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Earlier today, I was speaking with a physician colleague about his commitment to continue to improve person-centered care in his primary care practice and to enhance patient experience. We talked about the potential value of greeters in the practice, of a patient council to offer feedback and recommendations, and, with training, increasing the scope of service of medical assistants to allow nurses, advanced practice nurses, and physicians to spend more time with more complex care.

When reflecting on his comments about gracious greeters and coaching non-clinical and clinical staff on communication, I was reminded of a video from many years ago of the former CEO of Ritz Carlton that started with his passion and conviction about the importance of "a warm and sincere greeting." When Apple was entering the retail arena, Steve Jobs benchmarked Ritz Carlton for Apple retail stores to emulate for the ultimate in customer service.

Though the  "Consumer Assessment of Healthcare Providers and Systems" (CAHC) with all of iterations of home health, hosptials, health plans, ambulatory care, and, most recently medical homes, is frequently cited by health plan and health system leaders, adminstrators and clinicians, we are inconsistent at best in our abilities to deliver on good service. We point to the complexity (sometimes self-induced) of health care and the pain, discomfort, anxiety and/or fear that people may be facing in their interactions with health care workers (true, but not always), and, the time pressures that we face (nearly universal in today's hurried culture).

We should not hide behind excuses. A warm and sincere greeting is only a beginning, but it is certainly a great way to begin!

Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey – Robert Wood Johnson Medical School, and is Governor, American College of Physicians, New Jersey South.

Steve Jobs famously staked his claim at the intersection of technology and creativity. Health insurers are looking for the intersection of technology and benefits knowledge, but are not quite sure how to get there. Do you hire information technicians and train them in the ways of health coverage, or do you hire (or promote from within) people who know insurance and train them to be IT savvy? It’s a pressing question given that the government anticipates a shortage of about 50,000 qualified health information technology (HIT) workers between 2010 and 2015, according to the PwC study “Solving the Talent Equation for Health IT” .

“Across the health sector, senior executives describe a challenging paradox: just as they are preparing to make major increases in technology investments they are encountering shortages in key personnel and are concerned about the industry’s ability to absorb change and integrate new workflows with HIT,” the study states.

The Affordable Care Act, with its emphasis on accountable care organizations and health insurance exchanges, means that insurers will have to sell to patients more than they did in the past. “In many ways they are playing catch up with many other industries — such as retail — in attracting, engaging and building loyalty among consumers.”

Gary Harvey, vice president of information technology at Blue Cross Blue Shield of Michigan, told researchers that “We can easily find someone who knows a tool, how to extract data from using it, and how to technically layer the data. But it’s very difficult to find someone who can look at the data and determine whether it is the right data to answer a business question or solve a problem. We see a huge gap in the talent pool for analytics talent. And it’s even harder for us to find people with clinical expertise.”

Remember the adage about giving someone a fish as opposed to teaching him to fish? Well, it doesn’t apply here. But your thoughts do, so please do tell. What are you doing about this problem?

The author is managing editor of Managed Care.

Forty-four thousand dollars is certainly a meaningful amount of money to me, but apparently not so meaningful as to encourage a sizeable portion of physicians to adopt meaningful use standards for electronic health records.

“As of May 2012, a total of 62,226 eligible professionals had attested to meaningful use under the Medicare program,” according to a letter in the February 21 edition of the New England Journal of Medicine. “This represents 12.2 percent of the estimated 509,328 eligible physicians in the United States, including 9.8 percent of specialists and 17.8 percent of primary care providers.”

So while the growth in the number of participating doctors might seem dramatic at first glance (see our chart from the January issue of Managed Care), the actual numbers are underwhelming, according to the letter written by Adam Wright, PhD, of Brigham and Women’s Hospital. (Reach him at awright@partners.org.)

“Although these data suggest rapid growth in the number of providers achieving meaningful use, this pace must accelerate for most eligible professionals to avoid penalties in 2015,” he writes. “Barriers to EHR adoption and meaningful use include cost, lack of knowledge, workflow challenges, and lack of interoperability.”

There are 15 core objectives that must be met in order for the government to underwrite up to $44,000 in new technology costs per physician, but the Centers for Disease Control and Prevention noted in January that doctors are flailing. “Some physicians with systems supporting the 13 core objectives examined in this report may not have a system that supports the remaining two objectives, as well as 5 of the 10 Menu Set objectives required for payment.”

In April of last year, I wrote about the first release of recommendations from the American Board on Internal Medicine Foundation in conjunction with nine medical societies as part of a campaign: Choosing Wisely. The campaign aims to draw attention to and call into question commonly ordered tests like chest x-rays before surgery, frequently performed procedures like colonoscopies, and frequently prescribed treatments like antibiotics for upper respiratory infections. The campaign is directed to clinicians and patients with both audiences asked to consider the evidence for not doing select tests and procedures in specific circumstances where the evidence supports not doing the test or procedure or treatment. 

Fast forward 10 months. The ABIM Foundation has released 90 more recommendations in conjunction with medical specialty societies for physicians, other clinicians, and patients/consumers asking us to consider the evidence and to choose wisely. We should applaud the ABIM Foundation, the National Physician Alliance, Consumer Reports and the dozens of medical specialty societies that have assumed the mantle of leadership to bring this information to health care professionals and to consumers in clear, crisp, and concise statements. 

Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey — Robert Wood Johnson Medical School.

Stories about underdogs (David and Goliath, Rocky, the 1969 Mets, the 2008 Barack Obama) are as much about overconfidence as they are about confidence. Yes, the challenger is scrappy. The favorite, on the other hand, needs just enough hubris to make his or her downfall ensure that the lesson resonates with every would-be David and Goliath — and in its entirety because we all have a little of each in us.

Many insurers want to participate in health benefit exchanges, one of the bedrocks of the Affordable Care Act. We’ve been following this at Managed Care. See, for example, here (http://tinyurl.com/Carroll-Exchanges), here (http://tinyurl.com/gov-exchanges), and here (http://tinyurl.com/vision-exchanges).

Of course, in the exchanges, insurers won’t face just one antagonist but a whole marketplace full. It might be enough to give them pause and, in fact, it may have. They’re still confident, though, according to a recent survey by KPMG, the audit, tax, and consulting company. Take a look:

Assuming your organization’s participation, how confident are you in your management’s ability to successfully participate in an exchange?

I suppose that’s the attitude an organization needs when it’s about to step into the unknown. Perhaps it’s because they feel they have implementation under control.

By when do you expect your organization to start marketing and delivering products that are consumer-focused?

As KPMG notes, success will mean “transforming their marketing efforts from a business-to-business focus to a business-to-customer focus.” That’s not the only concern and while insurers — and about two thirds of KPMG respondents are commercial health plans — may be confident, they’re not blind to the challenges.

What is the biggest challenge in building out a customer-centric organization?

That 58 percent say “all of the above” to this question might signal, again, the level of effort and focus being displayed. Or, to a more skeptical viewer, it might — just might — suggest that organizations are scurrying about in a bit of a panic. Please, weigh in.

— Frank Diamond, Managing Editor

Amgen is making a huge bet on biosimilars and helping to define the market.

The company announced that it is targeting 6 biotech blockbusters and will start selling them as  biosimilars in 2017. The initial targets: Avastin, Herceptin, Rituxan, Erbitux, Humira and Remicade. That’s over $40 billion in product. Even a small savings, like 15% to 20%, would result in a huge change in premiums.

It is still unclear what hurdles will need to be cleared from the FDA and/or other regulatory bodies, but a few other things have become very clear:

• The biotech industry is starting to see biosimilars as more of an opportunity and less of a threat.
• A large company like Amgen can bet on its qualifications and reputation to be a trusted manufacturer of biotech products introduced by other companies.
• The more that companies like Amgen announce forays into the biosimilar space, the more that payers will be counting on price relief from specialty Rx products.

 It will be curious to see which company makes the next announcement and how aggressive it will be.

Neil Minkoff, MD, is medical director of MediMedia  Managed Markets and also an independent health care consultant.

The Department of Labor has issued new guidelines concerning the wellness provisions of the Affordable Care Act (ACA) that relate to the use of financial incentives, and the Office of Health Plan Standards and Compliance Assistance is seeking public comment. This document proposes “amendments to regulations, consistent with the Affordable Care Act, regarding nondiscriminatory wellness programs in group health coverage." These regulations increase rewards for wellness participation or outcomes from 20 to 30% or up to 50% related to reducing tobacco use. (Federal register)

In the past several years, StayWell Health Management has published several studies concerning the use of financial incentives in wellness programs, so my colleagues, Drs. David Anderson, David Gregg, and I, felt obliged to offer some reactions to the proposed new language. All public comments will be posted at: http://www.dol.gov/ebsa/. By way of summary, we commended the department for its painstakingly earnest attempt to placate the detractors of the original proposal who believe that incentives could too readily become a subterfuge for insurance underwriting. Still, we believe their attempt to divide incentives into participation based or health contingent models may well shed more heat than light on the matter.

Proposed regulations

The proposed regulations regarding a health-contingent wellness program include a provision that appears to say members must be offered the total reward even when they have no medical condition that would make it unreasonably difficult to meet the health standard or medically inadvisable to attempt to do so, based solely on meeting a participation-based alternative standard. StayWell believes this effectively negates any substantive programmatic difference between a participation-based and health-contingent wellness program. Participation in a wellness program by an individual is, in effect, a default option for anyone who is not inclined to make an effort at even making reasonable progress toward the standard, much less achieve it. In effect, the health-contingent wellness program is fundamentally a participation-based program with a provision that allows an employer to waive the participation requirement for individuals who already meet the health standard.    Read more »

Researchers in Britain recently published a paper in Pediatrics showing a dramatic swing in admissions for childhood asthma after indoor smoking was banned by the British in 2007. A hospitalization trend that had been steadily around 2% fell to minus 9%. The trend was sustained.  10.1542/peds.2012-2592

I'm wondering, "What should Managed Care do with this information? What is the appropriate level of response? What haven't we tried already?"

We're already covering smoking cessation products and counseling. We've been trying to get our smokers to stop for a long time, but maybe this would be effective for those smokers with children. Is it a matter of further  education? I'd like to think so, but I doubt it. I don't believe that any smokers out there remain ignorant of the dangers to themselves or their families.

Is it a matter of incentives? Do we need to consider paying people to stop smoking? What about making smoking cessation free such as no cost-share on nicotine aids? I hear a lot about the robust public health systems in Europe, but smoking remains a serious issue there as well.

I hate to be on the ban-smoking bandwagon, but I'm at a loss at what to do. PLEASE let me know in the comments if you've got a smoking cessation program in managed care that really works.

Neil Minkoff, MD, is medical director of MediMedia  Managed Markets and also an independent health care consultant.

With apologies to James Taylor, I was recently introduced to a UNC-Chapel Hill professor of psychology, Dr. Edwin Fisher, from my alma mater and the university where the famous singer/ songwriter's father was dean of the School of Medicine. The work that Dr. Fisher is doing under the aegis of the American Academy of Family Physicians Foundation is on target for the Triple Aim.

Peers for Progress, designs, implements, and evaluates peer coach or peer educator programs worldwide. There are ample examples of successful and established programs led or facilitated by peer coaches, motivators, educators, or others, including Alcoholics Anonymous, Mended Hearts, and Weight Watchers. Peers for Progress is building a global network of peer-support organizations that are making a difference in the health of and lives of people affected by a range of health problems and their associated impact on the individual and on communities.

Peer support / peer coaching is truly a winning proposition with benefits to the coached, to the coaches, to better health and health care, and the price is right!

Peers for Progress:

http://www.aafpfoundation.org/online/foundation/home/programs/education/peersforprogress.html#.UQGC26xu48Q.email

Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey — Robert Wood Johnson Medical School.

Gordon K. Norman, MD, MBA

It’s hard to open any health-related publication these days and not find stories about accountable care organizations (ACOs). Commentary ranges from extolling ACOs as our last, best hope for achieving high-value care in the U.S., to others criticizing ACOs as a thinly disguised return to the 1990s model of managed care and HMOs.

While it’s too early to judge how effectively these provider-based organizations that assume greater financial risk for health care outcomes will ultimately perform, many are hopeful that ACOs offer a promising vehicle for achieving the elusive Triple Aim goal of health reform — achieving higher clinical quality and better experience of care with lower cost trends.

I am among them. The ACO model makes sense to me. While there are no guarantees, I believe that at least some ACOs will succeed in providing added value to patients, providers, and the nation’s health care system as a whole. But first they have a lot to do to assure that the reality of accountable care meets the promise. Many of the systemic problems with our current care system must be changed to achieve Triple Aim care, so ACOs have their work cut out for them.

In contrast to managed care, ACOs need to perfect “magnet care” — that is, offering the programs, providers, resources, and attributes that will attract patients, and keep them “sticky.” ACOs will need to provide convenient access and flexible availability, integration of care and data across sites and providers, and guidance on health habits and lifestyle, among other attributes —and all of this through convenient mobile apps and online portals.

Can ACOs Fulfill Their Promise?

The current debate about ACOs reflects the industry’s honest search for answers to the nation’s serious health care problems. If our goal as a nation is to provide a system that can care for large populations and commit to high quality, manageable costs and a satisfying experience of care, ACOs have the potential to achieve these goals.

Even for those organizations supporting the concept of ACOs, however, many questions remain. Given that so much of health care costs stem from patients’ personal choices, how can ACOs engage more patients in effective prevention and wellness programs? Given that so much is spent on care for the relatively small percentage of patients with chronic illnesses, how can we address their care needs more efficiently? And how can we optimally utilize technology, mobile devices, and social networks in an era of limited budgets?

Toward these ends, there is an attainable stepwise approach that many accountable care organizations will probably follow:

Phase 1: Commit to the digitizing of health information and exchange of interoperable data with other health entities, and deploy certified electronic health record, registry, and health information exchange systems that will enable “meaningful use” of heretofore siloed health information.

Phase 2: Develop patient-centered medical homes and neighborhoods that encompass team-based primary care, incentive payments, quality reporting, and coordination of care among all providers.

Phase 3: Create organizational relationships across the community that enable full collaboration among all providers and health care facilities, that have the potential for sharing risk, and that entail public reporting on costs, quality, and patient experience.

Phase 4: Foster population health management by building or partnering for technologies and capabilities needed to assess and optimize health risk across the continuum of care.

Along this journey, many of those seeking to create highly effective ACOs will collaborate with other organizations that have experience in managing population health, engaging patients in efforts to improve health status and working with providers by providing technology that enables better care coordination. Those who set out to do this alone will face a longer learning curve and a less predictable destination.

Final verdict?

Will every ACO be successful in achieving the Triple Aims of health reform? Surely not, given what we know about the local variability of health care cost and quality. But will some be successful enough to provide “proof of concept” so we can learn from these examples how to improve on ACO 1.0 as we build ACO 2.0 and beyond? I certainly expect so.

Are ACOs ideal for what ails U.S. health care? That may not be the pertinent question under the circumstances; rather, if not ACOs, then what? Does any other competing model of health reform offer a greater chance of success with a lower risk of negative unintended consequences? So far, I have seen no better ideas for achieving Triple Aim care over the next decade.

What if I’m wrong and ACOs are unable to overcome the significant challenges facing them? Are we going to passively accept unaccountable care and rampant cost escalation as inevitable? I doubt that very much. Or might we decide that time has run out for more experiments with market-based approaches and opt for a single-payer system, in the hope that that the Triple Aim can be achieved through Draconian top down controls?

I hope we can avoid this desperate and risky option.

Therefore, my plea is that health care leaders who want to be part of the solution embrace the components of ACOs that work, look for partners to help them expand on programs that are effective and communicate the value of these approaches to providers, patients, and other constituents to gain their engagement, and support. Iterative refinement of design and persistent process improvement can get us where we want to go.

Gordon K. Norman, MD, MBA, is chief medical officer of Geisinger System Services at Geisinger Health System.