Health Care Current: September 23, 2014

Consumer engagement: Is less more?

This weekly series explores breaking news and developments in the U.S. health care industry, examines key issues facing life sciences and health care companies and provides updates and insights on policy, regulatory and legislative changes.

Consumer engagement: Is less more?

I was lucky to be able to attend TEDMED 2014, held in Washington, D.C., September 10-12 at the Kennedy Center. I have been to more conferences than I can remember, but this one is really different and, without question, a lot of fun (and no, no drum circles, but yoga was offered). It was not just the music and other performances, the international and diverse mix of participants or the extraordinarily healthy food that made this conference different. What I probably liked best was having the chance to quiz and learn from the many innovators presenting their ideas in the Hive, a tent that was full of activity.

As I walked around the Hive, a trend began to emerge. I saw examples of health care products, many using mHealth applications and others using other technologies to collect consumer data so that providers could use it to monitor and manage care. Several speakers even talked about their inventions in this area.

In thinking about the range of technologies I encountered, they seemed to fall along a spectrum of consumer engagement. Some required little input from consumers while others required extensive interaction. Health care experts tend to hold two schools of thought in this area: One school of thought is that consumers who learn about their conditions will become “activated” and excited to take charge of their condition as informed patients. The other school believes that we don’t need to have consumers highly engaged in their care—perhaps the data can just come from them, and they don’t have to do much to produce it.

When I worked with a large, consumer-focused organization five years ago, there was enormous interest in the potential for personal health records (PHRs). These fall squarely in the first school of thought. As I listened to proponents describe the features of PHRs at the conference, I couldn’t help but stack up those exciting concepts with the reality of my personal experience of being a busy mother of two, working full time, with lots of experience helping my mother, her friends and a variety of other older folks navigate Medicare, Medigap and the rest of the health care system. I couldn’t picture myself, much less my mother, taking the time to document all the interactions with the health care system – it just seemed like too much work.

So it was with great interest that I listened to the presentation from Josh Stein, a “serial entrepreneur,” who said something squarely in-line with the second school of thought that really resonated with me. He said that some of the best ideas in the new technologies do not require patients or consumers to become actively engaged. Instead, the technologies take on as much of the job as possible. Josh’s company, AdhereTech, has invented a “smart pill bottle” that uses cell-phone technology to monitor whether patients are taking their medications. And when they forget, the system sends a text or calls to remind the patient to take the medication. Josh also talked about the Internet of Things (IoT) where things like this smart pill bottle might connect to other things (knees, other apps, refrigerators, electronic health records) to create data that could help a physician and care team remotely track a patient’s care pattern over time. The overall patient data could then be used to gain new insights on how people respond to therapies. Ultimately, this technology could lay the groundwork for better technology and care.

This presentation made me think that one aspect of mHealth is how much it makes the patient do. In my opinion, the less a technology makes people do, the more likely it will be in successfully getting the information into the hands of those who can use it to realize the potential for the IoT. On the other hand, I am happy to be proven wrong, as I love the vision of activated patients taking charge of their own conditions.

Two other examples of innovations I saw at TEDMED 2014 help illustrate examples in these two schools of thought:

MySugr Companion is an app that uses an adorable/irritating monster to help people with diabetes track their blood sugar readings. It also provides reminders and games intended to get users to eat right, exercise and understand their condition. It relies on consumers to enter the information and falls in the first school of thought: one could engage people to manage their diabetes and learn more about it.

By contrast, provides information that comes from a consumer’s smartphone sensors to their physician – patients are passive (after downloading the app, presumably). The technology has three components – the app, behavioral analytics engine and a provider dashboard – and the goal is to allow physicians to track care between visits.

I hope these innovators prove to be very successful. I will watch with interest as these companies work to find the right business models and markets for their products.

Deloitte’s surveys of physicians and consumers are finding that the market is demanding these products; consumers and physicians are beginning to catch on to the value of mHealth. But, while consumers march forward and adopt greater use of mHealth for managing their health improvement goals (44 percent), monitoring and managing health issues (46 percent) or even sending a photo of a health related issue to their provider (55 percent), physicians may not be quite as far along.1 Our 2014 Survey of U.S. Physicians found that only 24 percent of physicians use mHealth, even though 90 percent of them own smartphones.2 At some point, hopefully these two critical components of the health care system will come to agreement on the potential behind innovative mHealth technologies.

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1 Deloitte Center for Health Solutions, “mHealth: A check-up on consumer use,” 2013
2 Deloitte Center for Health Solutions, “Annual Check-Up on Physician Adoption of Health IT,” 2014

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My Take

By Sarah Thomas, Research Director, Deloitte Center for Health Solutions, Deloitte Services LP



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Implementation & Adoption

CMS: Medicare ACOs saved $372 million in health care costs in 2013

Last Tuesday the Centers for Medicare and Medicaid Services (CMS) issued the latest results from the Medicare Accountable Care Organizations (ACO) programs—the Pioneer ACO program and the Medicare Shared Savings Program (MSSP). Together these two programs have saved Medicare ACOs more than $372 million in health care costs, and the organizations qualified for more than $445 million in shared savings incentive payments. The participating organizations had better quality and patient experience outcomes than the benchmarks against which they were measured.

Pioneer ACOs: In the second year of the Pioneer ACO program, the organizations improved financial, quality and patient experience performance. Results included:

  • Savings: In total the organizations saved $96 million and qualified for $68 million in shared savings incentive payments.
  • Shared savings: Out of the 23 Pioneer ACOs, 11 received shared savings bonuses, three had shared losses and three are waiting until the third year of the program to finalize their payments.
  • Spending: Spending for the Pioneer ACOs grew more slowly than the Medicare fee-for-service (FFS) program, at 1.4 percent or 0.45 percent slower than FFS.
  • Quality: The mean quality score grew from 71.8 percent to 85.2 percent, a 19 percent increase. The organizations improved on 28 out of the 33 quality measures for the program (e.g., screening for tobacco use and cessation).
  • Patient experience: Patient and caregiver experience was better than the previous year for six out of seven measures.

MSSP ACOs: For the first year of the MSSP, 220 organizations participated. Results included:

  • Savings and shared savings: 53 out of the 220 ACOs earned performance bonuses of more than $300 million because their total spending came in $652 million lower than targets for the year. Another 52 ACOs reduced their costs, but not enough to qualify for shared savings.
  • Quality: The MSSP ACOs improved on 30 out of 33 measures for quality (e.g. screening for high blood pressure).

Earlier this month CMS researchers published findings from their analysis of the Medicare Physician Group Practice demonstration, an early model for the MSSP. The researchers concluded that while the demonstration reduced utilization and improved quality of care on most measures, the initiative led to small cost savings. The researchers said that these findings suggest that MSSP might have small or moderate savings for the first years. For more on the study, see the September 16, 2014 Health Care Current.

Related: Avalere Health analyzed the results from the MSSP ACOs to find that many of the organizations that achieved savings through the program were located in areas of the country that have traditionally had excess capacity and have large variation in spending. These organizations could have had more inefficiencies to address than other organizations as compared to other more efficient and lower cost organizations.

(Source: Erik Johnson, Avalere Health, “ACO Performance Results Demonstrate Savings to Medicare, Minimal Savings to Individual ACOs,” September 18, 2014)

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U.S. Census Bureau shows 13.4 percent of U.S. population was uninsured in 2013; CDC finds that uninsured rate continues to drop in 2014 

Last week the U.S. Census Bureau released its 2013 U.S. health insurance coverage report. According to the report, 13.4 percent (42 million) of the population was uninsured during all of 2013. Approximately 86 percent (271.4 million) of the population had coverage for all or part of the year. Additional highlights include:

  • Type of coverage: 64.2 percent of individuals were covered by private insurance, and the largest source of private coverage was employer-based insurance (53.9 percent). The population covered by government health insurance programs was 34.3 percent; 17.3 percent were covered by Medicaid and 15.6 percent were under Medicare.
  • Age: Older adults and children are the populations with the highest rates of coverage. An estimated 7.6 percent of children under the age of 19 were uninsured for some or all of 2013, and 98.4 percent of older adults had health insurance coverage during this period.
  • Race: Compared with non-Hispanic Whites (9.8 percent were uninsured), minorities were less likely to be insured: 14.5 percent of Asians, 15.9 percent of Blacks and 24.3 percent of Hispanics did not have health coverage for some or all of 2013.
  • Household income: People in low-income households had lower rates of coverage. 21.6 percent of low-income households (<$25,000) were uninsured, compared with 5.3 percent of households that earn $150,000 or more. Of households earning below $25,000 a year, 26.7 percent were privately insured and 62.5 percent were insured through government health insurance.

Related: Last week the Centers for Disease Control and Prevention also released results from the National Health Interview Survey, which showed a drop in the uninsured rate during the first quarter of 2014. 13.1 percent of respondents said that, at the time of the interview, they did not have insurance coverage. This compares with 14.4 percent for 2013. Notably, 17.8 percent of the respondents said they were uninsured for some part of the year prior to the survey, and 9.6 percent said they had been uninsured for an extended period of time (greater than one year). The survey was conducted from January through March of this year, and does not account for the marketplace enrollees whose coverage began on April 1; future surveys could show an even larger drop in the uninsured rate.

(Source: Smith, Jessica C. and Medalia, Carla. U.S. Census Bureau, “Health Insurance Coverage in the United States: 2013,” September, 2014; Cohen, Robin A. and Martinez, Michael E. CDC, “Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, January-March 2014,” September, 2014)

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GAO’s assessment found security and privacy control vulnerabilities 

The U.S. Government Accountability Office (GAO) recently reported that the website for the federally facilitated marketplace (FFM),, continues to have vulnerabilities in the privacy and security processes used to manage consumer data and the implementation of IT security controls. The report acknowledged that CMS has developed policies and procedures, enacted security agreements with partners and established privacy protections that aim to protect the security and privacy of consumer data. Despite these steps, GAO found remaining vulnerabilities and offered six recommendations for the agency to fully implement its information security program: connects with many state and federal systems, including the Departments of Defense, Homeland Security and Veterans Affairs, the Internal Revenue Service, Office of Personnel Management and Social Security Administration. Of the six recommendations made to CMS, the U.S. Department of Health and Human Services concurred with half and only partially concurred with the first, second and fourth recommendations.

Related: CMS Administrator Marilyn Tavenner testified before the House Oversight Committee on Thursday on the health insurance marketplaces and spoke to lawmakers about the findings of this report. According to her testimony, 7.3 million individuals have enrolled in and paid premiums for plans through the marketplaces (including the state-based marketplaces). Tavenner also indicated that the agency plans to assess the security of to identify any potential vulnerabilities before October.

(Source: U.S. Government Accountability Office, “ Actions Needed to Address Weaknesses in Information Security and Privacy Controls,” September, 2014)

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ONC: 1 in 4 individuals had access to online medical records 

The Office of the National Coordinator for Health Information Technology (ONC) released survey results last week that found that 28 percent of consumers were offered online access to their medical records in 2013. Of those, about half were given access by their provider only, 44 percent were given access by both their provider and health insurer and 7 percent by their health insurer only. One in three (37 percent) consumers experienced information exchange gaps:

Proportion of individuals who experienced one or more gaps in health information

In addition, of the 28 percent of respondents who had access to their medical records online, only 46 percent of them viewed their records at least once. Of those who accessed their records online, three quarters did so to monitor their health, and four in 10 did so to share their information with another provider. Sixty percent of respondents who accessed their online medical records said their experience was very useful.

Background: If providers wish to receive financial incentives under Meaningful Use Stage 2 (MU2) they must offer at least 50 percent of their patients access to online medical records. Additionally, Stage 2 calls for at least 5 percent of unique patients to use the “view, download and transmit capabilities” of the medical records software. The survey shows that 46 percent of consumers who have access to their records accessed them at least once, which is nine times more often than required by Stage 2.

(Source: Patel, Vaishali, Barker, Wesley, and Siminerio, Erin. The Office of the National Coordinator for Health Information Technology, “Individuals’ Access and Use of their Online Medical Record Nationwide,” September, 2014)

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Report: Health care spending grew by 4.3 percent in July; largest growth in prescription drugs 

The Altarum Institute’s latest monthly Health Sector Economic Indicator reported that national health care spending in July grew 4.3 percent over July 2013. This is slightly below the 4.5 percent growth rate seen in June. According to the report, health care spending accounted for 17.3 percent of gross domestic product (GDP) in July, up from 16 percent of GDP at the start of the recession in December 2007. Furthermore, although hospital (31 percent) and physician and clinical services (20 percent) accounted for the largest share of health care spending, over the 12 month period the largest growth in spending was for prescription drugs. Spending on prescription drugs also grew most rapidly.

Health care spending growth by category, July 2013 to July 2014

Related: Earlier this month CMS published updated projections for National Health Expenditures (NHE) for 2013 through 2023. Beginning in 2014, NHE are expected to grow faster due to insurance coverage expansions, a recovering economy and the aging population. NHE growth is projected to increase to 5.6 percent in 2014, and rise to 6 percent growth for 2015 through 2023. In 2014 prescription drug spending is expected to grow 6.8 percent, increasing from the projected growth rates for 2013 of 3.3 percent. For more information, see the September 9, 2014 Health Care Current.

(Source: Altarum Institute, “Health Sector Economic Indicators: Insights from Monthly National Health Spending Estimates through July, 2014,” September 17, 2014; Andrea M. Sisko, et al. “National Health Expenditure Projections, 2013-23: Faster Growth Expected With Expanded Coverage And Improving Economy,” Health Affairs, 2014)

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On the Hill & In the Courts

Lawmakers pass IMPACT Act for post-acute care providers

Last week lawmakers in the House and Senate voted to approve the Improving Medicare Post-Acute Care Transformation (IMPACT) Act. The IMPACT Act will standardize and make interoperable data from home health agencies, skilled nursing facilities, inpatient rehabilitation facilities and long-term care hospitals. In drafting this legislation, lawmakers hoped that the standardized requirements will allow comparison of outcomes across these settings. Ultimately, lawmakers hope to use this legislation as the foundation for future payment reform. Post-acute care providers will report to Medicare quality measures taken from standardized patient assessment data; the measures include functional status, medication reconciliation and incidence of major falls. The bill has gone to the president to sign. For more information on the IMPACT Act, see the July 1, 2014 Health Care Current.

Reaction: The National Association for Home Care & Hospice (NAHC) released a statement after the House passed the legislation, applauding the lawmakers for passing the IMPACT Act. NAHC agrees with lawmakers that greater oversight over hospice providers is needed. In addition to requiring that hospices be surveyed once every three years, the bill also gives CMS the authority to conduct medical reviews of hospice providers that have a larger than average proportion of long-stay patients. CMS was given this authority through the ACA, but a drafting error in that legislation has prevented the agency from acting on that authority.

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Lawmakers introduce bill to revise Meaningful Use reporting period for 2015

Last week House Representatives Renee Ellmers and Jim Matheson introduced a bill that would allow providers greater flexibility in reporting for Meaningful Use in 2015. The bill would reverse a CMS decision – implemented through a final rule – that made the reporting period for 2015 a full year, rather than the 90-day period that many providers desired. The Flexibility in Health IT Reporting (Flex-IT) Act would revert the reporting period to 90 days. CMS has said that the decision to make the reporting period a full year would help to maintain momentum of the Meaningful Use program. CMS has also said that making the reporting period 90 days might encourage providers to delay reporting until quarter three or four.

Related: The bill was introduced shortly after a group of 15 organizations, including the American Hospital Association, Federation of American Hospitals, American Medical Association, Healthcare Information and Management Systems Society (HIMSS) and the Medical Group Management Association sent a letter to CMS requesting that the reporting period be shortened to 90 days. The group said it appreciated that CMS allowed greater flexibility earlier this year when the agency addressed stakeholder concerns with transitioning to 2014 Edition software and Stage 2 Meaningful Use. However, the group said that the flexibility CMS created in those areas created misalignment with the future timeline for the program that was not addressed in the final rule. According to the letter, hospitals and physicians face hardships in transitioning to Stage 2, as 143 hospitals and 3,152 eligible professionals have demonstrated the requirements for this stage. 

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Around the Country

CMS: 279,000 unresolved cases of income data for marketplace need to be resolved and 115,000 could lose insurance coverage by September 30

Last week CMS released an update on the number of individuals at risk of seeing higher costs for their health insurance coverage through the FFM due to data inconsistencies. CMS has resolved approximately 897,000 cases of the 1.2 million households that had income inconsistencies as of May 30. The remaining cases with income data-matching issues will not lose coverage, but may see premium costs change should they fail to submit the requested documents. In addition, 966,000 individuals had citizenship or immigration data matching inconsistencies as of May 30. While 88 percent of those individuals have submitted the requested forms to validate their eligibility, approximately 115,000 individuals failed to respond by the September 5 deadline and could lose coverage on September 30. Last month, Florida, followed by Texas and Georgia, had the highest number of individuals at risk of losing coverage (see the September 9 Health Care Current for details). Individuals that lose coverage may qualify for a special enrollment period if they confirm their eligibility.

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California launches enrollment campaign, $94 million in outreach for marketplace 

Last week California revealed that Covered California, the state’s health insurance marketplace, will invest $94 million in marketing and outreach efforts for 2015. $46 million of the funds will be for a statewide advertisement campaign, and $14.6 million will go to community outreach grants. The remaining $33.4 million will go to organizations that promote enrollment and renewal. Organizations will receive grants from $50,000 - $750,000 based on their experience assisting special populations and their characteristics. State officials estimate that 500,000 additional individuals will sign up during the coming enrollment period, which runs from November 15, 2014 through February 15, 2015. This enrollment estimate would – if realized – result in a 43 percent increase in enrollment over 2014 levels. The total would be 1.7 million by the end of 2015 open enrollment. Of these, 1.5 million are expected to receive premium subsidies for their coverage and the rest (230,000 people) would get unsubsidized coverage.

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Breaking Boundaries

The importance of narrative in health IT

Today, most electronic health records (EHR) and health information exchanges capture a small part of an individual’s story – often excluding important parts of their personal health history and other details that are not included in patient records. The Health Story Project began in 2006 when an alliance of health care vendors, providers and associations combined resources in a rapid-development endeavor to create a comprehensive electronic record that can be shared to improve care through collaboration and analysis.

The Health Story is managed by HIMSS, and participation is open to all HIMSS members. Health Story stakeholders agree that a health record is the patient’s “health story” that should be shared among the patient and caregivers involved in his/her care. They also agree that the EHR and associated new technologies can help to support shared decision-making, document use of practice guidelines, and integrate evidence-based practices into patient care.

In its first three years, the Health Story Project produced eight Health Level Seven (HL7) data standards for the flow of information using common types of health care documents. HL7 and its members provide a framework (and related standards) for the exchange, integration, sharing and retrieval of electronic health information. These standards define how information is packaged and communicated from one party to another, setting the language, structure and data types required for effective integration between systems.

Analysis: During last week’s HIMSS 13th Annual Health Policy Summit in Washington, DC, Nick Mahurin, Chair of the HIMSS Health Story Project and Chief Executive Officer of InfraWare, a sponsor of the Health Story alliance, shared a presentation on the Health Story. He explained that Health Story operates under three key premises:

  • Although structured patient data has value, the patient’s story, including narrative, is important to improving health outcomes and the patient experience.
  • Real interoperability is possible.
  • Falling provider satisfaction trends can be turned around.

Mahurin emphasized that all other industries use standards to share data and that Health Story Clinical Data Architecture (CDA) standards can help solve many of the current health care documentation challenges plaguing the system today. This project focused on taking an existing implementation approach (CDA) and building a solution that embraces clinical workflows as they are now while building implementation guidance that is supportive of data capture on needed discrete data elements.

Health Story supports other interoperability efforts, as it provides finely structured specifications for the implementation of several clinical workflows in conjunction with standards such as Integrating the Health Enterprise (IHE) profiles, the Blue Button Plus project and Fast Health Interoperability Resources (FHIR). The HIMSS Health Story Project demonstrates use of a shared, comprehensive electronic record to improve care through collaboration and analysis; the record also supports the full electronic document lifecycle from information capture, to document management, encoding, processing and analytics.

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