One of the more audacious promises of the accountable care organization (ACO) movement is the idea that providers of medical services can play a larger role in improving a population’s health. It stems from a notion that health care financing reforms will move the focus of providers from “the tyranny of the office visit” to activities where success will be judged according to improvement in clinical metrics whether a patient visits the office or not. It’s the right vision from a health promotion advocate’s vantage point because it may serve as a preamble to an era where medical and public health practices and public policies truly intersect. Dartmouth’s Jack Wennberg famously observed predictable provider-centric small-area variation in the use of clinical procedures while the Centers for Disease Control and many other public health observers have long shown that ZIP codes have more to do with health than do medical codes. Can the next generation of health reforms reconcile the tension between these loosely related truths?
Recently a Minnesota school was evacuated after 10 students got sick during choir practice. A carbon monoxide leak was the presumed cause, given the similarity of student’s symptoms and the rapid spread of complaints. Thirty students in all were taken to the hospital and the school was closed for the day. Tests proved negative, recovery was quick, and the Minnesota Department of Health (MDH) now reports that the likely cause was psychogenic illness.
The state spokesman said that when people in a group become ill at the same time with subjective complaints, “It is no less real.”
It seems that when an affliction — real or imagined — hits, it can spread quickly among some people. According to one of the more recent CBS News Poll, 61% of Americans disapprove of how the ACA rollout is being handled. Nevertheless more Americans are in favor of fixing the law (48%) or keeping it as is (7%) than repealing the ACA altogether (43%). More telling perhaps, according to several opinion polls about the ACA since 2010, is the stability of opinions concerning Americans’ support for or opposition to the law.
Only time will tell whether the latest ACA anguish from the chorus will fade without treatment, but one thing seems increasingly obvious: Debates about the ACA are distracting from the inertia needed for additional reforms if we are serious about reducing health care costs and improving the health of the nation.
January 1, 2014 marks the most monumental day in the history of American health policy. The individual insurance mandate, the sunsetting of underwriting as we know it, and the planned obsolescence of the term “pre-existing conditions” in insurance all presage a fundamentally different era for access to health care. Of the 5.7% of those in the individual market, .6% will not be eligible for financial help if they want to continue buying in the individual market. In exchange, starting today, up to 47 million nonelderly uninsured will be eligible for new and/or more affordable health insurance. The good news is that there is no turning back from this miracle arrival. The bad news is there is no starting over either. The stork delivered it with warts and all.
The recent Health and Productivity Conference sponsored by the National Business Group on Health (NBGH) signaled the arrival of what social scientists have long held as vital to the success of wellness: a balance between personal and organizational engagement in health.
Though the Department of Health and Human Services and Department of Labor issued final regulations concerning “Incentives for Nondiscriminatory Wellness Programs in Group Health Plans,”1 employers and health plans must still navigate unresolved inconsistencies between the Affordable Care Act (ACA) and the Americans with Disabilities Act (ADA).
The latest ACA rules indicate that if a plan uses a “health-contingent” incentive scheme, that is employees are to meet certain standards related to a health factor (e.g., losing weight or controlling blood pressure) in order to receive a reward in the form of reduced premiums or deductibles, the plan must satisfy several requirements including offering a “reasonable alternative standard” for those who believe that the standard is not accommodating their unique circumstances.
The EEOC has remained silent on whether they deem wellness programs to be voluntary, a key concern of an agency committed to ensuring that all employees enjoy equal benefits and privileges of employment such as is guaranteed under the American with Disabilities Act (ADA).
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.
John Muir, the famous naturalist, wrote: “When one tugs at a single thing in nature, he finds it attached to the rest of the world.” It’s a concept that’s long overdue but now fully ensconced in the field of population health management. Employee health management (EHM) practitioners, in particular, are coming to understand that the environments in which health promotion interventions occur are a primary determinant of the effectiveness of the interventions. What’s more, many now fully acknowledge that the sustainability of healthy lifestyle improvements in diet, exercise, or tobacco use
I have long held that leaders can’t fake authenticity. When you’re passionate about your vision, it is felt by others whether they support you or not. It’s a realization that has been easy to come by because I’ve had so many great mentors.
As is always the case when I return from working abroad, it takes me longer, metaphorically speaking, to unpack my bags. I was ostensibly in Brazil to teach and consult about innovations in our population health management movement in America. But, as I expected, I was surely the greater beneficiary of teachings from leaders of the wellness movement in Sao Paulo, the business nexus for the world’s sixth largest economy.
Leaders of population health programs in Sao Paulo offer a self-assessment of being a decade or more behind the United States in the maturation of employee health benefits such as employee assistance programs (EAP), disease management, pharmacy benefits management (PBM), and wellness. I anticipated we would be discussing the “leapfrog” opportunities that come with later adoption of trends. For example, developing countries garnered advantage by skipping much of the costly infrastructure of cable by embracing wireless communications.
So I came to Brazil thinking about what aspects of American health care innovation I would skip over if I had a chance to learn from the trials and errors of America’s health reforms. For example, I found it curious that the Brazilian health care system is likely the closest to America’s with respect to the proportion of employer versus government financing, yet the country had yet to mobilize anything resembling a buyers’ coalition or a business group focused on health or health policy. When I happened upon Brazil’s health commissioner, he told me his main message for employers was to become more proactive with the government in setting health policy. I said “Be careful what you ask for.” It was advice borne out of an American sensibility that public/private partnerships are fraught with ideological perturbation.
I expect the next 10 years of policy debates, action, and inaction concerning how to curb our obesity epidemic to be an accelerated version of the last 30 years of public policy related to fighting tobacco.
This week’s HBO documentary, The Weight of the Nation, landed a flourish of solid blows against the wrong-headed notion that obesity is simply about lack of will power. The broadcast is based on the report “Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation.” It’s the product of an extraordinary, even historic coming together of the Institute of Medicine, the Centers for Disease Control, and the National Institutes of Health. The report and the documentary make one point exceedingly clear: Obesity is a multifaceted problem that will require multifaceted solutions.