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Health Care Reform Memo:
June 10, 2013

Deloitte Center for Health Solutions publication


The health care reform memos are issued on a weekly basis, highlighting news from the previous week's activities in the administration and implications for the C-suite and various stakeholder groups.

My take: Health reform and its impact on mental health and wellness 

From Paul Keckley, Executive Director, Deloitte Center for Health Solutions

There are many terms in health care that are frequently used with wide variation in their interpretation…

“Quality of care” means different things to different people. Among consumers (patients), it is associated with a personal touch by qualified professionals rather than quantifiable measures of efficacy, effectiveness, and outcomes embraced by medical professionals.

“Access” is another health care term with wide interpretation. In some circles, it means the availability of a doctor, emergency room, or public clinic; in others, it’s associated with insurance coverage that allows access to doctors and hospitals otherwise inaccessible.

And then there is “wellness.” On the surface, a fairly straightforward idea that can be interpreted as: individuals who enjoy a state of health void of major problems. But a deeper look prompts a litany of questions…what’s the right balance between physical and mental health, what’s the role of spirituality, is wellness absence of symptoms of a disease or state of mind, and so on.

On May 29, 2013 the U.S. Department of Labor, U.S. Department of the Treasury, and U.S. Department of Health and Human Services (HHS) issued a joint final rule on employer worksite-wellness programs per the Affordable Care Act (ACA). It establishes criteria for worksite-wellness programs that must be satisfied in order to ensure that they are non-discriminatory and open to all employees. Also, the rule raised the maximum permissible rewards—discounts, premium rebates, or reduced co-payments/deductibles—for employee participation from 20 percent to 30 percent of the total cost of coverage—and to 50 percent for smoking-cessation initiatives1. For employers and their employees, the difference is significant:

Premium variation at proposed incentive allowed value per ACA final rule

Maximum allowed incentive (%) Individual coverage (maximum ceiling) Family coverage (maximum ceiling)
@30%   $1,685 $4,723
@50% $2,807 $7,872

Source: Deloitte calculation based upon average annual premium for employer-sponsored health insurance in 2012 (individual premium of $5,615 and family premium of $15,745) Data source: Kaiser Family Foundation and Health research and education trust 2012

But the final rule lets employers define wellness for their employees, and to design wellness programs that achieve their goals within the framework of the law’s intent—that wellness programs are open to all employees (non-discriminatory) and inclusive of tangible rewards for employees that improve their health.

In this issue of the memo, there’s much about wellness programs (see Fact File) and mental health (see Legislative update). As a health services researcher, I think about wellness a lot: it’s a central theme in employer benefits strategies, and an emergent theme among consumers who are increasingly embracing alternative health in a dramatic fashion. It’s also deeply embedded in the ACA: explicitly in rules for employers and essential health benefits, and indirectly as a necessary goal for providers and health plans that share in savings from accountable care organizations (ACOs) and medical home pilot projects.

Ironically, with such attention, there’s no national consensus about what wellness means, or how to get there via public policy or private efforts. I suspect there’s more to wellness than smoking cessation, reduced alcohol consumption, and wearing seatbelts, but those are likely good places to start. My hunch is that wellness is also about dealing with stress reduction in a fast-paced society, physical exercise, food choices, preventive dentistry and primary care, and spirituality. But the trade literature is inconsistent about exactly the right combination of activities that constitute a comprehensive wellness program. It may be complicated and costly if not deciphered appropriately.

The ancient Greeks associated wellness and happiness. In some cultures, the two are not related directly, and in other countries like the U.S., they’re more aligned in our pop culture. I suspect wellness means something different to each individual represented in the thousands of organizations that subscribe to this weekly missive. But one thing’s for sure: we all know wellness is important…whatever “it” is.

Paul Keckely
Paul Keckley, Ph.D., Executive Director, Deloitte Center for Health Solutions

1 Office of the Federal Register website:

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HIX enrollment support through navigators and health centers: update 

On June 7, 2013 entities interested in serving as “navigators”—a program that helps consumers apply for coverage on the health insurance exchanges (HIXs)—had to submit their applications to the Centers for Medicare & Medicaid Services (CMS). $54 million in grant funding is available to entities operating in state-partnership and federally-facilitated exchange states. The anticipated award date is August 15, 2013.

Related: Health Resources and Services Administration (HRSA) anticipates announcing funding awards to health centers for enrollment and outreach assistance in July 2013. Health centers were required to submit applications by May 31, 2013. Per Section 10503 of the ACA, funding for health centers is being made available to ensure individuals are aware of the HIXs and are equipped with the tools necessary to apply for coverage.

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House committee hearing about solicitation of funding for ACA enrollment 

During a House Committee on Education and the Workforce hearing last week, HHS Secretary Kathleen Sebelius testified that her actions to help generate funding for the non-profit Enroll America—an organization dedicated to boosting enrollment and outreach for the ACA’s HIXs—was not illegal per Section 1704 of the Public Health Service Act.

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Employers challenged to provide pregnancy benefits  

Last week, complaints were filed against five employers because pregnancy related services are not offered to their employees’ dependents through the employer-sponsored health insurance plan. The issue: not covering pregnancy related services may be a violation of Section 1557 of the ACA, which prohibits gender discrimination in health care. 

Note: maternity and newborn care is one of ten essential health benefits that certain health plans and employers must cover beginning January 1, 2014.

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HHS launches call center to promote public awareness of ACA  

Last week, HHS Secretary Kathleen Sebelius announced that a call center will be operational July 1, 2013 to field questions from consumers on the ACA. The call center will be equipped to answer questions in 150 different languages.

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Senator Hatch seeks information about funding request for premium subsidies  

On June 5, 2013, citing a 107 percent increase in requested funding for ACA’s Advanced Premium Tax Credits (APTCs) in the President's budgets over the past three fiscal years, Senate Finance Committee ranking member Orrin Hatch (R-UT) asked the administration for a detailed explanation for the increased projection. In the Senator’s letter to HHS Secretary Sebellius and Treasury Secretary Jacob Lew, Senator Hatch asked for clarity about how much of the APTC funding was the result of employers dropping coverage or sending subsidized employees to the state health exchanges.

Background: APTCs are targeted to eligible households with income between 100 percent and 400 percent of the federal poverty level who are not offered coverage of minimum value by an employer. The White House budget for fiscal year (FY) 2012 estimated APTC outlays of $15.6 billion in FY14; its budget for FY13 was $21.6 billion in FY14—38 percent increase; and, its FY14 budget request is $32.3 billion—a 50 percent increase from FY13.

(Source: The United States Senate Committee on Finance website:

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Legislative update 

White House hosts mental health conference  

On June 3, 2013 at the White House National Conference on Mental Health, President Obama committed to making mental health a national priority, noting that mental illness impacts one in five adults and one in ten children every year and is an issue that must be addressed on a national level. He stated: “Too many Americans who struggle with mental health illnesses are still suffering in silence, rather than seeking help.” In his FY14 budget, the President called for an increase in mental health funding by $130 million to help identify mental health concerns early, improve access to mental health services, and support safer school environments. Among the biggest funding requests to support mental health programs and initiatives across the federal agencies:

  • National Institute of Health (NIH) research: $1.5 billion of the agency’s $31.3 billion budget.
  • Substance Abuse and Mental Health Services Administration (SAMHSA): $3.4 billion.
  • Veterans Administration (VA): $7 billion on agency’s $152.7 billion budget request.

In tandem with the conference, a number of parallel efforts were announced:

  • HHS Secretary Kathleen Sebelius announced the launch of as an online resource to learn about the signs of mental illness, how individuals can seek help, and how communities can host conversations about mental health.
  • SAMHSA released a “Toolkit for Community Conversations About Mental Health” to support community-wide discussions.
  • The Association of American Medical Colleges (AAMC) and the American Psychological Association (APA) announced a collaboration to expand a free, online collection of mental health educational resources for health care professionals and medical students. The materials will be publicly available and free online resource at the AAMC’s iCollaborative page.
  • The Department of Defense (DoD), VA, and HHS announced its progress on the President’s Executive Order to Improve Access to Mental Health Services for Veterans, Service Members and their families issued August 31, 2012. The VA met its goal to reduce wait times for veterans seeking help by hiring 1,600 new mental health professionals. Also, the VA is expected to host more than 150 mental health care summits in communities across the country this summer.
  • And Secretary Sebelius announced that HHS will release mental health parity final guidance by the end of 2013.

(Sources: President Barack Obama, The White House Blog, “The National Conference on Mental Health,” June 3, 2013.

Background: mental illnesses are prevalent in the U.S.:

Mental illness Annual percent of population with mental illness, by age
Children & adolescents* Adults
All disorders1 46.3% 26.2%
Anxiety disorders1 25.1% 18.1%
Attention deficit  hyperactivity disorder (ADHD)1 9.0% 4.1%
Major depressive episode (MDE)2 13.9%**  6.6%

*Data for mental illness prevalence for children & adolescents only include ages 13 through 18.
**This statistic includes ages 12 to 17.
1Source: NIMH, “Mental health data by age,” 2005
2Source: SAMHSA, “National Survey on Drug Use and Health: Mental Health Findings,” 2011

Funding for public mental health programs comes primarily from Medicaid, which includes both federal and state dollars, (48 percent); state-level general funds (42 percent); and other (10 percent).

Main funding sources for public mental health services Mental health services provided
State general mental health funds
  • Mental health services for non-recipients of Medicaid and some Medicaid recipients; community-based services; and state psychiatric hospital and inpatient services. Also used to fund treatment that is not covered by Medicaid.
  • Medicaid mental health services vary by state because federal law dictates that these services are optional for states to provide. Common services provided by Medicaid include: prescription drugs, case management, rehabilitation, and transportation to medical appointments.
  • Usually states must cover inpatient and outpatient hospital services for Medicaid beneficiaries. However, inpatient services in public psychiatric hospitals and similar facilities are often not reimbursed with federal Medicaid dollars for adults ages 22-64, and states must cover these costs.
  • States are also required to cover Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services for eligible children under age 21, which provides children with medically necessary services, even when services are not covered by Medicaid.
  • CHIP benefits vary by state; some states provide CHIP recipients with the full Medicaid mental health services.
  • The mental health parity mandate requires mental illness treatments to be covered at the same level as other medical care. States are awaiting final guidance from HHS on this law.
  • Inpatient treatment (up to 190 days during beneficiary’s lifetime); outpatient office visits with approved psychiatrists, psychologists, clinical nurse specialists, and other mental health professionals; prescription drugs.
  • Medicare requires co-pays of 50 percent for outpatient mental health treatments. By 2014, co-pays will be reduced to 20 percent.
  • Medicare does not cover community-based services.
Local government mental health block grants
  • Various mental health services are administered and funded by counties or municipalities.
Community Mental Health Services Block Grant (federal block grant)
  • Research to innovate and improve community-based services for mental illness.

(Source: National Alliance on Mental Illness (NAMI), “Public Mental Health Service Funding: An Overview,” January 2010)

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Report: nearly 30 percent of uninsured adults eligible for Medicaid expansion in 2014 have a mental illness  

The National Alliance on Mental Illness (NAMI) reported that 30 percent of the newly eligible Medicaid population is representative of individuals living with mental illnesses – about 2.7 million people nationwide. Per NAMI, mental illnesses contribute to seven million emergency room visits each year—one in eight of these by uninsured individuals. NAMI concludes that Medicaid expansion will increase access to health and mental health care and may reduce uncompensated crisis care. State by state breakdown from NAMI data:

State Percent of currently uninsured with a mental illness who will benefit from Medicaid expansion Uninsured adults with mental illness eligible for Medicaid under expansion State (cont.) Percent of currently uninsured with a mental illness who will benefit from Medicaid expansion Uninsured adults with mental illness eligible for Medicaid under expansion
Alabama 22.60% 78,691 Montana 16.70% 9,886
Alaska 16.80% 5,722 Nebraska 30.10% 24,309
Arizona 11.70% 49,318 Nevada 13.20% 26,489
Arkansas 23.20% 54,997 New Hampshire 15.00% 6,470
California 10.40% 256,202 New Jersey 10.00% 33,340
Colorado 12.20% 34,027 New Mexico 11.20% 19,093
Connecticut 19.30% 18,216 New York 13.20% 96,825
Delaware 24.20% 6,795 North Carolina 12.80% 87,624
District of Columbia 10.80% 1,536 North Dakota 11.10% 2,850
Florida 15.90% 244,272 Ohio 24.10% 136,765
Georgia 10.20% 86,058 Oklahoma 20.10% 59,043
Hawaii 10.50% 3,229 Oregon 18.90% 50,231
Idaho 20.90% 22,806 Pennsylvania 14.20% 68,544
Illinois 12.10% 82,467 Rhode Island 20.00% 8,881
Indiana 22.30% 86,574 South Carolina 21.20% 72,038
Iowa 21.00% 25,286 South Dakota 21.30% 8,490
Kansas 13.20% 21,293 Tennessee 20.40% 83,312
Kentucky 20.00% 64,608 Texas 11.20% 255,086
Louisiana 17.00% 59,320 Utah 20.30% 28,033
Maine 21.40% 8,805 Vermont 23.30% 2,934
Maryland 8.40% 16,425 Virginia 22.30% 76,974
Massachusetts 6.30% 5,753 Washington 10.40% 36,427
Michigan 19.90% 105,352 West Virginia 22.10% 27,713
Minnesota 30.10% 42,918 Wisconsin 20.00% 42,287
Mississippi 16.20% 42,312 Wyoming 17.90% 4,321
Missouri 15.50% 53,637 United States   2,744,582

(Source: NAMI, “Medicaid Expansion & Mental Health Care,” May 2013)

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SGR repeal update: issues remain about funding, replacement for physician payments  

Wednesday, the House Energy and Commerce Subcommittee on Health held a hearing on the Sustainable Growth Rate (SGR), the method used to pay providers through Medicare. Legislation is expected late July or August, but questions remain such as: what programs or agencies will experience cuts to pay for the $139 billion price of repeal and what method should be used to pay physicians going forward. Three proposals on the table have suggested replacement based on performance-based payments instead of fee-for-service, but various parties disagree on how the replacement should be structured, and how fast a change would be implemented. The Senate has held hearings on the SGR, but has not proposed legislation. For a more detailed analysis on the SGR, see the June 3 Monday Memo on Health Care Reform.

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House passes track and trace bill 

Last Monday, the U.S. House of Representatives passed an amended Safeguarding America’s Pharmaceuticals Act of 2013 (H.R. 1919) by voice vote. The U.S. Congressional Budget Office (CBO) projected that the legislation would add $39 million to discretionary spending between 2014 and 2018, and increase federal revenues $24 million from 2015 to 2023. The cost estimate was ordered by the House Committee on Energy and Commerce when the bill was introduced last month.

Background: H.R. 1919 would require the Food and Drug Administration (FDA) to establish national standards for monitoring prescription drugs through the production, handling, distribution, and dispensing of drug products. The legislation would impose new regulatory requirements on such companies relating to the handling of drug products and recordkeeping of transactions, and would create notification rules concerning drugs that are potentially unsuitable for distribution. The agency would also be required to establish a licensing program for third parties that provide logistic services to support pharmaceutical manufacturers, wholesalers, and dispensers, and would authorize FDA to collect and spend user fees to cover the costs of the licensing program.

(Sources: CBO website:;

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CMS, ONC releases data promoting transparency  

At last week’s Health Datapalooza IV an annual gathering in Washington D.C. HHS Secretary Sebelius announced that CMS has released additional data on charges for the 30 most common hospital outpatient procedures and Medicare spending and utilization. Last month, data about average charges for the 100 most common inpatient procedures for over 3,300 hospitals were released. In addition, the Office for the National Coordinator for Health IT (ONC) released data on the adoption of specific electronic health record (EHR) systems from Regional Extension Centers including brands of EHR products used by 146,000 doctors stratified by state, specialty, and each doctor’s stage in meaningful use attestation.

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State update 

State round-up: Medicaid 

To date, 27 states and D.C. have said they will or are in support of expanding their Medicaid programs; 20 states have indicated they are unlikely to expand their programs in 2014:

Announced or Governor in support of expansion Not participating or highly unlikely to participate Undecided or undeclared

Democratic Governor Republican Governor Independent Governor

Sources: NASHP, PoliticoPro, Kaiser Family Foundation. Updated May 27, 2013.

  • The Connecticut legislature approved a two-year budget of $37.6 billion reducing hospital funds by $550 million and altering accounting for Medicaid spending, i.e. the state will only include state dollars associated with Medicaid—opposed to federal and state dollars—in its budget. Over the next two years, Connecticut plans to spend $10.4 billion on Medicaid, with the federal government to cover around $6 billion.
  • The Maine Senate voted 23-12 to allow for Medicaid expansion with the option of rolling back the program after three years when the federal match decreases from 100 percent for the newly eligible population. The Senate version will return to the House, which voted 89-51 on June 3, 2013 in favor of expansion. The Senate was one vote short of the two-thirds requirement to override a veto from Governor Paul LePage (R-ME), which seems likely.
  • The New Hampshire Senate passed a two-year budget by a 12-11 vote that does not allow for Medicaid expansion, but instead establishes a commission to study the impact of expansion on the state. The state health department estimated Medicaid expansion would increase enrollment in Medicaid by 58,000 people by 2020.

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State round-up: HIX 

Seventeen states—12 led by Democratic governors, four led by Republicans, and one Independent—and the Democratic mayor of D.C. have announced plans to operate state-based exchanges. Seven states—five led by Democratic governors and two led by Republicans—will participate in state-partnership exchanges. The remaining 26 states will default to a federally-facilitated exchange.

State-based exchange State- partnership exchange Federally- facilitated exchange

Democratic Governor Republican Governor Independent Governor

*Utah’s individual market will be a federally-facilitated exchange; SHOP will be a state-based.
Source: HHS

  • As of June 4, four insurers submitted letters of intent to sell on the Arkansas state-partnership exchange. Cynthia Crone, director of the HIX planning process, believes participation of these four insurers will provide enough competition to keep premiums low in the state.
  • In the District of Columbia, four insurance companies have submitted proposed rates for approval for approximately 300 health insurance plans to be sold on the D.C. Health Benefit Exchange.

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State round-up 

  • Starting July 1, Mississippi doctors and midwives will be required to take umbilical cord blood samples from babies born to women under the age of 16 to compare samples to the state DNA database in order to identify if the father is more than three years older than the woman per HB 151. If so, state statutory rape law will apply. Of the 6,100 births to teenagers in 2012, 111 were babies born to girls under the age of 15, and roughly 65 percent of teenage pregnancies in Mississippi are between teens one to two years apart. Fourth Amendment protections come into question because the law does not explain how the state can require health care workers to collect evidence without probable cause, a search warrant, or permission from involved persons.
  • According to a Health Affairs study published last week, California fair pricing legislation passed in 2006 led to more affordable care for 6.8 million uninsured Californians. Under state law, uninsured patients are protected from having to pay full billed charges. Researchers found that 97 percent of California hospitals offer free care to uninsured patients with incomes at or below 100 percent of the federal poverty level, and most California hospitals adopted financial assistance policies by 2011 in response to the law.
  • A Wisconsin initiative to expand access to a public health insurance program for low-income, childless adults significantly reduced hospitalizations according to a Health Affairs article published last week. Researchers concluded that in one year, outpatient visits for the study population increased 29 percent and emergency department visits increased 46 percent; inpatient hospitalizations declined 59 percent and preventable hospitalizations fell 48 percent.
  • The Federal Trade Commission (FTC) is challenging a new Connecticut law that allows physicians in “cooperative arrangements” sovereignty from antitrust laws. Similar legislation has been passed in several states enabling physicians to negotiate payment rates with insurers. “The bill's attempt to confer antitrust immunity is unnecessary for legitimate collaborations and, if effective, would encourage groups of private health care providers to engage in blatantly anticompetitive conduct,” the FTC's 10-page comment letter concluded. “In summary, FTC staff is concerned that this legislation is likely to foster anticompetitive conduct that is inconsistent with federal antitrust law and policy, and that such conduct could work to the detriment of Connecticut health care consumers.”

(Source: Federal Trade Commission website:

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Industry news 

Report: premiums reduced as result of ACA  

Individual policyholders are expected to receive a combined $241 million in rebates later this summer as a result of medical loss ratio (MLR) violations by health plans, totaling an estimated savings of $2.1 billion for 2012, according to a Kaiser Family Foundation analysis released June 6, 2013. Researchers estimate that individual premiums would have been $1.9 billion higher in 2012 without the MLR requirements established by the ACA.

(Source: Cynthia Cox, Gary Claxton, Larry Levitt “Beyond Rebates: How Much Are Consumers Saving from the ACA’s Medical Loss Ratio Provision?” Kaiser Family Foundation, June 06, 2013)

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Health care employment continued to trend up May: Bureau of Labor Statistics  

Over 11,000 health care jobs were added in May. Job gains in home health care services (+7,000) and outpatient care centers (+4,000) more than offset a loss in hospitals (-6,000). Over the prior 12 months, job growth in health care averaged 24,000 per month. 

(Source: Bureau of Labor Statistics website:

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ACO risk sharing with commercial insurers, Medicare  

ACOs participating in shared risk arrangements with commercial payers are less likely than Medicare to contract on an “upside-only” basis, per analysis of 85 ACOs. One-third of these are for upside-only shared savings—where savings are split evenly between insurers and providers and there are no penalties imposed for failing to meet goals. But of these, 21 percent are offered by commercial payers; more than half are through the Medicare Shared Savings Program or Medicare Advantage.

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Medical spas: medical treatments and beauty treatments?  

There are approximately 1,750 medical spas in the U.S.—up from 471 in 2003 per the International Spa Association. Some are sponsored by physicians—dermatologists, cosmetic and reconstructive surgeons, and obstetricians. States including Florida, Maryland, and Pennsylvania are now trying to determine if they should be licensed by states since they provide some medical treatments covered by insurance. Some physicians favor tougher rules; stay tuned.

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Medical oncologist survey: Cancer drug shortage  

Based on a survey of 250 medical oncologists:

  • 94 percent said the shortages had an impact on patients’ treatment
  • 83 percent were unable to provide standard chemotherapy
  • 13 percent reported that shortages interfered with clinical trials
  • 78 percent switched treatment regimens
  • 43 percent delayed treatment

(Source: Survey conducted in 2012 by Keerthi Gogineni, University of Pennsylvania School of Medicine for the American Society of Clinical Oncologists)

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Immunotherapy strategy gets attention at national meeting  

The buzz at the American Society of Clinical Oncology (ASCO) meeting in Chicago last week was the potential of a second line of attack in treating cancer: the traditional approach uses chemotherapy that can have debilitating side effects. The newer strategy is based on immunotherapy wherein a promising class of drugs is used to disable the immune system’s receptor that feeds the cancer. Investigators are conducting studies to advance immunotherapy solutions toward market adoption.

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Research snapshots 

Meaningful Use Criteria and Managing Patient Populations: A National Survey of Practicing Physicians

Objective: “to evaluate physicians’ reports of EHR adoption, ease of use, and their ability to use EHRs for patient panel management.”

Methodology: national mailed survey of 1,820 office-based practicing physicians (response rate of 60 percent) conducted late 2011 thru early 2012.

Key findings: “43.5 percent of physicians reported having a basic EHR, and 9.8 percent met Meaningful Use criteria. Computerized systems for managing patient populations were not widespread; less than one half of respondents reported the presence of computerized systems for any of the patient population management tasks included in the survey. Physicians with such functionalities reported that these systems varied in ease of use. Physicians with an EHR that met meaningful use criteria were significantly more likely than those not meeting the standard to rate panel management tasks as easy.”

My take: it is not surprising that few physicians could meet Meaningful Use criteria in early 2012, which involves using computerized systems for patient-panel management. I suspect the use of computerized systems is changing fast as three of four physicians are on the road to Meaningful Use, and it may widen the gap between larger technology enabled practices and smaller practices that stay behind.

(Source: Catherine M. DesRoches, DrPH; Anne-Marie Audet, MD; Michael Painter, MD; and Karen Donelan, ScD Meeting “Meeting Meaningful Use Criteria and Managing Patient Populations: A National Survey of Practicing Physicians” Annals of Internal Medicine, June 4, 2013)

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“Starting in January, insurers will no longer be able to set premiums for small-group plans—which apply to employers with fewer than 50 or 100 employees, depending on the state—based on a firm's industry or the health or gender of its staff. Insurers will still be able to take into account the age of a firm's workers, though to a lesser extent, and whether or not those people use tobacco. The result: the cost of health care will be more evenly spread among small businesses, as employers with mostly young and healthy workers pick up the costs of firms that comprise the opposite. The rebalancing will drive up premiums for some companies in industries with lots of young, healthy workers, such as technology, while moderating rate increases for firms with older and sicker workers, and in higher-risk industries such as industrial manufacturing.”

- Sarah Needleman, Wall Street Journal, “How the New Health Law Could Raise Costs for Young, Healthy Employees,” June 7, 2013

“A lot of opponents of the Affordable Care Act … had all kinds of sky-is-falling, doom-and -gloom predictions that not only would the law fail, but what we would also see is costs would skyrocket…It turns out that what we are seeing in the states that have committed themselves to implementing this law correctly, we’re seeing some good news…. If you're one of 6 million Californians or tens of millions Americans who don't currently have health insurance, you'll soon be able to buy quality, affordable care just like everybody else...All of this is happening because of the Affordable Care Act.”

—President Obama speech in San Jose, California, June 7, 2013

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Fact file 

Consumer perspective of wellness and healthy living programs

  • Participation in wellness and healthy living programs sponsored by employers or health plans: declined between 2011 (25 percent) and 2012 (10 percent). Both insured and uninsured consumers reported lower rates of participation in 2012 compared to previous years. (Source: Deloitte Center for Health Solutions (DCHS) Survey of U.S. Consumers 2012)
  • Use of primary care for preventive health: in 2012, 65 percent say they had a wellness check-up in the past 12 months—down from 2011 (76  percent), 2010 (68 percent), and 2009 (73 percent).The insured are twice likely to report seeing a doctor for a well visit or routine check-up in the past year vs. those adults without insurance (72 percent  vs. 36 percent). (Source: DCHS Survey of U.S. Consumers 2012)
  • Consumers purchase a wide variety of alternative and supplemental health products (i.e. the nutrition industry, vitamins and health supplements): spending has increased in these categories over previous years and is anticipated to continue. (Source: DCHS, The Hidden Costs of U.S. Health Care: Consumer discretionary health care spending)
  • Self-perception of healthiness: most adult consumers in 2012 believe themselves to be in good health (84 percent), slightly fewer than in 2011 (91 percent), but 52 percent say they have been diagnosed with one or more chronic conditions (similar to 2009, 2010, and 2011). (Source: DCHS Survey of U.S. Consumers 2012)
  • Incentives to participate: few consumers (5 percent) say they are willing to pay full cost for health coaches and 8 percent of consumers would pay full cost to undertake annual health screening. If incentives are offered, 55 percent say they would meet with a health coach. If meeting with a health coach was offered for no out-of-pocket cost, 57 percent say they would be willing to use a health coach and 66 percent would undergo an annual screening exam. (Source: DCHS Survey of U.S. Consumers 2012)
  • Willingness to change health habits: around half (49 percent) of consumers who engage in tobacco use and one-quarter (24 percent) who drink alcohol say they are trying to reduce intake. (Source: DCHS Survey of U.S. Consumers 2012)

Employer sponsorship of wellness programs

  • Employer sponsorship: 90 percent of U.S. companies with 200 or more workers that provide health benefits. In 2011, investment in health improvement programs was estimated at around 2 percent of companies’ medical spend.(Source: Kaiser Family Foundation and Health Research & Educational Trust, Employer Health Benefits: 2012 Annual Survey, 2012)
  • Participation by employees: 20 percent of an employer’s eligible population participate in an employer-sponsored program. (Source: Soeren Mattke, Christopher Schnyer, and Kristin Van Busum, A Review of the U.S. Workplace Wellness Market, RAND Corporation, July 2012)
  • Association between participation and cost savings: high participation for both health risk assessments (HRAs) and biometric screenings completion has been associated with a trend toward lower health costs, with companies with high participation achieving an average 6 percent health cost growth compared to between 7.2 percent and 7.5 percent for companies with lower participation. (Source: S. Nyce, “Boosting Wellness Participation Without Breaking the Bank,” Towers Watson Insider, July 2010)
  • Popular elements in employer sponsored programs: The most popular programs sponsored by employers offer weight loss services, online education, smoking cessation and discounted fitness facility access:

Incentives in program design: evidence about the association between incentive value and participation rates is spotty:

  • A 2009 study found that HRA participation rates increased by 1.58 percent for every $20 of incentive value. (Source: E. L. D. Seaverson et al., “The Role of Incentive Design, Incentive Value, Communications Strategy, and Worksite Culture on Health Risk Assessment Participation,” American Journal of Health Promotion 3, no. 5 (2009): pp. 343–352)
  • A study projected that participation in HRAs would increase by 7 percent for each $100 increase in incentive value, achieving a maximum 100 percent participation with a $700 incentive. Integrating an incentive level of $200 into a health plan is claimed to raise HRA participation rates from between 20 percent and 40 percent (without the use of incentives) to close to 90 percent. (Source: G. d’Andrea and M. Dermer, Impact of Incentive Values on Participation in Comprehensive Wellness and Health Risk Assessment Interventions, November 2009)
  • A 2008 study found a relationship between incentive amount, organizational conditions, and HRA completion. In this study, companies with high levels of health care-related communication and organizational commitment to wellness programs needed an incentive value of $40 to achieve 50 percent participation in completing HRAs; companies with medium levels of communication and organizational commitment required an incentive value of $80, and companies with low levels an incentive value of $120, to achieve the same target (Source: M. S. Taitel et al., “Incentives and Other Factors Associated With Employee Participation in Health Risk Assessments,” Journal of Occupational and Environmental Medicine 50 (2008): pp. 863–872)

Interested in learning more? Check out the Deloitte Center for Health Solutions’ report: Breaking Constraints: Can incentives change consumer health choices?

Employer opinions about wellness and healthy living

  • Employer perception of value: 43 percent of employers believe wellness programs provide high value for dollars invested in the health system behind primary care (61 percent), prescription drugs (50 percent), hospitals (47 percent), and specialty medicine (46 percent) and ahead of insurance companies (39 percent) and retail clinics (31 percent) (Source: DCHS 2012 Survey of US Employers)
  • Employer investments in wellness: employers expect to maintain or slightly increase investments in their wellness programs:

(Source: DCHS 2012 Survey of US Employers)

Long term plans for wellness: Employers anticipate increasing investments in wellness programs in tandem with increase shifting of financial responsibility (accountability) to employees:

What changes do you anticipate making to your benefits strategy in the next 3-5 years?

(Source: DCHS 2012 Survey of US Employers)

Major ACA provisions impacting wellness

To view more information on the major ACA provisions impacting wellness, download the table.

(Sources: HHS, ACA)


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Subscribe to the health care reform memo 

Health care reform memo — The weekly health care reform memo is available for subscription. Please visit /healthmemos/subscibe.

  • Step 1, confirm your sector(s) of interest. 
  • Step 2, select the health care reform memo as one of your subscriptions.

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