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Health Care Current | October 4, 2016
Is wellness the unicorn of health care?
This weekly series explores breaking news and developments in the US health care industry, examines key issues facing life sciences and health care companies and provides updates and insights on policy, regulatory, and legislative changes.
- My Take
- Implementation & Adoption
- On the Hill & In the Courts
- Around the Country
- Breaking Boundaries
By Sarah Thomas, Managing Director, Research, Deloitte Center for Health Solutions, Deloitte Services LP
The recent announcement that wearable activity trackers might not help people lose weight put the health care world in quite a whirl. Critics raised questions about the study – whether the data were old, whether the technology is outdated, etc. While I wouldn’t have been surprised if the study had found no differences, I was surprised that the findings suggest that people who used wearables lost less weight than the people who did not use them!
The topic of wellness – curating the perfect combination of technology and incentives to keep consumers engaged over time – is a commonly debated one in health care. While maintaining a healthy weight is just one part of the wellness equation, you may read about research like this and come to the conclusion that achieving wellness is just like trying to catch a unicorn.
My hypothesis is that fitness trackers and wearables tend to be most popular among people who already are committed to exercise and activity or were about to start a program anyway. There also is concern that workplace wellness programs tend to get the greatest take up among the same group of people, at least in the long term. Moreover, they might be typical “early adopters” – the ones that wait excitedly for new, improved versions of technology to come out so they can quickly snatch them up as soon as they’re in stores.
I’ve also read the articles that show that losing weight is much more driven by diet than by exercise. Yes, there are diet trackers. But, most require a lot more diligence on behalf of the user – entering meals and snacks to count calories – than trackers based on movement and distance, which mostly operate passively in the background.
These studies have convinced me that the perfect strategy for achieving weight loss is incredibly challenging in reality. While a lot of strategies show success…a lot do not: millions and millions of people have lost weight, but the real challenge can be sustaining their success in the long term. Many scientists believe we are biologically and psychologically programmed to like calorie-rich food, and often it is relatively cheap to eat food of poor nutritional value. We are also programmed to hold on to weight in case of famine, though in modern times, that trait tends to hurt us more than help us.
Wellness programs are popular among many consumers and employers. Deloitte’s research on the subject found that many consumers with and without chronic conditions are interested in and see value in employer wellness and disease management programs. Most are willing to participate in programs: Only 6 to 12 percent of surveyed consumers say they are not willing to participate in optional initiatives such as biometric screenings or healthy lifestyle programs. And, almost all (96 percent) of surveyed employers that offer incentive programs agree or somewhat agree that wellness programs help to control medical costs, even if fewer than half are measuring the return on investment.
Even if the effectiveness of wearables for losing weight is in question, wearables and tracker technologies may improve health by monitoring vital signs and promoting adherence to treatment for people who have chronic conditions. And many wearable technologies are improving over time and becoming better integrated into consumers’ daily lives. Some research indicates that remote-monitoring technologies – which can include wearables and other applications of biosensors in smart devices – may have enormous potential for improving health care. So they may be an important investment opportunity for stakeholders:
- Some can be used to take vital signs and transmit the data back to health care providers – whether it’s monitoring for complications after a procedure, preventing an acute event like a heart attack, or tracking chronic health conditions (e.g., diabetes). As an example, I have an app on my phone to measure my heart rate that is incredibly easy to use. Health care plans and employers are picking up on this potential application. Aetna recently announced it will use the Apple Watch® to monitor vitals to create an early warning system for heart attacks.
- Others can be used to remind people to take their medicine. It is by no means the whole solution, but increasing medication adherence can be critical to improving both patient health outcomes and provider performance on value-based care and related quality initiatives. Many health care organizations are developing strategies and tools to help patients adhere to their medication regimens. These include sophisticated programs that combine sensors to see whether people take their medications, electronic reminders, communication with family members, and innovative benefit designs.
Deloitte’s 2016 Survey of US Heath Care Consumers found that many consumers are interested in using remote patient monitoring; interest was strongest in using it for caregiving (38 percent) rather than for self-care. So there is another really interesting application to consider.
Even for these use cases, I tend to think that apps, devices, and incentives alone are not enough. Integrating them with clinical care from primary care physicians, nurses, care coordinators (as relevant), or even nutritionists and dieticians could make them more successful. Strategies may also need to use lessons from behavioral economics, tailoring approaches to what drives each individual. No matter how great the technology, the human connection can be important for patients and consumers.
All in all, relying only on one technology, incentive, or program to encourage wellness or better health for those with chronic conditions may be a limited strategy. These technologies and programs likely work best in combination, tailored to the tastes, motivations, and preferences of the consumer. Social determinants – the environment where people live and work, issues of food insecurity and housing, and challenges like lack of transportation – matter, too.
As health systems, health plans, clinicians, biopharma, and medtech companies respond to the incentives to improve population health, I expect we may see more experimentation around integrating these technologies into a sophisticated and effective approach. As a result, success in improving wellness over time may be less of a mythical creature in health care.
Implementation & Adoption
10 percent of health plans achieve highest quality rating
The National Committee for Quality Assurance (NCQA) released the annual health plan quality ratings report for 2016-2017. NCQA rates health plans based on their performance in three major categories: consumer satisfaction, prevention, and treatment. Of the 1,012 health plans assessed, 105 achieved the top quality ratings of 4.5 or 5.0 out of 5.0. In contrast, 23 health plans received the lowest ratings of 1.0 to 2.0.
The report rates commercial, Medicare, and Medicaid health plans based on clinical quality, member satisfaction, and accreditation survey results. NCQA did not rate health plans offered in the federal marketplace, as the US Department of Health and Human Services (HHS) will release national ratings for those plans separately.
Key takeaways from the report include:
- Plans in New England and Great Lakes regions have the highest ratings: Seven states in those areas had the highest percentage of plans who received either 4.5 or 5.0 quality ratings.
- Most plans fall within the middle of the scale: Of the total number of plans rated, 10 percent received top ratings of 4.5 or 5.0 and 3 percent received lowest ratings of 1.0 or 2.0.
(Source: NCQA, Press Release, “NCQA Releases 2016 Health Insurance Plan Ratings,” September 26, 2016)
The American Medical Association (AMA) surveyed US physicians on their use of digital health tools and found that most would like the tools to fit seamlessly with their current technology systems and workflows. The top functions physicians want are for digital health tools to not increase liability, ensure data privacy, and integrate into electronic health record (EHR) systems. Many also would like to bill payers for time spent using them.
Most physicians (85 percent) reported that they see the potential for digital tools to improve patient care. All types of physicians are using digital health tools, but primary care physicians (PCPs) and physicians in larger, more complex practice settings are the most interested. PCPs already communicate and share electronic clinical data to consult with specialists and make referrals and/or transitions of care at higher rates than specialists. Many PCPs are also very interested in using more remote-monitoring tools in order to improve efficiency and care.
Analysis: Though they’re only one type of digital health technology, EHR systems can be important tools. Deloitte’s 2016 Survey of US Physicians found that nearly all surveyed physicians said that they would like to see their current EHR systems improve: 62 percent want them to be more interoperable, and 57 percent want improved workflow and increased productivity. Physicians rated low some aspects of health information technology and EHRs. Three out of four physicians reported that EHRs increase practice costs, outweighing any efficiency savings, and seven out of ten physicians reported that EHRs reduce their productivity.
Interoperability of digital health tools such as EHRs is a key issue getting attention under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The president of AMA, Steven Stack, has said that the lack of interoperable systems is one of the fundamental reasons why the potential of EHRs has gone unfulfilled. Congress made interoperability a core focus of MACRA.
(Source: AMA, “Digital Health Study: Physicians’ motivations and requirements for adopting digital clinical tools,” September 2016)
The Medicare Payment Advisory Commission (MedPAC) sent a letter to US Centers for Medicare and Medicaid Services (CMS) Acting Administrator Andy Slavitt last week, recommending improvements to the Hospital Quality Star Rating program methodology. Under the star rating system, CMS gives hospitals a score between one and five stars. Scores are published on the Hospital Compare website. CMS published the first year of program data in late July of this year (see the August 2, 2016 Health care Current).
According to MedPAC, hospitals’ scores varied based on which measures they reported. CMS rates hospitals across 64 quality measures using a weighted average of seven quality measure groups. Hospitals must submit enough information for three of the seven groups, and at least one outcome group has to be represented. Four of the measure groups are related to patient outcomes:
- Safety of care
- Patient experience
MedPAC found that hospitals that reported on all four of the outcomes measures groups tended to have lower star ratings than hospitals whose reporting was less complete, so better reporting could potentially penalize hospitals. MedPAC also says that the star ratings may not adequately control for patient severity. It found that, on average, lower-rated hospitals had higher rates of patient admissions through the emergency department (ED). As admissions through an ED tend to be for more severe or urgent conditions, these hospitals may have been treating a greater share of high-acuity cases.
MedPAC says that CMS should adjust scores for differences in patient acuity and emphasize outcome measures over process measures in star ratings. MedPAC also says that the star rating program should be better aligned with other quality reporting programs, such as the Hospital Value-based Purchasing program, which includes a comprehensive set of measures and redistributes payments from lower-to-higher performing hospitals. MedPAC will continue to discuss the methods used to compare hospitals and the formula for incentive payments and will work with CMS to continue to improve the Hospital Compare system in the next performance year.
CMS launches new millennial outreach strategy for open enrollment
At the White House’s Millennial Outreach and Enrollment Summit last week, CMS announced a series of initiatives to increase enrollment in the fourth open enrollment period for the public health insurance exchanges, which begins on November 1, 2016. CMS’s outreach initiatives will target young people who remain uninsured and have limited interactions with the health care system.
CMS is leveraging mobile technology and social media platforms to reach the population. One in five Millennials accesses the internet exclusively through a mobile device, so CMS has developed a mobile-friendly interface for Healthcare.gov. This initiative, called “Mobile 2.0,” will allow enrollees to navigate the site and compare plans before purchasing. It also will provide an end-to-end mobile enrollment experience. CMS is organizing a social media campaign, #HealthyAdulting. Groups like Tumblr and Autism Speaks are participating in the campaign to promote enrollment across a variety of channels. CMS will conduct outreach on Twitter, Facebook, and the video gaming platform Twitch.
CMS also plans to partner with other federal agencies in its outreach strategies. For example, the Department of Defense (DoD) will give young adults leaving the military information about how to enroll in exchange plans. And, the Internal Revenue Service (IRS) will reach out to those who paid an individual responsibility penalty for forgoing coverage last year, roughly 45 percent of whom were under the age of 35.
Background: Millennials are less likely to be insured than older Americans. Approximately 13 percent of people age 18-24 are uninsured, compared with only 8 percent of people over 35. An estimated 90 percent could be eligible for premium tax credits, which can help make plans more affordable. CMS and many health plans would like to increase the number of young, healthy enrollees in the exchanges to strengthen the risk pools and support long-term stability in the market.
On the Hill & In the Courts
CMS issues final rule for long-term care facilities
Last week, CMS issued final regulations to reduce hospital readmissions and infections, improve quality of care, and strengthen safety measures in long-term care (LTC) facilities. The rule aims to improve quality of care for nearly 1.5 million residents in over 15,000 LTC facilities.
This is the first update to LTC facility regulations since 1991. Key changes include:
- Supporting residents’ rights by changing the way that legal disputes in LTC facilities are handled.
- Ensuring that facility staff are trained on how to care for residents with dementia and how to prevent elder abuse.
- Staffing facilities with teams that develop comprehensive care plans and provide person-centered care.
- Improving care and discharge planning for all residents. This should include engaging caregivers and providing follow-up information to any receiving facilities or services.
- Allowing dieticians and therapy providers to write orders under physicians (where state licensing laws allow for it).
- Mandating that facilities have an infection prevention and control officer and an antibiotic stewardship program with use protocols and monitoring systems.
Bill would reduce regulation and encourage financial risk for MSSP ACOs
Lawmakers from the House of Representatives recently introduced a bill to reduce regulatory burden for accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) and encourage organizations to take on additional financial risk. The bill, “The ACO Improvement Act of 2016,” has broad support among industry leaders, who suggest that the policy changes could improve the long-term viability of MSSP.
Key provisions of the bill:
Currently, under MSSP Track 1, CMS assigns ACOs patients to clinicians based on their utilization patterns and spending at the end of the performance year. Many organizations say this retrospective system makes it hard to project and track spending and outcomes.
The legislation also would ease rules around telehealth, which could improve access to care. Currently, in order to qualify for Medicare reimbursement for telehealth services, beneficiaries must reside in a non-Metropolitan Statistical Area or a rural Health Professional Shortage Area. The bill proposes to waive this rule for all MSSP ACOs.
Analysis: This bill comes as the industry prepares for the first reporting period under MACRA. The final rule for MACRA, which CMS has said it will release by November 1, 2016, is expected to lay out which alternative payment models (APMs) will count as advanced APMs. The proposed rule indicated that Track 1 MSSP ACOs will not qualify as advanced APMs even though most organizations participating in MSSP are under this track. However, if this bill were passed, organizations might be more interested in participating in models that require more downside risk, a key requirement for an APM to qualify for incentive payments under MACRA.
Big data, real-world evidence, and patient input are top regulatory priorities for CDRH
The US Food and Drug Administration’s (FDA) Center for Devices and Radiological Health (CDRH) recently released updated regulatory science priorities, highlighting the importance of grounding regulatory decisions in real-world evidence, big data, and patient-reported data. CDRH also said that high-risk medical devices need improved clinical trial design tools, and that including precision medicine design during the lifecycle could lead to better optimization of those devices.
CDRH is responsible for ensuring the quality, effectiveness and safety of medical devices. Updates to regulatory science priorities are meant to align with goals of having approvals reflect new evidence and emerging issues.
GDUFA II: Review for priority generic drug submissions will take eight months
The FDA is proposing two major changes to the generic drug approval process as a part of the Generic Drug User Fee Amendments (GDUFA) II. To reduce the backlog in abbreviated new drug applications (ANDA), the FDA would simplify and consolidate reviews. GDUFA II would also establish faster review goals for priority submissions: A standard ANDA review will take ten months from submission, and a priority review would take eight months from submission.
The FDA and generic drug companies reached an agreement on a fee structure that will provide the agency with predictable and adequate revenue to fund the drug review process. GDUFA II would include an annual program fee for ANDA holders.
This comes shortly after the FDA announced it had fulfilled its commitment under GDUFA I to review 90 percent of backlogged ANDAs more than a year ahead of schedule (see the August 2, 2016 Health Care Current). Most of the backlogged ANDAs have been told about their deficiencies. Since GDUFA I was enacted, capacity for review has increased, and the amount of time between submission and review has declined. The legislative authority for GDUFA I expires at the end of September 2017, making Congressional reauthorization of GFUDA II critical for continuing to collect generic drug user fees.
Around the Country
Vermont releases all-payer waiver proposal
Last week, Vermont Governor Peter Shumlin released a preliminary waiver agreement that would reform care delivery in the state and aim to cap spending growth at 3.5 percent per capita annually. Under the proposal, CMS would give the state’s Green Mountain Care Board (GMCB) power to oversee a Vermont All-Payer ACO Model Agreement. GMCB would control self-insured plan, commercial health plan, Medicaid, and Medicare fee-for-service payments to providers.
If finalized, Medicare would provide the state with roughly $51 million between 2017 and 2022 to expand primary care medical homes and home- and community-based services. That includes a one-time investment of $9.5 million in 2017 to establish the ACO’s infrastructure.
In 2014, health care spending in Vermont grew 4.6 percent. The waiver seeks to limit health care cost growth across the state but also sets a Medicare-specific cost growth target of .2 percent lower than the national average.
The waiver awaits final approval by CMS and Vermont officials.
Evidence that telehealth works continues to mount
An aging population, increasing chronic illness, the importance of self-care, accelerating health costs, regulatory reform, and new payment models are driving interest and growth in telehealth. Under new value-based payment models, telehealth may be a cost-effective solution for improving access to care and, ideally, reducing unnecessary hospital care. Several new studies contribute to the growing body of evidence that telehealth can be a cost-effective solution for certain conditions and patient populations.
One study, published in the Annals of Allergy, Asthma and Immunology, focuses on patients who scheduled an appointment for asthma-related concerns at an allergy clinic. The patients could choose to keep their original in-person appointment or change it to a telemedicine visit, which involved going to a local clinic where a registered nurse or respiratory therapist conducted the visit remotely. Of 169 children, 100 were seen in-person and 69 used the telemedicine option. Of the patients that completed all three visits (34 patients were in-person and 40 telemedicine patients), all had a small improvement in asthma control over time. After the six month follow up, the researchers concluded there was no difference in outcomes between the telemedicine visit and the in-person visit. This is encouraging news for patients with asthma who live in underserved areas where specialists are not always available.
Another study from the University of Pennsylvania found that linking family members of patients in the intensive care unit (ICU) via a videoconference could be more beneficial to clinicians than having family members physically present in the room. The video link cut down on distractions and made it easier for clinicians and family members to communicate. In the ICU, it is not always possible for family members to be present, and they are not always comfortable asking clinicians questions in this busy setting. A telehealth platform can also incorporate translators when necessary.
Kaiser Permanente published results of its telestroke program in its publication, The Permanente Journal. The program brings specialized treatment to patients in hospitals that lack an in-house stroke neurology or neurological intensive care unit. Images of the patient’s brain are shared remotely with a specialist, who can assess the patient via video to determine if the patient needs tissue plasminogen activator (tPA). tPA is a treatment for acute ischemic stroke that needs to be administered within 60 minutes of the onset of stroke symptoms and is more effective the sooner the patient receives it. The remote neurologist can sometimes assess the patient before the ambulance arrives at the ED. Among the 2,600 patients in the study, use of tPA increased from 6.3 percent among acute ischemic stroke patients to 11 percent after telestroke implementation, and overall bleeding complications were reduced slightly, from 5.1 percent to 4.9 percent. Treatment times also improved. Median time for a patient to receive diagnostic imaging went from 56 minutes to 44 minutes, and time to tPA administration was shortened from 66 minutes to 55 minutes.
Analysis: Deloitte’s recent report, Realizing the potential of telehealth, provides an overview of trends in telehealth, the regulatory landscape, and the potential barriers and enablers for telehealth in the coming years. The report highlights findings from the 2016 Deloitte Survey of US Health Care Consumers that show interest in telehealth continues to grow.
As the federal and state policy landscape evolves to reduce barriers to telehealth, providers may consider strategies for targeted populations within value-based care models. And, as health plans move toward narrower provider networks for exchange plans in order to reduce premiums, telehealth is one important strategy that could help them meet network adequacy standards more cost-effectively – and help providers deliver care to underserved areas more efficiently. Studies that show telehealth works in the commercial market may aid the federal government in setting policy.
(Sources: Elisabeth A. Stelson, Brendan G. Carr, Kate E. Golden, Therese S. Richmond, M. Kit Delgado, and Daniel N. Holena, (Perceptions of family participation in intensive care unit rounds and telemedicine: A qualitative assessment), American Journal of Critical Care, September 2016; Jay M. Portnoy, Morgan Waller, Stephen De Lurgio, and Chitra Dinakar, (Telemedicine is as effective as in-person visits for patients with asthma), Annals of Allergy, Asthma and Immunology, September 2016; Kori Sauser-Zachrison, Ernest Shen, Navdeep Sangha, Zahra Ajani, William P. Neil, Michael K. Gould, Dustin Ballard, Adam L. Sharp, (Safe and effective implementation of telestroke in a US hospital community setting), The Permanente Journal: July 29, 2016)