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News Round the Web…compiled by MCOL
Page 2
How-To… HEDIS ACO Measures
Page 6
Tips…. In getting the most out of your MCOL membership
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Blog… Remind Me Why We Have Insurance
Page 10
Blog… Three Ways Health Plans are Using Twitter to Engage Their Members
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Blog… Round Up the Usual Suspects
Page 16
Blog… How are Providers Managing the Transition in Payment Structures?
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Factoids…Selected Factoids
Page 21
HealthSprocket…Selected Lists
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Announcements
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Quoted
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 2012, MCOL. All rights reserved.
This publication is exclusively for the use of MCOL paid members.
October 2012
Feature stories making news as reported from key web sites, and compiled by MCOL
Hospital Observation Units Could Save Billions in Health Costs, Study Says
HealthDay News reports that wider use of hospital observation units could save the U.S. health care system
billions of dollars a year, a new study indicates.
HealthDay News via US News & World Report, September 27, 2012
http://health.usnews.com/health-news/news/articles/2012/09/27/hospital-observation-units-could-save-billions-inhealth-costs-study-says
Study: States, Feds Recover Billions In Medicaid Drug Fraud Settlements
Kaiser Health News reports: Eager for revenues, states are settling more cases than ever — and at record
amounts — with drug makers accused of defrauding Medicaid programs, according to a new analysis from the
consumer group Public Citizen.
Kaiser Health News, September 27, 2012
http://capsules.kaiserhealthnews.org/index.php/2012/09/study-states-feds-recover-billions-in-medicaid-drug-fraudsettlements/
Big Firms Overhaul Health Coverage
The Wall Street Journal reports that two big employers are planning a radical change in the way they provide
health benefits to their workers, giving employees a fixed sum of money and allowing them to choose their
medical coverage and insurer from an online marketplace.
Wall Street Journal, September 26, 2012
http://online.wsj.com/article/SB10000872396390444549204578020640220260374.html
Inspector general: Medicare wrongly paid for $25M in refills on painkillers, other drugs
The Associated Press reports that Medicare routinely refilled pain pills and other restricted medications that are
barred by federal law from renewal without a fresh prescription, government inspectors said in a report Thursday.
Associated Press via the Washington Post, September 26, 2012
http://www.washingtonpost.com/national/inspector-general-medicare-wrongly-paid-for-25m-in-refills-on-painkillersother-drugs/2012/09/27/824579ce-0859-11e2-9eea-333857f6a7bd_story.html
Making the 'Pharmacy Crawl' - Painkiller Crackdown Forces Patients to Shop Around to
Fill Their Prescriptions
The Wall Street Journal reports: Robin Haas used to visit just one pharmacy a month to get the painkillers she
needs to relieve the chronic aching in her injured neck and back.
Wall Street Journal, September 26, 2012
http://online.wsj.com/article/SB10000872396390443720204578004873138298306.html
 2012, MCOL. All rights reserved.
page 2
October 2012
News Around the Web Continued
Lawmaker Pitches New FDA Office Of Mobile Health
Kaiser Health News reports: There are already tens of thousands of mobile health applications available for
download on smart phones and tablets, allowing consumers to do anything from count calories to monitor their
blood sugar level and fight depression. But it can be hard to know which ones actually deliver on their health
claims and provide accurate information.
Kaiser Health News, September 26, 2012
http://www.kaiserhealthnews.org/Stories/2012/September/27/FDA-Mobile-apps.aspx
Just What the Doctor Ordered: Medical Apps to Improve Care, Health
FOX Business reports: In the face of rising health-care costs, consumers are looking for any assistance to reduce
medical expenses and stay healthy. At the same time, doctors are seeking ways to improve their communications
with patients, increase patient adherence to drug regimens and care plans and overall improve the quality of care.
Both parties are turning to the same tool: mobile health.
FOX Business, September 26, 2012
http://www.foxbusiness.com/personal-finance/2012/09/26/just-what-doctor-ordered-medical-apps-to-improve-carehealth/
Health Firms Size Up Election Outcomes
The Wall Street Journal reports that the close presidential election race is forcing the health-care industry to size
up potential policy changes that could eventually switch millions of seniors to private insurance plans.
Wall Street Journal, September 26, 2012
http://online.wsj.com/article/SB10000872396390444180004578018781205887420.html
Hospitals: Feds share billing blame
Politico reports that a threat from Health and Human Services and the Department of Justice to crack down on
questionable Medicare billing has drawn a fairly strong rejoinder from two major hospital groups who say federal
regulators deserve part of the blame.
Politico. September 26, 2012
http://www.politico.com/news/stories/0912/81667.html?hp=l8
Branding Health Insurance Exchanges To Make The Sale
Kaiser Health News reports that as states work to comply with the federal health care law, many are designing
their insurance exchanges, where people will be able to shop for coverage.
Kaiser Health News, September 25, 2012
http://www.kaiserhealthnews.org/Stories/2012/September/25/california-health-insurance-exchange.aspx
Report: Double-digit premium hikes seen in 7 of 10 top Medicare prescription drug plans
The Associated Press reports that millions of seniors enrolled in some of the most popular Medicare prescription
drug plans face double-digit premium hikes next year if they don’t shop for a better deal, says a private firm that
analyzes the highly competitive market.
Associated Press via the Washington Post, September 25, 2012
http://www.washingtonpost.com/politics/health_care/report-double-digit-premium-hikes-seen-in-7-of-10-topmedicare-prescription-drug-plans/2012/09/25/6d7c5e6a-06db-11e2-9eea-333857f6a7bd_story.html
 2012, MCOL. All rights reserved.
page 3
October 2012
News Around the Web Continued
Health insurance costs grew slowly for two years. Now, they’re speeding up.
The Washington Post reports that U.S. spending on health insurance grew at an accelerated rate in 2011,
breaking a two-year trend of smaller cost increases. The culprit, a new study suggests, is not Americans seeking
more treatment but rather rapid growth in the price of medical care.
Washington Post, September 25, 2012
http://www.washingtonpost.com/business/economy/2012/09/24/8b14a526-066e-11e2-a10cfa5a255a9258_story.html
Kids' prescriptions often going unfilled
Reuters reports that a large share of medication prescriptions to children on Medicaid may go unfilled, a new
study suggests.
Reuters, September 25, 2012
http://www.reuters.com/article/2012/09/25/us-kids-prescription-idUSBRE88O0X520120925
Prescription-drug use drops among young people
USA TODAY reports that prescription-drug abuse in the USA declined last year year to the lowest rate since 2002
amid federal and state crackdowns on drug-seeking patients and over-prescribing doctors.
USA TODAY, September 25, 2012
http://www.usatoday.com/news/nation/story/2012/09/25/prescription-drug-use-drops-among-youngpeople/57838964/1
Consumer Reports: Annual Health Plan Rankings Find Non Profits Leading the Pack
NCQA reports that non profit health plans are leading the pack in the annual health plan rankings from the
National Committee for Quality Assurance (NCQA), published in the November issue of Consumer Reports.
NCQA Press Release, September 24, 2012
http://www.ncqa.org/Newsroom/2012NewsArchive/NewsReleaseSeptember242012.aspx
Workers Eye 'Consumer-Directed' Plans in Bid to Cut Health Costs
The Wall Street Journal reports: It soon will be time for the autumn ritual of open enrollment, as people who get
insurance through their employers sign up for next year's coverage. But this season, which kicks off next week,
also will mark a seminal shift—with more workers than ever weighing whether a "consumer-directed" health plan
might pay off for them.
Wall Street Journal, September 24, 2012
http://online.wsj.com/article/SB10000872396390444620104578010612491680672.html
Health Plan Open Season Brings Rising Premiums And More Expensive Dependent
Coverage
Kaiser Health News reports that the fall health insurance open enrollment season is when many people consider
changes to their health coverage.
Kaiser Health News, September 24, 2012
http://www.kaiserhealthnews.org/Features/Insuring-Your-Health/2012/health-insurance-open-enrollment-michelleandrews-092512.aspx
 2012, MCOL. All rights reserved.
page 4
October 2012
News Around the Web Continued
Health insurers begin to provide user-friendly plan guides
Reuters reports that the Obama administration on Monday began requiring health insurers to provide user-friendly
guides to patients that explain their benefits, aiming to make buying insurance nearly as easy as scanning
packages of food for nutrition facts.
Reuters, September 24, 2012
http://www.reuters.com/article/2012/09/24/us-usa-healthcare-insurance-idUSBRE88N0Y620120924
Boom In Trauma Centers Can Help Save Lives, But At What Price?
Kaiser Health News reports: When Orange Park Medical Center won preliminary state approval in November
2011 to open the first new trauma center in northeast Florida in almost 30 years, executives said the decision
would save lives.
Kaiser Health News, September 24, 2012
http://www.kaiserhealthnews.org/Stories/2012/September/25/trauma-centers.aspx
U.S. Warns Hospitals on Medicare Billing
The New York Times reports: Saying there are “troubling indications” of abuse in the way hospitals use electronic
records to bill for Medicare and Medicaid reimbursement, the Obama administration warned in a letter to hospital
associations Monday that it would not tolerate what it called attempts to “game the system” and vowed to
vigorously prosecute doctors and hospitals implicated in fraud.
New York Times, September 24, 2012
http://www.nytimes.com/2012/09/25/business/us-warns-hospitals-on-medicare-billing.html
Study Links Longer Office Hours, Lower Health Care Costs
Kaiser Health News reports that after primary care doctors close their doors on weekends and evenings, patients
turn to urgent care facilities, pharmacy ‘minute clinics’, and emergency rooms to get the care they need. In doing
so, they may also be contributing to the nation’s skyrocketing health system costs.
Kaiser Health News, September 24, 2012
http://capsules.kaiserhealthnews.org/index.php/2012/09/study-links-longer-office-hours-lower-health-care-costs/
Variation in antibiotic prescribing hints at overuse
Reuters reports that seniors in the U.S. are prescribed at least one antibiotic each every year, on average - but
the rate of prescribing varies quite a bit across the country, a new study finds.
Reuters, September 24, 2012
http://www.reuters.com/article/2012/09/24/us-variation-in-antibiotic-prescribing-h-idUSBRE88N0YA20120924
Liking It or Not, States Prepare for Health Law
The New York Times reports: Like many Republican governors, Jan Brewer of Arizona is a stinging critic of
President Obama’s health care law. When the Supreme Court upheld it in June, she called the ruling “an
overreaching and unaffordable assault on states’ rights and individual liberty.”
New York Times, September 24, 2012
http://www.nytimes.com/2012/09/24/us/like-it-or-not-states-prepare-for-health-law.html
 2012, MCOL. All rights reserved.
page 5
October 2012
HEDIS ACO Measures
The National Committee for Quality Assurance (NCQA) has introduced HEDIS measures for ACOs, publishing
HEDIS 2013 Technical Specifications for Accountable Care Organizations, providing detailed guidance to facilitate
ACO collection and reporting of quality performance in standardized ways. This Primer provides specific information
about these new HEDIS ACO measures.
Overview
NCQA is a private, non-profit organization, founded in 1990, that accredits and certifies a wide range of health care
organizations. It also recognizes clinicians and practices in key areas of performance. NCQA's Healthcare Effectiveness
Data and Information Set (HEDIS(R)) is the most widely used performance measurement tool in health care.
NCQA accredited health plans face a set of more than 60 standards and must report on their performance in more
than 40 areas. These plans cover 109 million Americans or 70.5 percent of all Americans enrolled in health plans.
NCQA HEDIS measures are incorporated in health plan and physician accreditation.
The new HEDIS ACO technical specifications were designed to help ACOs define populations for ACO
measurement, follow appropriate sampling and data collection methods and report ACO performance to NCQA. All
ACOs are eligible to submit measure results, which will enable NCQA to create performance benchmarks and track
ACO improvement over time.
NCQA ACO Accreditation includes two major components: standards, an evaluation of an ACO's structure and
processes; and measures, an evaluation of an organization's capability to report performance results.
The program evaluates organizations in seven categories:
1.ACO Structure and Operations
2.Access to Needed Providers
3.Patient-Centered Primary Care
4.Care Management
5.Care Coordination and Transitions
6.Patient Rights and Responsibilities
7.Performance Reporting and Quality Improvement
NCQA ACO Accreditation includes three levels, representing varying degrees of capability for coordinating care
and reporting and improving quality.
 2012, MCOL. All rights reserved.
page 6
October 2012
How-To continued
NCQA's ACO Accreditation program debuted in November 2011. NCQA states that their ACO program "aligns with
many aspects of the Medicare Shared Savings Program; addresses expectations common among private
purchasers; [and] uses three levels of accreditation to signify differing levels of ACO readiness and capability."
2013 HEDIS ACO Core Measures
Prevention and Screening
Adult BMI Assessment (AABA)
Weight Assessment for Children/ Adolescents (AWCC)
Childhood Immunization Status (ACIS)
Immunizations for Adolescents (AIMA)
Breast Cancer Screening (ABCS)
Cervical Cancer Screening (ACCS)
Colorectal Cancer Screening (ACOL) *
Chlamydia Screening in Women (ACHL)
Care for Older Adults: Medication Review (ACMR) *
Respiratory Conditions
Appropriate Testing for Children With Pharyngitis (ACWP)
Appropriate Treatment for Children With Upper Respiratory Infection (AURI)
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis (AAAB)
Use of Spirometry Testing in the Assessment and Diagnosis of COPD (ASPR)
Use of Appropriate Medications for People With Asthma (AASM)
Cardiovascular Conditions
Cholesterol Management for Patients With Cardiovascular Conditions (ACMC)
Controlling High Blood Pressure (ACBP)
Diabetes
Comprehensive Adult Diabetes Care (ACDC)
Note: This measure includes 7 core ACO measures as indicators.
Musculoskeletal Conditions
Disease Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (AART) *
Osteoporosis Management in Women Who Had a Fracture (AOMW) *
Use of Imaging Studies for Low Back Pain (ALBP)
Behavioral Health
Antidepressant Medication Management (AAMM)
Follow-Up Care for Children Prescribed ADHD Medication (AADD)
Follow-Up After Hospitalization for Mental Illness (AFUH)
Medication Management
Annual Monitoring for Patients on Persistent Medications (AMPM)
Medication Reconciliation Post-Discharge (AMRP)
Potentially Harmful Drug-Disease Interactions in the Elderly (ADDE) *
Use of High-Risk Medications in the Elderly (ADAE) *
 2012, MCOL. All rights reserved.
page 7
October 2012
How-To continued
Access/Availability of Care
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (AIET)
Utilization and Relative Resource Use
All-Cause Readmissions (AACR) *
Relative Resource Use for People With Diabetes (ADRI) (under development)
Relative Resource Use for People With Asthma (ARAS) (under development)
Relative Resource Use for People With Cardiovascular Conditions (ARCA) (under development)
Relative Resource Use for People With Hypertension (ARHY) (under development)
Relative Resource Use for People With COPD (ARCO) (under development)
* Option provided to report Medicaid separately except for these measures
NCQA Accountable Care Organization Accreditation
http://www.ncqa.org/Programs/Accreditation/AccountableCareOrganizationACO.aspx
NCQA Accountable Care Organization Fact Sheet
http://www.ncqa.org/Portals/0/Programs/Recognition/RP2/NCQA%20ACO%20Fact%20sheet_2.10.12.pdf
NCQA ACO Measure Grid
http://www.ncqa.org/portals/0/publiccomment/ACO/Appendix%20A_ACO_Measure_Table.pdf
 2012, MCOL. All rights reserved.
page 8
October 2012
Tips
In getting the most out of your MCOL paid membership
Your clients, friends and colleagues can get a MCOLFree membership too, at no cost,
simply by going to http://www.mcareol.com/freepage.htm.
If you haven’t joined already, you’re encouraged to join the LinkedIn Managed Care OnLine group where you can network and discuss issues with other MCOL members. You’ll
find a link to the group in the paid member web site main menu.
MCOL does not share your e-mail address with third parties, as stated in the MCOL
member privacy policy, available at http://www.mcareol.com/mcoprvs1.htm
If you ever would like any assistance or information regarding any aspect of your
MCOLFree membership, feel free to contact MCOL anytime at [email protected] or call
209.577.4888. MCOL offices are open business days 8AM to 5PM Pacific time.
You can follow MCOL on Twitter at http://twitter.com/M_C_O_L
You can also follow Healthsprocket on Twitter at http://twitter.com/healthsprocket
If you’re looking for specific content in the member web site and aren’t sure how to find it,
feel free to e-mail or call MCOL anytime and we’ll assist you with your search, free of
charge.
You might consider upgrading to a MCOL paid membership for just $15 per month. Paid
members receive many valuable exclusive e-newsletters and e-magazines, and a paid
member web site with comprehensive features and resources. What’s more, Paid
members get 10% discounts on MCOL’s e-learning software and HealthQuest
Publications, when ordering from the Managed Care Store (www.managedcarestore.com)
Paid members also get a 50% discount when registering for Healthcare Web Summit
events (www.healthwebsummit.com) Make sure you identify your self as a MCOL member
when placing these orders.
Check out HealthSprocket, the home for healthcare lists. The healthsprocket community
of health care professionals and others can read, rate, comment on, and post lists. Lists
can be designated as fact or opinion based, and involve business or clinical aspects of
health care, health insurance and all things related.
Check out MedicareHMO, the learning resource for professionals interested in Medicare
Advantage, Medicare Prescription Drug Plans, and related programs.
 2012, MCOL. All rights reserved.
page 9
October 2012
A selected Blog entry from the month of September 2012 from MCOLBlog.com
Remind Me Why We Have Insurance
by Kim Bellard, September 24, 2012
A recent article in The Columbus Dispatch reported on the practice of doctors providing
discounts to patients if they paid directly instead of using their insurance. It got me thinking
about far health insurance has strayed from its original purpose. We ask health insurance to do
a lot of things: lessen concern about catastrophic expenses, reduce financial barriers to care,
smooth out cash flow of health expenses, even help us manage chronic conditions via disease
management and wellness programs. Insurance does these things because, frankly, there
haven’t been many good alternatives. But that doesn’t mean there couldn’t be.
The Affordable Care Act -- ObamaCare -- requires expanded coverage for preventive care with
no cost-sharing, on the premise that this will help people get those serves. It troubles me that
some, perhaps most, people won’t get necessary preventive services unless it is “free” to them
at point-of-care. That tells me something is really, really wrong with how we look at health. But
why does health insurance needs to be the mechanism for providing incentives to take care of
one’s own health? The Dispatch gave several examples of physicians and hospitals offering
significant discounts – up to 40% - to patients who pay directly, in order to avoid the
administrative burdens of dealing with health insurers. It also quoted Tom Blue of the
American Academy of Private Physicians as indicating they believed there were 4400
physicians nationally who replied in part or entirely on direct payments from patients, although
that would seem to include uninsured patients.
A more direct patient-physician financial relationship may be an idea whose time has
come…again. So-called “concierge medicine” started several years ago, and has developed
to the point where it has its own trade association, the aforementioned American Academy of
Private Physicians. The concept of concierge medicine is that patients pay a fixed fee,
monthly or annually, and in return they get guaranteed 24/7 access to their personal physician.
No insurance, no billing, no out-of-pocket payments.
Examples of concierge practices include EliteHealth, MDVIP, and SignatureMD, There’s even
a television series featuring a concierge practice, USA Network’s Royal Pains. Prices for
concierge service vary widely, with some practices aimed at wealthy families and costing tens
of thousands per year, while others are more affordable at $1,500 - $2,000 annually.
Proponents believe it greatly reduces the number of patients physicians have to see, reduces
hassles with third party payors, and ensure a closer, more accessible physician-patient
relationship. Then there’s “direct primary care” model. Like concierge medicine, patients pay
flat fees for access to personal primary care physicians.
The lines between the two approaches are somewhat blurry, at least to me, but direct primary
care tends to use monthly fees instead of annual retainers, and appears to be generally less
expensive, often under $100 per month.
 2012, MCOL. All rights reserved.
page 10
October 2012
MCOL Blog: Remind Me Why We Have Insurance continued
It also has its own trade association – Direct Primary Care – and has had legislation passed in
both Oregon and the state of Washington to specifically allow the approach.
Examples of direct primary care practices include Qliance and MedLion. The DPC website
lists over 80 practices in 19 states, some of whom are also listed in the American Association
of Private Physicians website. DPC argues that by cutting out insurers and the practices
expenses devoted to billing and administrative hassles associated with third party payors,
direct primary care can save 40% of the health care dollar.
Concierge medicine and direct primary care both emphasize primary care and flat payments to
cover essentially unlimited access to primary care services (and, in some cases, many routine
services). Both seek to eliminate insurers from the equation. It’s interesting that while these
efforts are happening, Medicare and many insurers are experimenting with patient centered
medical homes (PCMH), which also seek to reestablish primary care as the centerpiece of a
patient’s health care needs. In the PCMH model, of course, insurance is still very much part of
the picture, providing additional financial support to the involved primary care physicians. In an
ACO world, though, health insurance may be less integral to PCHM practices.
For all these models, I can’t help but be reminded of 1990’s capitated gatekeeper approaches,
which also featured fixed per-member payments (from insurers) and primary care physicians
coordinating all care. It will be interesting to see how these new approaches – concierge,
direct primary care, or PCMH – deal with patients with complex needs. Just as there was with
capitation, there will be financial temptation to triage them off to specialists who are still on feefor-service, and there will be similar concerns about such practices skimming off healthier
patients, not to mention wealthier patients.
I don’t know if concierge medicine or direct primary care will ever evolve out of niche offerings,
and their development will be interesting to watch. The model I think is potentially even more
disruptive to the current system is the encroachment of corporate approaches to retail
medicine – e.g., TakeCare, Minute Clinic, Walmart’s recent entry into immunizations, among
others All of them work with health insurance, because that’s where the money is now, but all
are also quite happy to take consumer’s money directly and to do so in a way that is more like
we buy other goods and services, with clearly delineated lists of services and prices. If other
parts of the health care system think those kinds of approaches aren’t coming to them, they
are deluding themselves.
Two things I feel strongly that our health care financing mechanisms should achieve is that low
income people need assistance with paying for health care services, and no one should have
to go broke due to medical bills. Even for those, though, I can think of solutions which do not
require health insurance. As for cash flow management and chronic condition management,
health insurance may actually be one of the less efficient solutions to address those. I am not
saying there shouldn’t be any sort of health insurance, but given the mess we find out health
system in – expensive, uneven access and quality, high administrative costs, etc. – maybe it’s
time we rethought what it looks like. It’s too bad that, as we start to decide what constitutes
essential benefits under ObamaCare, we’re still playing small ball.
 2012, MCOL. All rights reserved.
page 11
October 2012
A selected Blog entry from the month of September 2012 from MCOLBlog.com
Three Ways Health Plans are Using Twitter to
Engage Their Members (and Potential Members)
by Marshall Riddle, September 20, 2012
Case Studies in Health Care Social Media
Last month MCOL released its 2012 update to its Benchmarking Healthcare Social Media
Learning Kit. The base of the learning kit is a white paper which covers a study on 216 social
media accounts representing 58 healthcare organizations from five sectors and takes data
from Twitter, Facebook and YouTube. A number of benchmarks and ratios were developed for
the study including the Twitter engagement ratio which measures the “quality” of an
organization’s followers.
Quality in this case pertains to an audience who interacts and is more likely to be interested in
the content an organization is tweeting about. The engagement ratio is the percent of followers
who are of “quality”. If a health plan’s goal in using twitter is to engage and be engaged by their
members (and potential members), then this ratio is a relevant way to measure whether their
approach to Twitter is effective.
Based on Twitter accounts utilized by health plans that were looked at in this study there are
three basic approaches to using twitter in this industry sector:
1. Promoting company brand and activities: tweeting what would normally go out in a company
press release
2. Customer Assistance: helping plan members with questions and navigation of their
coverage whether solicited or not
3. Health/wellness/fitness advice: promoting the well being of their members in order to create
a positive and interactive brand image
One account type not listed here and not focused on in the study were those which focused on
job listings. This type of account does not have the goal of engaging with consumers and thus
is not relevant to this list.
The 36 Twitter accounts from eight health plans that were included in this study spanned all
three approaches. Examples of each are detailed below.
 2012, MCOL. All rights reserved.
page 12
October 2012
MCOL Blog: Three Ways Health Plans are Using Twitter to Engage continued
Promoting Company Brand and Activities
As Twitter has become as much a news aggregator as a social media platform, some health
plans have focused their use on this aspect which was a natural progression from posting
press releases in the media section of their website.
One plan which operates an account that spotlights its brand is Health Care Service
Corporation (@HCSC). @HCSC tweets about:
Company achievements:
Company Programs:
How the company supports the community
@HCSM will also occasionally send out tweets with wellness and health information, though
many of them link back to one of their plan’s press releases.
@HCSM has an engagement ratio of 1.58% which is below the average engagement ratio of
plans included in the study at 2.83%. While @HCSM’s audience is not as engaged as other
plan’s its maintenance takes much less effort than the other two approaches health plans are
using on Twitter.
Customer Assistance
Whether a company has a presence on twitter or not, people will be talking about them, usually
to complain. When a health plan has a customer service style account and someone tweets a
complaint (or insult) at them or about them they are able to respond with an offer of help.
Kaiser Permanente is one plan which does this with their @kpmemberservice account.
 2012, MCOL. All rights reserved.
page 13
October 2012
MCOL Blog: Three Ways Health Plans are Using Twitter to Engage continued
They respond to:
Negative references:
Questions or help with member services sent to any of their organization’s accounts:
And the very rare compliment:
 2012, MCOL. All rights reserved.
page 14
October 2012
MCOL Blog: Three Ways Health Plans are Using Twitter to Engage continued
@kpmemberservice has an engagement ratio of 4.15% which is above the health plan average
of 2.83%. While this is a high engagement ratio for a health plan (most accounts of this style
are similarly high), some of the engagements driving this are negative as seen above.
Health/wellness/fitness advice
Some health plans choose to focus one of their twitter accounts (or there whole twitter
presence) on creating a positive brand image rather than promoting their company or services.
They do this by tweeting about healthy living, nutrition, and fitness. Much of the time they tweet
in the form of questions in order to start a conversation about a positive non controversial topic.
Humana has been using this approach with their @humanavitality account. Their positive
tweets include:
@humanavitality has an engagement ratio which falls more towards the average at 2.96%.
This is a lower engagement rate than what you would get from a customer service style
account, but on the whole, the engagements with users are positive.
Each approach has its pros and cons. Promoting company brand and activities puts out the
exact information a plan wants to and is low maintenance, but has limited engagement with
consumers. Customer Assistance has a very high engagement ratio but does attract negative
comments (though the negativity much of the time is already out there.) Health/wellness/fitness
advice accounts have a good engagement ratio and have mainly positive engagements. The
only drawback to the advice accounts is the plan is not able to offer material information on
their plans and services.
To see how your plan stacks up to plans with similar accounts and to learn more about the
study and benchmarks used check out The Benchmarking Healthcare Social Media Learning
Kit 2012 (https://www.managedcarestore.com/ymcol/HCSM.htm).
 2012, MCOL. All rights reserved.
page 15
October 2012
A selected Blog entry from the month of September 2012 from MCOLBlog.com
Round Up the Usual Suspects
By Kim Bellard, September 11, 2012
Two recent reports have added more empirical support to the widely held belief that our health
care system wastes significant amounts of money. I’m shocked, shocked! As Captain
Renauld said in Casablanca, round up the usual suspects. The first report, published in Health
Affairs, was from UnitedHealth Group. The authors examined data from 250,000 physicians
around the country, focusing on the privately insured population. Consistent with the years of
data from the Dartmouth Atlas on the Medicare population, it showed widespread variation.
The authors report episode costs for procedures vary 2.5 times, while episode costs for
chronic conditions vary 15-fold. Overall, the report concludes that costs could be 14% lower if
delivered by physicians meeting certain quality and cost-efficiency designations.
An even more assertive claim was made by the prestigious Institute of Medicine (IOM). Their
report, Best Care at Lower Cost, believes that as much as a third of spending is wasted –
some $750 billion based on 2009 health spending. The IOM is no stranger to big claims,
including the oft-quoted 98,000 deaths annually due to medical error in their landmark report
To Err is Human. In their new report, they conclude that 75,000 deaths could be avoided if
every state delivered care as well as the best performing state. The IOM was more granular
than simply claiming the waste is all unnecessary care: $210 billion in unnecessary services,
$190 billion in excessive administrative costs, $130 billion from inefficiently delivered services,
$105 billion due to prices that are too high, $75 billion in fraud, and $55 billion in missed
prevention opportunities. That’s a lot of targets of opportunity.
The IOM notes some lessons from other industries, and believe significant improvement is
possible, on a variety of fronts: using information technology more effectively, creating systems
to manage complexity, more focus on making health care safer, improving transparency of
costs, quality and outcomes, promoting teamwork and communication between providers,
partnering with patients, and decreasing waste/improving efficiency. They believe that the
technology is here to support all these, and the problem is better application of it to health care
systems and processes. No mention was made of “death panels” (!), although I’m waiting for
someone to bring up that specter.
There are too many examples that illustrate the flaws in the current system. For example,
Johns Hopkins recently reported that as many as a quarter of adult patients in ICUs may die as
a result of missed or incorrect diagnoses, resulting in some 40,500 deaths annually. The
authors note that is more people who die each year from breast cancer. One would think that
ICU patients are getting pretty close attention, more than other patients, which make these
results all the more troubling (to be fair, of course, they likely have complicated sets of
conditions, making diagnosis harder).
More troubling are recent allegations and lawsuits about unnecessary heart surgeries aimed at
increasing hospital revenue/physician income, including HCA and St. Joseph-London in
Kentucky. If these allegations are shown to be valid, these practices may just be the tip of the
iceberg.
 2012, MCOL. All rights reserved.
page 16
October 2012
MCOL Blog: Round Up the Usual Suspects continued
Throw in recent warnings about the overuse of well-intended but over-used diagnostic tests
like screenings for ovarian cancer or prostate cancer, or the cost-benefits from increased
exposure to radiation via increased imaging, and it makes one wonder if treatment
recommendations should come with a warning label.
The IOM cited technology as a tool to help support improvement in how the health system
performs, and there is data which suggest this hope is not in vain. The CDC reports that 55%
of physicians had an electronic health record in 2011, and half of the remaining physicians
expected to be using one in the next year. Clearly, HITECH has helped spur this adoption, as
has the trend of health systems purchasing physician practices. Solo practitioners significantly
lag in adoption (29%), and CDC reports a statistically significant difference in adoption from
physicians over 50: 49% versus 64%. More importantly, about three-quarters of adopters
believe that the EHR both enhances patient care and meets Meaningful Use criteria.
Also encouraging is a report from Medpage Today on physician technology use. They report 9
out of 10 physicians experienced an increase in the use of the Internet in their practice: 71%
spend 3 or more hours a day on a computer, 24% use a mobile device 3+ hours a day, and
18% use a tablet 3+ hours per days, all in support of their practice. Unlike the CDC results,
though, they see very little impact of age on technology adoption, except in use of a
smartphone. The Medpage respondents are a stressed bunch, seeing more patients each day
and, as a result, seeing fewer drug reps, spending less time with each patient, and reading
fewer medical journals/attending fewer conferences. The last point is particularly concerning
to build the nimble “learning” culture that the IOM advocates, which helps account for the
finding that almost all respondents are using their devices to keep up-to-date on clinical news
and medical education.
I’ve often been critical of physicians’ reluctance to adopt technology solutions, but I’m
increasingly coming to the point of view that it is technology that is failing them. We’ve
laboriously endeavored to get medical records into an electronic state, when the real challenge
is deciding what health data we want tracked, and what views/inputs are needed by different
types of users – including patients. I’ll point to a nice column by Shahid Shah that details
some of the kind of patient-centered forward thinking we need, as well as to a recent study by
Hripcsak and Albers that reminds us that poorly designed data going in has damaging effects
on the usefulness of that data.
Maybe we need to scrap all those legacy practice management systems and EMRs and study
what modern CRM systems in other industries can teach us about tracking and knowing
patients, as well as take advantage of lessons learned from just-in-time manufacturing to
improve care delivery efficiencies. Add to those all the real-time data that mobile tracking apps
and other monitoring devices can provide on patients’ health and we have a shot at disruptive
innovation.
Job number one in improving our health system has to be measuring who is doing what to
which patients, and what impact it is having on those patients’ health. Without better data on
those, we’ll still just be rounding up those usual suspects.
 2012, MCOL. All rights reserved.
page 17
October 2012
A selected Blog entry from the month of September 2012 from MCOLBlog.com
How are Providers Managing the Transition with
Conflicting Incentives in Payment Structures?
By Clive Riddle, September 7, 2012
In the just released September issue of Accountable Care News,the monthly subscription
newsletter covering Accountable Care, a thought leader panel was asked: “Given the
conflicting incentives of ACO and other FFS lines of business, how are providers managing the
transition? Stratifying patient populations based on payment incentives? Managing all patients
the same and absorbing the revenue losses? Structuring compensation differently for care
team members and individual physicians?
It’s an interesting question. Here’s what the Accountable Care News thought leaders had to
say about this issue:
Joel C. Hoffman, ASA, MAAA, FCA, Senior Vice President, OptumInsight Payer Solutions
responds that “Provider-sponsored organizations (PSOs) are not going to change who sees
which patients, how they manage/coordinate their care, or what they pay their salaried
physicians depending on the type of reimbursement received.
Physicians must move to
delivering value regardless of how they are reimbursed.
The historic fee-for-service (FFS) incentives for volume and high-intensity services are already
shifting to a blended volume/value system, and this transition will continue to accelerate over
time in favor of value.
Many of the leading PSOs are already acutely focused on simultaneously improving patient
quality/safety while reducing costs of care, even in their legacy FFS reimbursement
relationships. Provider reimbursement will evolve to keep pace with the delivery of clinically
integrated, coordinated care – case in point, the growth of value-based reimbursement that is
expected to help expedite the transformation of the nation’s healthcare delivery system and
make it stick. But FFS reimbursement by necessity will never totally disappear -- today’s PSOs
are showing they can positively transform regardless.”
Douglas A. Hastings, JD , Chair, Board of Directors, Epstein Becker & Green, PC, states in
part that “there is not, nor should there be, any single or simple answer to managing the
transition. The pace of change varies around the country due to historical circumstances,
current market activity, and a variety of other variables.
The constants are the need to perform well on evolving consensus quality measures and to
contain costs in order to absorb reduced reimbursement in whatever actual form that takes.
 2012, MCOL. All rights reserved.
page 18
October 2012
MCOL Blog: How are Providers Managing Transition in Payment Structures? continued
In addition, there are affirmative investments necessary to make a successful transition, further
underscoring the need for capital and operating cost reductions…..Nevertheless, even the
most progressive providers will have a foot in both fee-for-service and value-based payment
for a period of time.
Approaches to patient care and financial incentives while different
payment methodologies co-exist will vary. My sense from watching and talking to the most
recognized and advanced “Triple Aim”– oriented delivery systems is that they aggressively
align treatment protocols and financial incentives within the system toward Triple Aim goals
from the outset, even though this approach may cost more in the short run.
They argue that such costs are the price of innovation and doing the right thing and that this
approach will pay off in the long run. I think that they are correct.”
Tom Cassels, Executive Director of Research & Insights, The Advisory Board Company says
“disciplined providers aren’t waiting for the conflict created by today’s uncomfortable ‘foot in
two boats’ transition to value-based contracting to sort itself out.
Rather they are executing clear strategies to identify areas where investments of time and
resources in new care models can yield real near-term returns. For instance, these providers
realize that they are already at risk for the total cost of their employee health benefits plans as
well as the expense of uncompensated (e.g., uninsured) and under-compensated care (e.g.,
chronically ill Medicaid patients seeking primary care in the ED). By following the flow of
dollars to areas where reduced spending falls directly to their bottom lines, these organizations
are making principled decisions to target segments of the populations they serve where their
incentives match the objective of reducing the total cost of care.
This is why some of the most exciting innovation in enhanced primary care, patient navigation,
and support for patient self-management is coming out of health systems’ management of their
own employees and their dependents. In the words of one progressive health system CFO,
‘Our own spending shows us where we have the opportunity to create value, and if we can
learn to shave on our own face we’ll be more credible to other purchasers as a population
health manager in the future.’ ”
Nalini K. Pande, JD, Principal Policy Director, American Institutes for Research reports that “a
recent Commonwealth Fund study has recommended that ACOs align as much of their
business as possible with value-based payments. In fact, providers are currently transitioning
to a value-based model that uses incentives to reward value and moving away from the
traditional fee-for-service (FFS) model that rewards volume.
How are providers managing this transition? They have focused on changing their systems
and the way they do business. They are utilizing new care practice models to optimize
utilization of services. This includes predictive modeling to risk stratify a population to identify
individual opportunities for intervention. Providers are also engaging patients in managing
their own care and using IT systems to assist with clinical decision support, medical error
reduction, and patient safety.
Providers have also adopted new care coordination models with continuous quality
improvement and a payment structure that recognizes the added value to patients.
 2012, MCOL. All rights reserved.
page 19
October 2012
MCOL Blog: How are Providers Managing Transition in Payment Structures? continued
Further, they have set up new infrastructures and systems that allow a shift from quality and
efficiency ‘measurement’ to quality and efficiency ‘management’.”
Finally, Peter Boland, PhD, President, Boland Healthcare states in part that “hundreds of
organizations are still struggling with variations of the ‘what do we want to be when we grow
up’ syndrome. The realists understand that bearing increasing levels of financial risk (and
reward) with payers and purchasers is becoming the norm.
The straddlers still cling to fee for service and volume-based reimbursement despite the
inability of Medicare and employers to support such payment. Many providers have recently
taken the plunge into the ‘brave new world’ of Medicare Shared Savings Program with an eye
towards a gradual transition to modest risk and gain sharing over a five-year period. ….It is an
illusion to think that health delivery organizations can have it both ways. The industry is at the
tipping point where accountability for price and service (the value equation) is ‘the new normal’.
Good medicine dictates that patients not be stratified by type of payment. Good business
requires meaningful performance metrics to be agreed upon – and tracked -- as the basis for
compensation.”
Accountable Care News includes the Thought Leaders panel answering a timely question of
the month in each issue, in addition to several feature stories, industry news briefs, and a
profile interview with a prominent person involved with accountable care. You can check it out
at www.accoutnablecarenews.com.
 2012, MCOL. All rights reserved.
page 20
October 2012
Selected Factoids from the MCOL Daily Factoids e-newsletter
Satisfaction with Healthcare Visits Compared to
Other Consumer Services
Among the 84% of Americans who visited a doctor's office within the past year, 47% reported being very
satisfied with their last medical visit; an additional 36% described themselves as somewhat satisfied.
Medical visit satisfaction appears to rise with both age and education: very satisfied ratings range from 35%
among ages 18-35 to 56% among ages 67+, and from 44% among those with a high school education or less
to 52% among those with post graduate education.
As might be expected, satisfaction falls short of levels observed for several other industries: very satisfied
ratings are behind those reported for Americans' last restaurant visit (63%), their last online purchase (62%),
and their last bank visit (59%). Very satisfied ratings are comparable to those recorded for U.S. adults' last
hotel stay (49%), car purchase (47%) and department store visit (44%), and are ahead of those observed for
their most recent health insurance company interaction (29%) and last mobile phone store visit (28%).
Dissatisfaction with most recent healthcare provider visits (17%) is comparable to levels observed for recent
mobile phone store visits (also 17%) and health insurance company interactions (18%).
Source: The Harris Poll #53, September 10, 2012, Harris Interactive,
http://www.prnewswire.com/news-releases/patient-choice-an-increasingly-important-factor-in-the-age-of-thehealthcare-consumer-169140306.html
Top Medicare Advantage Plan National Enrollment
Humana
2,061,295
Unitedhealthcare
2,024,965
Kaiser Foundation HP, Inc.
1,106,083
Aetna Health Inc.
434,088
Cigna/Healthspring
406,249
Anthem Health Plans, Inc
307,750
Health Net
228,575
Blue Cross Blue Shield of Michigan
219,296
Highmark, Inc.
197,471
MMM Healthcare, Inc.
175,442
Source: Source: NCHS Data Brief, Number 98, July 2012, National Center for Health Statistics
http://www.cdc.gov/nchs/data/databriefs/db98.htm
 2012, MCOL. All rights reserved.
page 21
October 2012
The home for health care lists
Selected healthsprocket lists from the healthsprocket.com
Fact Based List
States with Highest Total Medicare Fee‐For‐Service
and Medicare Advantage Payment Reductions for
2013-2022 (Millions)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
CALIFORNIA-$60,562.46
FLORIDA-$44,395.96
TEXAS-$43,047.76
NEW YORK-$39,851.00
PENNSYLVANIA-$28,197.72
ILLINOIS-$22,503.01
MICHIGAN-$22,303.97
OHIO-$21,216.15
NEW JERSEY-$17,980.06
NORTH CAROLINA-$16,456.34
Source: Carlson School of Management at the University of Minnesota
Opinion Based List
Seven Benefits of Data Mining for Health Plan
Design
1. Determine what diseases and conditions are driving trends.
2. Target intervention to high-risk segments of the population and those who need the most care.
3. Identify gaps in medical treatment and direct employees to the proper care.
4. Identify the best, cost-effective network providers and guide employees to use them.
5. Improve health habits through wellness, health promotion, education and care-management
programs that increase awareness and engage employees in their own care.
6. Measure the performance of vendors and administrators and hold them accountable for quality,
cost-effective treatment by comparing their results to national benchmarks.
7. Determine what level of cost-sharing improves employee health and cuts cost.
Notes: PayerFusion highlights seven benefits of data mining for self-funded health plans.
 2012, MCOL. All rights reserved.
page 22
October 2012
Announcements
Items of interest from MCOL
The Accountable Care Learning Kit Version 5
$395 Flash Drive
The Accountable Care Learning Kit Version 5 has been designed by MCOL to provide you and your organization
the tools to understand and reference key information, insights and resources regarding Accountable Care
Organizations. Priced individually, this Learning Kit would retail in excess of $1,000. The Accountable Care
Learning Kit is available to you and your organization for just $395.
Using this learning kit, you can view a number of insightful 2012 and 2011 presentations from national experts
covering a variety of issues concerning ACOs, browse a directory of executive profiles with contact information on
ACO leaders, review and reference key ACO articles, overview and regulatory documents, and even take an
interactive quiz on basic ACO knowledge.
Contents
Video of Nineteen Faculty Presentations
Thirty One key Accountable Care Articles
An Overview of ACO Information
164 Executive Profiles
A Brief Interactive Quiz
Additional Information
Visit https://www.managedcarestore.com/YMCOL/acolearningkit.htm to order online: select Media and
click Add to Cart at left
To order by phone: call 209.577.4888
To order by mail/fax: download product flyer with order form
www.healthquestpublishers.com
 2012, MCOL. All rights reserved.
page 23
October 2012
Quoted
From MCOL’s Quotes of the Week during September 2012
“CO-OPs have the competitive advantage of writing from a blank slate. We don't
have legacy systems - business practices that we're locked into. We can look at the
data and target resources to the providers who have the best outcomes. We can
focus on primary care, and I think a lot of us will work with the medical home model."
John Morrison, President, National Alliance of State Health Cooperatives (NASHCO)
"The mobile healthcare paradox is that developed markets know mHealth can reduce
costs, but it's considered disruptive to established practices, while emerging
markets with limited healthcare access see it as a main solution." Christopher
Wasden, EdD, Global Healthcare Innovation Leader, PwC
“Our 2012 Employer Health Benefits Survey found a 4% increase in premiums this
year, continuing the recent trend of moderation in health costs and spending
reported in several studies. Double digit increases in premiums were once a
common occurrence, but we have not seen any since a 10% increase in 2004 and
13% growth in 2003." Drew Altman, Ph.D., President and CEO, Kaiser Family Foundation
“Few challenges to healthcare are as complex as is the effective reducing of rehospitalizations, and few challenges demonstrate the absence of collaboration and
coordination between the various constituencies in healthcare delivery as does rehospitalization." James (Larry) Holly, MD, CEO, Southeast Texas Medical Associates
(SETMA)
MCOL Monthly
1101 Standiford Avenue Suite C-3
Modesto, CA 95350
Phone: 209.577.4888
Fax: 209.577.3557
e-Mail: [email protected]
Web: www.mcol.com
 2012, MCOL. All rights reserved.
We welcome your feedback
anytime regarding this issue of
MCOL Monthly or any other
aspect of your membership.
Thank you for being a MCOL
member!
page 24