Tag Archives: mayo clinic

Walmart Shows Way on Health Benefits

Walmart, a true leader in benefit innovation, is taking the next right step, expanding its popular and successful Centers of Excellence.

When Walmart workers, called associates, use Centers of Excellence, deductibles and co-pays are waived. All travel expenses are paid for the patient and a companion.

Starting next year, if covered folks at Walmart have spine surgery outside of a Center of Excellence, it will be considered out of network, and only 50% of the costs will be covered.

This is a huge step and is reminiscent of the early days of preferred provider organizations (PPOs), provider networks and health maintenance organizations (HMOs). At the beginning, if you got care through a PPO, your deductible and co-pay were waived. In a few short years, those programs evolved into ones that paid regular benefits with deductibles, etc., if you used PPO doctors, but applied higher deductibles and co-pays if members went out of network. Of course, in most HMOs, if members went out of network, nothing was paid.

See also: Walmart’s Approach to Health Insurance  

What Walmart is doing now, while a very logical extension of what benefit plans have been doing for more than 30 years, is a huge step forward in truly controlling waste, overtreatment and misdiagnoses in health plans.

Kudos.

Here is the press release:

The Right Care at the Right Time: Expanding Our Centers of Excellence Network

Starting next year, Walmart will double the number of world-class medical facilities available to our associates who have been told they need a spine surgery. Whether you’re a cashier in Wyoming who’s been with the company for six months or you’re a 20-year associate running a store in Miami, if you have Walmart health insurance, you have this benefit.

We are adding the Mayo Clinic facilities in Arizona, Minnesota and Florida to our current list of Centers of Excellence (COE) for spine surgeries, which are Mercy Hospital Springfield in Missouri, Virginia Mason Medical Center in Washington and Geisinger Medical Center in Pennsylvania. Our COE program is about more than just access to these facilities and their specialists; it covers these procedures at 100%, including travel, lodging and an expense allowance for the patient and a caregiver.

Why would Walmart offer a benefit like this? It’s pretty simple – we care about our people and want them to receive the right care at the right time.

Walmart started offering this benefit in 2013, and our data tells us we are making a difference for our people, but we want to do more. That’s one of the reasons for adding more eligible medical facilities to the program. Other reasons these medical facilities were selected are that each facility:

  • Fosters a culture of following evidence-based guidelines, and, as a result, only performs surgeries when necessary.
  • Structures surgeons’ compensation so they [have incentives to provide] care based on what’s most appropriate for each individual patient and look at surgery as a last option.
  • Is geographically located throughout the country to provide high-quality care to participants in one of Walmart’s health benefits plans.

Research, as well as our own internal data, shows about 30% of the spinal procedures done today are unnecessary. By utilizing the Centers of Excellence program, our associates are assessed by specialists who are [given incentives] differently to get to the root cause and prescribe appropriate treatment.

Our associates are very important to us, and we want to make sure they and their families receive the highest level of quality care available.
Preventing a surgery that someone doesn’t need is only part of our Centers of Excellence. The other, even more important aspect is making sure our people receive the right diagnosis and care plan for their pain. In The New Yorker, renowned surgeon and public health researcher Atul Gawande underscored the importance of this approach:

“It isn’t enough to eliminate unnecessary care. It has to be replaced with necessary care. And that is the hidden harm: Unnecessary care often crowds out necessary care, particularly when the necessary care is less remunerative. Walmart, of all places, is showing one way to take action against no-value care—rewarding the doctors and systems that do a better job and the patients who seek them out.”

Walmart is not alone in this approach to appropriateness of care. One example is the Choosing Wisely initiative, which is backed by recommendations from more than 70 specialty societies including the American Academy of Orthopaedic Surgeons, North American Spine Society and the American College of Surgeons. The stated purpose of Choosing Wisely is to help patients choose care that is supported by the evidence, not duplicative of other tests or procedures already received, free from harm and truly necessary – we couldn’t agree more.

To further encourage our associates to take advantage of this offering, next year, spine surgeries at one of our six Centers of Excellence medical facilities will continue to be covered at 100% with travel and lodging paid for the patient and a caregiver. If the surgery is performed outside of a COE facility, it will be considered out of-network and paid at 50% in most cases.

Our associates are very important to us, and we want to make sure they and their families receive the highest level of quality care available. 

We have seen spine surgeries performed often when they are not necessary. By making these changes in our benefit offerings next year, Walmart wants to make sure that our associates and their family members are diagnosed correctly and that they get the best possible treatment.

See also: There May Be a Cure for Wellness  

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.

The Dangers Lurking for Health Insurers

Heathcare is changing, creating opportunities but also dangers. Here is where healthcare is changing and why you should care in the insurance industry.

Providers. The physician you once saw and had a relationship with is now maybe a physician assistant or a nurse practitioner. Healthcare has turned care over to “mid-levels” and concentrated physician time on revenue-intense practice like surgeries or high relative-value-unit (RVU) patients such as elderly, as a reaction to the pressure on revenue and proliferation of data, The coding needs to be high for a patient to get physican attention, and the low coders, the healthy, are attended by mid-levels.

A mid-level is paid only a fraction of a physician. Makes sense? Expect care to reflect the nuance of matching. The result will be variation in diagnoses in health benefit insurance and workers’ compensation.

Isn’t there better data now? Yes, but who has time as a caregiver to be giving it thought? The ACA has driven more people to buy insurance, but that means less time per office interaction. Hospitals have bought physician practices, which now face new effectiveness expectations such as referral level and relative value unit per caregiver.

Caregivers are under enormous pressure to produce at your expense. Who can question “do no harm”?

Insurance industry. If you are a medical malpractice insurer, how does higher-deductible health insurance affect you? How does higher premium for health insurance mean you are at higher risk in offering medical malpractice? Can data be working against you?

The onus of care is now on the patient, and the patient is relying on engagement and education from anywhere it can be found. Google and the Mayo Clinic have teamed up to help by presenting search results verified by suitable medical communities, but the patient is on her own under the direction of a healthcare practice that is inundated with new patients and lots of data she can’t get to. And don’t forget that the attention is now being guided away from your physician. The standard of care has not changed, but the frequency of visits has lowered, and the time for every visit has decreased. Less care, too much data, too much patient expense and the same expectations of medical care. Not a picture of profit in medical malpractice. Maybe time to raise the price?

Workers’ compensation will get hit with increase in frequency and severity as care is slid to less dependable providers. You get what you pay for. One miss is worth a thousand hits in health. Providers are seeing patients too briefly to be always trusted, and the data…the providers are not even looking at the data. They are too busy plugging in data to appropriately spend effort on what it means.

General liability is a scarier risk as more patients mean more chaos and more visitors to the facilities. Who is watching security when the waiting room is packed up? Who is shoveling the lot? By the way, a patient fall is either medical malp-practice or general liability. Forget the $1,200 annual GL premium. Think $2,000.

Cyber liability is a huge concern as hackers get more sophisticated and the stakes in stolen health profile skyrocket.

Insurers can be venture capital. VC has figured out that there is a ton of money in health, but do they know much about health and what it does for insurers? Aetna’s CarePass was a great idea that needs to go on. Insurers should get on board with funding innovation. The VC money is slow. Technology is a VC specialty, yet health desperately needs people in play who know health. Physicians generally are not greatly interested in innovation. A tremendous opportunity is here for insurance companies to innovate with technology. Silicon Valley and insurance could team up and solve lots of issues. Now that it Google is out there, it is a great innovator in insurance. The opportunity is to bridge technology and insurance acumen. But VCs like to invest in people they know, like technology folks, so a gap indeed exists. Just saying.

Patients. High deductibles and high premiums for health insurance, combined with busy caregiving and new technology to grasp, mean the patient has a place at the healthcare table, finally, but no one to help much. It is up to the patient to take care of the patient. And your caregiver is very busy now that everyone has some kind of insurance. What a time to be finally given a place at the table.

How long of a visit does a patient get with his provider? Is it enough to rightly ascertain what is going on with a patient? Is surgery really the solution? Does chiropractic seem all that bad, Mr. Insurer? Does the caregiver get managed by how many referrals it proffers? Does the patient need to call the caregiver every time there is a stuffy head? Waiting rooms are filled, and time with the caregiver is down. Having a place at the table should mean more.

Innovators. Lots of techies are going after health care. Do they know healthcare? Not as much as you would hope. The right approach is to find innovators who get insurance and health and then parse technology. Not the other way around. Innovators look for faster capital and more knowledgeable partnership.

Make the data personalized and simple, as even caregivers cannot find time to analyze data. Health has a consumer face today, and lots of people looking for care guidance. The consumers want it simple and mobile. Anybody think insurance could be an available partnership candidate?

Healthcare vertical recombination is a major opportunity in insurance. Are you ready to lead?

Case for Reimbursing for Telemedicine

There is a tremendous amount of change taking place in healthcare right now as the Affordable Care Act is in the early stages of implementation. Patient home, accountable care organization (ACO) and other clinical integration models are top-of-mind, and, with them come new potential risks to be considered. The same is true for “telemedicine.”

Also known as “telehealth,” telemedicine is a way of delivering healthcare to patients when the physician is not in the same room as the patient. Doctors can use two-way video systems and reach many more patients in remote locations. Many patients do well with telemedicine and find it more comfortable than coming into the physician’s office or an urgent care center.

Telemedicine has been expanding its reach for healthcare systems across the U.S., adding services as technological advances allow. The associated savings – mostly in time for both patients and physicians – create additional incentive. Routinely, emergency departments use remote access to consult with specialists around the clock, and home-care services provide follow-up via phone and video for patients with chronic diseases.

But even though delivering care through telemedicine channels saves money, it is not reimbursed by Medicare. Medicare only reimburses providers and healthcare facilities if the physician is bedside. And Medicare reimbursement sets the trend for the private insurance market. Limited reimbursement is a major barrier to the expansion of telehealth.

Only time will tell if the seemingly inherent risks involved with little or no direct patient contact will outweigh the convenience and cost savings. As the healthcare landscape changes, so will the potential liability of healthcare professionals. And that means that insurance companies – both direct healthcare insurers and professional liability insurance carriers – will have to adapt based on the risks associated with a new, less personal way of delivering care.

An article about the Mayo Clinic, where telemedicine technology is used to deliver care in an intensive care unit, makes the case for reimbursement. As the article explains, unfortunately, technology is way ahead of figuring out how to get reimbursed for these services.

Carpal Tunnel Syndrome: It’s Time to Explode the Myth

Carpal tunnel syndrome (CTS) has caused a firestorm of controversy in recent years. CTS is a perfect example of how popular beliefs are not supported by medical evidence.

It is time to set the record straight.

Although the popular belief is that keyboard use causes CTS, the science shows otherwise. Nine studies have reviewed this relationship, including ones by the Mayo Clinic, Harvard Medical School and a Swedish study reported in Orthopedics Today. The scientific research shows that keyboards are safe to use and do not cause CTS. Furthermore, keyboard design had no effect on the incidence of CTS. Symptoms may increase with many activities, including the use of keyboards, but keyboards do not cause CTS.

According to the AMA Guides to the Evaluation of Disease and Injury Causation, “85% of patients who meet the National Institute of Occupational Safety and Health (NIOSH) guidelines and requirements for a diagnosis of CTS would not have a true CTS confirmed by nerve conduction testing.”

What complicates the diagnosis and treatment of CTS is that there are multiple causes of the symptoms. These include: diabetes, pregnancy, use of birth control pills, menopause, various vitamin deficiencies, insufficient water consumption, exposure to cold temperatures, incorrect sleeping positions, smoking, knitting, playing musical instruments, recreational sporting activities and other non-work-related activities.

What complicates the diagnosis and treatment of CTS even further is that there are literally dozens of other diseases and conditions that mimic CTS-like symptoms. These include: tendonitis, bursitis, sprains, fractures, dislocations, gout, rheumatoid arthritis, osteoarthritis, thoracic outlet syndrome, myofacial trigger points, as well as an array of neck, shoulder, back and cervical conditions. In fact, there are 59 medical conditions that have been identified to be associated with CTS-like symptoms.

A common error in diagnosis and treatment is the tendency of physicians to treat a case as if there were a single physical site causing all the problems. In fact, it would be extremely rare for only one nerve location to be involved. This means that pain in the wrist may be the result of nerve entrapment in the neck or shoulder. This is referred to as the “whole-nerve syndrome.”

Even the popular name is incorrect. The correct clinical name is Median Nerve Compression Neuropathy. According to the AMA Physicians Guide to Return to Work, “CTS is actually a condition with a known pathology and not a syndrome, but the name ‘carpal tunnel syndrome’ has become so well-known that CTS is used.”

Medical studies have shown that as many as 85% of patients who are told they have CTS are misdiagnosed. The overwhelming number of cases are determined to be work-related–a major problem in the workers' compensation industry for the past two decades–and it has been reported that as many as 70% of those diagnosed go on to receive CTS surgery.

Currently, 250,000 people a year in the U.S. have CTS release surgery. If 85% of those are based on misdiagnoses, that would mean more than 210,000 unnecessary surgeries per year. At a cost of $5,000 to $10,000 per surgery, that's some $1.5 billion a year spent on inappropriate surgery, much of it paid for by workers' comp.

According to a University of Maryland Medical Center study, “CTS surgery does not cure all patients and because it permanently cuts the carpal tunnel ligament some wrist strength is often lost. A number of experts believe that CTS release is performed too often.”

A medical director at a leading insurance company told me, “I recommend that all CTS cases have surgery because that is where all the cases end up anyway.” Needless to say, I will not recommend that insurer to my clients.

The good news is that CTS can be diagnosed accurately. In many cases, it can be treated successfully with conservative treatment in a matter of weeks and is easily prevented.

The bad news is that primary-care physicians more often than not misdiagnose CTS. This results in incorrect treatment and unnecessary surgery, which leads to chronic unresolved conditions, no relief to the patient and staggering costs to U.S. employers and insurers.

Leading medical experts such as Dr. Peter Tsairis, retired chairman of neurology at the Hospital for Special Surgery in New York, said the biggest concern is the automatic assumption that the clinical problem is work-related. “It is a significant problem, since many of these patients do not have CTS,” he added. He has often seen patients already scheduled for surgery whose primary-care physicians did not perform a thorough physical exam or conduct any electrical diagnostic testing to confirm the CTS diagnosis.

Dr. Ron Safko, a New York-based, board-certified chiropractic orthopedist, has also seen many cases of misdiagnosis by primary-care physicians. “It boggles my mind how physicians do not even consider other underlying conditions and do not even examine other areas, such as the neck, back, shoulder or cervical spine,” he said.

Just because it has become a widely accepted urban myth that CTS is caused by keyboarding and, therefore, a work-related injury, should not give treating physicians the liberty to avoid performing a thorough patient history, physical examination and appropriate diagnostic testing based on widely accepted and evidenced-based medical protocols.

Isn’t it about time the workers’ compensation industry got it right?

This article first appeared on Annmarie Communicates Insurance.