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6 Limitations of Big Data in Healthcare

Claims data captures the services provided to a patient. This information can be grouped into different cohorts—those getting preventive exams, those seeing specific physicians or hospitals for conditions, etc. The data can be grouped by diagnosis. However, all claims data is just a collection of medical bills. Medical bills do not contain a complete look at the patient, such as important information about a patient’s prognosis. That’s a gap. Thus, it is important to set appropriate expectations on the use of the data.

Here are six limitations that should be placed on the expectations:

Number 1 (one of the most important): Avoid the averages
Most claims data sets are not normally distributed, so the averages do not provide relevant information. In most discussions today, employers evaluate the average cost of employees with specific conditions, e.g., diabetes or high blood pressure. This is a flawed approach because spending by employees with various chronic conditions is skewed, thus not really “averageable.” For example, assume 90% of an employee population with diabetes is spending $10,000/year and 10% is spending $250,000/year; the average will be a meaningless $34,000/year. All too often, a wild goose chase ensues, when in fact the focus should be on the $250,000 cohort to understand why they were so much more expensive.

See Also: Why Healthcare Costs Bleed Firms Dry

Number 2: Follow the money
A superior use of claims data is to look at distributions of spending. In most plans today, roughly 8% of enrollees are consuming 80% of plan dollars, and these 8% typically change every 12 to 18 months. (We still run into benefit managers who were unaware of that turnover.) The future belongs to micro-managing these “outliers,” rather than the 92% who spend only 20% of the dollars. If you study those outliers carefully, you will find that only about 7% of their spending possibly would have been preventable, and then only if they faithfully did what their doctors told them to do decades earlier. A cardiologist recently told me that, of the patients he has seen with a significant acute blockage, about 25% had no known health risks of any kind…no high blood pressure, cholesterol, diabetes, obesity, smoking, genetic predisposition, etc. As such, there is a component of randomness in terms of who gets blocked arteries. The same holds true for cancer. For the other 75%, their physicians have usually counseled them on the importance of exercise and nutrition and the dangers of tobacco use, but to no avail.

Number 3: Realize the limitations for quality designations
Yet another big error is trying to use claims data to determine the best-quality doctors. You had better be really, really talented to try that one. Why? We are in an era in which many doctors are making their “quality” and “outcomes” look better by referring their most complex and riskiest patients to someone else. (Much has been written about this.) On the other hand, there are highly effective doctors who take responsibility for their riskiest patients, but as a consequence score poorly on so-called “quality measures.” The real travesty is that the low-scoring doctors may be the most cost-effective and provide the best care.

Number 4: Misdiagnoses are a real cost driver
Another huge shortcoming of claims data is one that readers of Cracking Health Costs know about. Namely, a large number of patients with complex health problems are simply misdiagnosed – today, that’s about 20% of the outliers in benefit plans, accounting for 18% of claim dollars. Thus, you cannot rely on diagnoses in claims data, and you cannot tell who is getting diagnoses right or wrong – this takes detective work beyond claims data. Click here for a good article by the Mayo Clinic on rates of misdiagnoses. We have sent hundreds of people to the Mayo Clinic for second opinions and can verify by personal experience the truth in that article…same for other clinics we have used for employers. Our first rule in selecting a Center of Excellence is its success in correctly diagnosing patients with complex health problems. Huge amounts of claim dollars are spent on treatments or surgeries that are either completely erroneous or clearly suboptimal. An executive at a Fortune 100 company once said to me that the biggest quality failure in healthcare is to misdiagnose a patient…everything that follows harms the patient.

See Also: To Go Big (Data), Try Starting Small

Number 5: Coding can affect the data analysis
During a data analysis for a very larger employer, with more than 250,000 covered lives, executives told me they had not paid for a solid organ transplant in a number of years. Based on their size, they should have been paying for about 25 a year. After further detective work, we discovered their consultant was using a DRG grouper that coded all transplants as ventilator cases…who knows why…but a huge error. The benefit team had no idea they were really paying for about 25 a year at an average cost over five years of about $1.5 million each.

Number 6: Reversion to the mean
One thing we’ve learned from years of claims analysis of big companies’ benefit programs is that if you have enough life years of data, it all looks about the same, i.e., it reverts to the mean. If the workforce is comparatively older, they will have somewhat more high-cost claims.

What Makes Us Get Sick? Look Upstream

The headline comes from a TED conference speech by Rishi Manchanda, who has worked as a doctor in South Central Los Angeles. After about 10 years, he realized, “His job isn’t just about treating a patient’s symptoms, but about getting to the root cause of what is making them ill-the ‘upstream’ factors like a poor diet, a stressful job, a lack of fresh air. It’s a powerful call for doctors to pay attention to a patient’s life outside the exam room.”

This story has a WOW factor.

Let me repeat: Dr. Manchanda came to realize it’s not enough to treat a patient’s symptoms, but to get to the root cause of what makes people sick. Regular readers of Cracking Health Costs will know this is a familiar message. Of all the things that cause us to die too early, medical care can only deal with about 25%. The rest is about how you live your life.

This also explains why typical corporate wellness programs fail. They’re trying to ameliorate symptoms but ignore the root cause of syndromes such as high blood pressure, high cholesterol, etc. It’s not enough to walk into a smoke-filled house and turn on the exhaust fan. You need to put out the fire, too.

Wellness buyers, e.g. benefit managers, need to have the same epiphany as Rishi Manchanda.

I’ve been writing a series of posts about root causes of illness: loneliness, job stresses, life dissatisfaction, etc. I also firmly believe the time is right to start thinking about employee ailments in an entirely different way.

My next book, An Illustrated Guide to Managing Your Health—How to Improve Your Health in 40 Common-Sense Steps, could well be called, “For better health, look upstream.”

Affordability, Effectiveness, and Wellness, Part 5

This is Part 5 in a five-part series which presents a creative solution for today’s health care crisis. Additional articles in the series can be found here: Part 1, Part 2, Part 3, and Part 4.

An Ideal Health And Wellness Program
Based upon our actuarial analysis we find that as much as 75% – 85% of the potential savings from health and wellness programs can be directly attributed to six specific and objectively measured factors:

  • Obesity (i.e., as measured by the BMI or Body Mass Index)
  • Fasting blood sugar
  • LDL cholesterol (i.e., bad cholesterol)
  • Blood pressure
  • Smoking/non-smoking, and
  • Personal fitness

Ironically, all of them with the exception of smoking/non-smoking are directly related to Body Mass Index. As individuals solve their Body Mass Index problem, they gradually solve most of their other problems. Some individuals with genetic predisposition to certain conditions may require ongoing medications to keep one or more factors in control, but the vast portion of problems can be significantly improved and eliminated by eliminating obesity and achieving an ideal Body Mass Index or by at least improving it and moving closer to the ideal level.

This suggests that significant gains can be made by creating a BMI-focused health and wellness program. Since smoking/non-smoking is somewhat independent, perhaps a two pronged program (i.e., BMI and smoking cessation) is the best way to implement a program. This “tight” focus enables the program to quickly succeed, where other “loose” focus programs have failed or had significantly less results.

Although the actual results are significantly impacted by characteristics of the studied population (i.e., the population's average Body Mass Index scores and the proportions of smokers to non-smokers), we find that in a fairly typical population, overall health care costs can be reduced by as much as and possibly more than 20% – 30% if each of the individuals in an overall population advance to their ideal health status. On an individual by individual basis the cost reductions on some is much more than this. A tangential benefit of this improvement is that the cost savings continues to occur for many years, not cost savings in just one year.

Every health and wellness program needs reliable ways of accurately measuring the program's effectiveness. Each of the above six factors can be objectively measured through relatively inexpensive means. For example, a simple blood test can be used to measure blood sugar or LDL levels. Blood pressure can easily be measured by a trained individual or even by automated machines. Fitness can be broadly defined as the ability to function efficiently and effectively, to enjoy leisure, to be healthy, resist disease and to be able to cope with emergency situations. The health related components of physical fitness that could be measured include body composition, cardiovascular fitness, flexibility, muscular endurance and strength. There are various ways to measure fitness depending on available resources and facilities. There are several available Health Risk Appraisal (HRA) packages that can give a report that incorporates both objective measures as well as subjective responses to a set of questions.

As mentioned earlier, it is also critical to provide hope to the participants. A believable example or champion is always beneficial to motivate participants. One interesting example of this is one of the authors of this series of articles.

Nicholas J. Yphantides, MD, Dr. Nick as he is known, the author of “My Big Fat Greek Diet”2, used to weigh 467 pounds, has lost more than 270 pounds, and has successfully kept it off for almost seven years. His significant and relatively quick weight loss journey is chronicled in the book. Dr. Nick outlines Seven Pillars of Weight Loss Success, which are critical to successful weight loss and are integrated in the Individual Change Management Model.

They can be summarized as follows:

Pillar I: “Change the way you see before you can change the way you look.” As discussed, change is at the core of what is needed but rather than focusing on changing specifics, first one has to undergo a change in their perspective which will naturally lead to a change in habits and behavior.

Pillar II: “Slash your calories by eating for the right reasons.” Way too much focus is spent on diets and what to eat. Critical to healthy living is having a healthy relationship with food and rediscovering its role as fuel and not as a means of dealing with any number of other personal emotions or needs.

Pillar III: “Fill your tank with the right amount of the right foods.” Rediscovering an appropriate sense of satiety by responding to the body's signals and as a result of eating an appropriate amount of the right kind of food is core to learning how to eat to live healthy.

Pillar IV: “Burn calories like never before.” It is imperative and necessary not only to lose weight but not to rediscover it again once lost (i.e., gain it back). As individuals become more physically active, they will keep it off. Strategies to have fun and pleasure burning calories are important for it to be a sustainable habit.

Pillar V: “Plan a radical sabbatical.” Most need to take some kind of a break from the routine if we are going to establish a healthier lifestyle. Combining pleasure and benefit and carving out time that one can focus on their health as a priority for lasting vitality is core to successful weight loss.

Pillar VI: “Don't travel alone.” The assumption is that this is an ongoing journey for most. There are times where initial momentum is present but for many, the notion of support, encouragement and some level of accountability are going to be key factors to long term success. It is so important to people committed to the group nature of accountability and healthy co-reliance on healthy living.

Pillar VII: “Realize that your weight loss journey is for a lifetime.” Many people see weight loss interventions as a temporary lifestyle modification where in reality it is a lifelong commitment to a new set of habits and behaviors. Its not about losing the weight. Its about losing it and not rediscovering or finding it again that really counts.

Weight loss programs (i.e., Body Mass Index improvement programs) aligned with these key principles have demonstrated much greater success than those missing these. Most current efforts fall short of lasting impact in that they target the stomach. Many overweight people who have health related consequences for their extra weight do not have a problem with their stomachs as much as they do with their “heads and hearts.”

Focusing first on those with Body Mass Index concerns accomplishes the greatest value in the health and wellness program. Dr. Nick's approach proves to be quite effective in making those changes. The second focus is on those currently smoking, using traditional smoking cessation programs and interventions. This approach could be called wellness triage, focusing on those who need it the most. The prioritization in such a program is as follows:

  • Body Mass Index improvement
  • Smoking Cessation
  • Blood pressure reduction and control
  • LDL reduction and maintenance
  • Fasting blood sugar reduction and maintenance
  • Fitness improvement

Integration With Health Benefits Program
The above health and wellness approach can be further enhanced through the integration of it with the health benefits program. Combining an organization's change management model along with the individual model could lead to a radical transformation in the workplace and in the individual's lifestyle. There are several approaches that can be used to effectively accomplish this, however, one popular approach is linking the six key health status indicators to a health and wellness points system, and then linking the points system to a particular benefit level.

One effective approach provides individual incentives for improvements in each of the targeted health and wellness categories. Linking benefit design, employee cost, and health and wellness results provides strong motivation for health and wellness change. This type of program builds on the concepts discussed earlier:

  • Incentive driven — the better the wellness scores, the lower the deductible; best benefits are given even if there is one bad area
  • Redemptive — encourage those who are trying by giving partial credit
  • Hope-filled — build wellness program around concepts that work
  • Focused — BMI-centric with wellness triage

It is critical that programs of this kind consider federal anti-discrimination regulations. It is our understanding that current regulations permit health and wellness programs which reduce deductibles/copays for improved health status. Regulations impacting this are continually changing, and it is critical to keep this in mind when designing such programs.

Health and wellness programs can be structured in many different ways. As health plans and plan sponsors decide to impact the wellness of their customers, it is critical that the programs achieve the financial success they were intended to get. Since so much change is happening today, it is important to track these issues very closely to assure the greatest health cost savings possible.

There is a significant potential for health cost reductions from appropriately implemented health and wellness programs. Not every program will be able to achieve the entire 20% – 35%; however, in the current economy, a minimal savings of 5% – 10% would be significant to most health care planners. Additional savings can be achieved if health and wellness principles are strategically combined with effective care management principles.

2 Yphantides, Nicholas, “My Big Fat Greek Diet”, Nelson Books, 2004, ISBN 0-7852-6025-0

David Axene collaborated with Nicholas Yphantides in writing this series of articles. Dr. Nicholas Yphantides serves as the Consulting Chief Medical Officer for San Diego County and is the National Director for Health & Wellness with Axene Health Partners. He is a cancer survivor and is an advocate for those in his community who need it the most. For nine years, Dr. Nick served as Chief Medical Officer of one the largest network of Community Clinics in San Diego County.