Tag Archives: primary care

Walmart May Redefine Primary Care

When Catalyst for Payment Reform hosted a webinar that provided a glimpse into Walmart’s healthcare strategy and management plans, Lisa Woods, senior director of U.S. benefits, talked about a new program to simplify and improve healthcare, particularly primary care, for Walmart’s million-plus associates and their families.

She alluded to Walmart’s well established and continuously expanding Centers of Excellence (COE) programs, as well as two new programs. First is a personal healthcare Assistant, powered by healthcare navigation firm Grand Rounds, that helps Walmart associates with billing and appointment issues, finding a quality provider, understanding a diagnosis, coordinating transportation, arranging child care during appointments and addressing other important patient needs.

Walmart has also broadened its telehealth offerings, including for preventive health, chronic care management, urgent care and behavioral health. All video visits have a $4 copay, and associates can book an appointment with a primary care physician within one hour and a behavioral health visit within one week, making services highly accessible. Partners for this program are Doctors on DemandGrand Rounds, and Healthscope Benefits.

Daniel Stein and Matthew Resnick, from physician profiler partner Embold Health, described how their data collection/analytics approach identifies physicians with histories of providing the most appropriate care. In three markets – Northwest Arkansas, Tampa/Orlando and Dallas/Ft. Worth – Walmart’s “Featured Provider” program will connect patients to the high-performing providers that Embold has identified in eight specialties: primary care, cardiology, gastroenterology, endocrinology, obstetrics, oncology, orthopedics and pulmonology. Walmart has been a key partner in the development of Embold Health – Stein, the CEO, Stein is a former Walmart medical director – and its efforts to accurately profile the quality of healthcare delivery at the individual physician level. The health outcomes improvements and savings associated with only using high-performing physicians should be profound.

See also: 11 Ways Amazon Could Transform Care  

The changes that Walmart has announced reflect a laser focus on solving specific problems, like overtreatment and patient difficulty with navigating the system, that plague all primary care programs. The company has been tinkering with and testing different primary care models for a decade or more. As with its COE program, the goals of Walmart’s new healthcare programs are a more refined, disciplined and methodical set of innovations focused on driving better care, a better patient experience and lower cost and that, for the most part, are not yet available to most primary care patients elsewhere in U.S. healthcare.

As a side note, it’s worth recognizing that, in an ideal world, the major health plans – e.g., United, CIGNA, Aetna, Anthem – with many millions of lives covered, would have pioneered these approaches to manage healthcare risk, to improve health outcomes and to reduce cost. The fact that payers haven’t been motivated along these lines is a reflection of the perverse incentives that have driven the U.S. health system for decades, that all patients and purchasers are up against and that have facilitated the kinds of innovations discussed here.

Walmart attacked these problems because it is at risk for its population and its costs. Few employers have the resolve and the resources available to develop key innovations that can move an industry like healthcare forward.

Not surprisingly, Walmart appears to see an opportunity here and has larger plans. Walmart almost certainly believes its healthcare efforts are applicable beyond its own population, and, like HavenKroger and Costco, has staked out a healthcare business strategy. Primary care are logical services to begin with, and Walmart has announced that its pricing will be 30% to 50% below conventional primary care prices. Walmart’s focus on improving experience, health outcomes and cost, combined with its national footprint and deep resource base, could immediately catapult it to the first rank of competitors in this space.

No doubt, Walmart has its eye on providing primary care services to groups as well as individuals. Relationships with health plans would allow the company to share in the savings it generates through the primary care platform and associated programs.

Think about the territory covered here. Walmart intends to:

  • Develop highly price competitive primary care clinics across the country.
  • Offer very low-cost telemedicine that can be a convenient pathway to primary care and other care, streamlining care processes.
  • Implement a personal healthcare assistant that can simplify navigating the healthcare system and expedite a much enhanced patient experience.
  • Connect to the highest-performing local physicians and regional COEs in each specialty, driving appropriate and disrupting inappropriate care and cost, in strong contrast to the inappropriate care and cost patterns that have come to dominate U.S. healthcare.
  • Develop some tie to health plans that would allow the company to benefit from the health outcomes improvements and savings that its management approaches create.

A vigorous primary care campaign by Walmart would undoubtedly threaten traditional primary care models and spur competitive innovation among progressive primary care organizations, especially if the company publicly conveyed a dedicated focus on transparent management of full continuum health outcomes and cost. This would powerfully differentiate Walmart’s primary care efforts from those of competitors like Walgreens and CVS, whose convenience care primary care models are mainly dedicated to maintaining the status quo.

See also: Avoiding Data Breaches in Healthcare  

Walmart’s activities in this space are one signal that the old paradigm in health care is waning and that a new, value-based healthcare market is emerging. It can’t happen soon enough.

Employee Benefits: Themes for 2018

Here are the themes I am seeing most often in health and welfare benefits:

ThemeFinancial Wellness – Americans are struggling to get ahead, and the middle class is declining. Successful retirement and wealth planning for many people is a simple act of good accounting decisions multiplied over many years. Instant gratification has eroded good decision-making, and large majorities of people have no savings or retirement funds. Smart employers are taking steps to help their people make good decisions and become better stewards. This encapsulates retirement strategy, education, student loan assistance, emergency loan assistance and the like.

Sub-Theme: Student Loan Repayments – Extremely hot benefit right now; it’s one of the most requested benefits by new employees.

Theme: Dependent Care – People are living longer, and in sub-optimal health. Huge portions of the workforce are now having to spend large quantities of time managing the health and care of their dependents and loved ones. Smart employers are looking for ways to relieve this burden and improve the productivity of the workforce.

See also: Dissecting Landmark Decision on Wellness  

Theme: Hospital Department Quality vs. Physician Quality – More and more data is becoming available regarding hospital and doctor quality scores. How do we think about it? How is it used? Which firms are stepping forward to help people access quality? If I contract directly with a hospital, am I hurting patient access to the highest-quality providers who aren’t with that hospital? These questions are important and could be addressed with the right sessions.

Theme: Member Steering and Plan Strategy – The best plans are seeking new and improved strategies to steer members. As more cost and quality data becomes available, proper healthcare procurement begins to depend on the firm’s ability to steer members. A few firms are leading the way to get exceptional procurement and steerage, and most employers could learn much from them to save millions and get control of (arguably) the hardest budget item in the firm.

Theme: The Care-Knowledge Gap – There is a devastating time period between when a therapy is discovered and when the therapy is available in most major hospitals. This gap has grown to 17 years; thus, the healthcare of 2035 is available today if you can find it. Smart employers and activist entities are working hard to reduce this wait time to save lives and accelerate the improvement of American healthcare.

Theme: Augmented Primary Care – Primary care has had a rough decade. At worst, it has been vanishing, and, at best, it has been acquired and used as a referral source for hospital systems. Smart employers realize that, for them to get control of their spending, they need to partner with primary care doctors whose interests are aligned with the employer and the member. This interest is to keep members healthy by consuming the minimum effective quantity of healthcare services, from professionals operating at the top of their respective licenses, in settings offering the best value. Direct primary care represents the best approach to achieve this objective, and building appropriate technology into these settings can significantly reduce the dependence on the greater hospital system.

See also: Wellness Works? Prove It–and Win $$$  

Themes Losing Steam: These topics appear (to me) to be losing their luster very quickly:

  1. Wellness
  2. Medical tourism
  3. Price transparency
  4. Disease management
  5. Private exchanges
  6. PBMs and non-specialty Rx

Why Healthcare Costs Soar (Part 3)

In Part 1 and Part 2 of this series, David Toomey and I described a wildly successful collaboration with Virginia Mason Medical Center (VM) and a few Seattle employers.

During the the time of the VM collaboration, we invited major physician groups to meet with the employers. One of the most memorable meetings was with the CEO and chief medical officer (CMO) from a very well-regarded physician group in Seattle that has high fees but low performance.

As you would suspect, the employers were better prepared for this meeting than they had been for the meetings with VM. When the CEO and CMO talked about their strong emphasis on quality, the employers asked about quality monitoring and the process of care. Rather than acknowledging opportunities for further analysis and professing an openness to collaboration, the providers responded with confidence about their model of care.

Afterward, the employers expressed concerns about whether this premier provider could improve care and reduce costs. We posed a couple of questions: Are you saying you don’t want this provider in the network? Are you really ready to tell your leadership that this physician group, which many executives use, is not in the top tier?

The employers were aware of the dynamics with network configuration and the trouble that businesses have when a provider is dropped from the network and even a few employees complain. The employers responded that they wanted to have additional meetings with this group, because of its reputation.

After a couple of follow-up meetings, the employers recognized that this group was not committed to the process of care that they expected. They decided that the group should not be in the performance-based network. Importantly, the employers were now equipped to discuss their rationale with their leadership teams.

The CEO of the provider group felt respected, because of the time the employers spent with him, even though he did not like the outcome. He eventually acknowledged the group had work to do.

Employers make purchasing decisions with suppliers every day. For some reason, the healthcare procurement process involves the carriers and other vendors but often skips the actual suppliers of healthcare (except in a fairly small, but rapidly growing, number of major corporations).

The big question is: Why are more self-insured employers not engaging directly with providers?

In a broad network, there will be a bell curve around performance. Most employers say they want quality providers in their networks, but half the providers in their broad-based networks are below average. While everyone espouses “quality,” the variation in care is significant, and the medical ethics around treatment often drive that differential. Healthcare is big business. It is time to reward employees and channel them to primary care physicians and specialists who are truly committed to medically appropriate care.

A major reason why healthcare costs grow faster than general inflation is because most self-insured employers are simply not dealing with healthcare providers in the way we have described in this series of posts.

A New Focus for Health Insurance: ‘Negaclaims’

Historically, the “do more, bill more” fee-for-service model of healthcare measured success by increased billings. In the fee-for-value era, we need a new framework for assessing healthcare results. Quality indicators are logical, but they are mostly geared toward measuring actions taken. We can borrow a concept from the energy sector for an additional metric.  We need a concept for removing waste and unnecessary care that could be inspired by a concept from the energy sector described in this blurb from Wikipedia for something called Negawatts.

Negawatt power  is a theoretical unit of power representing an amount of energy (measured in watts) saved. The energy saved is a direct result of energy conservation or increased energy efficiency. The term was coined by the chief scientist of the Rocky Mountain Institute and environmentalist Amory Lovins in 1989, arguing that utility customers don’t want kilowatt-hours of electricity; they want energy services such as hot showers, cold beer, lit rooms, and spinning shafts, which can come more cheaply if electricity is used more efficiently. Lovins felt an international behavioral change was necessary in order to decrease countries’ dependence on excessive amounts of energy. The concept of a negawatt could influence a behavioral change in consumers by encouraging them to think about the energy that they spend.

The healthcare parallel would be a “Negaclaim™” — i.e., an unnecessary claim avoided. This isn’t about simply denying care. Just as consumers aren’t interested in kilowatt hours, patients aren’t interested in claims — they want health restored and diseases prevented, which can be done more efficiently and effectively. When individuals are fully educated on the trade-offs associated with interventions, they generally choose the less invasive approach. A nice byproduct is that the invasive approaches are frequently more costly and medically unnecessary. The following are a few of many examples of how unnecessary care can be eliminated while improving the patient experience:

  • Day-to-day and chronic disease care: One of the key reasons Direct Primary Care (DPC) has proven itself to be the Triple Aim  leader is that a proper primary care relationship involves time spent with patients to explain trade-offs of various medical options.  Without incentives to push for “more,” DPC providers have demonstrated that they can reduce unnecessary utilization by 40-80%. By contrast, “hamster wheel” primary care has effectively turned primary care into 7-minute, drive-by appointments that leave little time to do anything but direct patients toward additional costly items, whether it’s ordering a prescription, test, hospitalization or specialist visit. In many cases, those could be avoided with a robust primary care relationship.
  • High Cost Procedures: Leah Binder wrote about what major employers such as Walmart, Loews, Pepsico and others are doing to reduce risk to their employees while also saving money, in What We Can Learn From Walmart: How Our Healthcare System Can Save Lives and Dollars. Employees found that 40% of the transplants that were recommended by local hospitals were deemed medically unnecessary by top physicians at the Mayo Clinic and other nationally renowned facilities. Employees were thrilled to avoid risky (and expensive) procedures. It also sent a great message to employees that their employer valued them enough to send them to the best medical centers in the world for second opinions.
  • End of Life: Quality of life is affected dramatically by the end-of-life decisions we make. This was outlined in How Not to Die. The system is oriented to do more even if it is at odds with quality of life. Doctors themselves recognize this when they are the patient, as described in Why Doctors Die Differently. While quality of life is the driving factor for patients and families, there is a second-order benefit that the procedures that reduce quality of life are typically very expensive.

The problem in healthcare has been that providers have incentives to do stuff because of the flawed reimbursement models that dominate our present healthcare system. Respected studies such as from the Institute of Medicine demonstrate that there is more than $750 billion in waste. PwC stated that more than half of healthcare spending is waste. Incentives have driven providers to encourage more interventions, and consumers have been led to believe that more is better even though, in many cases, less is more.

That has added a challenge for health insurers. The general perception is that health insurers reflexively deny claims (sometimes getting in trouble for that). This has resulted in health insurers having the lowest Net Promoter Score of any industry. Consumers have clearly decided that health insurers aren’t doing this for consumer benefit. Fair or not, they have concluded it’s simply for the financial health of the insurer. Clearly, health insurers need a different approach if they want to improve their image and the health of their customers while ensuring their financial viability.

One incentive that has changed revolves around the Medical Loss Ratio (see Aetna’s explanation here).  In contrast to “customer service” reps focused on claims, an investment in patient engagement can have the same or greater effect on reducing claims while qualifying as a healthcare expense. Enter patient engagement.

Patient Engagement Is the Blockbuster Drug of the Century
Leonard Kish made the case that if patient engagement was a drug, it would eclipse all blockbuster drugs before it. Kish cited results of studies showing benefit when patients were successfully engaged in their health.

Compared to those not enrolled in the study, coordinated care “patients have an 88 percent reduced risk of dying of a cardiac-related cause when enrolled within 90 days of a heart attack, compared to those not in the program.” And, clinical care teams reduced overall mortality by 76 percent and cardiac mortality by 73 percent.

Rather than reflexively denying claims and building up a mountain of ill will, insurance companies should invest resources in helping their customers get engaged in their health. Their customers would, in effect, “self-deny” their own claims.

Note that when I describe patient engagement, I’m including family members and caregivers. Did you know that families provide care valued at more than $450 billion per year  – more than our total spending on Medicare! Thus, much of what is outlined below speaks to caregivers (particularly with elderly patients), not just the patient. Having more resources/tools as a caregiver would be welcomed, as most of us have no clinical background and are thrown into a caregiving role virtually overnight.

[Disclosure: My patient relationship management company is one of the organizations providing patient engagement tools to healthcare providers, which is why I'm familiar with these examples.]

Just about every myth has been debunked about how patients of all types supposedly won’t get engaged in their health, whether it’s low-income diabetes patients, native American populations or the elderly. However, providers are largely failing in their efforts at engaging patients as they haven’t had the incentives, tools or training.  Provider-patient communications guru Stephen Wilkins points this out clearly in a few pieces.

Despite less than stellar results that Wilkins highlights, the initial attempts by providers at engaging patients are welcomed just as a muddy puddle of water in the Sahara Desert is welcomed. However, much more can be done.

Catalyzing Patient Engagement in Health Plans’ Best Interests
A wave of new requirements and challenges have crashed on top of providers. Insurers could help if they focus in the right areas and are mindful of the challenges. JAMA recently wrote a piece highlighting one facet of patient engagement — shared decision-making (SDM). Physicians aren’t going to magically take on this challenge without a change.

The brevity of visits constrains the opportunities to address these elements of SDM. Furthermore, clinicians are not adequately trained to facilitate SDM, especially eliciting patient values and preferences for treatment.

[Note: Resources to train clinicians on patient engagement are emerging. One would expect that a host of continuing education courses will emerge. One example is HIMSS (the professional association for healthIT), which released a seminal book on patient engagement.]

In the places where providers have successfully achieved the Triple Aim objectives with challenging patient populations, they have had payment aligned with outcomes. Teams were unleashed, led by doctors, to get creative about how to tackle the challenges. While doctors are vital, they use non-physicians for a substantial part of the interaction with patients. It turns out, for example, that doctors and even nurses can be less effective at effecting behavioral change in patients than non-typical care team members. Rather than being relegated to low-level tasks, medical assistants and health coaches play a vital role in the successful models. Once again, while the goal is an improved health outcome, there is a second-order benefit that being more effective lowers costs by avoiding complications, and the medical assistants and health coaches are generally paid less than doctors and nurses. Unfortunately, in a typical fee-for-service reimbursement model, these types of services typically aren’t compensated despite their impressive results.

Dr. Rob Lamberts described this problem in detail in Washington, We Have a Problem. He summarizes the conflict between people’s desires and healthcare’s flawed reimbursement framework.

This is why, I believe, any system that profits more from people with “problems” than those without is destined to collapse. Our system is opposed to the goal of every person I see: to stay healthy and stay on as few drugs, have as few procedures, and avoid as many doctors (and drug companies) as possible.

Health insurers have implicitly viewed their customers as adversaries by creating a claim-denying framework as the default. The smart health plans will figure out how to harness the consumer goals. This isn’t some fanciful dream as it has been demonstrated (profitably, I might add) by the physician-entrepreneur organizations outlined in The Hot Spotters Sequel: Population Health Heroes.

This isn’t about minor tweaks to a fundamentally flawed model. Rather, as one physician-entrepreneur put it, too many models are “putting wings on cars and calling them airplanes.” Rather, it’s supporting proven models where they have rethought care delivery – here’s how one physician-entrepreneur describes rethinking care delivery from the ground up (video).

While financial rewards are important, most physicians are not motivated primarily by money but by autonomy, mastery and purpose. In the successful models, the physician-entrepreneurs created their own autonomy and recognized that the focus of their mastery and purpose had to fundamentally shift. A nice byproduct was the growth of “Negaclaims” as the educated and empowered patients better understood the significant risks of overtreatment and errors.

Too frequently, health plans have tried to micromanage clinical processes. With proper financial incentives combined with a move toward enabling clinical teams to become masters at driving patient engagement, the health plan is much more likely to achieve the desired outcomes. As the Stephen Wilkins pieces referenced above illustrate, clinicians haven’t been trained or rewarded directly or indirectly for encouraging patient engagement. It should be no surprise that most haven’t achieved mastery in helping their patients achieve patient engagement. Instead, the language of medicine has been punitive and demeaning, talking about “non-compliant” patients as though they were petulant criminals. That doesn’t further the partnership between patients and their care teams, which is necessary for optimal outcomes.

Previously, I outlined the strong business case for patient engagement. Those who have understood that business case have moved on to practice the 7 habits of highly patient-centric providers. It’s clear that past efforts by health plans to reduce claims have fallen short and created ill will and sub-optimal health outcomes. Putting the patient/member at the center need not be a marketing gimmick. Rather, it’s central to the notion of “Negaclaims” and to a winning strategy in the fee-for-value era.