Can someone say “problem”?

While companies pick up the majority of it, the average employee is paying $8,584 of that for their family. That’s a strong reinforcement for the NPR article earlier this week about how it’s hard even for the insured to afford their healthcare…much less the uninsured.

The one thing that I think many of us miss is that there are ways to fix this beyond simply waiting for the Holy Grail of health reform to transform us overnight. (I’ll let you in on a secret…even if it’s not overturned, it’s not going to fix everything.) Let’s just look at some articles about our healthcare system:

1. This story talks about the importance of communications in healthcare.
2. This story talks about non-adherence even with cancer patients and high cost medications.
3. This story talks about pharmacy waste.
4. This story is about the scary amount of wrong diagnoses.
5. And, here’s one about how infrequently evidence-based medicine is followed.

So, if you combine the systemic issues with the human behavior issues, it seems like a low likelihood of getting the best care. That’s why we all need some “big brother” who’s watching out for us. Someone monitoring our claims. Someone providing counsel to us to help us make informed decisions. Even the physicians in the ACO or PCMH concepts need that.

Jeff’s focused on some of HCSC’s consumer efforts including their work with Bloom which they bought with Wellpoint and BCBSMI. As we know from lots of surveys (e.g., Medco survey, Towers Watson survey), consumerism is a hot topic with lots of recent articles about the work that companies like Change Healthcare and Castlight are doing (see Money article or Bloomberg article). From Jeff’s presentation at the conference, he pointed out that 6M Americans are in consumer driven health plans today and that $550-$600B in premium dollars are already controlled by individuals. A key driver in this area is the adoption of defined contribution plans in healthcare which like retirement plans is a model where employers set aside a fixed amount of money for employees to spend on healthcare and then give them options from which to choose.

Bloom Health, established in 2009, provides employers and employees greater flexibility, access and choice of health care services by simplifying how they select and pay for health insurance. Through its platform, Bloom Health helps employers define and better manage their health benefits spending through a defined contribution model. The employer contributes a defined amount per employee toward the cost of employee health care benefits. Employees and individuals are presented with a wide selection of benefit plans through an online “marketplace” to best fit their individual needs. (from Bloom PR link above)

Bloom is a platform for defined contribution to help consumers manage multiple choices and to facilitate them making choices. Essentially, as Jeff explained it, Bloom allows the employer to act as an automated broker. Bloom provides both technology and call center support to enable front end enrollment (not claims processing). Right now, it sounds like they are focused on small groups and national accounts, but they are adding Medicare in the future. To me, it sounds like this is the kind of front end GUI that consumers need to help them begin to understand healthcare options and make educated tradeoffs about what choices fit them best.

One of the interesting things that we talked about is the Bloom “configuration engine” (my term) which uses survey data about individual health, financial, and personality data to match you with the best health offerings for your needs. Ultimately, this makes me think about how individuals can create a personalized health insurance plan in the future rather than picking from a subset of options today. I don’t think consumers are ready to do that since we’re not good at predicting the future, but there are algorithms that could help with this especially if Bloom were to load our claims history and health risk assessment data in and use it as part of the guidance process.

Today, the basic process is:

1. Employer implements a defined contribution plan.
2. Employer defines what the consumer can see in terms of options.
3. The Bloom Health tool helps the consumer select their best option.
4. The consumer selects their plan.
5. Bloom then transfers the process to the plan for implementation and ongoing management.

So, what does this mean in the future? This will play into the Health Insurance Exchange part of the health reform. Bloom offers a private exchange platform today. I think the Kaiser Family Foundation does a good job of identifying several key components of Health Insurance Exchanges:

1. Offering consumers a choice of health plans and focusing competition on price
2. Providing information to consumers
3. Creating an administrative mechanism for enrollment
4. Moving towards portability of coverage
5. Reforming the insurance market

Perhaps not surprisingly, even with health reform’s fate still in the air, the government and health plans appear to be moving down this path based on an article yesterday.

I took a quick look at some data from the Thomson Reuters 2010 PULSE Healthcare Survey about screenings by age compared to recommendations. Here’s what it showed (in summary):

BUT, this has huge implications.  If we’re trying to get people engaged in their care at a pre-disease point (i.e., pre-diabetic) or trying to engage them earlier in their chronic kidney care continuum, this matters.  They’re likely to ignore the outreach about wellness and disease management if they don’t think it applies to them.  I guess it’s like thinking that you’ll win the lottery.  Or thinking that the last dose of chemotherapy (even though you’re about to die) might just save you.

But, if you dig into the data, you do see some differences by age and by income (per Thomson Reuters 2010 PULSE Healthcare Survey):

• 35.5% of those making >$100K think of themselves in excellent health versus 11.1% of those making less than $25K.
• Only 1.1% of those making >$100K think of themselves in poor health versus 14.3% of those making <$25K.

(While we know that there are healthcare discrepencies tied to income, this wouldn’t explain this great of a gap in self-perception.)

• 61.7% of those <35 perceive themselves to be in very good or excellent health versus 40.7% of those >65 (but a lot of that could be explained away since they are much more likely to have symptomatic diseases at that age)

(comments in parenthesis are my perspective not from the study)

While it has long been called juvenile diabetes, the reality is that of the 30,000 new cases diagnosed each year, about ½ of them are in adults. The key question is whether you could screen for this. There is now a blood test which is being used at Type 1 Diabetes TrialNet (18 research centers conducting clinical trials) which can help physicians identify the onset of the disease as early as 10 years before symptoms.

Right now, people that qualify can get the test for free, but I think this brings into play the larger question. When is it appropriate and cost effective to screen people about future diseases? In today’s US healthcare model, the “churn” of membership often downplays the long-term public value of prevention. Unless you know a member will be with you in the future when these costs come to be, should you bear the costs of the test today?

A few stats from yesterday’s WSJ on this:

• 3 million Americans have Type 1 diabetes (compared to 22M who have Type 2)
• 80 people a day in the US that are diagnosed with Type 1 diabetes
• 3% annual increase in the Type 1 diabetes cases world-wide under the age of 14
• 11-14 is the peak age for Type 1 diagnoses

So, the key question is how do you know if you’re at risk…

The primary factor that was identified in the article was whether you have a family member with the disease. If yes, you’re 15x more likely to have Type 1 diabetes than the general population. Perhaps as part of an HRA (health risk assessment), we should be asking about Type 1 diabetes in the family and screening those that say yes. Or, we could look at medical or pharmacy claims and reach out to family members about being screened.

“To change behavior, mobile health applications need to go beyond self- tracking, providing tips or access to an online community. Such applications need to address disconnects between long-term intentions and moment-to-moment choices. The most effective tools will creatively instantiate well-evidenced behavior-change principles with data mining, social networking, location awareness, and other capabilities of mobile technologies.”

- Margaret Morris PhD, Senior Researcher, Intel

The idea is to improve patient engagement and outcomes by using games and the idea of competing, earning rewards, and solving challenges to improve health.  I think this is especially relevant with all the chronic diseases and obesity challenges in kids, but there are gamers of all ages.  Certainly, Wii and other technologies that respond to movement and integrate into social media help enable this.

Keas is certainly one company whose name I’ve heard a few times in this space for healthcare.  But, I think lots of people are talking about this and trying to figure it out.  A simple Google search pulls up lots of discussion on the topic.

With the upcoming Facebook IPO and their success working with Zynga on gaming, it makes me wonder if they’ll make any movement in this space.  They’ve generally stayed out of the healthcare space other than exercise and diet, but with their recent effort around organ donation, one could speculate about what they could do with all the money they’re raising.

Gabe Zichermann, the author of Game-Based Marketing, speaks of balancing the fun and frivolity of gamification with the task of making life easier for cancer patients. He says, “I don’t presume to think that we can make having cancer into a purely fun experience. But, we have data to show that when we give cancer patients gamified experiences to help them manage their drug prescriptions and manage chemotherapy, they improve their emotional state and also their adherence to their protocol.”