assignments for this course for which you receive credit in another course unless by prior agreement with the instructor. Building on a line of work begun in another course or leading to a thesis, dissertation, or final project is acceptable. Makeup Work for Legitimate Absences: Students will not be penalized for absence during the semester due to unavoidable or legitimate circumstances. Such circumstances include verified illness, participation in intercollegiate athletic events, subpoenas, jury duty, military service, bereavement, and religious observances. Such circumstances do not include voting in local, state, or national elections. For complete information, please see: http://policy.umn.edu/Policies/Education/Education/MAKEUPWORK.html. Appropriate Student Use of Class Notes and Course Materials: Taking notes is a means of recording information but more importantly of personally absorbing and integrating the educational experience. However, broadly disseminating class notes beyond the classroom community or accepting compensation for taking and distributing classroom notes undermines instructor interests in their intellectual work product while not substantially furthering instructor and student interests in effective learning. Such actions violate shared norms and standards of the academic community. For additional information, please see: http://policy.umn.edu/Policies/Education/Education/STUDENTRESP.html. Sexual Harassment "Sexual harassment" means unwelcome sexual advances, requests for sexual favors, and/or other verbal or physical conduct of a sexual nature. Such conduct has the purpose or effect of unreasonably interfering with an individual's work or academic performance or creating an intimidating, hostile, or offensive working or academic environment in any University
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activity or program. Such behavior is not acceptable in the University setting. For additional information, please consult Board of Regents Policy: http://regents.umn.edu/sites/default/files/policies/SexHarassment.pdf Equity, Diversity, Equal Opportunity, and Affirmative Action: The University will provide equal access to and opportunity in its programs and facilities, without regard to race, color, creed, religion, national origin, gender, age, marital status, disability, public assistance status, veteran status, sexual orientation, gender identity, or gender expression. For more information, please consult Board of Regents Policy: http://regents.umn.edu/sites/default/files/policies/Equity_Diversity_EO_AA.pdf. Disability Accommodations: The University of Minnesota is committed to providing equitable access to learning opportunities for all students. The Disability Resource Center Student Services is the campus office that collaborates with students who have disabilities to provide and/or arrange reasonable accommodations. If you have, or think you may have, a disability (e.g., mental health, attentional, learning, chronic health, sensory, or physical), please contact DS at 612-626-1333 or [email protected] to arrange a confidential discussion regarding equitable access and reasonable accommodations. If you are registered with DS and have a current letter requesting reasonable accommodations, please contact your instructor as early in the semester as possible to discuss how the accommodations will be applied in the course. For more information, please see the DS website, https://diversity.umn.edu/disability/. Mental Health and Stress Management: As a student you may experience a range of issues that can cause barriers to learning, such as strained relationships, increased anxiety, alcohol/drug problems, feeling down, difficulty concentrating and/or lack of motivation. These mental health concerns or stressful events may lead to diminished academic performance and may reduce your ability to participate in daily activities. University of Minnesota services are available to assist you. You can learn more about the broad range of confidential mental health services available on campus via the Student Mental Health Website: http://www.mentalhealth.umn.edu. The Office of Student Affairs at the University of Minnesota: The Office for Student Affairs provides services, programs, and facilities that advance student success, inspire students to make life-long positive contributions to society, promote an inclusive environment, and enrich the University of Minnesota community. Units within the Office for Student Affairs include, the Aurora Center for Advocacy & Education, Boynton Health Service, Central Career Initiatives (CCE, CDes, CFANS), Leadership Education and Development –Undergraduate Programs (LEAD-UP), the Office for Fraternity and Sorority Life, the Office for Student Conduct and Academic Integrity, the Office for Student Engagement, the Parent Program, Recreational Sports, Student and Community Relations, the Student Conflict Resolution Center, the Student Parent HELP Center, Student Unions & Activities, University Counseling & Consulting Services, and University Student Legal Service. For more information, please see the Office of Student Affairs at http://www.osa.umn.edu/index.html. Academic Freedom and Responsibility: for courses that do not involve students in research: Academic freedom is a cornerstone of the University. Within the scope and content of the course as defined by the instructor, it includes the freedom to discuss relevant matters in the classroom. Along with this freedom comes responsibility. Students are encouraged to develop the capacity for critical judgment and to engage in a sustained and independent search for truth. Students are free to take reasoned exception to the views offered in any course of study and to reserve judgment about matters of opinion, but they are responsible for learning the content of any course of study for which they are enrolled.* Reports of concerns about academic freedom are taken seriously, and there are individuals and offices available for help. Contact the instructor, the Department Chair, your adviser, the associate dean of the college, or the Vice Provost for
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Faculty and Academic Affairs in the Office of the Provost. [Customize with names and contact information as appropriate for the course/college/campus.] OR:
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Academic Freedom and Responsibility, for courses that involve students in research: Academic freedom is a cornerstone of the University. Within the scope and content of the course as defined by the instructor, it includes the freedom to discuss relevant matters in the classroom and conduct relevant research. Along with this freedom comes responsibility. Students are encouraged to develop the capacity for critical judgment and to engage in a sustained and independent search for truth. Students are free to take reasoned exception to the views offered in any course of study and to reserve judgment about matters of opinion, but they are responsible for learning the content of any course of study for which they are enrolled.* When conducting research, pertinent institutional approvals must be obtained and the research must be consistent with University policies. Reports of concerns about academic freedom are taken seriously, and there are individuals and offices available for help. Contact the instructor, the Department Chair, your adviser, the associate dean of the college, or the Vice Provost for Faculty and Academic Affairs in the Office of the Provost. [Customize with names and contact information as appropriate for the course/college/campus.]
* Language adapted from the American Association of University Professors "Joint Statement on Rights and Freedoms of Students". Template update 6/2014
