Perspectives

Health Care Current: September 1, 2015

Partners in care: The evolving patient-physician dynamic

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.

Partners in care: The evolving patient-physician dynamic

“Hi, I’m Dr. Williams.”

This is how the first conversation with one of the two specialists I recently started seeing began. Nothing about the way that Dr. Williams introduced himself struck me as out of the norm. But, it did stand in stark contrast to my conversation with Dr. Bhattarai, who walked into the exam room and introduced himself as “John.” While over the years I’ve gotten to know many physicians both professionally and personally whom I call by their first name, this was the first time that a doctor I was seeing asked me to call him by his first name.

John’s last name is, admittedly, both difficult to spell and to pronounce. So at first I thought he was saving both of us from the “it’s pronounced like this” conversation. After thinking about it for several days, I asked him about it. John explained that he feels it builds rapport with patients and that perhaps patients would be more at ease telling him about their concerns and asking questions. Similarly, he feels he is much more likely to get the information he needs – observations about the patient’s condition – that will improve outcomes if he goes by his first name with the other members of his care team.

Results from Deloitte’s 2014 Survey of US Physicians demonstrate that John is not the only physician concerned with rapport and communication. When asked about the most important capabilities future physicians will need, 91 percent of the respondents rated interpersonal and communication skills as important or very important, beating out health IT capabilities and managerial expertise. This held true across the board, whether the respondent was a primary care physician (PCP) or a specialist.

This may seem like a “no brainer” to many, but to me it was striking. Maybe going on a first-name basis is one step toward better interpersonal communication?

When I picture the ideal physician-patient relationship, I see patients (or consumers) and physicians as partners in treatment decisions. Each side brings its own vantage point to the table: Consumers bring their values and priorities, information about their symptoms, and willingness to take steps to manage their own condition. Physicians bring their knowledge, experience, and willingness to listen.

Results from Deloitte’s 2015 Survey of US Health Care Consumers suggest that more than ever, consumers today prefer to partner with their doctor rather than having their doctors make treatment decisions for them. Nearly half (48 percent) of consumers prefer to partner with their doctor, which is up from 40 percent in 2008. Fewer people want to make decisions by themselves and fewer want their doctor to make decisions for them. To me, this suggests a healthy dynamic and increasing patient engagement.

However, the survey also revealed that only one in three consumers strongly believes physicians should encourage patients to research and ask questions about their treatment. I wondered whether a different, less formal relationship with physicians (maybe even calling them by their first names) might encourage consumers to become more aware of options, side effects, and steps they can take to manage their condition.

Despite general support for the idea of patients questioning doctors about treatment options, the share of people who report actually doing this is low. Only 16 percent of consumers who received care for an injury, illness, or health condition reported asking their doctor to consider treatment options other than the one he or she initially recommended.

The picture changes a bit when we shift the focus to cost of care. Although about two-thirds of physician respondents told us they consider comparative clinical and cost-effectiveness information when making treatment decisions for their patients with high cost-sharing, fewer (53 percent) said that they were comfortable discussing the cost of treatments with patients. Contrast this with the consumer respondents, where 58 percent said that doctors should provide this information. This may be another scenario where better communication – whether it is supported by a first name basis or not – might encourage more engaged consumers, which so many are hoping to see in the future.

I asked a group of friends what they thought about being on a first-name basis with their physicians. Most in my age and professional group preferred to use more traditional last names. One friend even said, “If I am standing there without any clothes on, I want to be Mrs. Smith and for the doctor to be Dr. Jones.”

For now, maybe the best bet for a strong partnership between patients and physicians – at least on the name front – is just asking each what they prefer.

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P.S. In observance of the Labor Day Holiday, we will not publish a Health Care Current on Tuesday, September 8, 2015.

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My Take

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

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Study: Cadillac tax could impact more than one in four employers in 2018

According to a recent analysis by the Kaiser Family Foundation, in 2018, approximately 26 percent of employers could be susceptible to the Affordable Care Act’s (ACA) tax on high-cost employer-sponsored health coverage, frequently referred to as the “Cadillac tax.”

Kaiser researchers modeled the impact the Cadillac tax could have on US employers by looking at the distribution of employer-sponsored health plans and projected premium growth rates. It also factored in employer contributions to health savings accounts (HSAs) and health reimbursement arrangements (HRAs) and employer and employee contributions to flexible spending accounts (FSAs) and their projected annual growth rates. According to the analysis, by 2028, more than four in 10 employers could be offering at least one health plan that exceeds the cap for individual coverage if employers do not make changes to their current benefit offerings.

There are several strategies employers might use to avoid hitting the Cadillac tax threshold. Employers may increase plan deductibles or other cost sharing, cap or eliminate contributions to HSAs, HRAs, and FSAs, or offer health benefits to employees through a private exchange. In particular, the analysis shows that many employers could delay incurring the Cadillac tax by no longer offering FSAs to employees.

Background: The Cadillac tax begins in 2018 when the Internal Revenue Service (IRS) will impose a 40 percent excise tax on premium amounts above the threshold amounts of $10,200 for individual coverage and $27,500 for family coverage. After 2018, the IRS will adjust the premium thresholds using the consumer price index (CPI). The tax would apply to many types of employer-sponsored coverage, including FSAs, HRAs, HSAs, coverage provided by government plans, including federal and state governments, coverage for on-site medical clinics, retiree coverage, and multiemployer plans.

(Source: Gary Claxton and Larry Levitt, Kaiser Family Foundation, “How Many Employers Could be Affected by the Cadillac Plan Tax?” August 25, 2015)

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Implementation & Adoption

Report: OpenNotes project is improving quality and patient engagement

Five years after the start of OpenNotes, a project in which 105 physicians in three cities shared their notes with 20,000 patients, many health care professionals and patients think it has improved care and quality. Physicians at Beth Israel Deaconess Medical Center in Boston started OpenNotes in 2010. The initiative encourages health care professionals to share their patient notes and invites patients to read and review notes that their doctors, nurses, and other clinicians write after an appointment. The notes summarize discussions, findings, and treatment plans. Since the pilot project began in 2010, other groups have expanded OpenNotes to approximately five million patients nationwide.

The group founded OpenNotes to give patients more control, thereby helping to improve care quality and encourage patients to take better care of themselves. A recent review of the program published in The Joint Commission Journal on Quality and Patient Safety evaluated five years of notes on over 2,000 patients. Patients and physicians enrolled in the program agreed that the program helped improve medication adherence, reduce medical errors, and mitigate diagnostic delays. The authors identified several additional benefits to the program.

However, increasing transparency into patient notes and medical records could create additional challenges for physicians. More patient engagement could also mean more calls and questions. Physicians also may need greater support to help them distinguish between false alarms or trivial errors and potentially critical ones. Finally, some are concerned that greater transparency might lead patients to question diagnoses or care plans too often.

(Source: Singall Bell, Patricia Folcarelli, Melissa Anselmo, Bradley Crotty, Lydia Flier and Jan Walker, The Joint Commission Journal on Quality and Patient Safety, “Connecting Patients and Clinicians: The Anticipated Effect of Open Notes on Patient Safety,” August 2015)

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Report: Plans off the exchanges not substantively different from on-exchange plans

A recent report from the Commonwealth Fund found that plans in the individual market both on and off the health insurance exchanges (HIX) are enrolling healthy, low-risk enrollees. Before the HIXs were established, many stakeholders were concerned that some plans outside of the HIXs might attract more healthy, low-risk individuals, leaving only sick, high-risk individuals in the HIX plans.

The researchers looked at federal filings and analyzed more than 1,000 products from 570 insurers to determine if consumers and/or the types of plans on and off the HIXs differ significantly. They looked at three comparisons between plans on and off the exchanges.

(Source: Michael McCue and Mark Hall, The Commonwealth Fund, “Comparing Individual Health Coverage On and Off the Affordable Care Act’s Insurance exchanges,” August 2015)

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FDA releases draft guidance on biosimilar naming

Last week, the US Food and Drug Administration (FDA) published a proposed rule on how it plans to name branded biologics and biosimilars. For each product's nonproprietary name (i.e., not the name given to the product by the drug sponsor), the FDA proposes to use the generic name and then attach four random letters to the end of it. This naming convention is different from the name it gave the first approved biosimilar product, which had four letters that represented the drug sponsor’s name at the end of it (Filgrastim-sndz).

The FDA seeks to rename several products that are already on the market. In a separate document, the FDA proposed to rename Amgen's Neupogen®, changing it from Filgrastim to Filgrastim-jcwp, and Sandoz’s Filgrastim-sndz, changing it to Filgrastim-bflm.

Analysis: Over the past several years, biologics have gained significant traction in the biopharma industry, representing more than $150 billion in global sales in 2013. Biologics are projected to generate $290 billion and make up 27 percent of the biopharma market by 2020. It is still an open question how much of that will consist of biosimilars. This, along with the increasing worldwide focus on improving health care access and costs, presents an attractive opportunity for biosimilar – or follow-on biologic – manufacturers. However, as explained in Winning with biosimilars: Opportunities in global markets, US life sciences organizations should consider tackling a series of critical assessments before determining how quickly they rush into the biosimilars market.

Interchangeability, production complexity, and competition are just a few of the challenges that biopharma stakeholders face in this market. Regulatory uncertainty is a top challenge for many. The regulatory policies governing biosimilars are still in flux. Major markets like China lack consistent and clear approval pathways. In the US, biosimilars guidance has been out since 2013, and the FDA has begun to finalize a formal pathway, but it continues to be the subject of litigation.

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On the Hill & In the Courts

Court rules that the FTC can regulate cybersecurity

Last week, the US Court of Appeals for the Third Circuit affirmed a lower court’s ruling that the Federal Trade Commission (FTC) has the authority to regulate cybersecurity. It has this authority under the Federal Trade Commission Act, which prohibits “unfair or deceptive acts or practices in or affecting commerce.”

The case originated in 2012, when the FTC filed a suit against a large company after the company was hacked three separate times from 2008-2009. The hackers stole personal and financial information for more than 619,000 consumers and charged more than $10.6 million in fraudulent charges. The FTC said in the suit that the company stored credit card information improperly, had insufficient authentication requirements (e.g., easily guessed passwords), failed to use firewalls to protect the system, failed to monitor its system for malware, and more. The FTC also said that the company overstated its privacy policy on its website.

In health care, the US Department of Health and Human Services (HHS) Office of Civil Rights typically handles data breaches. However, as major breaches among health care organizations increase, the FTC could start pursuing more cases under this authority.

Background: The Ponemon Institute found earlier this year that 90 percent of health care organizations have experienced at least one data breach in the past two years. This has cost the health care industry an estimated $6 billion annually. Moreover, a single electronic security incident has an average cost of $2.1 million to a health care organization.

The HIPAA Omnibus Final Rule requires health care organizations to submit a four-part risk assessment after each electronic security incident. However, Ponemon found that only 50 percent of respondents to its survey follow this procedure. Awareness of the threat to patient data has increased significantly among health care organizations over the past five years. However, greater investment in proper resources, such as human capital, finance, and technology, and reinforcement of appropriate employee protocol could help improve information security in the future.

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CMS: Medicare ACOs saved more than $411 million in 2014

Last week, the US Centers for Medicare & Medicaid Services (CMS) announced that 20 Pioneer accountable care organizations (ACOs) and 333 ACOs participating in the Medicare Shared Savings Program (MSSP) saved Medicare more than $411 million in 2014. Nearly one-third of MSSP ACOs held spending below their benchmarks, saving a total of $341 million and earning them bonus payments. In 2014, none of the Track 2 ACOs, which assume upside and downside risk, owed money to CMS. From 2013 to 2014, Pioneer ACOs improved on 28 of 33 quality measures and MSSP ACOs improved on 27 of 33 measures.

Analysis: The changes that CMS has recently made to the programs are likely to influence participating organizations over the next three-to-five years. Track 2 of the MSSP allows ACOs to share in more savings if they agree to pay money back for losses. But, many of the participating ACOs have not moved into Track 2 yet. Many see it as encouraging that these organizations continue to show positive trends. It is likely that many analysts are reserving their judgment on the programs' overall performance for a few years from now, when organizations have had more experience in the programs and may show greater quality improvements and cost savings.

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Survey: Health and human services agencies identify data integration as top challenge

MeriTalk recently surveyed 155 IT executives and managers at US health and human services agencies to find that the biggest challenge they face in accurately determining eligibility for health care benefits is data integration. Forty-four percent of IT managers were unable to use all of the available data because of system and/or integration challenges. Additionally, 43 percent of the respondents believe that current processes for eligibility and verification make it hard to meet the needs of beneficiaries.

According to the respondents, it takes an average of 16 days for health and human services agencies to confirm eligibility for new beneficiaries and 14 days to verify the status of current beneficiaries if asked about it. More than half of the respondents believe that better data integration could improve customer experience, accelerate eligibility requirements, and reduce costs by accurately identifying recipients.

To correct these issues, many of the IT executives surveyed believe that agencies should hire additional staff, improve data integration, and improve automation.

The report makes three recommendations based on the findings. Agencies should audit their current systems and processes to evaluate how well the eligibility and verification processes are working. They should also prioritize data integration and improve collaboration between case workers and IT departments.

(Source: MeriTalk, “The Economics of Eligibility: The Cost of Eligibility and Verification Challenges for Government Healthcare Benefits,” 2015)

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Around the Country

Study: Plans with narrow networks are common in the exchanges, but most states have a choice of plans without narrow networks

In a recent analysis of provider networks among silver level plans in the HIXs, researchers from the Robert Wood Johnson Foundation and the University of Pennsylvania found that half of the 1,065 unique plans had narrow provider networks.

Researchers looked at the 394 unique provider networks issued by 267 different issuers and measured the size of the provider directories in each rating area. The researchers estimated network size based on how many eligible providers in each state rating area participate in the plan network. They defined five groups of network size: x-small (less than 10 percent), small (10-25 percent), medium (25-40 percent), large (40-60 percent), and x-large (more than 60 percent).

Some states like Delaware, Kansas, and North Dakota mostly had plans with large networks, while Georgia, Florida, and Oklahoma mostly had narrow network plans. Narrow networks have become increasingly common to control health care costs and keep premiums low.

Analysis: The Deloitte Center for Health Solutions 2015 Survey of US Health Care Consumers found that 19 percent of HIX enrollees identified limited networks as a reason that they are dissatisfied with their current plan. However, as the exchanges mature, stakeholders have identified addressing affordability as a key challenge, and plans that restrict networks in exchange for lower prices may be part of the solution for a growing number of consumers. According to the survey, up to 60 percent of insured consumers are now willing or somewhat willing to accept a smaller network of hospitals or a smaller network of doctors for a lower price, and just over half (52 percent) express some willingness to accept a network that does not include their current primary care provider. Younger people are significantly more willing than older people to consider this, especially within the HIX population.

(Source: Dan Polsky and Janet Weiner “State variation in narrow networks on the ACA marketplaces” August 2015, Robert Wood Johnson Foundation)

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New algorithm has the potential to reduce harm and death caused by sepsis

Sepsis is a serious medical condition that is caused by an overwhelming immune response to infection. Annually, sepsis strikes more than one million Americans and kills approximately 200,000 individuals. Invasive medical procedures such as vascular catheters can introduce bacteria into the blood and bring on sepsis. A new study shows that there may be a more effective way to identity patients who are at risk for sepsis and prevent septic shock.

When caught early and treated aggressively, vulnerable patients, such as those in hospitals and nursing homes who are receiving invasive procedures, can avoid septic shock and have an increased chance for survival. But, with every hour that passes without antibiotics, the risk of death greatly increases. Current tools do not predict who will develop sepsis until very late. Researchers from Johns Hopkins University used readily available data from patient monitors and an EHR to develop an algorithm that serves as a targeted, real-time early warning score that can predict in advance which patients are at risk for septic shock.

The new algorithm correctly predicts septic shock in 85 percent of cases, without increasing the false positive rate from screening methods that are currently used. More than two-thirds of the time, the algorithm is able to predict septic shock before any organ dysfunction occurred. That is a 60 percent increase compared to existing screening methods.

The study relied on EHRs for more than 16,000 patients who were admitted to intensive care units from 2001 to 2007. Researchers developed an algorithm that combines several factors that are already routinely collected into a scoring system to measure the risk of septic shock. The researchers say that the algorithm could be programmed into an EHR system and used to alert clinicians about a high risk patient.

Analysis: Integrating useful alerts into an existing workflow can help health care providers treat patients at risk of developing life-threatening conditions, such as septic shock or sepsis. Alert fatigue occurs when a health care provider is subjected to an overabundance of notifications, typically from having to monitor multiple devices or platforms over the course of treatment. If notifications are both too frequent and agnostic between non-life-threatening and life-threatening changes, there is a risk of alert fatigue on the part of the health care provider, and the provider could miss critical alerts. To both integrate alerts and prevent alert fatigue, it is important to tailor alerts to each patient’s treatment and ranked by potential severity or treatment complication.

When developing applications to improve workflow, developers should consider both the technical level (i.e., ability of the system to perform complex queries) and the functional level (i.e., ensuring it is user-friendly for clinicians). Though the ability to perform complex queries with an EHR is an innovative strategy, the retrieved data must be actionable for the clinician to provide optimal patient care.

(Source: Katharine E. Henry, David N. Hager, Peter J. Pronovost, and Suchi Saria, Science Translational Medicine, “A targeted real-time early warning score (TREWScore) for septic shock,” August 5, 2015)

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Breaking Boundaries

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