An Exemption to the Insurance Mandate That Looks A Lot Like Insurance Without the Assurance

A few months ago, while flipping through an issue of Christianity Today magazine, I came across an interesting full-page advertisement. Usually, I’m more interested in the articles on theology and the ads for new books from contemporary pastors, but this time the ad that I noticed was for a company that was advertising the Christian alternative to health insurance. I read the ad fully, and then ventured onto the web to find out more about this company, what exactly it was offering, and how it was supposed to work. I learned a lot. In fact, I learned about the existence of something in U.S. health care that I never learned about during 8 years of graduate school and postdoctoral training in health policy. As it turns out, there are a number of these “faith-based insurance alternatives.” Among the largest nationally are Medi-Share, Christian Healthcare Ministries, Liberty HealthShare, and Samaritan Ministries. While there may be some slight differences between the various organizations, they all work in basically the same way, so for simplicity’s sake, I’ll just give you the broad overview.

The idea is simple: You sign up for membership, then you pick a plan level, and you pay the corresponding monthly membership fee. You receive a membership card that you can show to your provider, which may entitle you to a discount on services rendered. Then, if and when you get sick and incur a charge from a health care provider, you pay the bill and submit paperwork to the medical sharing organization, which will pay a portion of your costs using the monthly fees paid by other members. Before you are eligible to have a portion of your costs covered by the program, you must first have paid out of your own pocket what is typically called your “annual household portion” in addition to your monthly membership fee. That’s basically all there is to it.

If that sounds a lot like insurance to you, it should. After all, I could rewrite the preceding paragraph like this: You enroll in a plan and pay a monthly premium. You receive an insurance card that you show to your provider, and your insurance company has likely negotiated a contract for discounted services with providers in your network. If you get sick and incur a charge from your health care provider, you or they submit the bill to your insurance company, which will pay a portion of your costs using the premiums collected from other beneficiaries. Before you are eligible to have a portion of your costs covered by the program, you must first have met your deductible, the amount that you are required to pay out of your own pocket in addition to your monthly premium.

But these plans make a point of telling you that they are not insurance. That’s an important point–and it’s very true. Here are some of the key differences. First: Membership. It used to be that health insurance plans could discriminate a lot more on the basis of health conditions–either charging you a much higher premium or denying you coverage altogether. Under the Affordable Care Act, that has changed. You can no longer be denied health insurance coverage because of a pre-existing condition. However, membership in one of the “faith-based insurance alternatives” requires that you be a Christian. The way that these organizations define that, you cannot use tobacco or illegal drugs, must adhere to biblical principals regarding alcohol use, and must attend worship services regularly. While I think that all of those are very good things, it is important to take into account that just by excluding tobacco users, the plans are engaging in cream-skimming–that is only allowing the healthiest people to enroll. One firm even says you qualify if you “are healthy and live a healthy lifestyle.”

Second, these plans are not regulated by State Departments of Insurance. In fact, they are explicitly carved out as an exception in the Affordable Care Act. If you belong to a “faith-based insurance alternative” you are exempt from the individual mandate to obtain health insurance and you are not subject to the penalty for failing to buy coverage. So, this is an attractive option for people who are just anti-ObamaCare, as well as people with moral objections to things like abortion and contraception that they feel they are supporting by paying premiums to insurance companies whose plan benefits cover those goods and services. While I may not necessarily agree, I don’t have any issue with this.

Third, these plans do not offer typical benefits that most health insurers do. For instance, you may not have coverage for things like rehab for drug and alcohol abuse. You may not be able to get reimbursed for birth control, depending on the plan you choose. Even some types of important preventive care (e.g., mammograms and colonoscopies) often aren’t covered. Of course, proponents of these plans are likely to stress that that’s precisely the point (see the point above), and that’s fine, but it’s an important thing to know when you’re shopping for health coverage.

The fourth–and biggest–difference, as I see it, is that these plans that look so much like insurance, are really no assurance of insurance at all. As the Alliance of Health Care Sharing Ministries makes extremely clear, “Health Care Sharing Ministries do not assume any risk or guarantee the payment of any medical bill.” That means you pay them money every month and hope that things work out, but have little legal recourse if they do not. Related to that, there have also been financial scandals and court cases against some of these organizations, so potential members need to be just as careful with these programs as they would be with any other financial decision.

In light of these important differences, what do I think of these “faith-based insurance alternatives?” Well, I think that Christians should take care of their bodies, and that we are called to love our neighbors as ourselves. In that respect, many aspects of these “faith-based insurance alternatives” are clearly on the right track. But who is my neighbor? The parable of the Good Samaritan presents that everyone in need is our neighbor, even when we disagree with or are different from them. Even if they use tobacco products. Or illegal drugs. Or don’t regularly attend a worship service. This doesn’t mean that we condone these things, but we are to love even our enemies, and do good to those who persecute us, not alienate them. So I don’t necessarily agree with the restrictions placed on membership in these programs. It feels a bit like only letting people we deem to be “good” enter the doors of the church. But it is the sick who need a physician, not those who are well. Of course, in pointing out some of the perceived limitations with these “faith-based insurance alternatives,” I certainly don’t hope to imply that insurance companies are somehow occupying the moral high ground, because I don’t believe they are. On the contrary, I’m not sure that there is a moral high ground in U.S. health care financing these days. But I would encourage us to think broadly about who we consider our neighbors and how we care for them, and to engage with “faith-based insurance alternatives” with a keen understanding of the fact that they have many redeeming qualities, but that they are not–by their own admission and design–in the business of insurance.

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Who’s Who Of Health Care Join Forces For SMART Technology

In the new app-driven health economy, ease of use of IT for providers and patients is a must. Equally important is a sound technical approach and business plan for application creators looking for success, sustainability, and a large market for their innovations. Under the leadership of Boston Children’s Hospital’s Drs. Kenneth Mandl, Isaac Kohane, Joshua Mandel and an advisory committee that includes former U.S. Chief Technology Officer Aneesh Chopra, Harvard Business School professor and notable author Clayton Christensen, and Eli Lilly’s director of Clinical Open Innovation Thomas Krohn, the new SMART (Substitutable Medical Apps & Reusable Technology) Platform aims to revolutionize the way providers and patients use applications  to improve access to and quality of care. SMART apps are agnostic to the underlying electronic health record (EHR) or other IT platform. Like iPhone or Android apps, SMART apps are substitutable and can be readily added or deleted from EHRs.

Swapping Technology In Real Time

The SMART team has focused on enabling the property of substitutability in health IT through an application programming interface (API). This essentially allows innovators and developers who write an app to run it anywhere, and lets end users of health IT customize their systems with these substitutable apps.

“The opportunity is to create an ‘app store’ to extend the capabilities of EHRs,” says Dr. Ken Mandl of Boston Children’s Informatics Program . According to him, the trick to SMART is that the software developer doesn’t need to know anything about the underlying system just the format of data presented by the API, which will not change.

He makes an analogy to the original iPhones that used cellular towers to triangulate a user’s GPS, but shifted with the present day satellite GPS. When they did so, iPhone apps kept on working. The app developers did not need to know how the underlying system measured geo-coordinates. Similarly, SMART apps don’t need to know which electronic health record or pharmacy information system is in use at any given hospital. Instead, SMART app developers, like those developers for iPhone apps, simply use the original library to make upgrades and change out necessary components.

 

SMART Overview Video

This is exactly what developers like Justin Cranford in Raleigh, North Carolina say are ideal for functionality. “In the iPhone, the library is written by Apple, and that internal code changes, but the commands I call to build apps just pull those changes in without me ever knowing. Think about how Tinder pulls in Facebook photos and triangulates your location through the phone.” Or, as Ken Mandl quipped, “I don’t imagine that each time the creators of Angry Birds wanted to add a bird they had to fly to Cupertino for a meeting with the Apple technical team.”

This method, known as abstraction, allows technologies to be swapped out and improved inside the walls of hospitals, clinics and other care facilities. A natural extension of which might be the ability to share these substitutions and updates with patients, allowing them access not only to their data, but community and population trends inside the hospital and out – which is most important to advisors like Thomas Krohn from Eli Lilly. According to him, “I’m at the table because the pace of transformation is too slow. Measures are poor, the timeline is slow and the apps are not presently scalable.  This is the real opportunity,” he believes, “to allow innovation at the point of care.”

Clayton Christensen adds, “Modularized hardware and software are what make this unique. That element will determine the winners and losers.” When comparing it to his writing in The Innovator’s Prescription, he contends, “SMART fits the pattern of a successful business idea because the architecture is closed, proprietary and independent.”

Health Reformations Make SMART Possible

In addition to the creative ideas and established models that SMART is built upon, significant changes to the health system and technology in the United States have made advances such as this possible. Three specific incidences have had a particularly large effect on SMART.

First, the opening of health data has allowed payers, providers and patients access to new information. According to Aneesh Chopra, “The more data that is made available to consumers, the more ways data can be utilized and repurposed.” Although the Centers for Medicare and Medicaid Services (CMS) has not opened all of their data to the public, giving away payment information has opened many new doors for using payment information to better inform everyone in the health ecosystem.

Second, the digitization of health care has allowed for patient information to not only be collected, but to be used. By releasing patient information, our former CTO Mr. Chopra, who has a background in health, technology and policy believes that a patient revolution is on the horizon. He contends that the ultimate way to empower patients is to give them their own data to take beyond the four walls of the hospital or institution, and that means they can also use SMART in real time.

Third, payment reform in America is shifting us from a fee-for-service to an outcomes and value-based health system. Although there are significant flaws to the system, the mental shift for providers means that patient-centered care, outcomes and overall “value” will have new importance. The SMART team has faith that as payment reform occurs, their substitutable applications will not only create better care in facilities, but more informed providers and more engaged patients .

SMART Advisors And Partners

The advisors that have come together to make SMART a reality really are a who’s who of the health industry. In addition to the former White House CTO, universities and professors of note and the largest provider health systems, there has also been buy in from key technology companies, pharma, investors and consultants.

The list of advisors includes, but is not limited to:

–       The Advisory Board Company

–       AARP

–       Centers for Medicare & Medicaid Service (CMS)

–       England National Health Service (NHS)

–       Eli Lilly

–       Hospital Corporation of America (HCA)

–       BMJ

–       SureScripts

–       Canadian Institutes of Health Research

The strategic input by this team of advisors makes it almost impossible to fail. Additionally, the SMART Platform is already funded by a $15M grant from the Office of the National Coordinator for Health Information Technology (ONC) .

However, in the coming months it will be interesting to everyone in the health space to see how successful the platform is and just how substitutable the apps are. As we all know, apps have to work with providers and patients, if they are going to work for providers and patients.

 

Seeing Is Believing: Infographics Revolutionizing The Patient Experience

Infographics and visualizations are hugely popular in all cultures, and there is unlimited opportunity to use them in a complex field like health care. However, 15 seconds is all the time an online article has to capture a reader  according to data from Tony Haile of Chartbeat. The data also suggests that people don’t read content on the web the way we think they do, as much as visualize it. Health visualizations then, like media, only have mere seconds to get a patient engaged. With such great opportunity for improving health literacy, patient activation and outcomes, better health visualization must be easily digestible, and must engage the reader’s emotions instantly. What BuzzFeed does in the media space, we might find useful for health, too.  According to Devin Gross, CEO of Emmi Solutions, “Images, voice and text are all important parts of creating rich, emotional content that is relevant to individuals experiences. The goal is to bring real interconnectivity to the health space.”

A Picture Is Worth A Thousand Words

Pictures can give a patient a complete concept in seconds, where words alone often fall short. Tell a patient, “Don’t eat that next piece of cake, because excessive consumption of cholesterol increases the risk of heart disease and stroke”, and they will either ignore you or hear “Don’t eat cake, it kills you”. That’s neither true, nor encouraging. Visual cues can explain the opportunity for improvement in a more informative, fun and intriguing way.

However, to use visualizations successfully – to engage and grab the attention of both the well and the ill – requires really understanding people.  But if done appropriately, real improvements to public health might be possible. As David Spiegelhalter, Professor at Cambridge University in public understanding of risk says, “Often, numbers do not speak for themselves. They are part of narrative, and so there are no correct or objective ways of communicating them as text.”

At London’s recent WIRED Health conference, speakers made heavy use of data visualization to communicate the benefits of using certain technologies in health care and wellbeing. Although that was to an audience of medical professionals, entrepreneurs and media, data and charts could have been replaced with a wholly different narrative and disseminate the same story if need be for a lay audience.

Data visualization is not for everyone though. A crucial mistake in health would be to identify patients as one cohort – especially when they are a group of people suffering the same affliction. Therefore, Infographics and interactive visuals are one piece of the overall patient engagement goal.

Psychology Of A Patient

In a recent Business Insider post, columnist Milo Yiannopoulos asked why data journalism doesn’t always work; at least, not for most people who aren’t “data nerds.” He contends that news providers have forgotten that ordinary people are moved by pleasure and displeasure rather than spreadsheets. This is why money, sex appeal and humor all play major roles in media.

Ironically, many in the health space also seem to forget that patients are also people, and raw stats just won’t cut it. Health communicators must innovate to tell compelling, visual stories beyond the numbers. Or, as Emmi Solutions CEO says, “The dynamic of any relationship and subsequent health-related action come from feeling like you’ve been getting advice from a trusted friend. Learning in a friendly and meaningful way is really an extension of a relationship built on trust.”

Any communication professional will tell you, all people are different. Personality gurus Myers-Briggs split us into 16 broad personality types, describing how people perceive the world and make decisions. Based on analyses such as Myers-Briggs, we know that some people prefer the written word while others will want credible datasets to work through. Older people tend to have the time to want to do their own research and younger people tend to have no problem trading time for simplicity. But as a whole, almost all humans have a desire to connect with and relate to other people.

Many charities understand this well, such as Cancer Research UK, which collaborates with good PR agencies to tell trusted stories that tug at heartstrings. Yiannopoulos says that these stories get the most attention in the media because by the end, tears – whether from laughter or pain – are dripping onto the page.

Engage, Play, and Interact

The JBS3 risk calculator, developed by David Spiegelhalter and Mike Pearson at Cambridge University, is a tool to help visually communicate the risk of cardiovascular diseases and the benefits of interventions, whether lifestyle or pharmacological. It’s a good example of how to create engagement through instant feedback. Feedback is important because it contributes to the motivation and the emotional bond between data, good advice, understanding and future decision-making.

In a doctor’s office, the physician can use tools like this to tell a better story to their patients. Providers can more easily illustrate the potential of a different lifestyle choice, and the impact of behavioral changes. It further gives the patient choices, options and a vision of incremental benefit rather than black-and-white outcomes.

US-based Emmi Solutions is a company that provides multi-modal engagement tools that relay personalized, visually oriented health information throughout the entire care continuum, from prevention to surgery to self-care. Using teams of visual and graphic artists, voice artists, script writers and patient focus groups, the company creates content that, in theory, simplifies complex medical information to provide people with information that they can easily understand and respond to.

This idea also allows providers to have more meaningful conversations during notoriously short visits and better explain in-person what is happening, as well as send them home with reference material that they can interact with on their device of choice and when they’re ready to learn. Their results from over 12 years of being in operation prove that this approach does get people engaged and taking action.

On the academic front, the Robert Wood Johnson Foundation (RWJF) and the University of Michigan Center for Health Communications Research have joined forces for “Visualizing Health,”  a project examining how data visualization for risk behavior can be applied. Their premise is that people need to be able to understand and respond to multiple types of health risk information.

According to the RWJF report, once people have information they can understand, they set goals, recognize that risk exists, judge whether the level of risk is acceptable or not, and use that to make a decision among options. As we grow, around the world, to better understand the learning preferences and human behavior that influences comprehension and decision-making, the ability of presentation could have significant impacts on public health. By creating educational materials that allow people to interact in ways that make sense to them, we empower them.

 

Health Wonk Review: August Recess Edition

Today, it is my distinct pleasure to host the month’s only issue of the Health Wonk Review. You see, much like Congress, we academics and policy wonks tend to slow down our work considerably in the summer months. And yet, much unlike Congress, even then we are able to get at least something done. Thus, in this “August Recess” edition of the HWR I bring you some wonderful insights into health care spending, Medicare, and the ACA from the best health policy bloggers on the web.

Leading things off, Billy Wynne of the Healthcare Lighthouse blog will get you all caught up on implementation of the Affordable Care Act, with a focus on what happened in July. You usually have to pay for access to this stuff, folks. So, read it while it’s free, and you may be surprised to see that so much work continues on all fronts after the close of open enrollment period 1.0. I guess while Congress is in recess, the executive branch has to keep working, despite all the people outraged by President Obama going on vacation during world crises.

Louise, of the Colorado Health Insurance Insider, takes a look at fixed indemnity health insurance plans. As she says, “There are still a lot of moving parts in the ACA. New regulations are constantly being added to ensure that all of the parts work well, but they don’t all take effect immediately. So while regular major medical health insurance is guaranteed issue now, fixed indemnity plans are still being sold in the individual market–exempt from ACA regulations and quite possibly without the client understanding that the plan is not sufficient to avoid the individual mandate penalty. Far worse than the penalty however, is the possibility that a person could purchase one of these plans thinking that it’s ‘real’ health insurance, and only find out it’s not after incurring a significant claim.” Fortunately, some regulations are on the way for fixed indemnity plans starting January 1, 2015.

In other ACA-related news, it won’t be long before the Marketplaces are available once again for open enrollment. On the Health Affairs blog, authors Jon Kingsdale and Julia Lerche explain how the “one-two punch” of rate shocks from benchmark plan changes and delayed tax refunds could threaten the success of the ACA’s second open enrollment period, and they outline some steps that could address these challenges.

But, if rate shocks are such a big problem, why are we seeing such a significant slowdown in health care spending? Is it the recession still? Are we seeing a real shift towards paying for value rather than volume? To get to the bottom of it, read the Healthcare Economist’s latest post. There, Jason Shafrin explains that between 2000 and 2007, annual health expenditures in the U.S. grew by 6.6% per year. While between 2008 and 2011, the growth rate was only 3.3% per year. Shafrin investigates what is causing the change, and you should read what he has to say.

When it comes to health care spending, one of the first places policymakers turn (when they’re not back home or in the Hamptons for a family commitment), is the Medicare program. And one of the contributing factors is Medicare fraud, which Bob Vineyard writes about at the Insureblog. In his post, Bob points out that in South Florida, Medicare fraud is a bigger business than cocaine. Government’s always talking about reducing fraud, waste, and abuse, but they never seem to get around to doing anything about it, and his post may explain why. Still, the recent Medicare actuaries’ report presents some pretty good news–at least for some–that costs are not growing as rapidly as had been projected. As Joe Paduda, of the blog Managed Care Matters reports, while it is good news for the long-term health of Medicare, the downside is hospitals are going to be looking elsewhere to make up revenue shortfalls–and workers’ comp is a very soft target.

Speaking of workers’ comp, Julie Ferguson, of the Workers Comp Insider, provides HWR with its first Inception-like contribution. Here, within our own best-of-the-best roundup, Julie offers her own research roundup on a variety of topics including variations in costs for MRIs based on price transparency, state policies on provider market power post-ACA, disability risk factors following work-related injuries and more. It’s a roundup within a roundup, people. Don’t miss it.

In the world of pharmaceutical controversy, we have two posts. One from David Williams of the Health Business Blog, who writes about the misguided review of Zohydro ER by Consumer Reports, and another from Roy Poses, who explores the irrationality of spending hundreds of millions of dollars for drugs like Acthar, which are not proven effective, while spending almost nothing on a search for a vaccine for seriously life-threatening illnesses like Ebola. Seems like maybe there are some issues for Congress, the FDA, the NIH, and the CDC to straighten out when our lawmakers return from holiday.

Finally, what is Summer without a little vacation? Tinker Ready of Boston Health News paid a visit to the Hospital de la Santa Creu i Sant Pau in Barcelona, Spain. Check out her post for some gorgeous pictures of one of the oldest medical institutions in Europe. You’ll be transported.

Well, that’s it for this edition. The Health Wonk Review will be back in session in September when David Williams hosts the next edition at the Health Business Blog.

 

The First Amendment, In Your Medicine Cabinet

No American in 2014 who watches television, reads a magazine, goes online or visits a doctor’s office can escape the ever-present promotion of prescription drugs. Pharmaceutical promotion, both directly to doctors and to patients, has been the backbone of prescription drug sales for decades, with sales driving everything from drug access to stock prices to research and development. So what happens when the third largest industry in the United States changes the way it promotes products? We might find out.

Scott Liebman, head of the FDA Regulatory and Compliance practice at Loeb & Loeb LLP explains, “A confluence of events has primed the life sciences industry for a paradigm shift. First Amendment challenges to restrictions on off-label communications, evolving transparency in pricing and payments, the Affordable Care Act and other key regulatory developments are coming together in a way that could fundamentally change the sales of drugs, devices, and biologics in this country.”

The Promotion Paradigm: “Ask Your Doctor About…”

The United States is one of only two nations in the world that allows direct-to-consumer advertising of regulated medical products. It is no coincidence that we also rank as the world leader in pharma research and the world’s largest market for pharmaceuticals.  “In order to protect consumer safety while preserving consumer choice, regulators have developed numerous and rigid standards for promotional communications, especially those related to the marketing or advertisement of drugs off-label, in other words outside of their FDA-approved indication,” says Liebman.

 At present, any promotional statements about a prescription product that are inconsistent with the prescribing information in the label are prohibited according to the Food, Drug and Cosmetic Act. Liebman further explains, “Any promotional statement must be accurate, complete, not misleading and balanced with information related to both benefits and risks.” Along with these regulations comes a highly active enforcement system that generates billions of dollars in revenue at the federal and state levels through settlements and penalties.

In reality, many drugs may be effective in treating disease states or patient populations outside their FDA-approved indications, creating the potential for billions of dollars in new sales. The burdensome regulation placed on manufacturer’s speech is not, however, intended to stop doctors from prescribing drugs for any use they believe to be safe and effective. According to a 2006 Stanford study, an estimated 21% of all written prescriptions are for non-primary label use. Dr. Randall Stafford says in his 2008 New England Journal of Medicine article that, “Although off-label prescribing — the prescription of a medication in a manner different from that approved by the FDA — is legal and common, it is often done in the absence of adequate supporting data. Off-label uses have not been formally evaluated, and evidence provided for one clinical situation may not apply to others.” If that is true, however, how are doctors predicating their off-label prescribing decisions?

Off-Label Communications: The FDA Loses Ground In Court

Doctors have access to off-label information from the manufacturers themselves through a legal carve out for scientific communications made in response to an unsolicited request. If a representative provides off-label information without receiving an unsolicited request, however, the communication can be deemed illegal. In 2009, Allergan sued the FDA asserting that the FDA’s prohibition on the dissemination of off-label information violated the company’s First Amendment right of free speech.

At that time, Allergan had allegedly been promoting Botox® for the treatment of migraine and other indications that were not yet approved. The three resulting whistle-blower suits left Allergan facing enormous civil and criminal penalties, so in 2010 it negotiated a $600 million settlement to resolve its liabilities and entered into a Corporate Integrity Agreement that required the withdrawal of its First Amendment complaint.

A mere six weeks later, Botox® received FDA approval for prevention of headaches in adult patients with chronic migraine.

Allergan’s withdrawal left the industry without appropriate jurisprudence to guide decision making about off-label communications. That changed in 2012 when the US Circuit Court for New York decided US v. Caronia, determining that a sales representative for a pharmaceutical manufacturer had the constitutional right to discuss products for off-label uses. The Caronia case raised questions regarding the authority of the FDA, and to date, the FDA has not appealed.  “Although only valid in the Second Circuit, the Caronia case opened the door for additional challenges,” says Liebman.

Since the Caronia case, the FDA revised and reissued a draft Guidance document related to the distribution of scientific and medical publications on unapproved new uses for drugs. Echoing Allergan’s 2009 complaint, the Washington Legal Foundation, a prominent public interest law and policy center, has submitted a comment challenging the Constitutionality of this draft Guidance.

How Much Does That Cost?

Several sections of the Affordable Care Act (ACA) address the cost of healthcare services, including prescription drugs. On the highest level, the ACA intends to shift from a fee-for-service model to a value-based outcomes model. In addition, the law mandates the disclosure of vast amounts of pricing and outcome information. The ACA drew attention to the issue of transparency around the pricing and usage of drugs, such as the costs associated with promotion of regulated products. Further, the FDA recently requested comments regarding use of comparative price information in direct-to-consumer and professional prescription drug advertisements.

“Because of new reporting requirements, a shift toward insurers reimbursing for value to the patient and the ability to make information publicly available online, consumers have an unprecedented amount of information available to make healthcare decisions,” explains Liebman.

The New Consumer

Today’s patient has far better tools to become informed about the prescription drugs available to them. The proliferation of information publically available on the internet has left the FDA racing to issue guidance for the monitoring of interactive media and flooding federal websites with new data sets every month.  This same information is available to health care providers. Patients and physicians alike now have access to everything from peer reviewed journal articles to patient blogs. The industry is seeing the information gap close, creating a new patient-consumer who is able to make complex decisions that balance health and economic considerations. If a $50 injection can be used off-label to treat a patient’s condition with comparable safety and effectiveness to a $500 injection used on-label, wouldn’t price information be of great value in making the decision about which drug to use? More and more, patients have access to that type of information.

 

Evidence Mounting that Health Insurance is Necessary, But Not Sufficient for Good Health

It makes so much sense that it has to be true: Having health insurance means you can afford to go to the doctor, and going to the doctor typically improves health, so on average, having health insurance improves health. The problem is, that’s not what empirical research finds. But before you start using this as yet more ammunition that the Affordable Care Act–which makes expanding insurance coverage its foremost concern–is doomed to be a failure, keep in mind that failing to demonstrate that being insured improves health is not synonymous with health insurance having no value or no role in the process. That is, health insurance may very well be a necessary factor in producing better health, albeit not one sufficient to produce it in its own right. Let me explain.

A little over a year ago, a paper by Kate Baicker and colleagues came out in the New England Journal of Medicine that looked at a “natural experiment” in Oregon where there was a lottery for expanded Medicaid coverage. The paper got a lot of attention because it found that people who gained Medicaid coverage did not have better clinical outcomes as a result of becoming insured. Of course, the paper also reported that people who had insurance coverage did enjoy the mental peace of mind that comes from the financial protection and security afforded by having insurance coverage, but if all you’re looking for is evidence that expanding Medicaid isn’t going to make people healthier, you’ll tend to skip over that point and go straight to the conclusion: Obamacare isn’t going to make a difference.

Now, another paper has come out in Health Services Research. This one, by Tomasz Stryjewski and colleagues looks at Massachusetts–the very state whose health reform was more or less the template for the Affordable Care Act–and they also find that gaining health insurance doesn’t seem to improve some basic clinical outcomes like blood pressure, diabetes control (HbA1c), or cholesterol levels. Making their study even more compelling, they look at 3 years before the reform was implemented in Massachusetts and 5 years after the reform was implemented, which gives them the ability to establish some baseline trends and allows time for the effect–if any–of having insurance to kick in. Even so, they conclude that there were no improvements in health resulting from gains in insurance because of the reform. Again, if you are an opponent of Obamacare, you have more evidence to support your case. And, if you have a hard time letting go of the notion that health insurance must certainly lead to better health outcomes, you are left to try and critique the study, or at least scratch your head and wonder how in the world this could be.

And that is where I would interject that having health insurance is necessary, but not sufficient when it comes to improving health. You see, the Stryjewski study did not find that health outcomes worsened. Rather, they found no statistically significant change. In fact, they actually found improvements in all three measures, but the range of outcomes was too broad–some people got better, some people got worse, and on average, we can’t claim with 95% confidence that there was really an improvement. I take that to mean that health insurance is likely necessary, because it seems to make some difference in the right direction, but it’s not sufficient, because it alone isn’t enough to make a big enough difference in the right direction. So what else might be involved? Well, for brevity’s sake, let me label a whole host of things as “non-financial barriers” to care. This would include things like having transportation to get to the doctor, being able to take time off of work to go to your appointment, having someone to watch your kids while you’re at the doctor, having a provider who’s willing to accept the coverage you have, having a provider who can speak your native language, understanding what your doctor tells you, and complying with what your doctor tells you, just to name a handful. The point is: health insurance does one thing and one thing only–pools risk to help you pay for health care. If you don’t have insurance, that’s going to be your chief barrier to getting the care you need. But, just because you have health insurance, doesn’t mean that you aren’t going to encounter myriad other barriers to getting the care you need. Only when we remove both the financial and non-financial barriers to care will we be likely to see improved health outcomes. But, if we give up before then, because we wrongly conclude that studies show that health insurance doesn’t matter, then we’ll likely never see improved health outcomes, because health insurance may not be sufficient on its own, but there’s little question that it’s necessary.

 

10 Things Hospital Leadership Need To Know About Social Media And Marketing

Building any brand can be difficult, but in the US, hospital identity and branding are paramount to success within a community. By listening to patients, getting feedback on wants and needs, engaging individuals and creating new incentives, a better reputation, greater trust and improved health outcomes can all be achieved.

Below are 10 things hospital leadership should keep in mind when thinking about marketing and strategy in 2014 and beyond. 

1. In 2013, it was estimated that 62% of emails were opened on a mobile device. Checking email is the top mobile activity among smartphone and tablet users. More people in the world own a mobile device than a toothbrush, so using email to inform patients about new services, community events and preventative care tactics is a must.
2. The brain processes visual data 60,000 times faster than text. Additionally, 90% of information transmitted to the brain is visual. Whether it’s growing your brand identity or improving medication adherence through visual instructions, images are key to interacting with, informing and empowering patients.
3. Surprisingly, Grandparents are the fastest growing demographic on Twitter.  Not only does this indicate that it is here to stay as a social media platform, but it’s a great place to target our aging population who consume the majority of our health services.
4. In 2014, more than 50% of Internet users, or 102.5 million people in the US, will redeem a digital coupon. There are many new partnerships with retail clinics, pharma companies and other service providers that can use coupon-like strategies for patient cost-savings and adherence.
5. The number of devices connected to the Internet now exceeds the number of humans on earth.  So don’t forget to market on multiple platforms and for many different devices. Top sites include Twitter, Facebook, Pinterest and Instagram.
6. Social media influences 93% of shoppers final purchase decisions. Further, 90% of consumers indicate that they trust peer recommendations. Therefore, previous patients are your greatest allies. Their reviews online matter more than you think.
7. More than 78% of US Internet users research products and services online, and every month, there are more than 10.3 billion Google searches, with most people clicking one of the top four links. What your top hits say about your organization, your providers and your quality of care can influence your bottom line.
8. Targeted, content marketing costs 62% less than traditional marketing, and, per dollar spent generates about 3 times as many leads. When creating a marketing strategy for a particular service line, service, or physician group, think about exactly who needs to see what ad and what information they will be looking for.
9. Consumers that receive email newsletters from companies spend 82% more with those companies. Think about what that says for brand loyalty following engagement, and about the ability of constant, relevant engagement. Patients are consumers, and like email, newsletters keep them informed.
10. 70% of people surveyed claim they would rather learn about a hospital or company through articles rather than direct advertisements. Therefore, not only are advertising campaigns important, but so are the patient experience testimonies, community reviews and Forbes articles that highlight the work being done inside and outside of your hospital.