Paul E. Terry, PhD

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.

Steven R. Peskin, MD, MBA, FACP

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.

Steven R. Peskin, MD, MBA, FACP

Though the title might apply to many aspects of our daily lives and the world as a whole, in this instance I am referring to how Medicare and other insurers interpret the word reasonable to make coverage and payment decisions. A recent editorial in the New England Journal of Medicine highlighted this enduring challenge for Medicare.

Paul E. Terry, PhD

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 is fundamentally linked to our surroundings.  Indeed, in last week’s “HEROForum12”, a conference featuring EHM solutions, a third of the session titles included references to culture.  Moreover, no matter what the topic, the phrase “building a culture of health” was stated at nearly every session.

Steven R. Peskin, MD, MBA, FACP

As a baby boomer moving through middle age into the unspeakable age that follows “middle,” I was encouraged to read an article in the British Medical Journal that states that for seniors and super seniors, healthy behaviors that include regular exercise, not smoking, maintaining a normal Body Mass Index, and having a rich or moderate social network led to significant increases in longevity. From the study:

Paul E. Terry, PhD

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.

One of my favorites has been Stu Hanson, a pulmonologist, a health care executive, and a prime mover in Minnesota’s historic national leadership role in creating smoke-free workplaces. Stu would often say, “I’m trying to work my way out of a job.” Putting aside his recent retirement and the fat-chance odds behind his conviction even when he was mid-career, to know Stu is to understand that he wasn’t kidding.  Stu’s mantra was the ancient proverb: “When you are through changing, you are through.” Perhaps it is a philosophy born out of the Herculean-sized stubbornness needed to take on the intractability of an addicted smoker. Or maybe being wired to push for change helps you cope with the blowback and disappointments that come from working to change something as unyielding as a culture.

As a student of leadership as well as one interested in the intersections between health care business and public policy, I also can’t help but follow Toby Cosgrove, a cardiologist who became Cleveland Clinic’s CEO.  I have assumed that his equanimity about the controversy that surrounds his ban on hiring tobacco smokers is grounded in the righteousness that only a cardiovascular surgeon can feel at his core after having performed 22,000 operations, at least half of which were lifestyle-induced. What else explains his more recent foray into smoking bans at universities? In a speech to the Harvard Business School Club of Cleveland, Cosgrove said: “The fact that American universities are not smoke-free appalls me.” Though being right is a powerful buffer, it doesn’t change the likelihood that he’ll be disparaged.

Archelle Georgiou, MD

In May 1999, Abigail Sulerzyski was born deaf and blind with cerebral palsy and multiple other medical complications. While Victoria, her mother, was learning how to cope with the needs of a severely disabled child, she was also learning how to fight with UnitedHealthcare.

Steven R. Peskin, MD, MBA, FACP

A close friend of ours went with my wife to see a highly regarded physician for a persistent problem. This master clinician started with a warm greeting and a brief conversation about family, and then went through a detailed history of the problem that our friend had experienced for several months. He gave her an explanation of what he believed to be the underlying cause of her symptoms, gave a prescription for lab tests, and prescribed two medications. He also suggested that she see an ENT and recommended someone.

Robert Royce

One of the key downsides of market-based health care  — that if your costs regularly exceed your income you go out of business  — is not typically associated with the National Health Service in the U.K. That is about to change. It has just been announced that the three hospitals that constitute the South London Healthcare Trust in London, England are to be effectively declared bankrupt, the board suspended, and the organization put under a special administrator. He or she will have just 45 days to provide the Secretary of State with recommendations on what to do with an organization that provides emergency an elective services to about 750,000 Londoners but has racked up nearly $100 million of debt in 2011–12 alone.

Why is this of interest to U.S. readers, aside from adding to the long-running debate on the pros and cons of operating a market in health care? It is because one option is to privatize one or more of the hospitals. By privatize, I mean a whole range of options from franchising out the management to a private company to taking over the assets lock, stock, and barrel and then providing services back to the NHS.

Paul E. Terry, PhD

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.

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Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.