Health Care Current: September 9, 2014

Social media: opportunity or Achilles heel?

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.

Social media: Opportunity or Achilles heel?

I am a creature of habit, mainly because of the habits of my creature. Each morning around 6 a.m., my dog Tarot sticks his cold nose in my face to let me know it is time to get up and get going. We wind our way through the neighborhood and return home with a full poop bag and a mound of data, including my steps, average pace and calories burned and Tarot’s activity points from his GPS tracker. Uploaded automatically, I then compare myself to friends and colleagues, while Tarot determines whether he leads his buddy Tucker. Recently, however, our routine came to an abrupt end when I developed searing pain in my right Achilles tendon. But it also launched a new phase in my use of social media. Dethroned from my leaderboard, I posted my X-ray on Facebook and got some remarkably useful advice from several orthopedic surgeon friends, comical advice from a urologist classmate, and an outpouring of sympathy from others. And finally, after weighing my options, I went in for treatment last week.

Like me, nearly one in five consumers used social media in the past year for health-related purposes.1 Consumers share information, compare experiences and garner support, which can enable them to make more informed decisions and become more engaged in their own health and wellness. However, organizations that focus exclusively on consumer use of social media could be missing important opportunities. The health care industry can benefit from enhanced communication with consumers and operations, while gathering deeper knowledge of consumer needs, sentiments and even misperceptions that helps the industry improve products, services and outcomes. Data suggest that the industry sees this coming: While the average share of health care and pharmaceutical marketing budgets devoted to social media is relatively small today, it is expected to grow to over 20 percent in the next five years.2

Of the many applications of social media, two functions may be particularly useful as the industry shifts its focus toward population health: social listening and activation. Through monitoring of social media (i.e., social listening), health care organizations can access consumer insights like their level of awareness of particular issues and factors in decision-making and can even help predict outcomes. In a recent Deloitte Dbriefs webcast, we asked attendees where they saw the greatest benefit of using social media related to health care, and nearly half cited greater access to information.

Although many have questioned the ability of social media to achieve results, the recent ALS “Ice Bucket Challenge” clearly demonstrates that social activation can be extremely effective. Other health care organizations have been able to leverage social media to not only educate, but to spur action. The American Red Cross, for example, has created a digital operations center to identify areas of need, connect people with resources and engage volunteers where they are most needed (see the 2014 MIT Sloan Management Review and Deloitte social business study for more information).

As with adopting any new modality, obstacles remain. Regulatory and compliance concerns, particularly related to privacy and security, are especially acute in health care. In a recent Deloitte Dbriefs webcast, 45 percent of participants cited patient privacy as their greatest concern related to social media in health care.

In addition, unfavorable or untrue information and inappropriate use of social media by employees can quickly tarnish brand and reputation. Therefore, it is critical for industry stakeholders to take a risk-based approach to social media:

  • Strategy: A solid vision and strategy can help align social media activities to corporate standards and strategic objectives
  • Risk management: Social media-specific risk management can provide structured management and continuous risk monitoring
  • Governance: Social media governance can set the policy and process framework to manage and mitigate risks
  • Regulation and compliance: Social media compliance can help ensure adherence to relevant regulations, laws, standards and internal policies and procedures
  • Training, education and awareness: Ongoing training and awareness can allow employees to remain current on new and existing policies and procedures related to social media

In this way, organizations can begin to harness the value of social media. By first monitoring data to learn what is important to users, and then progressively engaging those users, health care might ultimately be able to integrate social media across sectors. With a thoughtful and flexible approach, results can come surprisingly quickly.

Now sporting a cast on my ankle, I’m hoping for some quick results myself. Through social media, I’ve gotten support from friends, connected with others undergoing similar rehab and gotten a pass from my Fitbit® team. However, Tarot still wakes up at 6 a.m., so my (much more athletic) wife, Kerry, is now taking him running. Watch out, Tucker.

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P.S. What’s your take on the use of social media in health care? Share with us on Twitter by mentioning @DeloitteHealth and don’t forget to follow me at @HarryGreenspun.

1 Deloitte Center for Health Solutions, 2013 Survey of U.S. Consumers
2 Duke University’s Fuqua School of Business, “The CMO Survey Report: Results by Firm & Industry Characteristics” commissioned by the American Marketing Association (AMA), February 19, 2014


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My Take

By Harry Greenspun, MD, Senior Advisor, Deloitte Center for Health Solutions, Deloitte LLP 



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Implementation & Adoption

CMS releases NHE projections: slow growth in 2013, but increasing in years after

Last Wednesday the Centers for Medicare and Medicaid Services (CMS) published an updated projection of National Health Expenditures (NHE) for 2013 through 2023. In 2013, NHE growth is projected to have slowed for the fourth year in a row, remaining below 4 percent for the year due to the slow economic recovery, sequestration and increasing cost-sharing on behalf of consumers for health care costs. However, 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. More detailed projections include:

While growth rates in health care have been slow in recent years, the authors point out the longstanding correlation between slow economic growth and low health care spending. Since the end of the recession in 2009, both the economy and health care have experienced slow growth. However, growth is expected to pick up in the coming years, and health care is projected to grow from 17.2 percent of gross domestic product (GDP) in 2012 to 19.3 percent in 2023. In addition to projecting rates of growth for health care, the CMS Office of the Actuary report included projections for the uninsured population in future years. The agency predicts that the number of uninsured in the U.S. will fall from 45 million in 2012 to approximately 23 million in 2023. This differs from the Congressional Budget Office (CBO) prediction of 31 million uninsured in 2023.

Related: In late August the CBO issued an updated projection for the U.S. federal deficit for fiscal year 2014, increasing the expected amount to $506 billion from April’s projection of $492 billion. This is still lower than the shortfall in 2013, which reached $680 billion, but CBO updated the projection for 2014 based on downward revisions to estimates for corporate income tax revenues. By the end of the fiscal year, total debt held by the public is expected to exceed 74 percent of GDP, and will rise to approximately 77.2 percent by 2024. An aging population, expansion of subsidies for health insurance coverage, rising per beneficiary health care costs and increased interest costs on federal debt are expected to contribute to increased government spending. Federal outlays for Medicare, Medicaid, Children’s Health Insurance Program and subsidies for insurance coverage are expected to increase by at least 85 percent over the next ten years, growing to 5.9 percent of GDP.

(Sources: Andrea M. Sisko, et al. “National Health Expenditure Projections, 2013-23: Faster Growth Expected With Expanded Coverage And Improving Economy,” Health Affairs, 2014; Congressional Budget Office, “An Update to the Budget and Economic Outlook: 2014 to 2024,” August 27, 2014)

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Survey: early SHOP marketplace implementation experience in eight states

Late last month the Urban Institute, with the Robert Wood Johnson Foundation, released an analysis of the Small Business Health Options Program (SHOP) under the Affordable Care Act (ACA) which found that states faced consistent challenges. Stakeholders were interviewed in eight states to analyze their early SHOP adoption experience, which fell into several types of challenges:

  • Little effort to publicize SHOP: Sources interviewed in six of the eight states were not aware of marketing strategies or state efforts around SHOP marketplaces.
  • Lack of SHOP awareness, understanding within small-employer community: Some interviewees cited a lack of understanding of the SHOP marketplace and its role in the market. Further, small employers often failed to see the value of the small-business tax credit. Many employers took advantage of early renewal of their plans in 2013 and missed the opportunity to go through SHOP for health insurance and some were discouraged by software issues that prevented enrollment.
  • Competition with SHOP and other issues: Stakeholders pointed to the increasing use of private exchanges as a future source of competition for the SHOP marketplaces. In addition, many small-group employers are exempt from market reforms if they have self-insured plans or coverage through a bona fide association (i.e., an association that was created for reasons other than obtaining insurance). Some sources also cited concern that if not enough small-group employers participate and as a result enrollment is low, health plans will not find it attractive to participate.
  • Mixed opinions on value of “employee choice”: Some employers, in Colorado for example, cited a preference for the limited employee choice model because they believe it is more cost-efficient (less time needs to be spent with employees to select a health plan). Others cited employee choice as the main draw to SHOP so long as the accompanying IT system is helpful. Others expressed concern that having employee choice creates more confusion for tax filings and requires employers to increase spending on accountants.
  • Involvement and frustration among agents and brokers: Brokers and agents are often trusted partners in the small business community. However, many were concerned that marketing campaigns excluded them and solely focused on the assisters and navigators that helped with marketplace enrollment. Some brokers and agents felt they were not sufficiently compensated for their time or trained to work in the context of the state-based marketplaces.

Researchers recommended development of a strategic framework for marketing and sales, administrative simplification and an improved enrollment website to improve the future success of SHOP marketplaces.

Related: Last week CMS announced it is opening the SHOP marketplace early in five states (Delaware, Illinois, New Jersey, Missouri and Ohio). Employers, agents and brokers in these states will be able to access and create accounts starting in October, but employers will have to wait until November 15 to complete their enrollment.

(Source: Blumberg, Linda J. and Rifkin, Shanna. The Urban Institute, “Early 2014 Stakeholder Experiences with Small-Business Marketplaces in Eight States,” August, 2014)

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On the Hill & In the Courts

U.S. Court of Appeals agrees to rehear Halbig v. Burwell

Last Thursday the U.S. Court of Appeals for the District of Columbia agreed to a full panel review of Halbig v. Burwell after the White House administration petitioned for a rehearing of the case. The original case ruled against subsidies being available to individuals in the federally-facilitated marketplace (FFM) and only to those who obtain insurance through the state-based marketplace (SBM). The new case will be heard on December 17 by all 11 judges in the full court. In ordering this “en banc” (i.e., full bench) review of the case, the Court ordered that the original judgment filed on July 22 be vacated. Even if the full panel of judges issues an opposite opinion, this case might end up with the U.S. Supreme Court. Another opinion issued by the 4th Circuit Court of Appeals upheld the subsidies for all of the marketplace arrangements.

Background: This decision follows a recent request by Halbig et al. to take the case to the U.S. Supreme Court, opposing the Administration’s request to hear the case en banc (see the August 26, 2014 Health Care Current). For more background on the original cases, see the July 29, 2014 Health Care Current.

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CMS finalizes Meaningful Use rule, extending timeline by a year

On Friday, August 26, 2014, CMS finalized a proposed Meaningful Use rule leaving it unchanged from the proposed rule and enabling hospitals and eligible professionals more flexibility to achieve requirements for the electronic health records (EHR) incentive program. The rule extends by one year the deadline for the third stage of Meaningful Use for the first group of adopters to January 2017. The rule also grants providers who encountered issues with 2014-certified EHRs an extra year to continue with 2011 Edition software. In the final rule CMS outlined multiple ways that providers who were unable to adopt EHR systems with 2014 Edition software can meet Stage 1 and Stage 2 of Meaningful Use.

Background: In 2015 all eligible professionals, hospitals and critical access hospitals will be required to use the 2014 Edition software to meet requirements for the incentive programs. Many organizations in the health care industry are frustrated by the final rule from CMS, believing that the rule change could reward organizations that waited to pursue Stage 2 with more lax regulations over those who chose to proceed with attestation to Stage 2.

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CMS finalizes auto-renewal guidance for FFM

Last week CMS released a final regulation on the renewal process for individuals who obtain health insurance coverage through the FFM. The final guidance is largely similar to the proposed policies first issued in June (see the July 1, 2014 Health Care Current). The final guidance stipulates:

  • Those who are currently enrolled in coverage through the FFM and wish to retain both their existing plans and premium subsidies will be auto-enrolled in their plan for the 2015 plan year. Approximately 95 percent of enrollees are set up to be automatically re-enrolled and will require no action if they choose to stay on their plan, CMS predicts.
  • FFM consumers will receive notices before the beginning of open enrollment on November 15, 2014 that explain the auto-enrollment process and steps they can take to apply for additional financial assistance or shop for a new plan.
  • Insurers will send enrollees information about their 2015 plan, including new premium information if applicable, and how much they could save on their premium if they were to receive a premium subsidy.

CMS will encourage consumers to return to to compare their current plan and determine whether they might benefit from switching plans or might be eligible for additional cost savings.

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IRS releases employer mandate draft guidance

Late last month the Internal Revenue Service (IRS) released draft guidance related to the employer mandate for insurance coverage. This came after the agency had released draft forms in late July without instructions or explanation, which employers will be required to fill out in order to comply with the mandate. The IRS posted versions of the draft Forms 1095 for the health insurance marketplaces, employers and health plans. The employer mandate, expected to affect approximately 4 percent of employers (most large firms already offer health insurance coverage), begins on January 1, 2015 for employers with 100 or more employees and January 1, 2016 for mid-size employers with 50-99 employees.

Reaction: The National Retail Federation issued a statement after the release of the instructions, stating that the guidance was helpful and welcomed by employers and the retail industry. The Federation said that companies can use this information to build their compliance strategies. Many other groups from the retail industry had expressed frustration over the delays in release of information to accompany the forms.

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Around the Country

CMS approves Pennsylvania’s alternative Medicaid expansion; Healthy Indiana 2.0 approval pending

In late August Pennsylvania became the 28th state in the U.S. to adopt the ACA’s Medicaid expansion. Following a year of negotiations, CMS approved Governor Tom Corbett’s five-year alternate proposal for Medicaid expansion, “Healthy Pennsylvania,” which would expand health coverage to more than 500,000 low-income residents in the state. Enrollment will commence on December 1, 2014, and coverage will begin January 1, 2015. Healthy Pennsylvania includes reforms in the current Medicaid program and a Private Coverage Option (PCO), including:

  • Aligning the Medicaid program with private and commercial health care benefits: The Medicaid program will transition 14 benefit plans into “low risk” and “high risk” coverage plans that include essential health benefits. The new benefits will be offered under the PCO.
  • Encouraging enrollee employment: The plan will include the Encouraging Employment program to encourage Medicaid enrollees to obtain employment. The program will include incentives to reduce cost-sharing in health care.
  • Changing the cost-sharing structure: To encourage personal responsibility, individuals in the Healthy Pennsylvania PCO and the current Medicaid program will be required to pay copayments during the first year of enrollment. In the second year individuals with incomes greater than 100 percent of the federal poverty level (FPL) will pay up to 2 percent of their income through monthly premiums, and will be liable to make a copayment for non-emergency use of emergency services. Failure to pay premiums after 90 days will result in disenrollment.
  • Adding options for reducing cost-sharing: Enrollees that participate in certain healthy behaviors, job training and work-related activities, pay cost-sharing bills on time and/or obtain an annual wellness visit will be eligible for cost-sharing reductions.

Related: In early August CMS returned a similar plan submitted by Indiana Governor Mike Pence, Healthy Indiana Plan 2.0, explaining that the state could resubmit their proposal once it received input from the Potawatomi Indians. On August 22 CMS accepted Indiana’s updated application and will now review the alternate expansion plan. Like Pennsylvania’s plan, Indiana’s expanded Medicaid program would use federal funds under the ACA to help eligible enrollees purchase private plans. For more information behind the states’ decisions on Medicaid expansion, see Health insurance exchanges: Map of enrollment by state.

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Thousands may lose federal marketplace coverage for failing to provide eligibility documents, including 94,000 in Florida

More than 94,000 Florida residents are at risk of losing the coverage they purchased through the FFM if they did not provide eligibility documents before the September 5, 2014 deadline. Florida is the state with the most individuals who still need to verify citizenship or immigration data with CMS in order to correct inconsistencies, followed by Texas (52,000) and Georgia (20,000). The federal government notified 310,000 individuals across the U.S. last month that they may lose coverage unless they provide proof of their citizenship or immigration status. CMS noted that data inconsistencies do not mean individuals are ineligible and that this sometimes happens because the government has incomplete or different information on file. Individuals must be legal residents or citizens to purchase subsidized health plans on the marketplace.

Related: On Thursday CMS announced Wisconsin can hold a special enrollment period for the FFM in the state due to changes that caused individuals in the state to lose their Medicaid coverage. Wisconsin residents who are eligible for this special enrollment period will have until November 2, 2014 to enroll in coverage on the FFM. Last year the governor and state legislature of Wisconsin only partially expanded their Medicaid program, BadgerCare, and this caused many to lose their coverage from the program.

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California passes bill to require reporting on network adequacy, timeliness under private insurance and Medicaid plans

The California legislature passed Senate Bill 964, “Health Care Coverage,” late last month requiring California health plans to submit an annual report on new access measures related to timely receipt of care and network adequacy. Health plans and provider contracts must comply with access to care standards adopted by the Department of Managed Health Care (DMHC), and insurers must submit annual reports on their compliance status. The bill requires:

  • Timeliness of care: DMHC must develop and adopt regulations that help ensure individuals receive timely health care services. The bill lists content areas for measuring timeliness, including wait time for physician appointments, receiving referrals and speaking to a physician or another health care professional. It requires contracts between plans and providers to ensure the standards are met and for plans to annually report how they have remained in compliance with the standards.
  • Network adequacy: Health plans must submit a report to DMHC that at least includes information on provider office location, area of specialty, hospital privileges, providers with open practices, the number of patients assigned to the provider and any grievances about network adequacy that were received in the prior year.

Background: California Governor Jerry Brown has until the end of September to pass the law or veto it. The bill was introduced after groups expressed concern over narrow networks and access to health care providers through the state’s health insurance marketplace, Covered California and through Medi-Cal managed care. The bill, which was sponsored by Health Access California, had the support of the California Medical Association, the National Health Law Program and AARP. Opponents of the bill, including the California Association of Health Plans and the California Department of Finance contend that the new requirements overlap with existing reporting on patient access to care and could raise their costs, which in turn would raise costs for the Medi-Cal program.

(Source: Paul Demko, Modern Healthcare, “Narrow-network controversy spurs tougher rules for California plans,” September 2, 2014)

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Breaking Boundaries

New digital tool may make physician workflow more efficient, secure

Much of the U.S. health care delivery system still relies on paper documents to collect and transmit information. Mountain View, California-based company Listrunner raised money from independent physician investors to continue building and testing its centralized clinical communication platform that helps bring hospital physicians into the digital age.

Many hospital clinicians still spend much of their day scribbling clinical notes on paper lists of patients printed from an electronic health record (EHR), or a spreadsheet built from the data. They then need to communicate that information to other clinicians and support staff. Often this communication is inefficient and does not always ensure patient data is secure. Even hospitals that rely on an EHR do not all have access to care coordination apps that are fully integrated into physician workflow.

Listrunner, which is currently being tested in 12 hospital departments, allows physicians to keep their patient lists, summaries, updates and task lists in digital form and exchange critical information with other caregivers and staff on a common, secure platform. Listrunner works with several common EHR platforms, and encrypts and stores clinical data on a central server that can transmit real-time data to other connected computers, phones or tablets.

Analysis: Digital health tools such as this one could improve workflow and acceptance of health information technology. This type of tool may improve health IT interoperability efforts by making it easier to capture quality clinical data in real time (reducing data transformations that are needed when data is simply scanned or transcribed from notes). If workflow is made easier, these tools could increase physician acceptance and use of EHRs. Improved workflow and data capture may reduce medical errors. It has been 15 years since the Institute of Medicine published its "To Err Is Human" report, which put a spotlight on the issue of preventable medical errors in the U.S. health care system, and more recent reports still demonstrate that avoidable errors in hospitals are a major cause of death every year.  

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