October 16, 2009 | George J. Pantos, Human Resource Executive Online
The proposed bills add costly new regulatory and administrative burdens that create significant uncertainty and will cause many employers to weigh their long-term business health-plan strategies, according to this opinion piece. The rationale for continued health coverage may be hard for some organizations to swallow and it is highly possible many will discontinue their health plans -- and instead opt to pay a fee to the federal government.
The quest for health reform by a divided Congress is echoing loudly across the employment-based landscape. The direction of House and Senate legislative proposals threatens to undercut the existing employer-based system and does little to improve health quality or contain costs.
Congressional proposals would establish a new government-centric healthcare system composed of state-based health-insurance exchanges; employer "pay or play" mandates; a new federal health-insurance entitlement program with subsidized coverage, excise taxes and fees on insurers and employers, and expanded eligibility for Medicaid.
The Congressional Budget Office estimates a net cost of $774 billion over 10 years for the proposed expansions in insurance coverage, credits and subsidies.
With vastly more people covered by the current employer-based health system than are outside that system, it is no surprise that millions of Americans view the cost and benefit impacts of these proposed changes with growing skepticism and suspicion.
Unless drastically revised -- just as the Employee Retirement Income Security Act was overhauled in conference committee 35 years ago -- the pending legislation poses a real threat to the future employment-based healthcare system.
A new federal structure and costly new regulatory and administrative burdens create significant uncertainty that will cause employers to weigh their long-term business health plan strategies. In this respect, the rationale for employers to continue health coverage may be hard for some to swallow and it is highly possible that many will discontinue their health plans -- and instead opt to pay a fee to the federal government.
Although Congress is divided and a final outcome is far from decided, the disturbing government-centric direction of the pending bills and their devilish details impacts significantly on employer-sponsored plans that now cover 165 million people.
Key Components
Four key common components of the 253-page plan unveiled by Senate Finance Committee chairman Max Baucus and the massive tri-committee House bill (H.R.3200) illustrate these concerns:
* Starting in 2013, all Americans would have to enroll in a health-insurance plan meeting minimum federal standards or face a financial penalty.
* New insurance reforms affecting such practices as guaranteed issue, pre-existing medical condition limits, medical-loss ratios and rating would go into effect in 2013.
* A system of new state-based health-insurance exchanges through which individuals could access subsidized health insurance would be established.
* A "pay or play" provision would require employers to offer health insurance coverage or pay a fee to the federal government.
In addition, the House bill calls for a controversial "public plan" run by the U.S. Department of Human Services to be offered in the exchanges; the Baucus bill does not include the public option but instead calls for nonprofit health cooperatives.
On a preliminary basis, the nonpartisan Congressional Budget Office estimates the Baucus plan will have a $463 billion cost impact in federal subsidies for coverage through the new insurance exchanges.
While slightly less onerous than the House measure, the Baucus plan would significantly raise the cost of employer-provided healthcare by imposing a variety of fees, taxes and penalties on employers, particularly firms with many lower-paid employees and very little participation in their health plans.
CBO estimates the revenues from the excise tax on high premium insurance plans ($8,000 for single policies and $21,000 for family policies) would be $274 billion over a 10-year period.
The 35-percent excise tax proposed by Baucus on "high-cost" plans will dramatically affect employers sponsoring plans for employees. This is a cost that must ultimately be borne by employers and employees because it is a tax that will either reduce wages, benefits or the number of workers on employer payrolls.
The Baucus proposal also calls for an assessment totaling $20 billion to fund a new government high-risk pool for individuals. Health insurers and self-insured employers would be required to contribute to this pool starting in 2013.
While hardly a model of clarity, the ambiguous language in the 1,000-plus page House bill and the Baucus plan would significantly impact the existing system; the diverging provisions also set the stage for troubling, conflicting interpretations of complex provisions that will ensure lucrative future employment for countless attorneys and lobbyists.
Impact on Employer-Based System
There is ample evidence that the overall impact of the both the House and Senate bills would diminish the major role of the employment-based system.
First, a new federal legal structure would be created that is superimposed over current law. Because ERISA does not pre-empt other federal laws, the new federal provisions would apply to insured plans as well as self-insured plans that cover nearly 75 million individuals.
New federal insurance standards designed primarily to eliminate certain restrictions and practices under insured plans would apply to self-insured plans as well, thus eroding the important distinction between insurance and self-insurance as funding methods for health benefits.
Among insurance reforms under discussion are pre-existing condition exclusions, provider-network adequacy rules, prompt pay, claims external-review procedures and subrogation.
Second, the House bill would allow for waivers from ERISA federal pre-emption. While not in the Senate bill, this misguided provision opens the door to state health-reform efforts that would further undermine an original purpose of existing federal law aimed at promoting uniform, cost-effective national benefits across state lines.
Third, the proposed House "pay or play" provision calls for employers with annual payrolls of at least $400,000 to elect qualifying coverage or pay an 8-percent payroll tax. Employers could elect to cancel coverage in exchange for paying a tax.
Moreover, states would be allowed to move ahead with their own employer mandate efforts, posing a serious problem for uniform health benefits sponsored by multi-state employers.
The Baucus plan does not explicitly require employers to offer health insurance, but employers with more than 50 employees who do not offer coverage would be subject to a penalty for any workers who obtain subsidized coverage through the insurance exchanges.
While the future of this provision is uncertain, it would open a crack in the "firewall" between the exchanges and the employer plan (for workers who have to pay more than 13 percent of their income for employer coverage).
As for the specifics, eventually all employers would be allowed to transition into the government-supervised exchanges; employees of existing plans can migrate at any time. The CBO says only 12 million to 15 million people would migrate by 2017, but the Lewin Group puts the figure at 83.4 million people, or nearly half (48 percent) of covered employees.
Exchange-based plans must offer a federally approved minimum "essential benefit package" for "core" and "tier" coverage. State-mandated benefits would be included in the basic package and the Department of Health and Human Services could add additional benefits such as substance abuse and mental health.
While some of these changes will provide greater access to health coverage for the uninsured, such reform will come at a significant cost. CBO estimates the House proposal would result in federal budget deficits of over $1 trillion (that's 12 zeroes) over the 2010-2019 period, including about $773 billion in federal subsidies for insurance purchased in new exchanges.
Considering proposed offsets, the House package under discussion would drive up future deficits by $240 billion or more -- hardly a ringing endorsement for cost containment.
Strengthen Employment-Based System
A recent Washington Post-ABC poll concludes most Americans believe current reform proposals will make their own health coverage worse. Surveys say that three of four individuals under age 65 have employer-health coverage and that the overwhelming majority are generally satisfied with benefits they get through their employment.
Evidence submitted during hearings underscored that the federal framework now regulating the job-related health-benefits system can be strengthened in a multiplicity of federal laws including ERISA. New incentives to stimulate transparency and greater use of technology to control healthcare costs are also needed.
Employers have been at the forefront adopting market-based cost-saving innovations, such as programs for wellness, disease management and pharmacy management. With greater employee engagement through social media, these programs can successfully address the nation's growing "disease burdens" (obesity, smoking, etc.) that adds billions of dollars to healthcare costs.
A common sense innovation -- health-plan performance management -- utilizing social media as well as data and predictive-modeling analytic technology is showing early promise in reducing health costs -- without the expenditure of a single dime in government spending.
New software programs can give employers the technical tools needed to manage their health plans just as they manage other aspects of their business. Employers proactively managing their plans with new technology report millions of dollars in cost savings.
Finally, differing House and Senate bills set the stage for a conference committee to resolve differences so a final bill can be sent to the president for signature. The challenge for Congress is to walk a fine line by adopting needed reforms, while strengthening the current system.
Congress should hold President Obama to his frequently stated promise that "if you like what you have, you get to keep it."
It took Congress nearly 10 years get it right when it enacted ERISA -- a successful model of health reform. Let's hope that the "world's greatest deliberative body" gets it right again.
George Pantos is former U.S. Deputy Undersecretary of Commerce and was general counsel to the Self Insurance Institute of America, He is now a senior adviser to WellNet Healthcare.
October 16, 2009
Copyright 2009© LRP Publications
Top of pageTexas' Transparency of Health Claims Data Law Serves as Model for Nation
October 16, 2009 | George J. Pantos, MyHealthGuide
Source: Employer’s Guide to Self-insuring Health Benefits, published by Thompson Publishing Group
Employers who sponsor health plans need meaningful claims information to make more informed choices about their plan funding options, including self-funding under ERISA. This report outlines the benefits of greater health claims data transparency, summarizes federal privacy provisions, and reviews the features of a unique new Texas law — the first of its kind in the nation — that could serve as a model for other states seeking solutions to escalating plan costs.
Just as consumers need reliable product information when they are in the market for the items they buy, so too employers that sponsor health plans need meaningful claims information and loss experience data when making decisions about how to spend their valuable health care dollars.
Timely and detailed claims information facilitates cost-efficient management and administrative decisions by employers that sponsor group health plans. By analyzing what they are spending on health insurance and the benefits received by their employees, employers are able to identify the services, risk exposures and utilization trends that lead to high costs and help them to make better choices about how to manage their plans
Detailed claims data helps employers to customize health plan design, including cost sharing, as well as to develop risk management strategies that improve plan performance and control costs.
Greater transparency of claims data also provides employers with important data to tailor valuable disease specific programs (for example, diabetes, cardiovascular) for employees, including special wellness programs and disease specific information programs.
Ready access to timely claims information allows employers to make informed decisions about plan financing options, including self-funding the plan under ERISA. An employer interested in obtaining competitive bids on new coverage — whether from an insurer or to consider self-funding — needs access to timely health insurance plan information.
Employers considering the self-insurance option will usually purchase stop-loss insurance to cover their liability above specific/aggregate attachment points. The cost of stop-loss coverage will depend largely on plan claims and loss experience data. Ultimately, complete and detailed claims information is vital so that the stop-loss carrier can quote medical stop-loss on a currently fully insured plan.
Barrier to Claims Data Transparency
Employer/plan sponsors seeking claims data have encountered resistance from many insurers who have raised concerns about possible exposure to liability for violation of privacy laws in connection with release of claims and loss data.
Insurance carriers have been reluctant to hand over plan claims data to employers, except in Texas where a state law requires transparency of plan claims data by insurers. This industry practice has been a barrier to transparency, depriving many employers from access to valuable information from their own health plans that can help them achieve significant cost control.
Data and predictive modeling technology based on analysis of plan claims data is producing significant results in controlling and reducing health costs — without the expenditure of a single dime in taxpayer funds. The claims data transparency issue is not squarely addressed in pending health reform bills.
HIPAA and Privacy Concerns
While Congress sought to protect the privacy of individual medical information in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) 1, the law provides federal standards and strict safeguards about the right of access to protected health information (PHI).
Under HIPAA, insurance carriers (often referred to as “issuers”) are permitted to release individual PHI to the employer/plan sponsor, either in its capacity as the Plan Administrator or as a fiduciary.2
ERISA defines “Plan Sponsor” as “the employer in the case of an employee benefit plan maintained by a single employer…”3
Generally, under the privacy rules, a health insurance issuer is allowed to disclose certain “summary health information” to the plan sponsor for the purpose of obtaining bids from other health insurers or health plans. This includes data relating to claims history and claims expenses, as well as total claims and total dollars paid.
However, clearly, more than summary health information is needed by the employer in order to perform its duties as a plan fiduciary. To obtain meaningful, competitive quotes from other insurers or to consider self funding the plan, comprehensive claims data is needed by the employer.
Administrative Functions
To facilitate access to more detailed information, HIPAA rules permit the release to the employer/plan sponsor of certain individual PHI data to allow the employer/plan sponsor to carry out its administrative functions. 4
ERISA defines “Administrator” as “the person specifically so designated by the terms of the plan…” 5. Generally, the Plan Administrator is responsible for all operations and administration of the plan.
Under HIPAA’s standards and rules, disclosure and use of plan information for “treatment, payment and health care operations” (“TPO activities”) is permitted without written consent or an individual authorization. Health care operations include:
Underwriting and other activities related to creation, renewal or replacement of a contract of health insurance or health benefits;
Ceding, securing or placing a contract for reinsurance or risk relating to claims for health care (including stop-loss insurance and excess loss insurance. 6
Compliance with these provisions must be carried out consistent with appropriate plan procedures and applicable legal requirements.
For example, HIPAA rules require covered entities (essentially health plans, issuers and providers) to establish a contractual arrangement with their business associates —accountants, attorneys, auditors, data processing firms, among others — that includes assurances for safeguarding the confidentiality of protected information. This is HHS’ approach to ensure that the law’s protection is extended to information shared with others in the health care system.
In summary, rather than serve as a barrier to the release of important claims and loss information, HIPAA is intended to streamline the flow of information integral to operation of the health care system while protecting confidential health information from inappropriate access, disclosure and use.
Texas Claim Data Transparency Law
HIPAA takes the position that the federal privacy rules permit the disclosure of health plan information to the extent required by other law. 7
Texas is the first state to pass a health care transparency law. The Texas law (HB 2015) amends the Texas Insurance Code and establishes new claims information disclosure requirements for health insurance carriers that contract with employers. 8
The Texas statute recognizes that in order to control health costs, employer/plan sponsors must be able to examine how they spend their money on health care for their employees. To do this, employers must have access to claims and loss experience information which demonstrates the amount spent on employee health care and the manner in which it is spent. 9
The legislative history acknowledges the problems encountered by employers in obtaining this data:
Despite the importance of this issue to a competitive health care market, most employers across the state are routinely unable to obtain timely and meaningful claims or loss experience information pertaining to their health plans. 10
Complementing the federal statute, the Texas law establishes the right of employer/plan sponsors in the state to have access to their own health plan claims data.
The legislation, which became effective January 1, 2008, calls for greater plan transparency through standardized disclosure of health claims data, including protected data, by requiring group health insurers operating in Texas to release claims data to the employer or group policyholder.
Texas Law Requirements
Setting a new legal disclosure standard, the Texas law requires an insurer to respond within 30 days after the date a written request for a written report of claim information is received from a plan, plan sponsor or plan administrator.
The claims information report is required to contain all information available to the insurer that is responsive to the request, for example, such as:
Aggregate paid claims experience by month;
Employee census data;
Total monthly premiums; and
Total dollar amount of pendant claims.
Insurers must provide a separate description and individual claims report when total paid claims exceed $15,000 in a 12-month period. Specific claims over $15,000 include a unique identifying number, characteristic, or code for:
The individual;
The amounts paid;
Dates of service; and
Applicable procedure codes and diagnosis codes.
The Texas law requires an employer/plan sponsor to provide the proper certification that appropriate plan amendments have been made by an authorized plan representative. This is required to insure that proper HIPAA safeguards are in place in compliance with federal regulations and state insurance provisions..
On receipt of the report from the issuer, the employer/plan sponsor may make a written request for additional information within 10 days for specified individuals. With respect to this request, the insurer is required to provide additional information relating to the prognosis or recovery if available for individuals in active case management, the most recent case management information, including any future expected costs and treatment plan that relate to the claims of that individual must be provided.
Caveat: An issuer is prohibited from disclosing protected health information if disclosure of the information is prohibited under another state or federal law that imposes more stringent privacy restriction than those imposed under HIPAA.
The Texas law is designed to facilitate timely and accurate exchange of information by allowing the health insurance carrier or HMO to send the information electronically or to post the information on a web site accessible to the requesting employer.
Health Reform and Transparency
Pending health reform legislation in the House (H.R. 3200) would require health plans to meet standards established by the Health Choices Commission relating to transparency and timely disclosure of plan documents and information, but does not reference health claims data transparency.
Employer health plan sponsors concerned about escalating health plan costs need access to claims information and loss data in order to assess plan performance, cost trends and how they are currently spending health care dollars. Employers with access to such information will be able to make sound business decisions about the more efficient operation of their health plans, including evaluating all available options for funding and coverage—whether insured or self-insured—that are beneficial to plans and covered participants.
Health reform legislation truly designed to achieve significant cost savings should require transparency of claims data so that employers who pay over $1 trillion dollars for health care can utilize available technology immediately to analyze plan trends and adopt actionable strategies to control health costs.
Notes
Health Insurance Portability and Accountability Act of 1996, as amended, 29 U.S.C.
Sec.1181, et. seq. (HIPAA).
45 C.F.R. Sec. 164.501 (2000)
Employee Retirement Income Security Act of 1974, as amended, 29 U.S.C. Sec.1002
45 C.F.R. Sec. 164.504 (f) (3)
29 U.S.C. Sec. 1002 (16) (A)
45 C.F.R. Sec. 164.506
HHS E-Mail, March 11, 2008
H.B. 2015, signed June 15, 2007 by Governor Rick Perry
Senator Smithee, Bill Analysis, (# 80R145888 DLF-F), May 13, 2007)
H.B. 2015, Section 1215.002-03.
About the Author, George Pantos, Esq.
George Pantos is former Washington General Counsel to Self-Insurance Institute of America (SIIA), and now a consultant with WellNet Healthcare in Bethesda, Md. He is an editorial board member of Thompson Publishing Group’s Employer’s Guide to Self-insuring Health Benefits.
October 6, 2009 | Brett Chase, Portfolio.com
Fed up with rising health costs, CEO Lewis Dickey of radio-station owner Cumulus Media has used software from WellNet Healthcare to identify $4.1 million in potential savings.
Chief executive Lewis Dickey is taking an unusual step toward tackling health care costs: He's taking charge of the matter himself.
The head of Atlanta-based radio-station owner Cumulus Media Inc. scours data to learn what drives cost increases. Fed up with his human resources department's inability to halt runaway costs, he personally took over analyzing health care trends for his 3,500 employees.
Most CEOs delegate such tasks. But technology is allowing top managers such as Dickey to get more involved. He uses a software system from WellNet Healthcare in Bethesda, Maryland, that tracks pharmacy claims on a daily basis, helping him size up and manage health care costs. WellNet helped him identify $4.1 million in potential savings for Cumulus. One way to save: using nurses to counsel employees at high risk for health problems in the hopes of reducing hospital visits. WellNet also saved the company $400,000 by negotiating prescription-drug pricing and is identifying ways to save more money by switching employees from branded medicines to cheaper alternatives.
"The more time I spend with it, the amount of inefficiencies become very apparent," Dickey says. "Most of this does not make its way to the C-level. It's handled at human resources. I think that's a big mistake today."
Surging health insurance costs are a challenge for companies big and small. The average family premium for all employer-based health plans is $13,375, up 34 percent from five years ago and up 131 percent from 10 years earlier, according to Kaiser Family Foundation. Another group, Business Roundtable, predicts premiums will rise to almost $30,000 a year a decade from now unless health reform is passed.
As high as health care costs are today, they would be even steeper if companies weren't using data to help develop programs to combat costs, says one industry expert.
"It would be unimaginable to not have this analytic capability," says Helen Darling, president of the National Business Group on Health. "It would be a little like not having financial statements."
Despite the increasing frequency of upward premiums, there are companies that buck the trend. Some even hold their health insurance costs in check, says Michael Miele, president of the Princeton, New Jersey-based Healthcare Analytics division of insurance broker Arthur J. Gallagher & Co.
"Almost every one of them will tell you that they started with a deep base of analytics," Miele says.
Miele's group looks for clues to rising costs by studying hospital admissions, prescription patterns, and medical management cases. Miele tries to save companies money by challenging a company's health care vendors when a problem is detected.
Some companies are turning to vendors like WellNet, which creates programs aimed at simplifying information so even CEOs who can't maintain a full-time focus on the health care problem can quickly understand what's driving higher costs.
Michael McBride, CEO of nursing-home operator HMR Advantage Health Systems of Easley, South Carolina, says in years past he relied on data provided by insurance brokers that was cumbersome and not as easy to understand.
"They were just basically a messenger for the carriers with no efforts made toward claims management," McBride says. "I just knew we couldn't sustain 18 to 19 percent increases a year when the revenue stream was going up 3 percent a year."
Like Dickey, McBride turned to WellNet.
Using pharmacy-claim data, WellNet identified 379 of 1,900 HMR employees as high- or moderate-risk for health problems. A high number were identified as having high blood pressure and other health issues. With their permission, WellNet's nurses reached out to 132 of those employees and found some were not taking prescribed medicines or following up with doctors about medical issues.
WellNet lowered McBride's company health costs by $1.8 million from the year prior by changing employee health practices through counseling. The savings came from fewer visits to the hospital, especially the emergency room.
WellNet found a way to save money on employees' prescription-drug costs too. It studied HMR's drug spending and found the cholesterol drug Lipitor was costing the company on average $466 per employee each year. So WellNet suggested that HMR try switching employees over to an older, cheaper drug by offering to pay for that medication for three months. Twenty of the 48 Lipitor users ultimately converted to the cheaper medicine, which will save HMR around $5,000 a year. WellNet says there are at least 30 other drugs HMR employees are taking that can be replaced with cheaper or generic alternatives.
"We're self-funded. The only way you can control costs is through reduced claims or manage the claims you have," McBride says. "Our attempts are to drive people to more healthy lifestyle with some coaching and managing."
WellNet President Keith Lemer says top managers should get involved with health care oversight. Chief executives and chief financial officers understand the economics of ordering paper better than they understand major expenses like health care costs.
"If they want to control it, they have to take control," Lemer says.
Dickey concurs. "I could immerse myself in office supplies, and in 15 minutes I could have a knowledge about that," Dickey says. "It's a simple thing to jump into. But understanding health insurance is different."
Claims Data Still A Secret Weapon in Care, Cost Containment
October 1, 2009 | Ken Krizner , Managed Healthcare Executive
The most potent weapon in the campaign to control costs—until EMRs reach critical mass—might be claims data. All the pertinent information is found there, including the provider, type of treatment or procedure, prescriptions, as well as the cost of service for the plan, sponsor and member.
While that information is useful, it only scratches the surface of what claims data can tell health plans and payers about their members. By accessing electronic claims data, health plans can mine, analyze and download information about members individually or collectively. This data can be used to determine which members are at risk for specific health issues and inform disease management program design to help them before the event occurs.
"So much of the information that would tell a plan what is driving the cost of healthcare is either unavailable or late," says Keith Lemer, president of WellNet Healthcare in Bethesda, Md. "What winds up happening is you don't get to the root cause of the problem—what is driving costs and what type of action can be implemented on the appropriate segment of the population to keep those costs down."
You Have No Idea What Health Costs; If You Did, You Might Just Want Real Reform
September 20, 2009 | Ezra Klein, The Washington Post
Washington, D.C. -- The most important health-care document released this week was not Sen. Max Baucus's Healthy Future Act. It was the Kaiser Family Foundation's 2009 Employer Benefits Survey.
While the proposal by Baucus, chairman of the Senate Finance Committee, outlines a direction for policy, the survey, which polls employers about health benefits to assemble a detailed look at the actual cost of health care, fits it squarely in our pocketbooks.
The truth is we all pay, and much more than we recognize, for health care.
Keith Lemer: Health Care Needs Competition, Transparency
September 10, 2009 | Keith Lemer, Business Week: In Your Face
BETHESDA, MD -- Reader Keith Lemer Writes: President Obama did an excellent job sharing his ideas and beliefs about the health care system and changes last night. Unmentioned details that are imperative to discuss, however, are transparency, employer and employee engagement, transportable medical records and increased competition. Wrapped around the removal of impediments to competition, all of the above will allow the private market to thrive. The call for increased accountability on the part of the nation's businesses requires more than a mandate to insure -- give cost-cutting technology to the entities paying the bills, as they have the greatest motive to find waste, overcharging, lower prices and alternative medical solutions. The end result of this is that the private market will force the insurers to be competitive. When transparency and alternatives are absent, consumers suffer from higher prices, fewer services and less choice - which is where we stand right now.
Mr. Lemer's comment was in response to the Obama: 'The Time for Bickering Is Over' article written by Catherine Arnst on September 9, 2009.
George Pantos: Charles Krauthammer's Article on The Great 'Prevention' Myth Does Not Tell the Whole Story
August 16, 2009 | George Pantos, Esq., Former Washington General Counsel to Self-Insurance Institute of America (SIIA), MyHealthGuide Newsletter
BETHESDA, MD -- Charles Krauthammer wrote the article, The Great 'Prevention' Myth, that was published on August 14, 2009 in the Washington Post. The article states that "President Obama has lost the health-care debate... Accordingly, Democrats have trotted out various tax proposals to close the gap" such as prevention as saving heath care costs.
"This inconvenient truth comes, once again, from the CBO. In an Aug. 7 letter to Rep. Nathan Deal, CBO Director Doug Elmendorf writes: 'Researchers who have examined the effects of preventive care generally find that the added costs of widespread use of preventive services tend to exceed the savings from averted illness.'"
"The fallacy here is confusing the individual with society. For the individual, catching something early generally reduces later spending for t hat condition. But, explains Elmendorf, we don't know in advance which patients are going to develop costly illnesses. To avert one case, "it is usually necessary to provide preventive care to many patients, most of whom would not have suffered that illness anyway." And this costs society money that would not have been spent otherwise.
"...a rigorous study in the journal Circulation found that for cardiovascular diseases and diabetes, 'if all the recommended prevention activities were applied with 100% success,' the prevention would cost almost 10 times as much as the savings, increasing the country's total medical bill by 162%. That's because prevention applied to large populations is very expensive, as shown by another report Elmendorf cites, a definitive review in the New England Journal of Medicine of hundreds of studies that found that more than 80% of preventive measures added to medical costs.
"... prevention is not, as so widely advertised, healing on the cheap. It is not the magic bullet for health-care costs. You will hear some variation of that claim a hundred times in the coming health-care debate. Whenever you do, remember: It's nonsense -- empirically demonstrable and CBO-certified."
George Pantos Responds
Mr. Krauthammer's premise is that preventive health care increases medical cost. He concludes that the added costs of preventive services such as clinical screenings exceed the savings from averted illnesses. However, his analysis is incomplete because he fails to note that prevention also can occur thru inexpensive (often free) individual risk profiles such as Health Risk Assessments (HSAs) that can detect a propensity for future problems before illness occurs. Based on completion of simple yet in-depth questionnaires , such non-laboratory related screenings can serve as a harbinger of problems related to cost drivers such as obesity and smoking which add nearly 80 billion dollars in cost to the nation's health bill.
Employer sponsored wellness programs are successful market-based examples of prevention (intervention) that is working without adding to medical costs. Predictive modeling and data analytics also show early promise in preventing illness and reducing health costs--without the expenditure of a single dime in government spending. Predictive technology ( the ACG System) developed by Johns Hopkins University, one of the world's most respected academic and medical research institutions, permits early identification of health risk based on analysis of already available claims data.
While clinical screening is valuable in detecting disease and can be costly, prevention that detects disease before it occurs is a "priceless" way to avoid expensive treatment while lowering costs and improving individual health .A 2009 Report from the Health Research Center refers to a Miliken Institute Report noting that savings from modest improvements in risk factors such as unhealthy behaviors could bring about 40 million fewer cases of chronic disease and reduce economic costs by $1.1 trillion annually in treatment costs and productivity by 2023. So much for the "myth".
Cost Control Lost Amid Public Option Debate
August 24, 2009 | Eliza Krigman , The National Journal
BETHESDA, MD -- Amid an August dominated by debate over the "public option," WellNet, a health technology company, maintains that the conversation is overlooking a critical variable: cost control.
The key to clamping down on health care costs will be increased transparency and information, said WellNet President Keith Lemer. Lemer's company creates software tools that help employers manage and understand their health care costs and advocates for two measures that would increase transparency and competition: leveling the playing field and unbundling benefits.
Leveling the playing field would mean eliminating "most favored nations" (MFN) clauses. Under MFNs, a health care provider cannot offer a lower rate than it does to the dominant insurer. To "unbundle benefits," employers would purchase medical and pharmaceutical coverage separately, resulting in greater clarity of the costs between the two. Presently, employers often purchase medical and pharmacy coverage together, hence the reason most people use the same insurance card at the doctor's office and at the pharmacy.
Before passing any major legislation, Lemer hopes lawmakers will take a step back to make sure they are addressing the root of problems with health care costs, not just expanding access.
WellNet Launches P2P Platform for Healthcare Consumers
July 14, 2009 | Eric Wicklund, Managing Editor, Healthcare IT News
BETHESDA, MD -- WellNet Healthcare is targeting the Web 2.0 movement with the release of Point to Point Healthcare, described as a “Facebook-like social networking platform” for healthcare consumers.
P2P, developed by the Bethesda, Md.-based company’s Healthcare Interactive subsidiary, creates a secure Web 2.0 platform from which consumers can manage their healthcare. It includes tools, a communication wall to allow the user to interact with healthcare providers, a pass-through version of the consumer’s electronic medical record (which can be posted on Microsoft’s HealthVault and Google Health, among others), and a view of prescription medications that includes potential substitutes and links to telemedicine, care management and wellness services.
P2P is designed to complement WellNet’s Active Reporting System (ARS), an application for plan sponsors and employers. Launched late last year, ARS is designed to provide aggregated, unidentifiable employee healthcare data in a real-time, secure dashboard, giving employers a comprehensive view of the effectiveness of their health plan. The two applications round out WellNet’s Healthcare Performance Management (HPM) software suite.
“America’s current health system is mired by disjointed, untimely and hard-to-find information, hidden profit centers and monopolies in some markets. Those using and paying for healthcare, whether employers or consumers, are saddled with its inefficiencies and exorbitant costs,” said Keith Lemer, president of WellNet Healthcare, in a press release. “The revolution in healthcare won't be in electronic medical records, but in using technology like P2P and ARS to find out how to cut costs to make service more affordable. WellNet’s HPM solution increases the transparency and the flow of information to both the consumer and the health plan sponsor (employer) so as to increase health and drive down cost.”
Company officials say P2P has been beta tested with select customers for the past year. One of those customers is Cumulus Media.
"In the past, I wasn’t able to see more detail on where my company’s healthcare dollars were going,” said Martin Gausvik, CFO of Cumulus Media, a Blackstone Group portfolio company. “With ARS, I now understand where I am spending my money and how I can avoid future expenses while raising the level of employee engagement with P2P.”
Healthcare Reform
Monday, June 8, 2009 | FROM TECHBISNOW - View the article here
As President Obama talks healthcare reform, earlier today we sat down with two tech minds who are already saving businesses oodles on costs: WellNet president Keith Lemer and Henry Cha, prez at Healthcare Interactive, a WellNet subsidiary.
Henry and Keith's Bethesda-based company created a web interface that lets execs manage healthcare spending and employees take a more active role in their coverage. "Healthcare is usually the second or third biggest expense a company will face, yet most businesses have no idea why costs keep going up," Henry says. Using different data streams (primarily pharmaceutical spending) and a simple interface, execs can see where dollars go and avoid cost increases before they hit.
If those are diplomas behind them, we'd hate to see the tuition bills. As for employees: To help engage workers, WellNet and Healthcare Interactive provides them with their own dashboard, along with incentives like gift cards and insurance cost reductions, to partake in particular programs. "The revolution in healthcare won't be in electronic medical records, but in using technology to find out how to cut costs to make service more affordable," Keith says.
A Message from WellNet's President
Monday, April 27, 2009Editor
Forbes Magazine
Attn: Letters to Editor
Mr. F. Mark Gumz correctly focuses on the CEO’s critical role in promoting employee wellness (CEO’s Rx: Improve Your Employees Health Now Apr. 18, see below for the piece). C-level management coping with health costs -- often one of the largest business expense line items -- increasingly recognizes the link between employee health, productivity and the bottom line. America’s corporate CEOs must become engaged in their health programs and lead the effort to improve the nation’s health. To reduce costs and reward outcomes, CEOs must adopt new corporate models that improve employee long-term health. This includes corporate wellness and disease management programs as well as technology-driven innovation that has always been at the core of successful U.S. companies. New business models now allow technology to be used by CEOs to make real-time strategic decisions about corporate health programs. Former Intel chairman Craig Barrett correctly noted the importance of CEO accountability for health by saying: “If you are a corporate CEO and you just send [this message] down your human resources chain of command for follow-up, you’ve missed the point.”
Keith Lemer
President
WellNet Healthcare
Bethesda, MD
///////
Leadership
One CEO's Rx: Improve Your Employees' Health Now
F. Mark Gumz 04.16.09, 2:40 PM ET
Providing your staff with quality health care options while managing bottom-line costs is harder than ever now. Chief executive officers have their hands full just addressing basic employee expenses like compensation. But we absolutely have to think creatively about improving the long-term health of our employees, and without spending too much.
Wise employee health care management saves money while bringing about long-term gains from increased overall employee wellness. Employees not performing at their full potential put their companies at risk just the way injured athletes put their teams at risk. That's why you need to find ways to enable your employees to make changes in their behavior that help themselves and help the company. It can have a turbocharged effect on your business.
All CEOs should know the top categories in their health care spending and address them head-on. The Centers for Disease Control informs us that more than 75% of the nation's health care costs can be attributed to patients with just five chronic conditions: congestive heart failure, asthma, diabetes, coronary artery disease and depression. The National Business Group on Health estimates that U.S. employers collectively spend $170 billion annually on smoking-related health expenses, lost productivity time and absenteeism. Know how such costs are affecting your company.
At Olympus Corporation of the Americas, the cost of insuring our 4,000 employees and their immediate families comes to more than $11,000 a year per family for the company-paid portion, which is at least 80% of the total cost per employee, so getting employees and their families to live a healthy life is very important for us. We have had great results with our overall employee wellness program by including benefits such as Weight Watchers programs, free flu shots, cancer screenings, and a personal wellness report that provides the findings from extensive blood tests and hypertension screening and offers confidential, customized suggestions to help employees identify and reduce their specific health risks, so they can lead healthier lives.
Why does the U.S. spend as vastly as it does on health care and still have so many challenges in health? Because people aren't as knowledgeable and active as they need to be about taking care of themselves. As consumers, employees increasingly seek out their own health care information. CEOs need to make sure to provide information that is thorough and correct, to help employees choose appropriate courses of treatment for themselves and their families. You can easily integrate online tools into your company's education program and offer information on new procedures and treatments. When educated employees change their behavior and that of their families, health care costs go down, sick days diminish and productivity rises.
It's also critical not only to offer health savings accounts but also to educate your employees in how to take advantage of them. HSAs not only help employees save money to pay medical bills; they also give them more control over how their health care dollars are spent.
Ultimately, every CEO has a responsibility to understand his or her line-item health care costs and know what he or she can do to produce a win-win scenario for the company: cutting bottom-line costs while improving employees' long-term health and thus productivity and morale. Employees appreciate an employer who cares about them and invests in them -- and that appreciation brings both immediate and long-term rewards to the company.
F. Mark Gumz is president and chief executive officer of Olympus Corporation of the Americas.
Keith Lemer Mentioned in Summit Series Recap
Thursday, April 9, 2009
Keith Lemer, President, WellNet Healthcare -- talk about a man on a mission! He’s articulate, sharp as a whip, bold, and determined -- thus destined -- to change the face of healthcare management. He’s staking a claim in a new territory self-described as Healthcare Performance Management (HPM) -- a way for CEOs to take control of their own healthcare programs. Watch out for him …
- Elizabeth Shea
A Message from WellNet's President
Thursday, April 2, 2009
Outlined below in the New York Times is a concise value-statement of WellNet's Healthcare Performance Management (HPM) software featuring the Active Reporting System and Point to Point Healthcare.
The article below from the New York Times describes where the focus of healthcare reform is today using technology vs. what's actually necessary to lower and manage healthcare expenses, long-term, for all stakeholders. Clearly, what Mr. Lohr and the other experts mentioned in the article are defining is WellNet's HPM.
Healthcare Performance Management software (HPM):
Minimizing or removing the annual healthcare procurement process altogether, HPM is a common technology platform that supports the shared responsibility between Plan Sponsors, Members and Providers to manage healthcare and the risk mitigation of costs in a simplified collaborative environment.
Similar to ERP (Enterprise Resource Planning) and CRM (Customer Relationship Management) software for traditional back-office operations, the HPM solution empowers corporations, for the first time, with innovative tools and methods to provide accurate, actionable information in real-time to measure and manage their healthcare expenses, as they fiscally manage every other aspect of their business.
Leveraging the prescription-drug portion of the medical-benefit plan, our technology and advisory services provide visibility and insight into our customers' plan risks, and combine patient-centric, Facebook-like social networking services to improve care, quality and efficiency, all operating within a fully-integrated, single-user interface that saves corporations
hundreds of thousands to millions of dollars annually.
Keith Lemer / President
Please click here to read the New York Times article.
WellNet in Washington Biz Journal
Friday, February 27, 2009 | By By Darlene Darcy, Staff Writer, Washington Business Journal
Private industry trailing the government in innovation may seem surprising. But in the use of technology to deliver and manage health care more effectively, the government is taking the lead — at least for now.
Health-related agencies such as the Department of Veterans Affairs and components of the Defense Department have been plugged into electronic medical records and medical information exchanges for years.
But many private hospital groups and small physicians’ offices have not adopted big-ticket tech systems and software because of various hang-ups, including the cost of technology.
President Barack Obama’s technology agenda, not to mention his massive stimulus package, include plans and billions of dollars for a nationwide electronic health information system to house and exchange patient records, insurance information and other medical data.
He sees these information technology improvements as the foundation for future health care reforms.
Obama’s health care proposals would invest at least $10 billion annually for the next five years to accelerate technology adoption.
In addition, the new $787 billion stimulus legislation, the American Recovery and Reinvestment Act of 2009, includes $19 billion to boost the economy through implementation of electronic medical records.
Tech industry officials hope the cash infusion leads to a broader adoption of health care IT, which might benefit many Washington-area companies, including those building and supporting systems for electronic medical records, data exchanges and Web sites that enable doctors to interact with patients.
Here are several local companies involved in the effort to fix a costly and inefficient health care system.
Symptom: Inefficient operations
Treatment: Systems integrator CSC has developed a system for the government that would enable insurance companies, hospitals and doctors’ offices to exchange electronic records over a nationwide network.
The Falls Church company has installed electronic records systems for organizations that include the National Institutes of Health’s research hospital in Bethesda and New York’s Medicaid program. But without a way for electronic records to be shared, those systems can’t realize their full value.
Prognosis: “There hasn’t been a commitment at the federal level to do this,” said Dr. Robert Wah, chief medical officer of CSC’s North American public sector business.
CSC is connecting systems for the National Health Service in the United Kingdom, where a budget of more than $17 billion over 20 years was committed years ago, he said.
The U.S. is “going toward a national medical records system driven primarily through legislation and regulation ... [and] the pace is pretty clearly defined,” Wah said.
Electronic medical records for all patients by 2014 is “probably achievable,” but incentives for doctors to spend money today is critical for a nationwide system to emerge.
Symptom: The paper-to-digital divide
Treatment: Wisper Technologies LLC in Reston, a subsidiary of IMC Inc., is developing software that uses speech-recognition technology to capture and organize patient-doctor conversations for planning patient care and billing insurance companies. The resulting electronic records can be fed into digital health information systems.
Wisper Technologies launched the software on a trial basis in 2004 but has not yet found a commercial market for the product because it is too costly for doctors.
Prognosis: “Doctors don’t have the money to buy sophisticated technology,” said IMC’s chief executive officer, Sudakar Shenoy. “The only people who can help them do that is the federal government.”
Stimulus funds used to reimburse doctors for investments in medical records technology could help reduce the barriers to adoption of Wisper’s software. But at hundreds of thousands of dollars for a hospitalwide implementation, IMC’s software will remain costly until high volumes of sales bring the price down, Shenoy said.
Symptom: Patient data unleashed
Treatment: McLean-based Trust Digital Inc., which provides mobile security software, has created an application that secures patient data stored electronically on a care provider’s mobile device.
Early in January the company landed deals with three health care organizations to support as many as 15,000 doctors, nurses and other health professionals in a single implementation.
Care providers and administrators at hospitals, physician practices and insurance companies are increasingly sending information over mobile devices, and they need an inexpensive way to make those transmissions securely.
Prognosis: “Trust Digital is already doing a brisk business with health care providers who use our product to protect confidential patient and doctor information stored on employee smart phones,” said Chief Executive Officer Nick Magliato.
The loss of a doctor’s phone could have a huge impact on patient privacy if data is stored there, and “obviously the stakes go way up as hospitals and other health care institutions, spurred on by funding from the government, quickly move to electronic patient records,” he said.
Trust Digital is counting on the new federal funding to advance more efficient care delivery systems and create new customers for the company.
Symptom: Choking on costs
Treatment: Health care management company WellNet Inc. is testing software designed to help employers understand the medical risks driving up their cost of employee coverage.
The software, called Point to Point Healthcare, was developed by Glenwood, Md.-based Healthcare Interactive Inc. and uses The Johns Hopkins University’s predictive modeling and pharmaceutical claims data to create charts and reports for employers. The data reveals cost-saving options by simulating changes to the company’s benefits plan.
Point to Point, which complies with privacy provisions of the Health Insurance Portability and Accountability Act (HIPAA), keeps employees’ identities confidential but lets workers access social networking tools to manage their care.
Prognosis: WellNet already has 100 clients testing the software, which the Bethesda-based company and Healthcare Interactive plan commercialize this year.
Employee health care is one of the biggest expenses for companies, but employers don’t know what is driving up their costs and employees don’t have tools to take preventive health measures before those costs hit them, said WellNet CEO Keith Lemer. “We give that data back to the employer.”
Symptom: Good information can be hard to find
Treatment: Ozmosis Inc. provides a social networking Web site that doctors can use for collaboration, continuing education and sharing “best practices.”
Formed by Joel Selzer and Jason Bhan in 2008, Vienna-based Ozmosis has 1,000 active members and will grow by invitation-only so that doctors’ identities can be verified and the site remains a trusted environment for trading information. The service is free to member physicians, universities and hospitals.
Prince William Hospital in Manassas is using Ozmosis within its electronic health information system.
Although not a traditional ad-supported site, Ozmosis will get revenue from pages sponsored by medical device and drug companies. Physicians can opt into those pages for new product information.
Prognosis: Ozmosis hopes to “benefit from the tremendous momentum low-cost, social media solutions are gaining throughout the health care industry,” Selzer said.
“With 84 percent of physicians now searching online for health care product information, the pressure to shift physician marketing and product education online has never been greater.”
Ozmosis needs to capture those marketing dollars to make its site sustainable.
Selzer warns that “just giving economic incentives to doctors to buy [electronic medical record systems] and hospitals to deploy them doesn’t mean they’re going to use them effectively.” That requires education — a role Ozmosis can fill, he said.
How much and how long?
Despite the increased use of electronic technology in health care, the cost of implementing new systems remains a major roadblock to a nationwide network.
President Barack Obama’s health care agenda includes a $50 billion investment in information technology over five years, but critics say he should be thinking more like $100 billion over 10 years.
The administration believes the savings will be worth the investment. A “fully functional” nationwide system could reduce health care costs by $200 billion annually by decreasing human error and fraud, according to the Department of Health and Human Services.
In addition to the $50 billion investment in Obama’s health care agenda, $19 billion will be provided through the new stimulus legislation to offer financial incentives to hospitals and physicians’ offices that implement electronic health records systems. A minimum of $2 million would be awarded to each organization that can show meaningful use of those health IT systems by 2011.
“The challenge for hospitals that haven’t committed a budget to purchase electronic systems is that current economic conditions will make it difficult to find the extra money to deliver these systems,” said Deward Watts, president of CSC’s commercial health care sector.
An additional $87 billion of the stimulus money will be used to offset state contributions to Medicaid. It is unclear how states would be allowed to spend their savings and if any of that money would go toward health IT.
Whatever money is spent now could be viewed as a down payment on a bigger investment in health, Watts said. “We need to put in place some technical foundation to make sure that is done ... in the best way possible.”
All contents of this article © American City Business Journals Inc. All rights reserved.
Cronin Appointment in MyHealthGuide
Monday, February 23, 2009 | My HealthGuide Newsletter
WellNet Healthcare appointed Dan Cronin, a longtime sales and marketing executive and acclaimed author of technical books is the new senior vice president of sales for WellNet Healthcare and Healthcare Interactive (HCI), two companies that recently launched the game-changing software and technology platform, Point to Point Healthcare.
In joining Bethesda, Md.-based WellNet and Glenwood, Md.-based HCI, Dan Cronin will direct the team responsible for delivering Health-Care Performance Management software to large employer groups that provide and pay for employee health benefits.
Cronin’s more than 20 years of executive sales-management experience for industry-leading Fortune 500 companies such as EMC, Oracle and Sybase has resulted in major, multi-year contracts for enterprise products and services. In addition, he has written the best-selling technical books, “Mastering Oracle” and “Microcomputer Data Security.”
“Dan’s background and success make him the perfect fit as we roll out our Health-Care Performance Management software nationwide,” says Keith Lemer, WellNet’s president. “He will undoubtedly be a major force in driving our companies to the next level.”
A comprehensive and unique solution, the Active Reporting System (ARS) and Point to Point platform empowers employers for the first time, providing them with accurate, actionable, real-time information to measure and manage their health plans as they would any other aspect of their business. The technology provides visibility and insight into customers’ plan risks, combined with patient-centric services to improve outcomes and lower medical-benefit costs for both employers and their employees.
“ARS and Point to Point will revolutionize the health-care sector, and I’m enthusiastic about playing a key role in marketing this technology to the business community and saving employers hundreds of thousands to millions of dollars on their health-care costs while getting their workers healthier,” Cronin says.
WellNet Healthcare is the majority investor in HCI, which developed ARS and Point to Point. The two companies launched a beta version of their Health-Care Performance Management software last year, offering it to WellNet’s existing client base. ARS and Point to Point are now available to the entire business community.
WellNet in Washington Post
Monday, February 16, 2009 | By Anita Huslin, Staff Writer, Washington Post
The $19 billion prescribed in Congress's economic stimulus package to bring America's health-care records into the electronic age is a welcome opportunity for information technology firms seeking to build market share in a still-young industry.
Although the federal government set a goal five years ago of creating an electronic health record for every American by 2014, the effort has lagged for several reasons. Roadblocks include concerns over lack of universal protocols for collecting data as well as rules that establish how, with whom and under what circumstances the data can be shared. Many health-care providers -- physician practices, testing facilities, hospitals and clinics -- fear liability if private information gets into the wrong hands. Embedded in all these issues is the cost, an estimated $150 billion, which has proven to be a significant barrier to that 2014 target.
Few expect the new spending to change things immediately. "The incentives for doctors and hospitals to use these tools have months of regulatory processes to go through," said David Brailer, former head of the Office of the National Coordinator for Health Information Technology, created under the Bush administration to establish standards for the collection and use of electronic medical records. "I don't think doctors will go out tomorrow and buy electronic records because there is a little bit of money coming."
To computerize their medical records, physicians and their practices stand to get $44,000 to $64,000 in incentives, and hospitals up to $11 million. But there are also penalties. Providers who treat Medicare and Medicaid patients and have not gone to paperless systems within five years could lose funding. With the federal government spending more than $600 billion annually on 80 million Americans through Medicare, Medicaid and other programs, that could prove a powerful incentive for providers to get on board.
At least that's what businesses such as CNSI, a Rockville company that sells Medicaid reimbursement systems in four states and is pitching more than a dozen others, would like to see happen. Arvinder Singh, senior vice president of CNSI, said the company hopes the stimulus money will bring more customers and allow CNSI to expand pilot programs. "This will help create more of a market for analysts and support staff, and create jobs," he said.
Others, such as WellNet Healthcare of Bethesda, hope to take advantage of spending on a medical data infrastructure system linking doctors and hospitals to insurance companies. Such technology could provide a broader arena for sales of their systems, which help companies monitor and manage their employee health-care costs.
Brailer cautioned that spending will not really grow until standards are set for secure collection and handling of medical information. He said there was some progress, but funding limits mean there's still a way to go.
Many doctors' offices and smaller hospital systems have held back from adopting available systems, vendors said, because of the cost and because they don't know whether the one they choose ultimately would comply with federal standards.
"There are too many unknowns as to what might be required, standards-wise," said Kevin Hutchinson, president and chief executive of Prematics, a Vienna firm that is one of the largest sellers of electronic prescription systems. His prospective clients know "there's lots of money they could be in line for, but they've in the past got so frustrated with chasing new ways of reimbursement and then lo and behold it disappears."
The anticipated demand for workers with technology skills who can help install medical record systems and then train physicians and health-care workers to use them will require training programs. Getting such programs off the ground is "not an easy thing to do," said Ritu Agarwal, director of the Center for Health Information and Decision Systems at the University of Maryland's Robert H. Smith School of Business.
"Study after study show that physicians in their small and medium-sized practices are extremely challenged with incorporating technology into their current flow. They haven't been able to afford it," she said. "We would anticipate seeing significant spending on training dollars . . . and if government is going to help pay for that, through some pilots and demonstrations, that will help move things along."
WellNet, for example, last fall rolled out a preliminary version of a system that puts patients' health information online so they can schedule appointments. Information can then be aggregated into detailed reports -- with individual identities removed -- that employers can use to track cost and medical use trends.
WellNet gave the program free to companies that agreed to load their pharmaceutical benefits data into it. Company representatives say much of their client introduction to the technology includes ample reassurances about privacy.
If the new package helps more potential clients get accustomed to the idea that online medical records, like personal banking information, can be a tool and not a security risk, WellNet officials see that awareness opening the door to more business.
"Hopefully this will help the marketplace look outside large corporations with existing operating systems and focus more on entrepreneurial and transparent organizations," said Keith Lemer, president of WellNet health management company. "One of the messages we are getting loud and clear from the new administration is that we are looking for a change."
The Los Angeles Times picked up the Post article. Read here.
HCI Partnership in MyHealthGuide
Sunday, February 1, 2009 | My HealthGuide Newsletter
Point to Point Healthcare, a game-changing technology for the health-care sector that will save employers across the country hundreds of thousands to millions of dollars on their medical-benefit costs, is adding to its arsenal of innovative solutions.
Healthcare Interactive, the Glenwood, MD-based developer of Point to Point, today announces that it has licensed an online tool for use in Point to Point that allows employers and their employees to access vital prescription-drug information.
WellNet Healthcare, with nine U.S. offices, is the majority investor in Healthcare Interactive, which is licensing the technology, called DestinationRx Drug Compare, from Los Angeles-based DestinationRx, a leader in consumer drug-comparison and purchasing technology.
DestinationRx Drug Compare allows self-funded employers, plan sponsors and consumers to reduce their prescription-drug spending by up to 20% by comparing their current therapeutics with lower-cost alternatives.
The DestinationRx technology enables consumers to find direct comparisons on prescription-drug prices as well as therapeutic safety and effectiveness, helping to improve medication compliance.
“One of the biggest flaws with the U.S. health-care sector is that employers and their employees don’t have the necessary information to make wise decisions about their prescription-drug spending,” says Henry Cha, Healthcare Interactive’s president.
“DestinationRx Drug Compare provides an accurate and convenient way for people to find less-expensive prescription drugs,” Cha says, adding that this tool is yet another important feature of Point to Point Healthcare, which he expects will revolutionize the health-care sector.
“Comparing and shopping for prescription drugs is one of the easiest and most effective actions consumers can take to save on their health-care costs,” says Toby Rogers, executive vice president of DestinationRx. “We are excited to be part of this innovative platform to help patients manage their entire health-care experience.”
Point to Point is a Web-based storage system for employers to analyze and interpret critical pharmacy and medical data combined with an online health-care social network that allows employees to connect with all their providers in a secure environment.
Healthcare Interactive and WellNet Healthcare, a data-analysis and health-management company, launched a beta version of Point to Point last August, offering it to WellNet’s more than 200 existing clients. Healthcare Interactive and WellNet will make Point to Point available to the entire business community in the first quarter of 2009.
This technology and administrative platform seamlessly links employees to, among other things, their pharmacy and medical data, care providers, scheduling, chats, gaps in care, drug-utilization alerts, predictive modeling and health-management programs.
About Healthcare Interactive
Healthcare Interactive, founded in 2007, is a privately held software company commercializing innovative technologies for health-care administration and insurance. Based in Glenwood, Md., Healthcare Interactive has developed an information portal and intelligence technologies to enhance existing health- are products that focus on predictive modeling, information sharing and Web services. The company’s signature product is Point to Point Healthcare. Visit www.hciactive.com.
WellNet in Washington Biz Journal
Tuesday, January 27, 2009 | By Darlene Darcy, Staff Writer, Washington Business Journal
WellNet Healthcare's' Healthcare Interactive has licensed a technology from DestinationRX in Los Angeles to help reduce medical costs for its customers.
Bethesda-based WellNet will use the technology, called DestinationRX Drug Compare, for comparing pharmaceuticals and identifying less expensive drug alternatives to enhance software that it developed with Glenwood-based Healthcare Interactive.
WellNet, which manages health care benefits for commercial customers, is the majority stake holder in Healthcare Interactive, which launched in 2007.
“One of the biggest flaws with the U.S. health care sector is that employers and their employees don’t have the necessary information to make wise decisions about their prescription-drug spending,” said Healthcare Interactive President Henry Cha. “DestinationRx Drug Compare provides an accurate and convenient way for people to find less-expensive prescription drugs.”
WellNet, led by Keith Lemer, and Healthcare Interactive will integrate the drug comparison tool with the Web-based software that the two companies launched in August 2008.
The software, which is compliant with the Health Insurance Portability and Accountability Act (HIPAA), allows employers to manage their employee health care plan by providing timely pharmacy and medical data translated into comprehensive and actionable charts and reports. HIPAA regulations ensure health care coverage and establish privacy standards for electronic communication about patients’ medical information.
The software also helps employers better manage their plans through predictive medical modeling and by linking employers and employees with care providers through social networking tools such as chats, alerts and scheduling.
A test version of the software is being used by 200 of WellNet’s existing health care management clients and is expected to be available commercially in the first quarter of 2009.
With 40 percent growth in 2008, WellNet’s annual revenue is about $100 million, Lemer said. The 50-person health care management company has a small internal sales team that Lemer expects to grow modestly. Lemer said he expects adoption of his software to increase through word of mouth as customers recognize savings.
All contents of this article © American City Business Journals Inc. All rights reserved.
WellNet in Thompson Publishing Guide
February 2009 | By Todd Leeuwenburgh, Editor, Thompson Publishing Group
Everyone’s heard that old saw: "20% of the population drives 80% of plan costs". If plan sponsors only knew exactly which plan participants are in that 20%, they could head off future acute conditions by managing high-risk conditions early on. But how should one identify those high-risk members?
It seems obvious: Ask plan participants, and analyze what prescription drugs they are taking, vendors and other experts tell the Employer’s Guide to Self-insuring Health Benefits ("Guide").
Bethesda, Md.-based WellNet Healthcare says prescription drug utilization data can identify those high-risk plan members. This will allow plans to understand their treatment needs, budget for those needs down the road, and adopt management strategies to change member behavior.
Predictive modeling software marketed by WellNet enables self-funded plans to use pharmacy benefit data to manage the plan as a whole. Based on the insights, plans may adopt strategies — such as chronic care management and wellness programs — to improve member health and manage utilization.
Many businesses use predictive modeling to build a picture of health risks, but only with medical data after the fact, company executives said. Claims processors and third-party administrators deliver data quarterly, but that’s often too late for the employer to take preventive action. Drug data enable the plan to micromanage care based on daily information.
Using Rx as the Leading Predictive Indicator
The advantage is that Rx data enables self-funded plans to manage benefits before expensive charges hit the system. And since drug claims come in faster than medical claims, companies can act more proactively. “It’s a window into the future,” WellNet Healthcare President Keith Lemer tells the Guide. The data analysis can also help the employer create personalized treatment plans and wellness initiatives.
WellNet executives say that drug data is 95% accurate at forecasting future risk. Analyzing drug utilization helps planning for the next three to five years, the company says. “Learning what’s driving costs in your health plan is not the same as shopping for vendors,” Lemer says.
Today’s Rx Data Reveals Tomorrow’s Risk
In a demonstration for the Guide, WellNet executives showed how the software sifts though a hypothetical 1,460-member self-funded plan to find the people who are most at risk. Without betraying patient privacy, the software found:
-Thirty-two employees who were at high risk of incurring major medical expenses soon. Those employees had an average of nine conditions.
-Two hundred and sixty-three employees were at medium risk. Those members had an average of five conditions each.
-That the total anticipated cost of high- plus medium-risk patients was $4.3 million to the plan, but it could go as high as $20 million.
The program revealed conditions that are most prevalent, and in this case they were: allergy/immunology, cardiovascular conditions, infections, and skin and respiratory problems. The software broke down these broad categories to more specific clinical conditions. For example, under cardiovascular, the software identified patients at high risk for high blood pressure, lipids, vascular disorders and congestive heart failure.
Software Lets You Tinker With the Plan
After the initial analysis, the software enables plan managers to plug in limited plan design changes and estimate outcomes. The design changes are mostly drug benefit tweaks like generic conversions, switches to OTC medications and mail order.
WellNet’s Plan Simulator gives plan sponsors a look at the impact of changes in drug plan design. It will predict savings from switching to generics and/or mail order.
Plan sponsors can also apply case management and other means to encourage treatment compliance, but the software will not predict impact in advance for these measures.
After 120 days with the design variation, the software measures results over time. It estimates what medical claims volume would have been without the intervention to claims volume since analysis and management strategies were applied.
The software highlights new prescriptions; those indicate a new diagnosis, and signal that it is the right time to reach out to the patient and maybe renew care management efforts on that person for the new diagnosis.
The approach builds on the self-funding plan’s access to data that insured plans don’t have. Insurers and PBMs do not share raw utilization data, because if inner workings remain secret, employers cannot question double digit cost increases, Lemer tells the Guide. WellNet’s program promises to fill in that transparency gap, he says.
Networking Software and Managing Health
Networking software takes the transparency further. “Point to Point Healthcare” offers online tools that connect employees to their utilization data, keeps track of health appointments, allows instant messaging with providers, and helps the employee create a network of providers he or she usually confers with.
Point to Point requires participation by the patient’s caregivers, by no means a given. Right now caregivers are invited to participate, but participation is voluntary.
Texas Office in Philadelphia Biz Journal
Friday, January 2, 2009 | By John George, Staff Writer,Philadelphia Business Journal
Southampton, Pa.-based WellNet Healthcare is expanding out West by opening an office in San Antonio. Led by Texas native Dr. Dan Van Ackeren, the new office will provide services to businesses in Texas, Arkansas, Colorado, Louisiana and New Mexico. WellNet, founded in 1994, designs, implements and administers employer-sponsored health benefits including prescription drug coverage … Pottstown Memorial Medical Center opened a wound healing center. Drs. Benjamin Eskra and Dennis Montiero, plastic surgeons on staff at Pottstown Memorial, are serving as co-medical directors of the center … Lourdes Medical Center of Burlington County in Willingboro invested $35,000 in an OB simulator, the Noelle S575 made by Gaumard Scientific, to better prepare and educate physicians, nurses and other staff members on how to manage rare but life-threatening labor and delivery scenarios. The simulator is comprised of a mannequin of a pregnant woman and a newborn connected to a motorized system that can create standardized and unique delivery-related scenarios. Lourdes Health System plans to expand the use of the simulator to Our Lady of Lourdes Medical Center in Camden early this year.
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- E-mail: service@wellnethealthcare.com
Topics this month focus on how technology can help to control soaring healthcare costs and take healthcare performance to the next level, as well as healthcare transparency, and more.
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