American Healthcare Primer, Part Two: Private Insurance

This is part two of a series on American healthcare. It may make more sense if you start with Part One.  As with Part One, much of this information comes from Ezekiel Emanuel’s Which Country Has the World’s Best Health Care?

 Where does money come from?

Of the United States’ about 325 million people, around 180 million are covered by employer-sponsored health insurance, accounting for approximately 20% of health care spending. Employees pay on average 18% of the cost of their premiums for individual plans and 31% the cost of their premium for family plans, equivalent to about one-third of median income. Employers pay the remainder of the premiums as a form of tax-exempt reimbursement. To some extent, employer contributions to insurance are taken from wages; it is widely acknowledged that employees would make more if their employers were not covering their health insurance.

More than half of employer-sponsored insurance prices are determined by insurance brokers working on commission. This system incentivizes brokers to negotiate higher rates. Some brokers are now working in other models like “pass-through” in order to minimize that incentive.

Another 22 million people purchase health insurance individually, 11 million of those through “exchanges” set up by the ACA. Eight million people receive insurance subsidies that were once paid for by the federal government. But after the recent discontinuation of these federal subsidies, insurers–still required by law to provide subsidies–were forced to increase premiums on non-subsidized patients in order to cover the cost. Overall, individuals pay for about 28% of all health care spending.

Roughly 28 million Americans, most of them between the ages of 20 and 40, have no health insurance. A small number of uninsured patients receive care through subscriptions to physician practices in a growing model called “Direct Primary Care.”

Where does the money go?

As with public insurance, hospitals consume about a third of spending. In most private insurance, both individual and employer-sponsored, payments to hospitals and physicians are negotiated individually and tend to be roughly two to three times rates paid by Medicare.

Like in public insurance, hospitalizations are covered according to “Diagnosis-Related Groups” (DRGs), fixed, pre-specified amounts paid according to the diagnosis codes attached to the hospitalization. Unlike public insurance, the rates paid for any given DRG can differ by many multiples. The highest rate a given hospital receives from any payer for a given DRG is known as the “charge master” price, and it tends to be exorbitant; when you hear about sixteen-dollar Tylenol or similarly absurd prices on the evening news, it is the charge master price that is being cited. Medicare rates are roughly 31% of the charge master rate.

Physician payments, as in public insurance, consume about 20%, of all health care spending. Commercial insurers base their payments on a multiple of the CMS Physician Fee Schedule.

Pharmaceuticals consume about 17%, of all health care spending and are considered the first- or second-most egregious source of excess spending (behind administrative complexity) in the American health care system. Pharmaceutical prices are not set solely by drug companies. Pharmacy benefit managers, or PBMs, are companies that manage prescription drug benefits for commercial health plans and self-insured employer plans, along with public insurers. PBMs have three revenue sources: supply chain fees paid for the work of managing the benefit plan, which is uncontroversial; “Spread pricing,” a controversial tactic in which the PBM keeps the difference between manufacturer and insurer prices for a drug; and manufacturer rebates, in which a fraction of the cost of the drug to the consumer is transmitted back to the PBM so that the manufacturer’s product can obtain preferred formulary placement over the products of competitors. Rebates have grown in magnitude out of proportion to the health care economy. Insulin has a typical rebate of 66%, for example. As such, revenues of PBMs exceed even those of the pharmaceutical companies with whom they negotiate. In 2017, Express Scripts’ revenue was roughly $100 billion. Pfizer’s revenue was $52 billion.

Outpatient pharmaceuticals are typically covered according to a tiered pharmacy benefits plan, with Tier 1 generic drugs costing ~$10/month, Tier 2 preferred branded drugs costing ~$35/month, Tier 3 non-preferred branded drugs costing ~$70/month, and Tier 4 specialty drugs often being covered under a “coinsurance” model of ~25% patient payment.

Dental and vision care

Private insurers cover dental and vision at varying rates. Most patients have supplemental insurance for this purpose.

Long-term care

Private insurers do not, for the most part, cover long-term care, and long-term care insurance is rare, with only 0.5% of employers offering it. Fewer than 10% of employees nationally have long-term care insurance, in spite of the ~$90,000 annual cost of nursing home care and projected steep rise in need in the next few decades.

Administrative complexity

The United States has much higher administrative cost and complexity than peer countries, owing to a patchwork of private insurance plans with few harmonized features. Overall overhead is 8%, but this rises to 14% if private insurance-related activity is included. Ten other wealthy countries average 3% overhead. We spend roughly four times what Canada spends on administrative overhead, for example. The $812 billion per year we spend on administrative overhead exceeds the entire budget of Medicare.

What do we get from our health care spend?

Medical innovation, at least in terms of new drugs, therapies, and surgeries, is quite high in the United States. America is first in the world in clinical trials, number one (by far) in Nobel Laureates in Medicine, number one in medical patents awarded.

That said, health outcomes in the United States generally lag behind peer countries. We have far more uninsured patients. We have the highest maternal and infant mortality rates in the developed world and the lowest life expectancy. We are in the bottom third of developed countries in happiness.

Our excess costs are not related to utilization of medical services, but rather to inflated prices. All excess cost of pharmaceuticals in America is due to higher prices than in other countries, not increased use. Rates of hospitalization and the length of stay of those hospitalizations are lower in American than in most peer countries.

Pre-pandemic, Bloomberg rated American health care as 35th best in the world, between Costa Rica and Bahrain. In 2000 the World Health Organization ranked the United States 37th (again, ironically, just behind Costa Rica).

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

American Healthcare Primer, Part One: Public Insurance

With the pending transition in Presidential administrations and a historic pandemic killing more than 1,300 Americans daily, we are in for a lot of health care policy talk over the next few months. To refresh our fund of knowledge about American health care, we at KBGH have decided to outline the big features over a series of posts. Much of this comes from Ezekiel Emanuel’s excellent Which Country Has the World’s Best Health Care?

Contrary to popular media, there is no “American Health Care System.” Instead, we have a patchwork of independent and overlapping systems, each with its own problems, bright spots, and idiosyncrasies. This week we’ll cover public insurance.

What do we spend on health care?

The United States spends more than $3.5 trillion annually on health care, equivalent to about 18% of gross domestic product, accounting for almost $11,000 per person. This is roughly double the per-capita average of Organization for Economic Cooperation and Development (OECD) peer countries like Japan and western Europe.

Where does money come from?

Roughly 45% of American health care is publicly financed: 28% federally and 17% by state and local governments. Medicare costs almost $600 billion per year, or 2.9% of gross domestic product (GDP), and covers 55 million senior and disabled Americans. Medicare Part A, covering hospitalizations, is funded by a 1.45% payroll tax from employers along with a 1.45% payroll tax from employees (plus another 0.9% payroll tax for individuals earning >$125,000 or couples earning >$200,000 annually).

Optional Medicare part B, covering physician visits, is financed by income-linked premiums averaging ~$130 per month for people who elect for the coverage. The premium covers ~25% of the cost, and the federal government covers the remaining 75%.

Medicare part C, or “Medicare Advantage,” can charge enrollees additional premiums.

Medicare part D is paid for by premiums paid by elderly beneficiaries and by other general governmental tax revenue.

Medicaid and the Children’s Health Insurance Program (CHIP) collectively cover 65 million mostly poor patients along with certain blind and disabled persons. Some beneficiaries are “dual-eligible,” meaning they are also covered by Medicare. The federal government pays ~57% of the cost of traditional Medicaid as the “Federal Medicaid Assistance Percentage,” while states cover the other ~43%. Medicaid accounts for 1.9% of GDP, or roughly $400 billion per year from the federal government. In many states Medicaid is the single largest fraction of the state budget. In expanded Medicaid under the ACA, in which Kansas does not participate, 90% of the cost is borne by the federal government with 10% borne by the state to cover patients whose income falls up to 138% the federal poverty line.

Kansas uses a “managed” form of Medicaid in which Medicaid is facilitated through third-party payers (Sunflower Health Plan, UnitedHealthcare Community Plan of Kansas, and Aetna Better Health of Kansas).

In Kansas MediKan covers adults with disabilities who do not qualify for Medicaid but whose applications for federal disability are being reviewed by the Social Security Administration. MediKan covers a scope of services similar to that covered by Medicaid, but with additional restrictions and limitations.

CHIP provides health insurance for children whose parents make too much to qualify for Medicaid but whose private health insurance does not allow them to get their children insured. CHIP is not open-ended like Medicaid, but is rather a block grant system varying slightly by state. The federal government pays 72% of the cost up to a year’s maximum allotment, and the State provides the remaining 28%.

The Veterans Health Administration (VA) covers 9 million former military service members. 2.2 million people of Native American descent are insured through the Indian Health Service (IHS). 9.4 million active-duty military and their families are covered through Tricare.

Where does the money go?

About 85% of health care spending is for chronic conditions like diabetes, hypertension, chronic obstructive pulmonary disease, and high cholesterol. About a third of patients with a chronic medical illness also have a comorbid psychiatric disease like depression or anxiety. This is thought to increase the cost of care of those patients by 60% or more.

Hospitals consume about $1.1 trillion, or 33%, of all health care spending

Medicare Part A covers hospitalizations. Hospitalizations are covered according to “Diagnosis-Related Groups” (DRGs), fixed, pre-specified amounts paid according to the diagnosis codes attached to the hospitalization. Medicare’s DRG rates are set by the federal government. Medicare does not negotiate DRG payments; hospitals may take them or leave them. But Medicare does adjust the base DRG rate via special payments to rural and other hospitals, via “Disproportionate Share Hospital” payments to hospitals who provide a large volume of uncompensated care, and via two forms of additional payment to hospitals who provide graduate medical education to resident physicians.

Hospitalizations in Medicaid are covered according to DRGs, with prices set by the states.

The VA owns its own hospitals.

Physician payments consume about $700 billion, or 20%, of all health care spending

American physicians are well-paid: primary care doctors like family physicians, pediatricians, and internists make an average of $223,000 annually, and specialists make an average of $329,000, though that number is inflated by the relatively large salaries of proceduralists like cardiologists and orthopedic surgeons who make roughly five times what peers in other developed countries earn.

Nurse practitioners make an average of $105,000 per year.

Public insurance payments to physicians differ markedly by specialty. Pediatricians make a large fraction of their income from Medicaid, since more than a third of American children are on Medicaid at any given point. Cardiologists, who treat a predominantly elderly population, make the majority of their income from Medicare.

The DRG payment mentioned above does not cover physician costs in either public or private insurance; physician services are billed separately under “Common Procedural Terminology” (CPT) codes. Most ambulatory and inpatient physician payments are still fee-for-service, with “Relative Value Units” (RVUs) converted by each insurer. The purpose of RVUs is to create a common metric to measure physician services based on the time, skill, and intensity of physician work along with practice expenses and malpractice premiums. One RVU via Medicare is worth about $36. After conversion, that $36 becomes about $56 for an office visit and about $77 for a gallbladder surgery (procedural skills are generally more valued than medical skills in the system).

The Relative Value Scale Update Committee (RUC), a 31-physician panel owned and organized by the American Medical Association, assists the Centers for Medicare and Medicaid Services (CMS) with assigning and updating RVUs. The RUC guides ~70% of all physician payment in the United States, equal to an estimated $500 billion each year. Its recommendations are made based on survey results of only about two percent of physicians updated only every 5-20 years, but RUC recommendations are accepted without change by CMS more than 90% of the time.

Physician payments are still mostly fee-for-service with RVUs converted by the federal government, but alternative payments models developed through The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), like capitation, bundled payments, and global budgets, are growing in utilization, currently making up about a third of all payments.

Medicaid physician payments are mostly fee-for-service with an RVU conversion set at the state level, but managed Medicaid providers are experimenting with “capitated” payments, in which a lump sum payment is paid to the physician to encourage reduced overall spending.

The VA and IHS employ their own physicians on salary.

Pharmaceuticals consume about $500 billion, or 17%, of all health care spending.

Drug prices in the United States are 56% higher than in peer European countries and represent our single biggest source of excess health care spending. Americans make up only 4% of the world’s population, but we account for almost 80% of pharmaceutical revenue. Pharma companies point to spending on research and development, but those budgets are dwarfed by advertising budgets. Pharmaceutical and health product manufacturers account for 7.3% of all lobbying money spent in the US, while no other sector accounts for more than five percent. Pharma is by a large margin the most profitable business sector in America.

Of the 17% of the health care budget consumed by drugs, 10% is in the outpatient setting and 7% is in hospitals, nursing homes, or doctors’ offices.

Some drugs, though, are not sold through pharmacies, but through physician offices as part of the “buy-and-bill” system. The most prominent example is cancer chemotherapeutics. Medicare caps physicians at billing six percent higher than the average wholesale price. This incentivizes physicians to use more expensive drugs to generate higher payments.

Medicare part D pays for pharmaceuticals. It is forbidden by law from directly negotiating drug prices, but is allowed do negotiate indirectly through a pharmacy benefit manager (PBM). Pharmacy benefit managers create formularies and negotiate prices in both private insurance and in Medicare. They may limit drug choices in all but six categories: immunosuppressants (as might be used in autoimmune diseases or organ transplants), antidepressants, antipsychotics, seizure medications, HIV medications, and cancer drugs.

Medicaid covers drugs on formularies determined at the state level, usually with a nominal co-payment of a few dollars per prescription.

The VA and IHS, unlike other public health insurers, are free to negotiate their own prices on pharmaceuticals. The VA by law gets at least a 24% discount from the manufacturer’s average retail price outside the federal government. Outpatient drugs are available with a copay of $5 for generics, and many vets are eligible for free prescription medications.

Dental and vision care

Medicare does not cover dental care, but some Medicare Advantage plans do.

Medicaid covers dental care for children. Coverage for adults varies by state.

Long-term care

Medicare covers part of 100 days per illness of long-term “skilled nursing care” as long as the care is triggered by a hospitalization of at least three days related to the illness needing long-term care. Coverage declines from 100% of the first 20 days down to $167/day for the remaining 80 days.

Medicaid is the primary payer for long-term care in the US, covering 62% of nursing home care and 50% of all long-term care nationally. In order for Medicaid to pay, patients must have no more than $2,000 in assets, excluding their car and a home valued up to $552,000; and require assistance with “personal care” like bathing and dressing. Medicaid requires a “look back” of five years to insure that assets have not simply been transferred to others.

What do we get from our health care spend?

Outcomes in Medicare tend to be slightly better than outcomes in private insurance. Outcomes in Medicaid tend to be slightly worse, probably owing to social determinants of health. For example, In commercial HMOs in 2018 the rate of hypertension control was 61.3% and in commercial PPOs 48.8%. Medicare rates of control were 58.9% in HMOs and 68.8% in PPOs. The Medicaid HMO rate of control was 58.9%.

After Thanksgiving we’ll talk about private insurance. Have a great holiday!

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

Why You Should be Glad CMS Now Covers More Ambulatory Blood Pressure Monitoring

CMS covers more ambulatory blood pressure measurements now. Wait! Before you fall asleep–this is a bigger deal than you think.

Of all medical interventions available to physicians taking care of adults, blood pressure control may have the largest potential impact on lives saved. Since more than a third of Americans have hypertension, every 10 percent increase in controlled blood pressures nationwide would save something like 14,000 lives per year. And right now, less than half of people with hypertension have a well-controlled blood pressure. Going from 50% control to 90% control could be expected to save almost 60,000 lives per year. Part of the problem with getting there, though, is that measuring a blood pressure accurately is astonishingly hard. Some of this is due to obvious errors by the measurer: using the wrong size cuff, taking the measurement over clothes, and talking to you while they inflate the cuff, for example.

But some of the error is less predictable. A clever recent study (paywall) found that when participants in the SPRINT study, a large trial of very intensive blood pressure control, were seen by their own doctors during the study but outside the study protocol, their blood pressures differed markedly from the blood pressures obtained by the fastidious measurement techniques of the protocol. People in the “intensive” control group, in whom investigators were aiming for a blood pressure <120 mmHg, had a routine blood pressure at their own doctors’ offices that was 7.3 mmHg higher. People in the standard control group who were aiming for a blood pressure <140 mmHg had an average difference of 4.6 mmHg between their study blood pressure and their routine blood pressure.

Unfortunately, your own doctor may not be able to put in the time or workflow that it takes to get a study-quality blood pressure. She may not be able to let you rest for 5 minutes before a reading, or she may not invest in automated blood pressure cuffs. She may not have the time to average the results of three separate readings. But what your doctor could do is prescribe “ambulatory blood pressure monitoring,” or ABPM. ABPM is a technique by which you wear a device at home that periodically monitors your blood pressure, even at night, without any input from you. Then it sends the results to your doctor. Because the device is unaffected by the technique and timing issues above, it is considered the gold standard for the diagnosis of hypertension. But it has been historically very hard to get insurance companies to pay for. Getting payment required documenting a high likelihood of “white coat hypertension,” that is, a blood pressure in the doctor’s office that was consistently higher than blood pressures obtained outside the office on more than one occasion. People with “masked hypertension,” whose blood pressures outside the office may have been substantially higher than those measured at the doctor, were excluded.

A recent rule change by Centers for Medicare and Medicaid Services (CMS), though, allows expanded use of ABPM not only for suspected white coat hypertension, but also for masked hypertension. Since CMS is the bellwether for other insurers’ behavior, we can surely expect private insurers to follow.

So check your blood pressures at home. Or go to your local fire station or EMS. They can check your blood pressure 24/7/365 for free, and they know what they’re doing. See the image below to locate all the EMS and Fired Department stations in Sedgwick County, or download your own copy here. There is also an area where you can track your out-of-clinic blood pressures to report back to your physician.

If your home readings don’t match what you’re getting from your doctor’s office, ask your doctor about doing ambulatory blood pressure monitoring. Better yet, encourage your employees to ask about it.

Note: the Kansas Business Group on Health receives CDC funding to improve the detection and care of high blood pressures. But we believe in it either way.

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

What's a Year of Life Worth?

Determining the value of treatment

You’ve probably heard the term “cost-effectiveness” thrown around in regard to medical treatments. In this blog we’ve made the case that much of the testing in “executive physicals” isn’t cost-effective, for example; we argued that the weird little tests that some executives get simply aren’t worth the money because they haven’t been shown to improve quality of life nor quantity of life, a measure we bundle into “quality-adjusted life years” or QALYs (pronounced “quollys”). But we’re not just picking on C-suite folks. When any new treatment, like a new pacemaker, costs more per QALY gained than the theoretical care its high cost displaces, like routine blood pressure treatment lost due to the extra cost resulting in nurses being laid off, the health of the population suffers.

Historically, even though the Centers for Medicare and Medicaid Services (CMS) have explicitly avoided setting policy according to cost-effectiveness for fear of rationing care, we’ve used Medicare’s payment for dialysis as an “apocryphal” benchmark. A year of dialysis in the early 1990s cost about $50,000. And without dialysis a person with end-stage renal disease will quickly die. So, the argument went, a year of human life must be worth about $50,000 and any new drug, therapy, or surgical procedure should cost no more than $50,000 for every resulting additional QALY. By this argument, a chemotherapy drug that adds five years to your life should cost no more than ~$250,000.

Other ways to use this model

This model based on precedent is far from the only way people have tried to define cost-effectiveness. A 2019 mathematical model found that Americans with an income of $50,000 should be willing to pay $100,000 for one additional year of ideal health. An extrapolation of patients in the United Kingdom’s National Health Service–where cost-effectiveness is tracked extraordinarily tightly–estimated that Americans would be willing to pay between $24,823 and $40,112 per QALY gained. A somewhat similar analysis comparing US health expenditures to other countries estimated $60,475 to $97,851 per additional year of life.

In an attempt to define a more home-grown, objective, US-specific threshold for cost effectiveness, David Vanness, James Lomas, and Hanna Ahn recently published a simulation to determine the number of people in a model population of 100,000 individuals resembling the US population who would lose insurance because of a $100 premium increase (1.6%, or $10,000,000 total for the population). They used 2019 premiums from the ACA marketplace as their baseline, and they were able to estimate insurance loss from historical data on coverage losses from the ACA Marketplace.

Next, using a study of mortality reduction observed with ACA Medicaid expansion, they were able to deduce the number of deaths among the newly uninsured in a year. To account for loss of quality of life among the survivors (since QALYs account for both quantity and quality of life), they benchmarked to a study on health-related quality of life by year of age.

Then the investigators ran a simulation with these “givens” 50,000 times. Here’s what they found: for each additional $10,000,000 in health expenditures passed through to patients as premium increases (remember, the equivalent of $100 per person, or a 1.6% increase), roughly 1,860 of the 100,000 simulated patients became uninsured. This resulted in five additional deaths, 81 QALYs lost due to death, and 15 QALYs lost due to illness.

So a new treatment costing the theoretical American population of 100,000 people $10,000,000 would need to increase QALYs by 96 to avoid reducing the overall health of the population. $10,000,000 divided by 96 equals $104,000 per QALY, about double the apocryphal $50,000 per QALY estimated by Medicare’s dialysis coverage.

What do you think? This is a question far better suited to the Halloween season we just left than to the Thanksgiving season we’re entering, but it’s a question we all have to ask ourselves: Is $104,000 per year a reasonable threshold for insurance companies to use in deciding on coverage of new drugs, tests, or services? Are you an Ebenezer Scrooge, unwilling to pay even $50,000 per year of life? Or are you a spendthrift, willing to pay more?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

Are ICHRAs Trouble for Low-Income Workers?

Losing any part of your health coverage is bad news right now, when the United States has just recorded its highest-ever new caseload of COVID-19. So depending on how you’re covering the health care needs of your lower-income employees, news out of the United Hospital Fund last week, brought to our attention from Modern Healthcare (paywall), may be especially alarming.

The UHF reported Friday that low-income workers who buy their health insurance through “individual coverage health reimbursement arrangements,” or ICHRAs, could lose ACA premium subsidies or lose their eligibility for free or low-cost coverage.

How do ICHRAs work?

ICHRAs, which became available in January of 2020 (probably too late for your most recent open enrollment periods), were designed with the intention to allow employer groups to establish “monthly allowances” for individual employees who could then submit their medical expenses back to their employers for reimbursement on a tax-free basis. The intention was to encourage employees to seek care on the individual market, and then reimburse the employees for some or all of their expenses. Employers offering ICHRAs have broad discretion over what is reimbursed, and how much; employers can choose whether to provide allowances for individuals or individuals and their families. They can offer different allowances based on workers’ ages, they can decide exactly what expenses can be reimbursed (premiums, cost sharing, or both), and the employers can decide whether or not to roll over unspent amounts from one year to the next.

What this could mean

Unfortunately, the downstream effect of this could be that “… some workers could also forfeit premium subsidies through the ACA or lose eligibility for free or low-cost coverage…comprehensive group coverage [could be] replaced with an ICHRA, which could mean benefit reductions and narrower provider networks,” as Peter Newell, director of UHF’s Health Insurance Project and author of the report, said. The report offers a theoretical to illustrate this:

In lower-cost Erie County, New York (Buffalo), workers with incomes of $48,000 would pay more for coverage with a minimum affordable ICHRA and without ACA tax credits than they would under straightforward employer coverage. Workers making ~$24,000 would lose eligibility for the $20-per-month Essential Plan, and to obtain comparable coverage it would cost them more than $700 per month, a net loss of $680 per month. The only workers who would clearly benefit from an ICHRA in such an environment would be those making more than ~$50,000 annually, who would be ineligible for ACA premium subsidies.

Potential solutions

To correct this, the UHF recommended three changes at the Federal level (either congressional or regulatory): First, they recommend allowing low-income workers to opt out of ICHRAs without an affordability test. Second, the UHF recommends that individuals participating in ICHRAs be allowed to keep their ACA tax credit if they’re eligible for both, regardless of income. And third, the authors recommend the government discourage employers from replacing employer-sponsored plans with ICHRAs through new regulations. Given the enthusiasm of the current Presidential administration for ICHRAs (along with short-term limited duration insurance and association health plans), this third recommendation seems completely dependent on the results of the November 3 election. But your company’s decision on ICHRAs is not dependent on the election at all. If you have low-wage employees who have had success or problems with individual coverage health reimbursement arrangements, we’d love to hear your experience.

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

Ho Ho How to Avoid Holiday Weight Gain (Encore)

You can already see it coming: the weight we all gain over the holidays is as predictable as the weight we try to take off for the summer. A few years ago researchers used WiFi-enabled “smart scales” whose buyers were aware that their weights would be used for research to track the weights of American, German, and Japanese subjects for one year. The scales are important: people frequently misreport their weight, or they change their diets when they know they’ll have to report somewhere to be weighed. By having the scale in their house and wirelessly communicating with the database, the investigators hoped to reduce this bias. For any given holiday the researchers compared the maximum weight at no more than 10 days after the start of the holiday to the weight that was measured 10 days before the holiday.

The results? In all three countries, the participants’ weight rose in the 10 days after Christmas Day, compared with the 10 days before Christmas (+0.4% in the U.S., +0.6% in Germany, and +0.5% in Japan). The raw amount of weight gained wasn’t large: only 1.3 pounds for an average American. But the researchers pointed out that since the population of this study—people who spent ~$150 on a scale—is probably wealthier and more motivated toward weight loss than average, the results of the study probably underestimate the effect on the general population. For example, the average worker gains 2-3 pounds per year (half of that between Halloween and New Year’s Day, naturally) and weights in this study had gone down to pre-holiday levels within six months or so.

So: what can we do to help our employees prevent this weight gain in the first place?

An interesting answer comes from two groups of researchers who elected to try a “weight prevention” approach rather than a traditional weight loss approach. First, investigators at the University of Georgia developed a program they called Holiday Survivor for state employees. Participants were divided into teams and were instructed by a worksite wellness professional on self-monitoring and regular weigh-ins from the end of October to mid-January. Efforts were put toward increased awareness of food intake and physical activity through self-monitoring, but the program was geared not toward teaching new knowledge, but instead to build social support for positive behaviors. Each team of four employees received points for participating in weekly program activities like a healthy potluck, a 5 km run/walk, or “lunch and learns,” and for completing weigh-ins. Individual participants also received points on two occasions for providing proof of food logs (not the logs themselves). In early January a prize ceremony was held to celebrate team and individual achievements.

In spite of the emphasis on weight maintenance, the employees lost an average of 4.4 pounds (from 196.7 in October to 192.3 pounds in January).

A second group of investigators in the U.K. randomized workers in a variety of jobs to either get a pamphlet on the dangers of holiday weight gain (without dietary advice) or to get instruction on recording their weight at least twice weekly (ideally daily), ten tips for weight management, and pictorial information about the physical activity calorie equivalent (PACE) of holiday foods and drinks (that is, information such as “13 minutes of running for a can of sugared soda”). The goal was for participants to gain no more than ~1 pound of their baseline weight.

Over the holiday season the group getting the pamphlet alone gained on average 0.8 pounds, while those weighing frequently, getting tips on weight management, and informed of the PACE of holiday foods lost 0.27 pounds.

The Kansas Business Group on Health generally takes a prosaic view of traditional worksite wellness practices. We tend to believe that true health is hard to define and harder to measure, and that improvements in health are rarely as simple as old-fashioned carrot-and-stick rewards or punishment. But this strategy of proactively engaging employees to manage a known occupational hazard (the holiday season) is novel and promising. If any members have had similar luck we’d love to hear about your strategies!

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

Use a Checklist for Your Checklists

I’m a big fan of physician-author Dr. Atul Gawande. Like, a big fan. Want evidence? Once upon a time the screen background of my phone was a picture of my wife and I with Dr. Gawande:

Just me, Atul, and Dr. Tracy Williams. No big deal. Eat your heart out on that plaid jacket, Pete Campbell.

My screen background is now a picture of my kids at a bike race (I’ve grown). Recently, and not because of garden-variety celebrity worship, I’ve been re-reading some of his 2009 book The Checklist Manifesto. I highly recommend it, and I thought I would share some of the lessons of the book that might especially resonate in the Time of Remote Work Due to COVID.

Gawande is careful to craft a message that a true checklist to help us accomplish involved tasks is not like your grocery list. It’s more like a catalyst to action, meant to free people up rather than restrict them. To help us write checklists that meet these needs, he recommends a “Checklist for checklists,” of sorts. Here are the parts that I find especially useful:

1. Try to define what kind of problem are you trying to solve. Is it fairly simple, like baking a cake? Is it complicated, like launching a rocket, where many, many things can go wrong? Or is it complex, like raising a child, where the inputs into the problem and the child’s response to them are constantly changing?

2. With the complexity of the problem in mind, what kind of list do you need? Some lists are more oriented toward “doing,” like baking that cake, while others are more oriented toward “reviewing,” like the pre-flight checklists in airplanes.

3. What kind of items do you need? Some checklists, like building an addition to your home, will require mostly actions. Other checklists, like preparing for a recurring meeting, are mostly communications.

4. Remove any items you assume list users will just do without prompting. In the process of compiling this I’ve deleted bullet points around identifying decision points and defining the problem. You already know to do those.

5. Identify the critical items and keep them. Consider emphasizing them by highlighting or installing alerts, such as on your phone if it’s a personal list, or on a poster or any software package the task needs in order to run if the list is shared among many, such as in the clinics we at KBGH work in.

6. Leave room for judgement. No one wants to sit through a meeting where the food for the office Christmas party (remember those?) is debated for an hour. Leave someone with a budget and any attendees’ life-threatening food allergies and see how she does.

7. Simplify the language if possible.

8. If the checklist is shared, adjust the order and layout for clarity if possible.

9. For checklists that have dire consequences, like the aviation checklists above or the preoperative checklists pioneered by Dr. Gawande, trial the list in real-world situations if possible before it goes into daily use.

10. Gather feedback from every potential user and refine the list based on that feedback. Dr. Gawande’s surgical checklist wasn’t just written and reviewed by surgeons. It was reviewed and modified by everyone involved in the care of the patient, from the orderly wheeling her into the room to the surgeon and anesthesiologist to the circulating nurses.

11. Maintain the list over time to keep up with its context. Checklists and clinic protocols require care and feeding just like your pets.

12. Treat the list as a tool, not as a religious tome. We at KBGH are fans of the care guidelines developed and used within the Kaiser health systems, such as this one for hypertension care (scroll to the bottom). But we know that a small number of patients will not be well-served by that care algorithm. That’s why doctors and nurses are trained to think critically.

13. Diffuse the list. Make sure it is available to everyone who may need it. That may mean posting it online.

Do you use checklists for complex tasks in your workplace? Let us know!

When will I get the coronavirus vaccine?

The importance of vaccine development and deployment is hard to overstate

About 700,000 Americans have died of HIV, ever. As of the writing of this blog post, roughly 210,000 Americans have died of COVID-19 in about seven months. And that number probably underestimates the real death rate by a quarter (paywall).

After a very eventful week for COVID-19, some good news is poking up through the weeds. We’re close enough to getting one or more functional vaccines that we need to start thinking about how to distribute those vaccines. The National Academies of Sciences, Engineering, and Medicine, in response to a request from NIH and CDC, formed a committee to “assist policymakers in the U.S. and global health communities in planning for equitable allocation of vaccines against COVID-19.” Their report, authored by Emory University’s Dr. William H. Foege and 17 other members, is now available for free download. Some highlights:

First, the committee recommends that shots be free of charge to all, and that efforts to distribute them should focus on disadvantaged areas to “remedy” racial health disparities. The report further suggests CDC hold back 10% or so of the vaccine in reserve for use in “hot spots” identified through the Social Vulnerability Index, a tool that uses 15 Census data points on race, poverty, crowded housing, and other factors to estimate risk in natural disasters. Look at the figure below to get a sense of this:

https://www.medrxiv.org/content/medrxiv/early/2020/07/06/2020.07.04.20146084.full.pdf

Don’t worry about the text, which I know is hard to read. Look at how the green and gold counties on the left figure, which represent high-risk areas in the Social Vulnerability Index, line up with the red counties in the figure on the right, which represent the highest per-capita mortality rates. You’ll notice a pretty neat fit.

But beyond those broad measures, the guidance of the NAS committee is that immunization should be implemented in “waves.” See which one you fit into:

Wave One

When vaccines and supplies are expected to be scarce, they recommend the first doses should go to high-risk health care workers in hospitals and nursing homes and to those providing home care. First responders also would be in this group, along with anyone who works in a hospital or clinic, from clerks through janitorial staff. This is because, somewhat counter-intuitively, models show that vaccinating the workers will save more lives than vaccinating the residents.

Wave Two

This wave would come at an undetermined time related to the successful production and deployment of vaccine doses, which would include older residents of nursing homes and other crowded facilities, along with people of all ages with high-risk health conditions. The report lists cancer, chronic kidney disease, and obesity among possibilities, but does not commit to a full list of conditions that should be included.

Later Waves

Subsequent waves would vaccinate teachers, child care workers, workers in essential industries (which may vary state-to-state, since even though Federal health officials have the final say on distributing the 300 million vaccine doses the government is buying under Operation Warp Speed, state and local health departments will decide many details), people living in homeless shelters, group homes, prisons, and other facilities, since like nursing home residents, they can’t simply isolate themselves if they’re infected..

Everyone else—healthy children, young adults, etc.—are recommended to wait until vaccine supplies increase. The AP reports that “Many health experts predict a vaccine won’t be widely available to all Americans until mid-to-late next year.”

So this is where we review the fact that a vaccine won’t be magical. It’s worth emphasizing that the vaccine will add to, not replace, present efforts. Let’s assume that the best vaccine is 70 percent effective. By the standard we’re accustomed to with influenza vaccination that’s pretty good. That means that if 330 million Americans receive the vaccine, 99 million will be left vulnerable. And we still don’t know how long the vaccine will protect us; it could be months or it could be years. You’ll likely need to take multiple doses for maximum effect. So alas, the practices of social distancing of some sort and masking in crowded places aren’t going anywhere soon. But that caveat aside, there may be a vaccine-tinted light at the end of a very long tunnel.

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This was a reprint of a blog post from KBGH.

Delphi for High Value Care

Can the Oracle of Delphi move us toward more high-value care?

Have you ever been in a meeting in which important decisions seemed to be made by or for the loudest voices in the room, even when you had a hunch that the secret consensus of the room was not in favor of the decision? If so, then you’ve been in a situation where the Delphi method would have helped.

In ancient Greece, Pythia was the high priestess of the Temple of Apollo. She was informally known as the “Oracle of Delphi.” The Oracle was consulted about important decisions throughout the ancient classical world, and her opinion was considered so valuable that Delphi was considered the center of the world. (I consider Byers, Kansas, my childhood home, the center of the world, but that fact has more to do with my robust self-esteem than it does with geographic fact or fiction.)

In modern times–the 1950s–the Delphi name was applied to a decision-making or forecasting strategy pioneered by the RAND corporation, a famous nonprofit policy think tank. (R ANd D; “research and development.” Get it?) Except this time, the decision was not to be made by an all-knowing oracle, but by the carefully considered and anonymous consensus of the group. They called it the Delphi method, and it is my favorite way to keep louder or more senior voices from always getting their way in meetings or organizations.

Here’s how it works:

• A panel of “experts” is convened, usually virtually or remotely, ideally with a diverse background but some technical expertise regarding the question at hand.

• Each expert is asked to make an anonymous judgement or prediction regarding the question(s).

• The participants remain anonymous, even through the completion of the final report, so that those who are more senior, more vocal, or more reputable cannot dominate the decision-making. (computers have obviously made Delphi much, much easier to facilitate than it once was)

This anonymity is also meant to free participants from any embarrassment about admitting error and to prevent the “bandwagon effect,” in which faddish ideas can become popular.

The experts’ initial answers to survey questions are collected, and irrelevant content is filtered out by a panel director. Then the survey and its answers are cycled back through the group so that others can revise their own opinions or forecasts. This process continues with a goal of gradually working toward consensus:

Wikipedia

This works for more than just complex decisions

Delphi has been adapted into “Wideband Delphi,” a technique in Scrum project management in which team members repeatedly, and anonymously, estimate the amount of time or work a project will take until they reach consensus. Then their wisdom is measured against the real-life velocity of the project to inform future estimates.

This is all prologue to what I really want to write about today, which is a solution for “guideline bloat.” Medicine, like many complex fields and like the field you likely work in, be it engineering, human resources, or accounting, continually develops and refines guidelines for use as tools to guide the screening for and care of specific illnesses. But medicine has a problem: there are too many guidelines, and they tend to encourage more care, not less. A well-known study estimated that a single primary care doc providing nothing but USPSTF screening and prevention recommendations for an everyday practice would need most of the day just for those, assuming no sick people ever came in the door. But an average primary care physician doesn’t just see people for screening and prevention, as you know. The average patient she sees has more than three problems or complaints.

So calls have come to prioritize guideline use, and some are saying that Delphi is the way to do it. In the last few weeks we’ve seen a demonstration (paywall) of how that might work. A team of investigators from several medical schools reviewed guidelines from the years 2011 through 2016 to identify “potential deintensification recommendations” in primary care medicine. That is, how can we take unnecessary care away from patients instead of adding more diagnostic work and potentially unnecessary therapies? They came up with about 50 possible recommendations and then reconfigured them to generate recommendations that 1) were actionable and measurable, and that 2) explicitly defined the deintensification action and which patients it might apply to. Then they convened a Delphi expert panel to review their synthesized evidence and judge the potential recommendations. The final work product of the panel was intoxicating if, like me, you’re the kind of person that believes that good medicine involves stopping as many treatments as you start. Here’s an example.

The original, pared-down guideline on colon cancer screening that was fed to the group of experts looked like this:

JAMA Internal Medicine

That’s a mouthful. But after a few runs through the Delphi machine, that word salad was chopped down to this:

JAMA Internal Medicine

That may still seem awkward and wordy if you’re not completely comfortable with medical jargon (FOBT is “fecal occult blood testing,” and FIT is “fecal immunochemical testing.” Enjoy your lunch). But to translate English to English, it just says that, in an average population, we should not repeat colon cancer screening very often unless past attempts at screening have been thwarted by too much poop in the patient’s colon for the doctor to be able to see through the colonoscopy camera. In other words, the health care system should not foot the bill for too-frequent cancer screening.

Two editorialists (paywall) write enthusiastically about the prospects for this kind of thinking about low-value care when low-value care is “driven by clinician behavior and a disjointed US health care system that pays for doing more, necessary or not.”

So two recommendations this week, neither of which have been run through a Delphi panel: 1) You should be using Delphi in your company if you’re not, especially if you have powerful voices that tend to dominate decision making. And 2) we should all be thinking about systematic ways like this to reduce the amount of low-value care being delivered by our healthcare system and paid for by our companies.

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This was a reprint of a blog post from KBGH.

Is the Broker Model Broken?

If you ever squirm through the seeping underbelly of dastardly health insurance tactics like we do here at KBGH, you may have seen this report from The Hill last week outlining some alleged underhanded tactics being used by health insurance brokers.

The tl;dr (too long; didn’t read) version of the story is that the Government Accountability Office (GAO) performed an undercover audit of insurance brokers to determine if companies selling health plans exempt from the Affordable Care Act coverage requirements were being honest about the limitations of those plans. After all, ACA non-compliant plans tend to be cheaper, but they also tend not to cover preexisting conditions.

Out of 31 undercover phone calls to representatives in Alabama, Florida, Kansas, Pennsylvania, and Wyoming, during which GAO agents posed as customers looking for health insurance that covered their preexisting conditions like diabetes or cancer, about a quarter of the time (eight calls) sales representatives engaged in “potentially deceptive marketing practices.” Examples included:

1. Representatives telling the undercover agents that preexisting conditions would be covered, even when the agents claimed conditions that were explicitly excluded by the plan in question.

2. Representatives refusing to provide documentation of coverage prior to enrollment.

3. Representatives implying or asserting that the customer was being enrolled in a comprehensive insurance plan rather than, for example, a health care sharing ministry or membership in an association with a bundle of limited benefit plans.

4. Representatives suggesting that no other coverage was available.

5. Representatives intentionally falsifying the caller’s health status on the application.

 Examples of call recordings are available online.

In spite of its shades of its Dateline NBC-esque qualities, this doesn’t seem to have been a showy, “gotcha” operation. The investigation was requested by Democratic senators Robert P. Casey and Debbie Stabenow as a follow up on an investigative report on misleading online ads for non-ACA plans. But the GAO is a nonpartisan organization. The Hill, which reported the story, is well-known as a centrist or even center-right publication. And as Katie Kieth points out in Health Affairs, this isn’t even the first report of its kind. Many other instances of this kind of behavior have been documented.

What does this mean for you, the employer?

This news alone may not be very relevant to your company’s health coverage. After all, these agents were posing as individuals seeking a non-ACA compliant plan. If you’re in Human Resources this is very unlikely to represent your interactions with a brokerage or the greater health insurance industry. But this isn’t the first time the insurance brokerage industry has been stung recently. In early 2019 a Propublica piece showed that brokers working on commissions–usually three to six percent of the premium–routinely increased the cost of benefits to companies. This isn’t a personality flaw in the broker agents; it’s a feature of a flawed system.

To my knowledge no one has been able to mount a significant defense against these allegations. To the contrary: the 2019 Propublica piece led to senators calling for disclosure of perks and fees paid to brokers, a position enthusiastically supported by Michael Thompson, the president and CEO of the National Alliance of Healthcare Purchaser Coalitions, of which KBGH is a member.

What you can do to protect yourself

KBGH believes that brokers can be a vital part of the health insurance marketplace. Health coverage is confusing, and it is worth good money to make sure your company is getting the best value for its health care dollar. Ideally, we would like to see all brokerages work on a fee basis and take no commission off your premiums, since that commission perversely incentivizes the broker to increase your health coverage costs. To make this easy, Health Rosetta has created a “Benefits Advisor Compensation Disclosure Form” that you can download for free to use with your broker.

But at the very least, we believe in transparency. Your broker should be able to disclose all the ways it is making money off its work with you up front. If your broker refuses to do that, we recommend that you find a new broker.

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This was a reprint of a blog post from KBGH.

Why Six Feet?

“We should all stand six feet apart to prevent the spread of COVID-19.” If you haven’t had that hammered into your head since March, let me be the hammer that takes the last lick at the nail.

Where did that number come from?

Six feet seems arbitrary. Why not five feet? Why not ten feet? In the August 25 issue of the British Medical Journal, “BMJ” for short, a few authors take us on a journey six feet long (or two meters, if you’re in one of the all-but-three countries that has switched from imperial to metric measurement; or two metres if you’re a true pedant).

The two-meter rule has a long history. Scientists in the 19th century, shortly after the very invention of germ theory, placed culture plates around patients who were then asked to cough or sneeze. Then the scientists could culture out whatever bugs landed on the plates. Most of the plates more than 1-2 meters from the test subject failed to grow anything scary. So, two meters became the default distance.

As cameras got better in the 1940s, visual representation of sneezes became possible:

Gross backlit sneeze snapshot brought to you by Wikipedia

One experiment showed that only 10% of droplets traveled as far as 5 ½ feet. So even though 10% of sneezers were able to eject harmful bacteria up to 9 ½ feet away, the two-meter rule was cemented. Unfortunately for hard-core two-meter adherents, recent studies have failed to fully support these original conclusions. Eight out of the ten studies included in a recent systematic review, for example, showed large numbers of respiratory droplets landing beyond 2 meters for particles up to 60 micrometers, a particle size large enough to contain thousands of copies of SARS CoV-2, although not small enough to deposit those viruses into your lungs.

Dragon breath-like eight-meter sneeze plume brought to you by Lydia Bourouiba via Wikipedia

What do we do with this information?

Not to pat my family on the back, but you do the same thing we did this weekend. You pretend that everyone in the world is a smoker, and you protect yourself from the imaginary PM2.5-rich smoke by wearing a mask and keeping your distance. On a shopping trip this past weekend, my wife and I ran into an acquaintance and talked with her, indoors, for several minutes. In our minds, she was actively smoking: we did not shake hands, hug, or get closer than a few feet, and everyone wore a mask.

Two days later, that person tested positive for COVID-19.

I’m going to be careful and self-isolate myself for a couple of weeks just in case; I’m fortunate that my work allows it fairly easily. But for the most part I feel safe because we were all masked, including the infected person, and we stayed relatively physically distant. Because as the authors of this review noted, the risk of transmission, even with prolonged exposure, is relatively low if everyone is masked and the environment is reasonably well-ventilated:

British Medical Journal

As we mentioned in a previous blog post, for example, two Missouri hairstylists who unknowingly exposed hundreds of people to the virus appear to have infected zero clients because of their fastidious facemask use.

So six feet isn’t magical. But it’s still a reasonable number, especially combined with good ventilation and good adherence to masking. The next time you see me, if I keep my distance and don’t shake your hand, it isn’t personal. It’s epidemiology.

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This was a reprint of a blog post from KBGH.

What is the value of a mask?

For various reasons the rate of infection in Kansas is back on the way up, and it’s bound to get worse as the weather cools and we all spend more time indoors together.

 As businesspeople, we want to see a return on our investment. But what if the investment we make isn’t in our business or in the stock market, but in our health, and specifically in COVID-19 protection? An analysis from Goldman Sachs recently tried to answer this very question.

How do masks affect usage, case rate, and fatality?

The investigators estimated that the “Effective Lockdown Index, or “ELI,” a statistic of their own that takes into account a combination of official social mobility restrictions and actual social distancing data, took away about 17% from American gross domestic product (GDP) between January and April this year.

Then they looked at data from multiple sources to make a couple big conclusions:

First, mask mandates immediately increase the number of people who mask by about 25%. This seems reasonable and in line with our local experience when the Sedgwick County and City of Wichita emergency orders went into place. (It’s also worth remembering on a national level that Florida and Texas, two of the most-affected states, still don’t have statewide mask mandates).

Second, mask mandates are associated with large reductions in cases and deaths from COVID-19:

Again, this is largely in line with the change seen in Kansas counties with mask mandates versus counties without mask mandates. So using some further reasonable assumptions and fancy statistical methods, the Goldman Sachs folks determined that a national mandate would cause a 15 percent rise in the share of the population that wears masks, which would in turn reduce the daily growth of cases by about one percent.

Gauging the economic impact of wearing a mask

With those numbers in their pockets, the investigators went back to their “ELI” to determine what fraction of the economy would be affected by another March/April-style lockdown:

They determined that another lockdown similar to this past spring’s would cost just short of 5% of total economic activity. As we said last spring, pandemic viruses cause recessions. Then authors writing in The Economist simply divided that share of GDP by the number of people who would start wearing masks under a mandate and came up with a value for mask wearing. They calculated that one American wearing a mask for one day prevents a fall in GDP of $56.14, or about double the initial fine that you would get in Wichita for being a recalcitrant mask non-wearer. As the authors of the Economist piece said, “Not bad for something that you can buy for about 50 cents apiece.” Clearly they’re not taking into account my designer taste in facial covering, but I digress.

 It’s tough to overstate how huge this potential cost savings is. For reference, doubling smoking cessation counseling services, as we covered in a previous blog post, returns about $215 per employee over ten years, the equivalent of about $0.06 per day. I’ll admit that’s not a fair comparison, since we’re comparing the benefit to the employer in the case of smoking cessation versus the benefit to the national economy in mask-wearing. But I think my point is made.

 I’m lucky to live in a mask-mandated city inside a mask-mandated county. But for the rest of us, if we want our businesses to stay open, and if we cannot count on mandates or enforcement at the city, county, state, or federal levels, we need to mandate mask use from our employees ourselves.

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This was a reprint of a blog post from KBGH.

Some telehealth codes are going away. How does this affect you?

In March of this year, you’ll recall that Centers for Medicare and Medicaid Services (CMS) let out the reins on telehealth services, resulting in telemedicine experiencing as much growth in three weeks as it had in the previous several years. Later, services were expanded even further to include things like physical therapy, occupational therapy, and many inpatient services.

The new proposed changes

Earlier this month, CMS released its proposed physician fee schedule for 2021, and they’ve predictably scaled back the services that are covered via telehealth. Gone are 74 codes that CMS finds have “no likelihood of clinical benefit” after the COVID-19 public health emergency ends. Some of the codes that are going away are for certain psychological testing, physical and occupational therapy, and several inpatient management codes.

In their place, though, CMS has approved nine new codes, covered through 2021 at least and ranging from care planning for patients with cognitive impairment to group psychotherapy. The mental health orientation of these new codes is exciting to us at KBGH because of our ongoing work with the Path Forward for Mental Health and Substance Abuse initiative, which includes improved access to tele-behavioral health as one of its five core areas of improvement. COVID-19 has brought an increased focus on the need for tele-behavioral health. Research released from the Wellbeing Trust reports that there could be an increase in “deaths of despair” with 75,000 more deaths due to suicide and drug misuse due to the pandemic. While more people are seeking mental health care, tele-mental health could make access easier, and also help overcome stigma still associated with mental health issues. We want to see telehealth used more extensively in mental health services! If you are interested in working with KBGH on this, please contact us.

But what’s the bottom line for the future of telehealth? It’s pretty positive overall. If your employee population is relatively healthy and unlikely to be hospitalized, and if you are located in a place with plenty of hospital beds staffed with ample physicians, then these new CMS rules aren’t likely to affect you much at all. For sicker patients, or for patients who may only have a hospital readily available that doesn’t have easy access to specialist physicians, these new rules may change their care compared to the last five months. But on the bright side, I hope that the several new telehealth services that are covered on a temporary basis are a signal that CMS has some willingness for experimentation moving forward.

Providing your feedback

If you’re interested in giving CMS feedback on these changes, please consider sending comments on the proposed rule at this link or by mail at:

Centers for Medicare & Medicaid Services, Department of Health and Human Services

Attention: CMS-1734-P

P.O. Box 8016, Baltimore, MD 21244-8016.

Comments on the proposed rule must be received by 5:00 p.m. on October 5, 2020.

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This was a reprint of a blog post from KBGH.

COVID-19 May Be Worse in the Fall. The Time to Protect Yourself is Now.

The rate of new COVID-19 cases is finally headed downward again in Kansas:

Statnews.com

We’re not through this yet.

With fall comes cooler weather and seasonal influenza stacked on top of the COVID-19 pandemic. This looming threat is causing foundational changes in our expectations of the season. Several college conferences have already cancelled sports. Theater releases of movies that cost hundreds of millions of dollars to produce have been delayed indefinitely, and others have gone straight to video on demand. The spookiness of the Halloween season is real, and getting realer every day.

So we and our employees should continue masking. Masking works (as long as the mask isn’t a fleece buff). We should continue socially distancing whenever possible, and we should obviously get vaccinated against seasonal influenza when we can. We should get the COVID-19 vaccine as soon as it is available. But what else can we do?

We can lose weight. Real disaster preparedness isn’t hoarding water or ammunition. It is largely the preparation of your body and your bank account for emergencies. A recent study in the Annals of Internal Medicine found that, especially in people younger than 65, obesity was one of the biggest risk factors for intubation and death with COVID-19. And the bigger patients were, the higher the risk. “Morbidly” obese COVID-19 patients–those with a body mass index, or BMI, of 40 kg/m2 or greater–were 60% more likely to die or require intubation, compared with people of normal weight:

Annals of Internal Medicine

And obesity may even decrease the effectiveness of a future SARS-CoV-2 vaccine.

So if you are one of the roughly 40% of Americans who are obese, then to protect yourself this fall, the time to start reducing risk is now. This isn’t about judgement or shaming. I’ve been very vocal in the past about my disdain for the opinion that obesity is some personal or moral failing. It is not. It is a product of genetics and environment, just like heart disease, cancer risk, and yes, risk for infections.

How can you, as an employer, help your employees reduce risk beyond vaccination?

Traditional worksite wellness programs are disappointing, unfortunately, although as we’ve blogged about in the past, some worksite strategies for weight loss have proven modestly effective around the holidays. And restricting one’s diet to “unprocessed” foods such as those in Group 1 of the NOVA Food Classification System appears to result in weight loss even without intentional dieting. If we take the problem seriously, though, we’re inevitably led to the question of coverage of weight loss programs like the Diabetes Prevention Program, coverage of weight loss medications, and coverage of bariatric surgery. [Disclaimer: KBGH is funded in part by two CDC grants that aim to identify obese or pre-diabetic people and refer them into programs like the Diabetes Prevention Program that help them lose weight and reduce their risk.]

If you’re not already covering these benefits, consider them the next time you update your employee benefits. And, as always, if KBGH can be any help in determining the potential benefits to your employees from these programs or treatments, please contact us!

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This was a reprint of a blog post from KBGH.

The COVID-19 vaccine will follow a legacy of remarkably safe vaccines

Trust in vaccines is waning

In addition to social distancing, masking, handwashing, and generally caring about the welfare of our fellow humans, we’re all counting on an effective seasonal vaccine to eventually get us out of the COVID-19 fiasco we’re in now. But survey data shows that a huge chunk of the population is wary of a potential vaccine. This is no surprise; even routine vaccinations are met with skepticism they didn’t receive a couple decades ago, in spite of a scientific literature that overwhelmingly backs up their safety and efficacy.

As you look for data to share with employees to encourage vaccination–not just for COVID-19, but for all vaccine-preventable illnesses–pay attention to work that was just published in the Annals of Internal Medicine (paywall). 

Understanding vaccine labels

Investigators from Sheba Medical Center, Rabin Medical Center, and Tel Aviv Sourasky Medical Center, all in Israel, performed a comprehensive review of “post-marketing surveillance” data over a 20-year period from January 1996 to December 2015. Specifically, they used the FDA’s Vaccine Adverse Event Reporting System (VAERS), a portal through which people can report possible medication adverse events, and then looked at the “labels” of vaccines, to see how the labels of 57 vaccines had changed over that period of time. Labels are those folded package inserts that come wrapped around any medicine bottle. Changes to labels are common after a drug hits the market. Invokana (canagliflozin), a diabetes drug that works extremely well for certain patients, for example, carries a “black box warning” on its label stating that it can increase the risk of foot amputation in certain people.  

But back to our study: for each safety-related modification to a vaccine’s label, researchers noted the date of the label change, the type of safety-related label change (like addition of a boxed warning like Invokana’s, a change in reasons to avoid the vaccine, or a change in other warnings and precautions), any safety issues related to the label change, and the source of the data that led to the label change (like post-marketing surveillance, publications in medical journals, or reassessment of data from old studies). 

Why vaccines labels might get changed

The investigators found that initial approval for 93% of the vaccines was supported by randomized controlled trials, the most reliable form of medical research. The studies were large, with a median 4,161 participants. So the vaccines got off to a good start. After approval, there were 58 label modifications over twenty years associated with 25 vaccines: 49 warnings and precautions, eight new contraindications to using the vaccine, and one safety-related withdrawal.

The most common source of safety data was post-marketing surveillance, which resulted in almost half of label changes. Most of that safety data was identified through the FDA’s VAERS, likely an indication of the quality of the FDA’s post-marketing surveillance of vaccines, even in the eyes of the Israeli docs doing the study. The most common safety issue resulting in a label modification was a change in the population to be vaccinated, such as adding or subtracting pregnant women or patients with abnormal immune systems. These made up about a third of label changes. Newly discovered allergies made up about a fifth of label changes, mostly due to changes in latex-containing packaging. 

We should still be encouraging vaccination

In spite of overwhelming evidence of vaccine safety, the researchers write that “Rates of vaccination uptake have been decreasing in recent years, partly driven by reduced public trust and parental concerns over safety. If vaccines are perceived as unsafe, uptake in the population will decrease further, and the prevalence of infectious diseases and their associated morbidity and mortality will increase.” 

It is our job as health and human resource professionals to have vaccination available, including an eventual COVID-19 vaccine, and to help our patients and employees make good decisions around vaccination. If you have had success in promoting vaccination in the past, to influenza, pneumonia, shingles, or other diseases; or if you have plans to launch a novel vaccination campaign around COVID-19 in the future, please share it with us!

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This was a reprint of a blog post from KBGH.

You don't pay for smoking cessation. It pays you.

Out of my email inbox’s daily deluge of medical journal push notifications and study updates, an article recently stood out. It outlined a study recently completed by Dr. Tami Gurley-Calvez and Jessica Sand at the University of Kansas School of Medicine to determine the cost-effectiveness of smoking cessation services. The study was commissioned by NAMI, the National Alliance on Mental Illness, with funding from the Kansas Health Foundation.

Increasing coverage for more quit attempts

A single “quit attempt” is defined as four sessions of counseling and 90 days of any single FDA-approved smoking cessation medications like nicotine replacement, varenicline, or bupropion. The investigators compared the costs to payers of continuing to cover two quit attempts per year (eight sessions of counseling and 180 days of medication, as currently mandated by the Affordable Care Act), versus increasing coverage to 4 quit attempts per year, equaling sixteen sessions of counseling and potentially a full year’s coverage of a medication. Costs were the sum of the cost of the counseling sessions and medication costs. Benefits were the projected reduction in medical spending attributed to a reduction in the number of smokers. The investigators assumed a 4.4% relapse rate in people who had quit smoking for more than a year.

For smokers under the age of 65, either model–two quit attempts or four quit attempts–broke even by year four; that is, money paid for counseling and medications was equaled by reduced medical spending. But by year six, the cost-savings of the additional counseling sessions and additional medication coverage really took off:

By year 10, the per-person benefit of covering four quit attempts per year–$215–was almost double that of two quit attempts, at $109. This is to say that your return on investment for paying for additional smoking cessation services appears to roughly double when you double the up-front investment in counseling services and drug coverage.

If you feel a little leery about modeling studies right now, considering the difficulty epidemiologists have had in modeling responses to COVID-19 interventions, know that the conclusions of this study in terms of quit rates are well-established by clinical trials in real people.

We should always be careful about acting on the results of a single study. But there is a strong signal here that, if your company currently covers the ACA-minimum two quit attempts per year, you may benefit financially from increasing coverage to four quit attempts per year. Dr. Gurley-Calvez and Ms. Sand rightly point out that some companies may not expect to keep employees for the five to six years needed to reach net economic benefit. But they also note, as we’ve long pointed out to KBGH members, that if this type of coverage were applied uniformly across a number of diverse companies, we could collectively achieve these economic benefits alongside a healthier employee population, even if the members of that population changed jobs frequently.

If you have strategies your company has used in smoking cessation or substance abuse that you’ve found successful, please share them with us!

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This was a reprint of a blog post from KBGH.

Diabetes Education is Important. It's So Important That You're Already Covering It

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

The burden of diabetes

34.2 million Americans—a little over one in ten—have diabetes mellitus, a group of disorders of glucose metabolism that causes a buildup of sugar in the blood. Diabetes is the leading cause of blindness, kidney dialysis, and non-traumatic foot amputation in the United States. The damage of diabetes isn’t limited to its physical or psychological burden. People with diabetes spend about 2.3 times as much on medical care than people without diabetes: $16,750 in medical expenditures per year, compared with $7,151 for non-diabetic persons.

Empowerment through education

In spite of the incredible disease burden and cost of diabetes, less than seven percent of people diagnosed with diabetes receive Diabetes Self-Management Education and Support (DSMES, or “diabetes education”) within a year of their diagnosis. This is a problem. Diabetes education is one of the most powerful interventions we have for keeping people with diabetes alive. One meta-analysis (a study that combines the data of several separate trials into one dataset) found that attending diabetes education reduced the hemoglobin A1c level, the measure of one’s average blood sugar over a three-month time period, by almost 0.6%, roughly equivalent to taking another daily diabetes medication. Another meta-analysis found that attending diabetes education cut the risk of death by 26%. If true, this is as powerful an effect on death as blood pressure control or treatment of cholesterol.

So the Kansas Business Group on Health is working with the Centers for Disease Control (CDC) to increase awareness of and referral into diabetes education programs. You’re probably covering diabetes education services for your employees already, whether you intend to or not. The Diabetes Coverage Act states:

“Any individual or group health insurance policy, medical service plan, contract, hospital service corporation contract, hospital and medical service corporation contract, fraternal benefit society or health maintenance organization which provides coverage for accident and health services and which is delivered, issued for delivery, amended or renewed on or after January 1, 1999, also, shall provide coverage for equipment, and supplies, limited to hypodermic needles and supplies used exclusively with diabetes management and outpatient self-management training and education, including medical nutrition therapy, for the treatment of insulin dependent diabetes, insulin-using diabetes, gestational diabetes and noninsulin-using diabetes if prescribed by a health care professional legally authorized to prescribe such services and supplies under the law.”

The benefit is still subject to the usual deductible and co-insurance, and medical necessity requirements.

And we believe employers should be working to get their diabetic employees to attend diabetes education classes. It may prolong the lives of workers, and it may save you, the employer, money (paywall). If you are interested in starting a program through your workplace to get more of your diabetic employees into diabetes education programs, please let us help!

If you’re not ready to go there yet, but you’re interested in finding a diabetes education program in your area, visit here.

How Employers Can Address Social Determinants of Health

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

What makes us healthy?

Modern medicine has something to do with it, and we should work to make sure everyone has access to good care. But visits to the doctor and the hospital probably only account for around 20% of health outcomes. Far more powerful predictors of health come from social and economic factors like family support and income, or from health behaviors like levels of diet, exercise, and smoking. So even countries with universal health coverage see differences in life expectancy between demographic groups, albeit smaller than those in the U.S. We call these predictors of health, the differences in conditions in the places where people live, learn, work and play, “social determinants of health.” They can be diced and divided a number of ways, but respected researcher Michael Marmot lists six categories: 1) conditions of birth and early childhood, like prenatal care and abuse; 2) education; 3) work; 4) the social circumstances of elders; 5) elements of community resilience, like transportation, housing, security, and a sense of community self-efficacy; and, 6) “fairness,” which he defines broadly as sufficient redistribution of wealth to ensure social and economic security and basic equity.

This can seem abstract, so to bring this idea home I encourage you to experiment with the CDC’s Life Expectancy Data Visualization Tool. You’ll see that the life expectancy in Wichita’s census tract 0027.00, centered on Seneca Street and Kellogg Avenue, is 67.1 years, far below the Kansas average life expectancy of 78.6 years. But go east to census tract 0073.02, centered on Rock Road and Douglas Avenue, and you’ll find a life expectancy of 83.8 years. Not coincidentally, the average income for census tract 0027.00 is $29,202, while the average income for census tract 0073.02 is almost three times higher, at $82,679. By my back-of-the-envelope calculations, traveling east from Seneca to Rock Road earns you an average of $8,488.41 additional annual income per mile and an additional 2.65 years of life expectancy per mile.

There are things we can do

That’s depressing. But what’s uplifting about thinking of health in terms of social determinants is that social determinants are modifiable. You can’t change your genetics or your family history of early heart disease. But you can, in theory, move to a safer neighborhood or get a higher-paying job or buy healthier food. And employers can help directly. Round two of what seems to be a revolving door of an infectious pandemic, as we’re experiencing now, may seem like a weird time to talk about this since many businesses are struggling even to keep their doors open and to hang on to essential employees. But I bring it up because COVID-19 has put a magnifying glass on the differences in medical outcomes between groups. Don Berwick has a powerful essay in last week’s Journal of the American Medical Association (paywall) in which he argues that due to political calcification, organizations–like your own company or employer–are possibly the best conduit for addressing social determinants of health, and they don’t have to be social workers to do it.

Help in some cases may be as simple as identifying employees that have been under-valued at your company and making sure they’re paid appropriately. People who make more money simply tend to live longer:

Taking care of employees also makes good business sense

This isn’t intended as a paean to socialism. It’s a strategy that may pay off for employers, too, and I don’t say that as a pointy-headed former academic. I’m simply repeating the case I’ve read in study after study. For example, in a well-known analysis in Harvard Business Review in the mid-aughts, researchers made the case that Costco, by paying its employees a higher wage with more generous benefits, not only had a superior, more stable workforce with less turnover than competitor Sam’s Club, but made almost twice as much money employee-for-employee: in the period of the study Costco made $21,805 in annual profit per hourly employee, compared with $11,615 at Sam’s Club.

Not everything is related to money. We know times are tight. If raises for certain employees aren’t in the cards, you could work within your own Human Relations department or with your employees’ physicians or payors to make sure your employees are screened for risk within social determinants, and it can be done via telemedicine. The University of California-San Francisco has compiled screening tools through its SIREN network. Your employees’ physicians may need some guidance with this. If so, tell them that they can document any positive findings and diagnosis codes from section Z55-Z65 in the ICD-10 catalog for billing and coding. If that seems too big a bite to take right now, organizations like 2-1-1 are ready to assist with local resources, even (or especially) during the current pandemic crisis.

If you decide to take on a project that aims for improvement in one of the social determinants, we are available to help with setting goals, managing progress, and measuring outcomes. Please get in touch with us as you move forward!

How you can help your employees make decisions

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Our work at the Kansas Business Group on Health straddles our employer-oriented pursuits and efforts to advance the goals of two grants from the Centers for Disease Control (CDC). One of the goals of our work with the CDC is to increase the number of people being screened for diabetes. For people who are “pre-diabetic,” meaning their blood sugars are higher than normal but not high enough to qualify for a diagnosis of “full-blown diabetes,” our goal is to get them into the Diabetes Prevention Program (DPP), a one-year behavior change program that, through dietary changes and increased physical activity, reduces the risk of progressing to diabetes by 58%.

This is a challenge. Though the DPP is a covered benefit through Medicare, it is not consistently covered by private insurers. And even with coverage, people’s enthusiasm for paying for and completing a program to treat a disease state that is asymptomatic is generally low. So we work with employers to make the DPP a covered benefit. You may have heard from us about this. If not, please contact us. But we also work with clinics on strategies to increase screening for diabetes and to increase patient use of the DPP.

So we were encouraged to see a paper in the Journal of General Internal Medicine this week (paywall) demonstrating a quick way to substantially increase the likelihood of patients agreeing to enter “intensive lifestyle interventions” like the DPP.

The investigators surveyed patients who qualified for the DPP to measure their intention to participate. 70% of patients at baseline said they would be willing to participate. Then the staff members of the health center presented this decision aid to the subjects by reviewing the icons, reading the written information out loud, and briefly discussing the participants’ needs and next steps:

Northwestern University

The backside of the decision aid, which I’m not showing here, contained open-ended questions assessing needs related to the prevention of type 2 diabetes and defining next steps for management. After seeing the decision aid, the participants in the study willing to participate in the DPP rose to 88%, a statistically significant increase.

This is encouraging for a couple of reasons. First, it didn’t matter who presented the decision aid to the participants. Staff members and medical assistants had similar results.

Second, this is the rare tool that has shown such a positive effect. Simply handing out pamphlets to patients repeatedly fails to change behaviors. When we try to induce behavior change through interaction with patients we have a bad habit of falling back on fear: “Quit smoking or you’ll die young.” “Don’t drink pop or you’ll get diabetes.” The trouble with this strategy is that it has almost no effect on complex, long-term behaviors like diet, physical activity, and smoking. Fear might work to convince someone to take an antibiotic for two weeks to keep from dying from pneumonia, for example. But for longer term decisions, we have to exploit people’s senses of autonomy, mastery, and purpose instead, just like we use in designing meaningful work for employees. (If you’re interested in this topic I recommend Drive by Dan Pink.) But those three components don’t lend themselves easily to a quick intervention. Doctors and nurses are trained in motivational interviewing to accomplish complex behavior change, but it requires a trusting relationship and time to work. This study showed that even a brief intervention, delivered both in writing and in person in a few minutes, can have a powerful effect. What if we could harness this strategy for other behaviors, like encouraging mask-wearing for COVID-19 protection?

The DPP, which is available both as an in-person class and via virtual platforms, has been shown to drastically reduce health care costs for employers of people at high risk of diabetes. If you want to know your own company’s potential savings, go to the American Medical Association’s Cost Saving Calculator. Let us know if we can help make this calculation. And if you’re interested in covering the DPP as a benefit to your employees, contact us!

What Are E-Consults, and Why Aren’t We Using Them More?

This is a re-print of commentary from a past Kansas Business Group on Health newsletter.

In the past, doctors routinely engaged in “curbside” consultation, where one doctor stops another one in the hallway or calls her on the phone to ask a question about patient care that he wasn’t quite sure rose to the level of needing an official in-person consultation. This was great for the system: the enquiring doctor got the information needed, and the patient theoretically benefited, all at zero cost. But the consulting, curbsided physician was not rewarded for her expertise. Enter “e-consults.”

With e-consults the inquiring physician, instead of paging or stopping the other doc, puts the question into a written format, usually through a secure online portal. Then the consulting doc can submit a written answer for a nominal fee. [disclosure: Justin Moore is an endocrine consultant for RubiconMD, an e-consult service]

This monetization of the curbside consultation has benefits: It keeps the care of the patient centered around his relationship with the primary care provider instead of fragmenting his care. It keeps the stakes low; if the primary care doc has chosen the wrong specialist by mistake, or asked a question that has little value, no one tends to be charged for the trouble. In the traditional system of consultation up to 40% of specialist referrals lack either medical necessity, correct specialist choice, or timely transmission of relevant documents. Finally, e-consults can be had immediately, often same-day. In the traditional system our most vulnerable patients, such as those cared for in Federally Qualified Health Centers (FQHCs), only 40% of intended specialist consults are ever scheduled, and there is a 40% no-show rate in those that are successfully scheduled.

This all translates to a $500 annual per-patient savings in one randomized trial of cardiology patients. Medicare even covers asynchronous consults like this now. So if your health plan doesn’t currently cover e-consults, consider a change in your benefits.