https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
PubH 6564
Private Purchasers of Health Care: Roles of Employers and Health Plans in
the U.S. Health Care System
Fall 2013
Credits:
2
Meeting Days:
Mondays, September 9 – December 11, 2013
Meeting Time:
1:25 – 3:20 pm
Meeting Place:
2-580 Moos Tower
Instructor:
Jon B. Christianson
Office Address:
15-225 Phillips Wangensteen Building
Office Phone:
612-625-3849
Fax:
612-624-2196
E-mail:
chris001@umn.edu
Office Hours:
By Appointment
I.
Course Description
For health care providers, payments received from private insurance companies, with these funds coming for
the most part from employer contributions towards employee health care expenses, are critical to their
financial survival. The purpose of this course is to help future health care managers understand the goals of
their “best customers” and how health plans and employers pursue these goals. The course examines the
role of employers and health plans in the health care system and, specifically, how the “payers of the bills”
for health care develop and implement strategies to achieve their organizational and health care system
goals.
II.
Course Prerequisites
Students must be admitted to the University of Minnesota’s Master in Healthcare Administration Program or
have consent of the instructor.
III. Course Goals and Objectives
Specific goals and learning objectives are listed in for each class period.
1
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
IV. Methods of Instruction and Work Expectations
Each class will include a didactic presentation on the part of the instructor; significant issues will be identified
and discussed, referencing the readings for the class period. There are no “required” readings for the
course. The amount that students learn in this course, and their performance on assignments, will depend to
a large degree on the time and effort they devote to the readings for each topic. In most class periods,
students will present results from individual or group assignments. Students will be expected to prepare for
each class by engaging with the readings prior to class, participating in the discussion during class, and
completing group and individual assignments as scheduled. “Further” readings are provided as starting
points for students who wish to explore specific topics in greater depth and to assist in the completion of
individual and group assignments.
V.
Course Text and Readings
1. To access readings click on link immediately following cite. If you have any problems accessing assigned
readings online, contact Jane Raasch at raasc001@umn.edu. If you do not have a University of
Minnesota Internet ID and password, call 301-HELP and support staff will help you set up an account (or
set up your own account at www.umn.edu/initiate and follow the directions.)
2. Optional background reading for this course: 1) PowerPoint lecture on the basics of health insurance
posted on Moodle. 2) Kongstvedt, Peter. Essentials of Managed Care, Aspen Publishers, Gaithersburg,
MD. This book is the most frequently used reference in the field. It covers most of the “basics” but may
not be current on all topics.
3. For each class session, overheads/PowerPoint slides and/or audio will be posted on the Moodle website
for downloading and viewing. To learn more about Moodle, watch Moodle: Online Orientation for Students
and/or visit the Moodle support website at http://www1.umn.edu/moodle/, which has a link for “Student
support” with user guides, help and FAQs
VI. Course Outline/Weekly Schedule
Date
Module / Topics
Background
September 9
Employer Goals for the Health Care System and Their Strategies for Achieving Them
September 16, 23 Present State of America’s Health Insurance Industry
 Presentation of Group Assignment 1 (10 pts.) – September 16
Health Plan/Provider Relationships
September 30
Measuring Provider Performance: The Foundation of Purchaser Strategies to Reform America’s
Health Care System
October 7
Provider Contracting and Network Management
 Discussion of Individual Assignment 1 (15 pts.)
October 14
Fundamentals of Provider Payment: Incentives and Rewards
October 21
New Payment Arrangements: Bundled/Episode-Based Payment
 Discussion of Individual Assignment 2 (15 pts.)
October 28
New Payment Arrangements: Total Cost of Care (TCOC)
 Guest Lecture
November 4
Utilization Management
 Discussion of Individual Assignment 3 (15 pts.)
Health Plan/Enrollee Relationships
November 11
Supporting Employees/Enrollees in Choosing Providers: Reporting of Provider Performance
November 18
Supporting Employees/Enrollees in Choosing Treatment Options
 Discussion of Individual Assignment 4 (15 pts.)
November 25
Supporting Employees/Enrollees in Maintaining and Improving Their Health
2
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
Date
Module / Topics
December 2
Supporting Employees/Enrollees in Managing Chronic Illnesses
 Discussion of Individual Assignment 5 (15 pts.)
December 9
What is on the Horizon for Purchasers and Health Plans?
 Presentation of Group Assignment 2 (15 pts.)
September 9, 2013
Employer Goals for the Health Care System and Their Strategies for Achieving Them
The two-decade period from the mid-1970s through the mid-1990s encompassed the ascendancy of a particular type of health plan – the
managed care organization  in the private health care marketplace and also as a contractor to Medicare and Medicaid. Responding to
pressures from employers and government to control health care costs, these organizations (in collaboration with risk-bearing provider
systems) instituted a variety of "supply-side" mechanisms, financial and non-financial, to influence provider behavior. Accompanying steps
were taken to manage access to care on the part of plan enrollees. The result, eventually, was "managed care backlash" on the part of
consumers and providers, precipitated in part by a redefinition by employers of their health benefits’ objectives. Since then, payers and
health plans have initiated a variety of new approaches directed at restraining cost growth and improving quality. In this first session, we will
describe the transition over the past decade towards a new paradigm of “managed” or “facilitated” consumerism, one that has much
broader support among significant actors in the health care arena than traditional managed care. We will discuss the challenges faced by
this new "facilitated consumerism," and the tools at the disposal of health plans.
Learning Objectives
Students should be able to:
1. Describe the origins and evolution of managed care organizations.
2. Explain the origins and nature of the "managed care backlash" of the 1990s, and its influence on the ongoing development of the
new facilitated consumerism.
3. Explain the factors influencing present employer demands on the health care system, and the role these demands have played in
changing America’s health care system.
Suggested Readings
Employer Involvement in Health Care
1.* Christianson, J.B. “Managed care.” Enycylopedia of Health Economics, Elsevier, United Kingdom, forthcoming. (posted on
Moodle).
2. Galvin, R.S. “Still in the game — Harnessing employer inventiveness in U.S. health care reform.” The New England Journal of
Medicine 359(14):1421-1423, 2008. Available at: http://www.nejm.org/doi/pdf/10.1056/NEJMp0805021
Field of Practice:
1) Moutray, C. “NAM/Industryweek 2013 Q2 survey: Outlook positive in the face of mediocre growth.” IndustryWeek, June
6, 2013. Available at: http://www.industryweek.com/global-economy/namindustryweek-2013-q2-survey-outlookpositive-face-mediocre-growth
Employer Strategies for the Health Care System
1*. Christianson, J.B., Ginsburg, P.B., Draper D.A. “The transition from managed care to consumerism: a community-level status
report.” Health Affairs 2008;27(5):1362-1370. Available at: http://content.healthaffairs.org/content/27/5/1362.full.pdf+html
2. RAND Corporation. “Expanding consumer-directed health plans could help cut overall health care spending.” May 7, 2012.
Available at: http://www.rand.org/news/press/2012/05/07/index1.html
3. Robert Wood Johnson Foundation and Aligning Forces for Quality. “How employers can improve value and quality in health
care.” January 2013. Available at: http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/01/how-employers-canimprove-value-and-quality-in-health-care.html
4. Thomas, S., O’Kane, M. “Value-based purchasing.” American Journal of Managed Care 18(11)”750-752, 2012. Available at:
http://www.ajmc.com/publications/issue/2012/2012-11-vol18-n11/Value-Based-Purchasing/
5. Goodell, S., Swartz, K. “Cost-sharing: Effects on spending and outcomes.” Policy Brief No. 20. Robert Wood Johnson
Foundation Synthesis Project, December 2010. Available at:
http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2010/rwjf402103
3
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
Field of Practice:
1) Murphy, T. “Humana CEO preaches power of health care consumer.” Seattle News online, February 24, 2011.
Available at: http://seattletimes.nwsource.com/html/businesstechnology/2014319626_apusceointerviewhumana.html
2) Baker, S. “Employers shifting toward high-deductible healthcare plans.” The Hill, July 25, 2012. Available at:
http://thehill.com/blogs/healthwatch/health-insurance/240089-employers-shifting-toward-high-deductible-healthcareplans
3) Mathews, A.W. Big firms overhaul health coverage. The Wall Street Journal, September 26, 2012. Available at:
http://online.wsj.com/article/SB10000872396390444549204578020640220260374.html
4) Los Angeles Times. “CalPERS picks four new HMO plans for 5-year contracts” Los Angeles Times, April 17, 2013.
Available at: http://articles.latimes.com/2013/apr/17/business/la-fi-calpers-hmo-changes-20130418
5) The New York Times. “Health care where you work.” September 2, 2012. Available at:
http://www.nytimes.com/2012/09/03/opinion/health-care-where-you-work.html?_r=0
The Role of Self-Insurance
1. Weaver, C., Methews, A.W. “One strategy for health-law costs: self insure.” The Wall Street Journal, May 27, 2013. Available at:
http://online.wsj.com/article/SB10001424127887323336104578503130037072460.html ‘
2. Lucia, K., Monahan, C., Corlette, S. “Cross-cutting issues: Factors affecting self-funding by small employers: Views from the
market.” Princeton, NJ: Robert Wood Johnson Foundation, April 2013. Available at:
http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf405372
Field of Practice:
1) Pear, R. “Some employers could opt out of insurance market, raising others’ costs.” The New York Times, February
17, 2013. Available at: http://www.nytimes.com/2013/02/18/us/allure-of-self-insurance-draws-concern-overcosts.html?pagewanted=1&_r=1&nl=todaysheadlines&emc=edit_th_20130218&
2) Viebeck, E. Study: Self-insured health plans on the rise for private-sector employers. The Hill, November 28, 2012.
Available at: http://thehill.com/blogs/healthwatch/health-insurance/269827-self-insured-health-plans-on-the-rise-studyfinds
Employer Perspectives on Health Care Reform
1. Darling, H. “Health care reform: perspectives from large employers.” Health Affairs 2010;29(6):1220-1224. Available at:
http://content.healthaffairs.org/content/29/6/1220.full.pdf+html
2. Abraham, J.M., Graven, P., Feldman, R. “Employer-sponsored insurance and health reform: Doing the math.” National institute
for Health Care Reform Research Issue Brief 11, December 2012. Available at: http://www.nihcr.org/ESI-and-Health-Reform
3. Buettgens, M., Blumberg, L.J. “Small firm self-insurance under the Affordable Care Act.” The Commonwealth Issue Brief,
November 2012. Available at:
http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2012/Nov/1647_Buettgens_small_firm_self_insura
nce_under_ACA_ib.pdf
4. Kliff, S. “Obamacare requires employers to offer insurance. What if it’s too expensive?” The Washington Post, March 4, 2013.
Available at: http://www.washingtonpost.com/blogs/wonkblog/wp/2013/03/04/obamacare-requires-employers-to-offer-insurancewhat-if-its-too-expensive/
Field of Practice:
1) Hall, S.D. Survey: Most employers won’t drop health coverage. FierceHealthPayer, August 29, 2012. Available at:
http://www.fiercehealthpayer.com/story/survey-most-employers-wont-drop-health-coverage/2012-08-29
2) Hancock, J. “Health care act? No thanks; we’ll take care of ourselves.” Delaware online, March 17, 2013. Available at:
http://www.delawareonline.com/article/20130318/BUSINESS13/303180038/Health-care-act-Owners-say-No-thankswe-ll-take-care-ourselves
Further Readings
1.
2.
3.
4.
5.
6.
Blumenthal, D. “Employer-sponsored health insurance in the United States – Origins and implications,” New England Journal of
Medicine 355(1):82-88, 2006. Available at: http://www.nejm.org/doi/pdf/10.1056/NEJMhpr060703
Blumenthal, D. “Employer-sponsored insurance – riding the health care tiger.” New England Journal of Medicine 355(2):195202, 2006. Available at: http://www.nejm.org/doi/pdf/10.1056/NEJMhpr060704
Draper, D.A., Hurley, R.E., Lesser, C.S., Strunk, B.C. “The changing face of managed care.” Health Affairs 2002;21(1):11-23.
Available at: http://content.healthaffairs.org/content/21/1/11.full.pdf+html
Hartocollis, A. “Insurer steps up fight to control health care cost.” The New York Times, January 25, 2010, p.A.1. Available at:
http://www.nytimes.com/2010/01/25/health/policy/25insure.html?pagewanted=all&_r=0
Izlar, A.C. “The corporate role in reducing disparities: Initiatives under way at Verizon.” Health Affairs 30(10):1992-1996, 2011.
Available at: http://content.healthaffairs.org/content/30/10/1992.full.pdf+html
PR Newswire. “New study shows lower costs, increased consumer engagement in account-based health plans.” Available at:
http://www.prnewswire.com/news-releases/new-study-shows-lower-costs-increased-consumer-engagement-in-account-basedhealth-plans-58789467.html
4
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
7.
8.
Robinson, J.C., Ginsburg, P.B. “Consumer-driven health care: promise and performance.” Health Affairs 28(2):w272-w281
(published online 27 January 2009). Available at: http://content.healthaffairs.org/content/28/2/w272.full.pdf+html
Swartz, K. “Cost-sharing: Effects on spending and outcomes.” Research Synthesis Report No. 20. Robert Wood Johnson
Foundation, December 2010. Available at:
http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2010/rwjf402103/subassets/rwjf402103_1
September 16, 23, 2013
Present State of the Health Insurance Industry
Health plans represent employer interests in the health care system, competing for contracts with employers. They structure their products
and actions to gain and retain the business of employer clients, which is critical to their own financial success. In doing so, they provide a
wide range of products and services in addition to traditional health insurance. In these two sessions, we trace the development of the
health insurance industry and describe its current state. We discuss market concentration, premium setting, and differences among health
plan products; describe how plans are evaluated by employers and consumers; and discuss public perceptions of the health insurance
industry.
Learning Objectives
Students should be able to:
1. Describe the structure of the health insurance industry
2. Distinguish among different types of health plans and health plan products.
3. Understand premium cycles in the health insurance industry.
4. Explain how employers assess health plan performance and choose among health plans.
5. Identify the major issues relating to health plan performance from the perspective of employers and the public.
Suggested Readings
Overview of the Private Health Insurance Market
1. Archer, D. “Private insurance is bankrupting Americans: Is Congress paying attention?” Health Affairs Blog, June 26, 2012.
Available at: http://healthaffairs.org/blog/2012/06/26/private-insurance-is-bankrupting-americans-is-congress-paying-attention/
2. America’s Health Insurance Plans. “Medical loss ratio – What you need to know.” December 5, 2012. Available at:
http://www.ahipcoverage.com/2012/12/05/medical-loss-ratio-what-you-need-to-know-2/
3*. Austin, D.A., Hungerford, T.L. “The market structure of the health insurance industry.” Congressional Research Service Report
#R40834, April 8, 2010. Available at: http://www.fas.org/sgp/crs/misc/R40834.pdf
4. American Medical Association. “New AMA study finds lack of competition among health insurers.” February 1, 2011. Available at:
http://www.ama-assn.org/ama/pub/news/news/competition-health-insurers.page
Field of Practice:
1) PR Newswire. “Blue Cross Blue Shield of Michigan continues providing funding for free clinics to help strengthen
Michigan’s health care safety net.” June 12, 2013. Available at: http://www.prnewswire.com/news-releases/blue-crossblue-shield-of-michigan-continues-providing-funding-for-free-clinics-to-help-strengthen-michigans-health-care-safetynet-211270581.html
2) Manos, D. “Humana ranked top payer in 2013.” Healthcare IT News, June 26, 2013. Available at:
http://www.healthcareitnews.com/news/humana-ranked-top-payer-2013
3) Fellows, J. “Providers grade health plans. Guess who still stinks.” HealthLeaders Media, May 1, 2013. Available at:
http://www.healthleadersmedia.com/page-1/HEP-291713/Providers-Grade-Health-Plans-Guess-Who-Still-Stinks
4) Murphy, T. “Aetna chairman, CEO compensation climbs 26 pct.” The Big Story, April 8, 2013. Available at:
http://bigstory.ap.org/article/aetna-chairman-ceo-compensation-climbs-26-pct
5) Humer, C. Analysis: Employees to face health care sticker shock. Reuters, October 28, 2012. Available at:
http://www.reuters.com/article/2012/10/28/us-usa-health-benefits-idUSBRE89R0EP20121028
6) Rau, J., Appleby, J. Brokers seek to preserve role in health insurance marketplace. Kaiser Health News, March 16,
2011. Available at: http://www.kaiserhealthnews.org/stories/2011/march/16/brokers-press-for-relief-from-healthlaw.aspx
7) Wisenberg Brin, D. Blue “Cross plans feeling pressure to consolidate; competition, high costs lead more to weigh forprofit conversions.” The Wall Street Journal, August 25, 2008, p.B.7. Available at:
http://online.wsj.com/article/SB121963099177268101.html
8) Appleby, J. “Health insurance from both sides: KHN interview of Aetna CEO Bertolini.” Kaiser Health News, April 7,
2011. Available at: http://www.kaiserhealthnews.org/Stories/2011/April/08/bertolini-aetna-q-and-a.aspx
9) Kliff, S. “Businesses think the growth of health insurance premiums s slowing. Yes, really.” Washington Post online,
August 6,2012. Available at: http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/08/06/the-growth-of-healthinsurance-premiums-is-slowing-yes-really/
5
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
10) De La Merced, M.J. “Aetna agrees to buy Coventry in $5.7 billion deal.” New York Times online, August 20, 2012.
Available at: http://dealbook.nytimes.com/2012/08/20/aetna-is-said-to-strike-deal-for-coventry-health-for-5-7-billion/
11) Rabin, R.C., Some hospital networks also become insurers. The Washington Post, August 25, 2012. Available at:
http://articles.washingtonpost.com/2012-08-25/business/35491800_1_private-insurers-insurance-product-hospitalsystems
Products Offered by Health Plans
1.* Kulkarni, S.S. “FAQ on HSAs: The basics of health savings accounts.” Kaiser Health News, November 9, 2011. Available at:
http://www.kaiserhealthnews.org/stories/2011/november/04/frequently-asked-questions-on-health-savings-accounts.aspx
2. Warner, J.P. “High deductible health plans with HSAs or HRAs.” August 25, 2010. Available at:
http://www.warnerbenefits.com/file/forms/High_Deductible_Health_Plans_Explained.pdf
Field of Practice:
1) Abelson, R. “High-end health plans scale back to avoid “cadillac tax.” The New York Times, May 27, 2013. Available
at: http://www.nytimes.com/2013/05/28/business/cadillac-tax-health-insurance.html?pagewanted=all&_r=0
2) Weaver, C., Mathews, A.W. “Employers eye bare-bones health plans under new law.” The Wall Street Journal, May
19, 2013. Available at: http://online.wsj.com/public/resources/documents/Reprint_Samples.pdf
3) Andrews, M. “Some individual policies offer a way to shrink deductibles.” Kaiser Health News, May 21, 2013. Available
at: http://www.kaiserhealthnews.org/features/insuring-your-health/2013/052113-michelle-andrews-on-shrinkingdeductibles.aspx
4) Blue Cross Blue Shield Minnesota. “No more one size fits all in choosing health care coverage.” March 22, 2012.
Available at:
http://www.bluecrossmn.com/bc/wcs/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=L
atest&dDocName=POST71A_170724
Developing Strategies of Health Plans
1.* Johnson, A. “Reforms prod insurers to diversify.” Wall Street Journal, May 12, 2011, p. B.1. Available at:
http://online.wsj.com/article/SB10001424052748703643104576291022457851278.html
2. Blue Cross Blue Shield of Michigan. “Blue Cross Blue Shield of Michigan saves an estimated $155 million over three years from
patient-centered medical home program.” Press Release, July 8, 2013. Available at:
http://www.bcbsm.com/content/microsites/blue-cross-blue-shield-of-michigan-news/en/index/news-releases/2013/july2013/bcbsm-saves-155-million-pcmh.html
Field of Practice:
1) Miliard, M. “Aetna to cite Leapfrog safety scores.” Aetna News Hub, June 5, 2013. Available at:
http://newshub.aetna.com/press-release/health-care-professionals-and-networks/aetna-highlight-leapfrog-groupshospital-safety
2) Health Care Service Corporation. “Health care consumers realize significant cost savings through benefits value
advisor program.” The Wall Street Journal, April 18, 2013. Available at: http://online.wsj.com/article/PR-CO-20130418906054.html
3) UCare Media Release. “UCare honors high-performing health care providers at June 18 salute to excellence! event.”
June 19, 2013. Available at: http://www.ucare.org/SiteCollectionDocuments/Media/20130618_UCare-P4P-event.pdf
4) Irwin, G. Topdjian, J., Kaura, A. “Putting an I in healthcare.” Strategy+Business, February 18, 2013. Available at:
http://www.strategy-business.com/article/00167?gko=80904
5) Von Bergen, J.M. “Independence Blue Cross and Michigan insurer to expand into Medicaid market.” Philly.com,
August 10, 2011. Available at: http://articles.philly.com/2011-08-10/business/29872468_1_medicaid-market-medicaidbusiness-independence-blue-cross
6) Weaver, C. “Managed care enters the exam room as insurers buy doctor groups.” Kaiser Health News, July 1, 2011.
Available at: http://www.kaiserhealthnews.org/daily-reports/2011/july/05/1khn-story.aspx?referrer=search
7) Weaver, C. “Health insurers opening their own clinics to trim costs.” Kaiser Health News, May 4, 2011. Available at:
http://www.kaiserhealthnews.org/stories/2011/may/04/insurers-turn-to-clinics-for-cost-control.aspx?referrer=search
8) Daily Finance. Cigna’s gains on health plan quality report card reflect improved health and well-being of customers.
October 30, 2012. Available at: http://www.dailyfinance.com/2012/10/30/cignas-gains-on-health-plan-quality-reportcard-re/
9) Reuters. Health insurers begin to provide user-friendly plan guides. September 24, 2012. Available at:
http://www.reuters.com/article/2012/09/24/us-usa-healthcare-insurance-idUSBRE88N0Y620120924
10) Wall, J.K. WellPoint spends $50M to burnish brand. Indianapolis Business News, September 17, 2012. Available at:
http://www.ibj.com/wellpoint-spends--50m-to-burnish-brand/PARAMS/article/36730
11) Nussbaum, A. “WellPoint to acquire Amerigroup for $4.9 billion. Bloomberg, July 9, 2012. Available at:
http://www.bloomberg.com/news/2012-07-09/wellpoint-to-buy-amerigroup-for-4-9-billion-in-cash.html
Issues Relating to Health Plan Behavior and Performance
1. Cantlupe, J. “More employers unhappy with health insurers, says PWC study.” HealthLeaders Media, January 19, 2010.
Available at: http://healthplans.hcpro.com/content.cfm?topic=HEP&content_id=245127
6
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
2*. Cohn, J. “How Blue Cross became part of a dysfunctional health care system.” Kaiser Health News, March 8, 2010. Available at:
http://www.kaiserhealthnews.org/columns/2010/march/030810cohn.aspx?referrer=search
3*. Drew, L.W. “Finding a path through the health insurance market ‘gobbledygook’” Kaiser Health News, April 21, 2011. Available
at: http://www.kaiserhealthnews.org/Stories/2011/April/22/insurance-black-hole.aspx
4*. United Press International. “Consumers give healthcare plans low marks.” February 20, 2012. Available at:
http://www.upi.com/Health_News/2012/02/20/Consumers-give-healthcare-plans-low-marks/UPI-17301329785602/
5. Terhune, C. BlueShield of California will return $50 million to customers. Los Angeles Times, October 31, 2012. Available at:
http://articles.latimes.com/2012/oct/31/business/la-fi-blue-shield-credits-20121031
6. Reuters. LA doctors, patients sue Health Net for denying claims. September 13, 2012. Available at:
http://www.reuters.com/article/2012/09/13/us-healthnet-lawsuit-idUSBRE88C19T20120913
Field of Practice:
1) Terhune, C. “Blue Shield, Anthem owe small firms millions of dollars in rebates.” Los Angeles Times, June 4, 2013.
Available at: Overland, D. “Blue Cross $991M surplus draws criticism, fear of monopoly. FierceHealthPayer, August
10, 2012. Available at: http://www.fiercehealthpayer.com/story/blue-cross-991m-surplus-draws-criticism-fearmonopoly/2012-08-10
2) Scolforo. M. “Pa. regulators probe health insurers’ practices.” The Associated Press, 2010. Available at:
http://www.boston.com/business/healthcare/articles/2010/06/09/pa_regulators_probe_health_insurers_practices/
3) Mathews, A.W. “Insurer sets earnings cap” Wall Street Journal, June 8, 2011, p. B.1. Available at:
http://online.wsj.com/article/SB10001424052702304906004576371902333544990.html
4) Appleby, J. “Analyst: Nonprofit Blues have huge reserves.” Kaiser Health News, June 29, 2011. Available at:
http://capsules.kaiserhealthnews.org/index.php/2011/06/analyst-nonprofit-blues-have-huge-reserves/?referrer=search
5) Snowbeck, C. “HMO cash cushions at issue in Minnesota legislature.” TwinCities.com, March 10, 2012. Available at:
http://www.twincities.com/localnews/ci_20141316/minnesota-health-care-hmo-cash-cushions-at-issue
6) Lee, D. “Worries grow as healthcare firms send jobs overseas.” Los Angeles Times online, July 25, 2012, Available
at: http://articles.latimes.com/2012/jul/25/business/la-fi-healthcare-offshore-20120725
The Health Insurance Industry and Health Reform
1. Carey, M.A. “House spending bill cuts funding for exchanges.” Kaiser Health News, March 7, 2013. Available at:
http://capsules.kaiserhealthnews.org/?p=17584
2. Emanuel E.J., Liebman, J.F. “The end of health insurance companies.” New York Times online, January 30, 2012. Available at:
http://opinionator.blogs.nytimes.com/2012/01/30/the-end-of-health-insurance-companies/
3. Pear, T. “Obama and insurers join to cut health care fraud.” New York Times online, July 25, 2012. Available at:
http://www.nytimes.com/2012/07/26/us/politics/obama-and-insurers-join-to-cut-health-care-fraud.html
4. Zamosky, L. Healthcare reform law to usher in new age of consumerism. Los Angeles Times, September 8, 2012. Available at:
http://articles.latimes.com/2012/sep/08/business/la-fi-future-of-health-insurance-20120908
5. Cunningham, P.W. “Mandate delay a ‘full-time’ headache for employers.” Politico, July 15, 2013. Available at:
http://www.politico.com/story/2013/07/obamacare-mandate-delay-muddles-workweek-94131.html
6. Baker, S. “Week ahead: GOP focuses on employer mandate delay.” The Hill, July 15, 2013. Available at:
http://thehill.com/blogs/healthwatch/health-reform-implementation/310909-week-ahead-gop-focuses-on-employer-mandate-delay
7. Fox News. “House Republicans to vote on ObamaCare, say Obama’s delay of employer mandate unfair.” July 14, 2013.
Available at: http://www.foxnews.com/politics/2013/07/14/house-republicans-to-vote-on-obamacare-say-obamas-delay-employermandate-unfair/
8. Millman, J. “Obamacare’s missing mandate.” Politico, July 13, 2013. Available at:
http://www.politico.com/story/2013/07/obamacare-missing-mandate-94105.html
Field of Practice:
1) Hancock, J. “Blue Cross-Blue Shield bets big on Obamacare exchanges.” Kaiser Health News, June 21, 2013.
Available at: http://www.kaiserhealthnews.org/stories/2013/june/21/obama-administration-blue-cross-blue-shieldinsurance-exchanges-marketplaces.aspx
2) Overland, D. “Cigna opts out of Connecticut insurance exchange.” FierceHealthPayer, March 6, 2013. Available at:
http://www.fiercehealthpayer.com/story/cigna-opts-out-connecticut-health-insurance-exchange/2013-03-06
3) Terhune, C. “Blue Shield and Aetna to raise healthcare rates over state objections.” Los Angeles Times, March 6,
2013. Available at: http://articles.latimes.com/2013/mar/06/business/la-fi-health-insure-rates-20130307
4) Mathews, A.W. “Corporate news: Health law puts Cigna in Ad mode.” Wall Street Journal online, September 19,
2011. Available at: http://online.wsj.com/article/SB10001424053111903374004576578533245560822.html
5) Weaver, C. “Health insurers respond to reform by snapping up less-regulated businesses.” Kaiser Health News,
March 19, 2011. Available at: http://www.kaiserhealthnews.org/stories/2011/march/20/health-insurers-reformbusiness.aspx
7
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
Further Readings
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Andrews, M. “Appealing an insurer’s denial is often a good strategy.” Kaiser Health News, June 20, 2011. Available at:
http://www.kaiserhealthnews.org/Features/Insuring-Your-Health/Michelle-Andrews-on-appealing-insurers-denial.aspx
Baicker, K., Chandra, A. “Myths and misconceptions about U.S. health insurance.” Health Affairs – Web Exclusive
2008;27(6):w533-w543 (published online 21 October 2008). Available at:
http://content.healthaffairs.org/content/27/6/w533.full.pdf+html?sid=6007f9ae-03c4-49e5-a693-a8fd37ec4443
Baker, S. “Businesses predict 7 percent jump in healthcare costs.” The Hill, August 6, 2012. Available at:
http://thehill.com/blogs/healthwatch/health-insurance/242349-businesses-predict-7-jump-in-healthcare-costs
Dolan, P.L. “Insurer-owned clinics bid to offer more patient care.” Amednews.com, May 16, 2011. Available at: http://www.amaassn.org/amednews/2011/05/16/bil20516.htm
Draaghtel, K. “Maximizing your competitive advantage with predictive modeling and consumer data.” Milliman, April 6, 2012.
Available at: http://publications.milliman.com/periodicals/rsa/pdfs/rsa-03-2012.pdf
eValue8 Health Care. “eValue8 2009: Measuring progress toward value-based purchasing.” Available at:
http://www.nbch.org/NBCH/files/ccLibraryFiles/Filename/000000000640/Evalue8%202009%20Annual%20Report.pdf
Girion, L. “Health insurer tied bonuses to dropping sick policyholders.” The Los Angeles Times, November 9, 2007, p.A.1.
Available at: http://www.latimes.com/business/la-fi-insure9nov09,0,3065397,full.story?coll=la-home-center
Haviland, A.M., Marquis, M.S., McDevitt, R.D., Sood, N. “Growth of consumer-directed health plans to one-half of all employersponsored insurance could save $57 billion annually.” Health Affairs 31(5):1009-1015, 2012. Available at:
http://content.healthaffairs.org/content/31/5/1009.full.pdf+html
Jaffe, S. “Consumers may be unaware of their right to a review of health plan decisions.” Kaiser Health News, June 10, 2011.
Available at: http://www.kaiserhealthnews.org/Stories/2011/June/10/external-appeals.aspx
Mathews, A.W., Adamy, J. “Health-plan buyers get a look under the hood.” Wall Street Journal (online), August 17, 2011.
Available at: http://online.wsj.com/article/SB10001424053111904253204576512494056148396.html
Mathews, A.W., Kamp, J. Humana brings doctors in-house. The Wall Street Journal, November 5, 2012. Available at:
http://online.wsj.com/article/SB10001424052970203347104578100774135846646.html
Overland, D. “Excellus defends proposed rate hikes despite big case reserves.” FierceHealthPayer, July 22, 2012. Available at:
http://www.fiercehealthpayer.com/story/excellus-defends-proposed-rate-hikes-despite-big-cash-reserves/2012-07-22
Overland, D. “Insurers develop next generation of mobile apps.” FierceHealthPayer, August 10, 2012. Available at:
http://www.fiercehealthpayer.com/story/insurers-develop-next-generation-mobile-apps/2012-08-10
Redig, A.J. “Adventures in (health-insurance-claim) wonderland.” Health Affairs 2009;28(5):1515-1520. Available at:
http://content.healthaffairs.org/content/28/5/1515.full.pdf+html
Robinson, J.C. “Consolidation and the transformation of competition in health insurance.” Health Affairs 2004;23(6):11-24.
Available at: http://content.healthaffairs.org/content/23/6/11.full.pdf+html
Shannon, M. Turning consumers into shoppers: Using high-deductible plans wisely. Health Affairs Blog, October 18, 2012.
Available at: http://healthaffairs.org/blog/2012/10/18/turning-consumers-into-shoppers-using-high-deductible-plans-wisely/
September 30, 2013
Measuring Provider Performance: The Foundation for Network Management, Provider
Payment and Public Reporting Efforts
Efforts on the part of health plans and employers to measure provider performance have intensified over the past decade. Health plans
construct measures of performance to: select providers for inclusion in networks; create tiered networks; structure provider incentive
payments; and produce provider performance reports for their members. These measures also can be used in public reports of provider
performance. The way in which performance measures are constructed and used has been a point of contention between employers/health
plans and providers. In this session, we describe methods used by employers and health plans to measure provider performance, common
issues in measure construction, and the use of “risk-adjustment” techniques, and alternatives for attributing patient to providers.
Learning Objectives
Students should be able to:
1. Describe and contrast different approaches to performance measurement.
2. Discuss strengths and weaknesses of these approaches.
3. Discuss the role of risk adjustment techniques in measure construction and how they are applied.
4. Discuss different alternatives for attributing patients to providers for measurement purposes.
Suggested Readings
The Basics of Provider Performance Measurement
1. Berenson, R.A., Pronovost, P.J., Krumholz, H.M. “Achieving the potential of health care performance measures. Timely analysis
of immediate health policy issues. Robert Wood Johnson Foundation, May 30, 2013. Available at:
8
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/05/achieving-the-potential-of-health-care-performancemeasures.html
2. Berenson, R. “Seven policy recommendations to improve quality measurement.” Health Affairs Blog, May 22, 2013. Available at:
http://healthaffairs.org/blog/2013/05/22/seven-policy-recommendations-to-improve-quality-measurement/
3. Miller, T.P., Brennan, T.A., Milstein A. “How can we make more progress in measuring physicians’ performance to improve the
value of care?” Health Affairs 28(5):1429-1437, 2009. Available at: http://content.healthaffairs.org/content/28/5/1429.full.pdf+html
4. Damberg, C.L., Sorbero, M.E., Lovejoy, S.L., et al. An Evaluation of the Use of Performance Measures In Health Care. Santa
Monica, CA: RAND Corporation, 2011. Available at: http://www.rand.org/pubs/technical_reports/TR1148.html
5. National Committee on Quality Assurance. “HEDIS measure development process. Desirable attributes of HEDIS. HEDIS life
cycle.” Available at: http://www.ncqa.org/tabid/414/Default.aspx
6*. National Quality Forum. “The ABCs of measurement.” Available at:
http://www.qualityforum.org/Measuring_Performance/ABCs_of_Measurement.aspx
7. Pronovost, P.J., Lilford, R. “A road map for improving the performance of performance measures.” Health Affairs 2011;30(4):569573. Available at: http://content.healthaffairs.org/content/30/4/569.full.pdf+html
8. National Quality Forum. Mission and vision. Available at: http://www.qualityforum.org/About_NQF/Mission_and_Vision.aspx
Field of Practice:
1) Consumer-Purchaser Disclosure Project. Available at: http://www.healthcaredisclosure.org/
Importance of Risk Adjustment in Performance Measurement
1. Draaghtel, K. “Concurrent risk adjustment.” Milliman, January, 2012. Available at:
http://publications.milliman.com/periodicals/rsa/pdfs/rsa-01-2012.pdf
2. Martin, K., Rogal, D.L., Arnold, S.B. Health-based risk assessment: Risk-adjusted payments and beyond. AcademyHealth.
Available at: http://www.hcfo.org/pdf/riskadjustment.pdf
3*. Schone, E., Brown, R.W., Goodell, S. “Risk adjustment: What is the current state of the art, and how can it be improved.” Policy
Brief No. 25, Robert Wood Johnson Foundation Synthesis Project, July 2013. Available at: http://www.rwjf.org/en/researchpublications/find-rwjf-research/2013/07/risk-adjustment---what-is-the-current-state-of-the-art-and-how-c.html
Field of Practice:
1) Draaghtel, K. “Milliman advanced risk adjuster, MARA.” Milliman, February 2010. Available at:
http://publications.milliman.com/periodicals/rsa/pdfs/coming-soon-milliman-advanced.pdf
2) Milliman. Milliman Advanced Risk Adjuster (MARA): Predictive value of inpatient risk score. November 2011. Available
at: http://publications.milliman.com/periodicals/rsa/pdfs/milliman-advanced-risk-adjuster.pdf
Challenges in Measuring Provider Quality
1. Conway, P.H. Mostashari, F., Clancy, C. “The future of quality measurement for improvement and accountability.” Journal of the
American Medical Association 309(21):2215-2216, 2013. Available at:
http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=927065&direction=P
2. Kupfer, J.M. “The morality of using mortality as a financial incentive. Unintended consequences and implications for acute
hospital care.” Journal of the American Medical Association 309(21):2213-2214, 2013. Available at:
http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=927065&direction=P
3. Wood, D.L. “Measure health, not care.” Minnesota Medicine, April 2012. Available at:
http://www.minnesotamedicine.com/PastIssues/April2012.aspx
4. Mathias, J.S., Baker, D.W. “Developing quality measures to address overuse.” Journal of the American Medical Association
309(18):1897-1898, 2013. Available at: http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=926917&direction=P
5. Seaman, A.M. “Many medical guidelines don’t consider costs.” Reuters, May 7, 2013. Available at:
http://www.reuters.com/article/2013/05/07/us-medical-guidelines-idUSBRE94610V20130507
6. Stefan, M.S., Pekow, P.S., Nsa, W., et al. “Hospital performance measures and 30-day readmission rates.” Journal of General
Internal Medicine 28(3):377-385, 2013. Available at: http://link.springer.com/content/pdf/10.1007%2Fs11606-012-2229-8.pdf
7. Nyweide, D.J., Weeks, W.B., Gottlieb, D.J. “Relationship of primary care physicians’ patient caseload with measurement of
quality and cost performance.” Journal of the American Medical Association 2009;302(22)2444-2450. Available at:
http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=4491&direction=P
8*. Berenson, R. A. “Moving payment from volume to value: What role for performance measurement?” Washington, DC: Urban
Institute, December 2010. Available at: http://www.rwjf.org/files/research/71568full.pdf
9. Rosof, B. The importance of accurate data in quality –of-care measurement (Editorial). Annals of Internal Medicine
2012;157(5):379-380. Available at: http://annals.org/issue.aspx?journalid=90&issueID=24808&direction=P
Field of Practice:
1) Neuman, H.B., Michelassi, F., Turner, J.W., Bass, B.L. “Surrounded by quality metrics: what do surgeons think of ACSNSQIP?” Surgery 2009;145(1):27-33. Available at:
https://www.clinicalkey.com/#!/BrowserCtrl/doBrowseTo/journalIssue/{"facet":["1-s2.0S0039606008X00133"],"issn":"00396060","contentType":"Journals"}
9
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
2)
Cheung, K. “AHA report: Not all readmissions avoidable, ‘ill-suited’ quality indicator.” Fierce Healthcare, September
15, 2011. Available at: http://www.fiercehealthcare.com/story/aha-report-not-all-readmissions-avoidable-ill-suitedquality-indicator/2011-09-15
3) Overland, D. Minnesota health plan releases doctor ratings despite opposition. FierceHealthPayer, January 20, 2011.
Available at: http://www.fiercehealthpayer.com/story/minnesota-health-plan-releases-doctor-ratings-despiteopposition/2011-01-20
Challenges in Measuring Provider Prices, Costs and Efficiency
1. Romley, J.A., Hussey, P.S., de Vries, H., Wang, M.C., Shekelle, P.G., McGlynn, E.A. “Efficiency and its measurement: what
practitioners need to know.” American Journal of Managed Care 2009;15(11):842-845. Available at:
http://www.ajmc.com/publications/issue/2009/2009-11-vol15-n11/AJMC_09Nov_Romley_842to845/
2*. Robinson, R.C., Williams, T., Yanagihara, D. “Measurement of and reward for efficiency in California’s pay-for-performance
program.” Health Affairs 2009;28(5):1438-1447. Available at: http://content.healthaffairs.org/content/28/5/1438.full.pdf+html
3*. Painter, M.W., Chernew, M.E. “Counting change: Measuring health care prices, costs, and spending.” Robert Wood Johnson
Foundation, March 2012. Available at: http://www.rwjf.org/qualityequality/product.jsp?id=74078
Field of Practice:
1) Alltucker, K. “Auction website lets patients suggest prices.” azcentral.com, June 16, 2012. Available at:
http://www.azcentral.com/business/articles/20120614medical-care-auction.html
Challenges in Measuring Patient Experience
1*. Browne, K., Roseman, D., Shaller, D., Edgman-Levitan, S. “Analysis and Commentary. Measuring patient experience as a
strategy for improving primary care.” Health Affairs 2010;29(5):921-925. Available at:
http://content.healthaffairs.org/content/30/4/569.full.pdf+html
Further Readings
1.
2.
3.
4.
5.
6.
7.
8.
9.
Greene, R.A., Beckman, H.B., Mahoney, T. “Beyond the efficiency index: finding a better way to reduce overuse and increase
efficiency in physician care.” Health Affairs 2008;27(4):w250-w259 (published online 20 May 2008). Available at:
http://content.healthaffairs.org/content/27/4/w250.full.pdf+html?sid=b7a69b28-401f-4081-a781-a8eea63b91b9
Higgins, A., Zeddies, T., Pearson, S.D. “Measuring the performance of individual physicians by collecting data from multiple
health plans: The results of a two-state test.” Health Affairs 2011;30(4):673-681. Available at:
http://content.healthaffairs.org/content/30/4/673.full.pdf+html
Hoefer, T.P., Hayward, R.A., Greenfield, S., Wagner, E.H., Kaplan, S.H., Manning, W.G. “The unreliability of individual physician
‘report cards’ for assessing the costs and quality of care of a chronic disease.” Journal of the American Medical Association
1999;281(22):2098-2105. Available at: http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=4646&direction=P
Mehrotra, A., Adams, J.L., Thomas, J.W., McGlynn, E.A. “Is physician cost profiling ready for prime time?” RAND Research
Brief, 2010. Available at: http://www.rand.org/pubs/research_briefs/RB9523/
Nelson, B. “Accurate Measures?” The Hospitalist, May 2011. Available at: http://www.thehospitalist.org/details/article/1056003/Accurate_Measures.html
Nelson, E.C., Gentry, M.A., Mook, K.H., Spritzer, K.L., Higgins, J.H., Hays, R.D. “How many patients are needed to provide
reliable evaluations of individual clinicians?” Medical Care 2004;42(3):259-266. Available at:
http://www.jstor.org/stable/pdfplus/4640735.pdf?acceptTC=true
Romano, P., Hussey, P., Ritley, D. “Selecting quality and resource use measures: A decision guide for community quality
collaboratives.” AHRQ Publication No. 09(10)-0073, May 2010. Available at: http://www.ahrq.gov/qual/perfmeasguide/
Scholle, S.H., Roski, J., Adams, J.L., Dunn, D.L., Kerr, E.A., Dugan, D.P., Jensen, R.E. “Benchmarking physician performance:
reliability of individual and composite measures.” American Journal of Managed Care 2008;14(12):829-838. Available at:
http://www.ajmc.com/publications/issue/2008/2008-12-vol14-n12/Dec08-3781p833-838/
Thomas, J.W., Grazier, K.L., Ward, K. “Economic profiling of primary care physicians: consistency among risk-adjusted
measures.” HSR: Health Services Research 2004;39(4, Part I):985-1003. Available at:
http://onlinelibrary.wiley.com/doi/10.1111/j.1475-6773.2004.00268.x/pdf
October 7, 2013
Provider Contracting and Network Management
A major factor in health plans’ success in securing employer contracts is their ability to negotiate favorable terms when contracting with
providers and to effectively “manage” provider networks. In this session, we will discuss the basics of provider contracting, including the
way in which health plans and providers attempt to exert leverage in the contracting process. We also describe steps that health plans are
taking to develop products based on subsets of “high performing” providers, and the reasons why this strategy has been controversial.
Learning Objectives
Students should be able to:
1. Discuss the nature of the contracting process from the health plan and provider perspectives.
10
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
2.
3.
Describe how provider reimbursement levels are determined.
Discuss issues pertaining to tiered provider networks.
Suggested Readings
Health Plan/Provider Leverage in the Contracting Process
1. Ginsburg, P.B. “Wide variation in hospital and physician payment rates evidence of provider market power.” Research Brief No.
16, November 2010. Washington, DC: Center for Studying Health System Change. Available at:
http://www.hschange.com/CONTENT/1162/1162.pdf
2*. Berenson, R.A., Ginsburg, P.B., Christianson, J.B., Yee, T. “The growing power of some providers to win steep payment
increases from insurers suggests policy remedies may be needed.” Health Affairs 2012;31(5):973-981. Available at:
http://content.healthaffairs.org/content/31/5/973.full.pdf+html
3. Melnick, G.A., Shen, Y-C., Wu, V.Y. “The increased concentration of health plan markets can benefit consumers through lower
hospital prices.” Health Affairs 2011;30(9):1728-1733. Available at:
http://content.healthaffairs.org/content/30/9/1728.full.pdf+html
4*. Kocher, B., Emanuel E.J. Overcoming the pricing power of hospitals. Journal of the American Medical Association
2012;308(12):1213-1214. Available at: http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=24967&direction=P
Field of Practice:
1) Terhune, C. “Small surgeries, huge markups.” Los Angeles Times, January 31, 2013. Available at:
http://articles.latimes.com/2013/jan/31/business/la-fi-high-price-knee-20130131
2) Hancock, J. “Expert: Hospitals’ ‘humongous monopoly’ drives prices high.” Kaiser Health News, March 4, 2013.
Available at: http://capsules.kaiserhealthnews.org/?p=17379
3) Merritt, G. “Children’s Hospital, Anthem reaches agreement after two-month standoff.” The CT mirror, June 12, 2012.
Available at: http://www.ctmirror.org/story/16625/childrens-hospital-anthem-reach-multi-year-agreement
4) Terhune, C. “Many hospitals, doctors offer cash discount for medical bills.” Los Angeles Times online, May 27, 2012.
Available at: http://articles.latimes.com/2012/may/27/business/la-fi-medical-prices-20120527
5) Lund-Muzikant. Providence severs contract with Health Net just as employers consider options for 2013. The Lund
Report, September 20, 2012. Available at:
http://www.thelundreport.org/resource/providence_severs_contract_with_health_net_just_as_employers_consider_opti
ons_for_2013
Tiered Networks, High Performance Networks, and Centers of Excellence
1. Rabin, R.C. “Report faults high fees for out-of-network care.” The New York Times, January 31, 2013. Available at:
http://www.nytimes.com/2013/02/01/health/insurance-industry-report-faults-high-fees-for-out-of-network-care.html?_r=0
2. Andrews, M. “When a plan overpays for a service, is a patient responsible for a refund.” Kaiser Health News, December 10,
2012. Available at: http://www.kaiserhealthnews.org/features/insuring-your-health/2012/121112-michelle-andrewsoverpayment.aspx
Field of Practice:
1) Overland, D. “Cigna to cover telehealth doctor consults.” FierceHealthPayer, April 24, 2013. Available at:
http://www.fiercehealthpayer.com/story/cigna-covere-telehealth-doctor-consults/2013-04-24
2) Terhune, C. Companies go surgery shopping. Los Angeles Times, November 17, 2012. Available at:
http://articles.latimes.com/2012/nov/17/business/la-fi-bargain-surgery-20121117
3) Boulton, G. Aurora-Anthem plan seeks exclusivity, promises savings. Journal Sentinel, October 24, 2012. Available at:
http://www.jsonline.com/business/auroraanthem-plan-seeks-exclusivity-promises-savings-0d7av36-175522981.html
4) Appleby, J. “Domestic medical travel is taking off for surgery deals.” USA Today, July 9, 2010. Available at:
http://www.usatoday.com/money/industries/health/2010-07-07-travelforhealth07_CV_N.htm
5) Kowalczyk, L. “Insurers may slash rates to hospitals; some patients might have to switch MDs.” The Boston Globe,
May 24, 2010, p.B.1. Available at:
http://www.boston.com/news/health/articles/2010/05/24/insurers_aim_to_cut_payments_to_hospitals_doctors_groups/
6)* Kaiser Health News. “Some heart care costs stay outside insurance coverage, Lowe’s does national comparison
shopping for employees’ heart surgery.” February 17, 2010. Available at: http://www.kaiserhealthnews.org/dailyreports/2010/february/17/cost-of-heart-care.aspx
7)* Andrews, M. “Insurance trade-off: Reducing premiums by eliminating expensive doctors, hospitals.” Kaiser Health
News, March 1, 2011. Available at: http://www.kaiserhealthnews.org/features/insuring-your-health/michlle-andrewson-premiums-and-prices.aspx?referrer=search
8) Gonzales, A. “Cigna offering lower co-pays at its own clinics in Phoenix.” Phoenix Business Journal, August 9, 2011.
Available at: http://www.bizjournals.com/phoenix/news/2011/08/09/cigna-offering-lower-co-pays-at-its.html?page=all
9) Weaver, C. “Aetna, doctors face off over costs.” Wall Street Journal online, July 4, 2012. Available at:
http://online.wsj.com/article/SB10001424052702303933404577505182228232366.html
10) Boulton, G. “Aetna, Aurora to begin offering new health plan.” Equities.com, July 27, 2012. Available at:
http://www.equities.com/news/headline-story?dt=2012-07-27&val=315527&cat=hcare
11
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
11)*Appleby, J. “Consumers hit by higher out-of-network medical costs.” Kaiser Health News, February 8, 2012. Available
at: http://www.kaiserhealthnews.org/stories/2012/february/09/consumers-hit-by-higher-out-of-network-medicalcosts.aspx
12) Crosby, J. “Medica teams with Fairview on new plan.” StarTribune online, March 8, 2012. Available at:
http://www.startribune.com/business/141693483.html?refer=y
13) Andrews, M. “Some insurers paying patients who agree to get cheaper care.” Kaiser Health News, March 26, 2012.
Available at: http://www.kaiserhealthnews.org/features/insuring-your-health/2012/cash-rewards-for-cheaper-caremichelle-andrews-032712.aspx
14) Toland, B. Highmark offers cheaper, UPMC-free plan. Pittsburgh Post-Gazette, September 11, 2012. Available at:
http://www.post-gazette.com/stories/business/news/highmark-offers-cheaper-upmc-free-plan-652783/
Provider Issues Concerning Contracts with Health Plans
Field of Practice:
1) Toland, B. “Medical ethics focus of insurance dispute between UPMC and Highmark.” Pittsburgh Post-Gazette, March
8, 2013. Available at: http://www.post-gazette.com/stories/local/state/medical-ethics-focus-of-insurance-disputebetween-upmc-and-highmark-678402/
2) Miller, V., Feeley, J. “UnitedHealth units to pay $24 million in hepatitis case.” Bloomberg, April 4, 2013. Available at:
http://www.bloomberg.com/news/2013-04-04/unitedhealth-units-told-to-pay-24-million-over-hepatitis-doctor.html
3) Fuhrmans, V. “Insurers stop paying for care linked to errors; health plans say new rules improve safety and cut costs;
hospitals can’t dun patients”. The Wall Street Journal, January 15, 2008, p.D.1. Available at:
http://online.wsj.com/article/SB120035439914089727.html
4) Associated Press. “AMA, others suing Aetna, Cigna over payments.” February 10, 2009. Available at:
http://blog.cleveland.com/business/2009/02/ama_others_suing_aetna_cigna_o.html
5) Reuters. “Aetna ranked tops in connection with doctors.” May 25, 2011. Available at:
http://www.reuters.com/article/2011/05/25/idUS189606+25-May-2011+BW20110525
6) Cheung, K. “AMA blasts insurers for costly 20 percent error rates.” FierceHealthcare, June 20, 2011. Available at:
http://www.fiercehealthcare.com/story/ama-blasts-insurers-costly-20-percent-error-rate/2011-06-20
7) Bernstein, N. “Insurers alter cost formula, and patients pay more.” New York Times online, April 23, 2012. Available
at: http://www.nytimes.com/2012/04/24/nyregion/health-insurers-switch-baseline-for-out-of-networkcharges.html?pagewanted=all
Further Readings
1.
2.
3.
4.
5.
6.
7.
8.
9.
America’s Health Insurance Plans. “Health plans collaborate on landmark initiative to reduce time, expense for physician office
practice ‘paperwork’.” Press Release, February 11, 2010. Available at:
http://www.ahip.org/content/pressrelease.aspx?bc=174|29422&pf=true
Bebinger, M. “’Tiered’ insurance confounds consumers, docs in Mass.” Kaiser Health News, January 17, 2012. Available at:
http://www.kaiserhealthnews.org/Stories/2012/January/17/Mass-Tiered-Insurance.aspx
Cantlupe, J. Physicians, insurers clash over medical necessity in CA. HealthLeaders Media, September 27, 2012. Available at:
http://www.healthleadersmedia.com/page-1/PHY-284876/Physicians-Insurers-Clash-Over-Medical-Necessity-in-CA
Casalino, L.P., Nicholson, S., Gans, D.N., Hammons, T., Morra, D., Karrison, T., Levinson, W. “What does it cost physician
practices to interact with health insurance plans?” Health Affairs 2009;28(4):w533-w543 (published online 14 May 2009).
Available at: http://content.healthaffairs.org/content/28/4/w533.full.pdf+html?sid=36420c5a-9240-4639-b71c-0cf279227dc4
Ellis, P., Sandy, L.G. Larson, A.J., Stevens, S.L. Wide variation in episode costs within a commercially insured population
highlights potential to improve the efficiency of care. Health Affairs 2012;31(9):2084-2093. Available at:
http://content.healthaffairs.org/content/31/9/2084.full.pdf+html
Kaiser Health News. “Cigna agrees to end use of database to determine payments for out-of-network medical services.”
February 18, 2009. Available at: http://www.kaiserhealthnews.org/dailyreports/2009/february/18/dr00057024.aspx?referrer=search
Mathews, A.W. “Out-of-network rates.” Wall Street Journal (online), June 19, 2011. Available at:
http://online.wsj.com/article/SB10001424052702304451504576394103294050580.html
News Release. AHIP files amicus brief on impact of hospital consolidation. America’s Health Insurance Plans, November 29,
2012. Available at: http://www.ahip.org/News/Press-Room/2012/AHIP-Files-Amicus-Brief-on-Impact-of-HospitalConsolidation.aspx
Terhune, C. Cedars-Sinai and UCLA cut from Los Angeles health plan. Los Angeles Times, September 21, 2012. Available at:
http://articles.latimes.com/2012/sep/21/business/la-fi-hospital-costs-20120921
October 14, 2013
Fundamentals of Provider Payment: Incentives and Rewards
During the 1980s through the mid-1990s, most provider payment arrangements employed by health plans were designed to influence
12
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
providers to reduce unnecessary service utilization. Over the past decade, health plans and purchasers have initiated a variety of new
payment approaches that have broader behavioral change goals, including improving quality of care, implementing evidence-based
medical practices effectively, and supporting the restructuring of care delivery. Recently, health reform legislation has encouraged
Medicare to institute payment reforms with similar objectives. We will discuss traditional methods of provider payment, as well as new
payment arrangements, in this session and the two sessions to follow.
Learning Objectives
Students should be able to:
1. Describe the basic reimbursement approaches used by health plans in contracts with providers, including their strengths and
weaknesses.
2. Describe the different types of pay-for-performance initiatives being undertaken by health plans and purchasers.
3. Describe how these approaches differ in their design and the challenges they pose for implementation, in comparison to previous
payment arrangements between health plans and providers.
Suggested Readings
Basics of Provider Payment
1. Robinson, J.C. “Theory and practice in the design of physician payment incentives.” The Milbank Quarterly 2001;79(2):149-177.
Available at: http://www.jstor.org/stable/pdfplus/3350546.pdf?acceptTC=true
2. Averill, R.F., Goldfield, N.I., Vertrees, J.C., McCullough, E.C., Fuller, R.L., Eisenbandler, J. “Achieving cost control, care
coordination, and quality improvement through incremental payment system reform.” Journal of Ambulatory Care Management
2010;33(1):2-23. Available at: http://ovidsp.tx.ovid.com/sp3.8.1a/ovidweb.cgi?WebLinkFrameset=1&S=PIKCFPCJGBDDLCLENCOKIDGCMIABAA00&returnUrl=ovidweb.cgi%3f%26TOC
%3dS.sh.18.19.22.25%257c2%257c50%26FORMAT%3dtoc%26FIELDS%3dTOC%26S%3dPIKCFPCJGBDDLCLENCOKIDGC
MIABAA00&directlink=http%3a%2f%2fgraphics.tx.ovid.com%2fovftpdfs%2fFPDDNCGCIDLEGB00%2ffs047%2fovft%2flive%2fg
v024%2f00004479%2f00004479-20100100000002.pdf&filename=Achieving+Cost+Control%2c+Care+Coordination%2c+and+Quality+Improvement+Through+Incremental+P
ayment+System+Reform.&link_from=S.sh.18.19.22.25%7c2&pdf_key=B&pdf_index=S.sh.18.19.22.25
3*. Berenson, R.A., Rich, E.C. “US approaches to physician payment: the deconstruction of primary care.” Journal of General
Internal Medicine 2010;25(6):613-618. Available at: http://link.springer.com/content/pdf/10.1007%2Fs11606-010-1295-z.pdf
4*. Reinhardt, U.E. “The options for payment reform in U.S. health care.” New York Times online, February 17, 2012. Available at:
http://economix.blogs.nytimes.com/2012/02/17/the-options-for-payment-reform-in-u-s-health-care/
Use of Provider Payment to Encourage and Reward Quality Improvement
1. Reinhardt, U.E. “Making surgical complications pay.” Journal of the American Medicine Association 309(15):1634-1635, 2013.
Available at: http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=926822&direction=P
2. Christianson, J.B., Leatherman, S., Sutherland, K. “Lessons from evaluations of purchaser pay-for-performance programs: a
review of the evidence.” Medical Care Research and Review 2008;65(6 suppl):5S-35S. Available at:
http://mcr.sagepub.com/content/65/6_suppl/5S.full.pdf+html
3. Rosenthal, M.E., de Brantes, F.S., Sinaiko, A.D., Frankel, M., Robbins, R.D., Young, S. “Bridges to excellencerecognizing
high-quality care: analysis of physician quality and resource use.” American Journal of Managed Care 2008;14(10):670-677.
Available at: http://www.ajmc.com/publications/issue/2008/2008-10-vol14-n10/Oct08-3648p670-677/
4. Werner, R.M., Dudley, R.A. “Making the ‘pay’ matter in pay-for-performance: implications for payment strategies.” Health Affairs
2009;28(5):1498-1508. Available at: http://content.healthaffairs.org/content/28/5/1498.full.pdf+html
5. Werner, R.M., Kolstad, J.T., Stuart, E.A., Polsky, D. “The effect of pay-for-performance in hospitals: Lessons for quality
improvement.” Health Affairs 2011;30(4):690-698. Available at: http://content.healthaffairs.org/content/28/5/1498.full.pdf+html
6. Rau, J. “Effort to pay hospitals based on quality didn’t cut death rates, study finds.” Kaiser Health News, March 28, 2012.
Available at: http://www.kaiserhealthnews.org/stories/2012/march/28/nejm-study-hospital-quality-and-death-rates.aspx
Field of Practice:
1) Editorial. “A view from the safety net.” Journal of the American Medical Association 309(21):2221-2222, 2013.
Available at: http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=927065&direction=P
2) Mathews, A.W. “WellPoint helps cut employers’ health cost.” The Wall Street Journal, June 26, 2013. Available at:
http://online.wsj.com/article/SB10001424127887323998604578567982013011300.html
3) Abelson, R. “Employers test plans that cap health costs.” The New York Times, June 24, 2013. Available at:
http://www.nytimes.com/2013/06/24/health/employers-test-plan-to-cap-medical-spending.html?pagewanted=all&_r=0
4) Blue Cross Blue Shield Michigan. “Blue Cross Blue Shield of Michigan and Trinity Health-Michigan achieve new
approach to reimbursement with landmark contract.” Trinity Health News Release, April 2013. Available at:
http://www.trinity-health.org/body.cfm?id=186&action=detail&ref=46
5) Kennedy, K. “Health care providers want faster changes in payments.” USA Today, April 14, 2013. Available at:
http://www.usatoday.com/story/news/politics/2013/04/14/health-care-providers-pushing-faster-paymentreforms/2074715/
13
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
6)
Metro, L. “Commercial Blues plans adopting the CMS do-not-pay list policy.” Modern Medicine, April 1, 2010. Available
at: http://license.icopyright.net/user/viewFreeUse.act?fuid=OTIxMDMwMw%3D%3D
7) BusinessWire. “Anthem Blue Cross and Blue Shield launches innovative program to enhance primary care by
rewarding physicians for quality and cost improvements.” February 1, 2012. Available at:
http://www.businesswire.com/news/home/20120201006036/en/Anthem-Blue-Cross-Blue-Shield-Launches-Innovative
8) BusinessWire. Humana’s provider quality rewards program distributes more than $35 million to primary care physicians
in Florida. November 14, 2012. Available at:
http://www.businesswire.com/news/home/20121114005577/en/Humana%E2%80%99s-Provider-Quality-RewardsProgram-Distributes-35
Payment for Patient Centered Medical Home (PCMH)
1. Merrell, K., Berenson, R.A. “Structuring payment for medical homes.” Health Affairs 2010;29(5):852-858, Available at:
http://content.healthaffairs.org/content/29/5/852.full.pdf+html
Field of Practice:
1) BusinessWire. Empire announces physician practices to participate in historic public-private partnership to strengthen
primary care. August 23, 2012. Available at: http://www.businesswire.com/news/home/20120823006208/en/EmpireAnnounces-Physician-Practices-Participate-Historic-Public-Private
2) Feder, J.L. “A health plan spurs transformation of primary care practices into better-paid medical homes.” Health
Affairs 2011;30(3):397-399. Available at: http://content.healthaffairs.org/content/30/3/397.full.pdf+html
Reference Pricing
1. Kanavos, P., Reinhardt, U. “Reference pricing for drugs: Is it compatible with U.S. Health care?” Health Affairs 2003;22(3):1630. Available at: http://content.healthaffairs.org/content/22/3/16.full.pdf+html
2.* Robinson, J.C., MacPherson, K. “Payers test reference pricing and centers of excellence to steer patients to low-price and highquality providers.” Health Affairs 31(9):2028-2036, 2012. Available at:
http://content.healthaffairs.org/content/31/9/2028.full.pdf+html
Field of Practice:
1) Terhune, C. “Hospitals cut some surgery prices after CalPERS caps reimbursements.” Los Angeles Times, June 23,
2013. Available at: http://www.latimes.com/business/money/la-fi-mo-calpers-hospital-surgery-prices20130623,0,6571991.story
Medicare Payment Reform Initiatives
1. Guterman, S., Davis, K., Schenbaum, S., Shih, A. “Using Medicare payment policy to transform the health system: a framework
for improving performance.” Health Affairs – Web Exclusive 2009;28(2):w238-w250 (published online 27 January 2009).
Available at: http://content.healthaffairs.org/content/28/2/w238.full.pdf+html
2.* VanLare, J.M., Conway, P.H. “Value-based purchasing – National programs to move from volume to value.” New England
Journal of Medicine 2012;367(4):292-295. Available at: http://www.nejm.org/doi/pdf/10.1056/NEJMp1204939
3. Ryan, A.M., Blustein, J., Casalino, L.P. “Medicare’s flagship test of pay-for-performance did not spur more rapid quality
improvement among low-performing hospitals.” Health Affairs 2012;31(4):797-805. Available at:
http://content.healthaffairs.org/content/28/2/w238.full.pdf+html
4. Rau, J. “Medicare announces plans to accelerate linking doctor pay to quality.” Kaiser Health News, July 22, 2013. Available at:
http://www.kaiserhealthnews.org/Stories/2013/July/22/Medicare-value-based-pay-for-doctors.aspx
5. Kuttner, R. “Medicare ‘cost-savings’ rules pushing costs onto patients.” Boston Globe, July 18, 2013. Available at:
http://www.bostonglobe.com/opinion/2013/07/18/medicare-disguised-form-rationing/W6sF7dkTW08oGOlSekzlFI/story.html
Field of Practice:
1) Galewitz, P. “Tulsa hospital gives Medicare patients cash back for surgery.” Kaiser Health News, October 26, 2009.
Available at: http://www.kaiserhealthnews.org/stories/2009/october/26/tulsa-medicare-hospitalbundling.aspx?referrer=search
2) Rau, J. “Medicare to begin basing hospital payments on patient-satisfaction scores.” Kaiser Health News, April 28,
2011. Available at: http://www.kaiserhealthnews.org/Stories/2011/April/28/medicare-hospital-patient-satisfaction.aspx
3) Rau, J. “Medicare announces rules for quality bonuses to hospitals.” Kaiser Health News, April 29, 2011. Available at:
http://www.kaiserhealthnews.org/Stories/2011/April/29/medicare-rules-for-hospital-quality.aspx
4) Pecquet, J., Baker, S. “Medicare proposal links surgical center payments to quality.” The Hill, July 1, 2011. Available
at: http://thehill.com/blogs/healthwatch/medicare/169497-medicare-proposes-linking-surgical-center-payments-toquality
Further Readings
1.
“Humana’s new provider quality program awarding nearly $10 million in quality awards to primary care physicians across the
U.S.” BusinessWire, July 20, 2011. Available at:
http://www.businesswire.com/news/home/20110720006098/en/Humana%E2%80%99s-Provider-Quality-Rewards-ProgramAwarding-10
14
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Abelson, R. “Hospitals pay for cutting costly readmissions.” The New York Times, May 9, 2009, p.B.1. Available at:
http://www.nytimes.com/2009/05/09/business/09relapse.html?pagewanted=all&_r=0
Abelson, R. “A health insurer pays more to save.” New York Times, June 21, 2010. Available at:
http://www.nytimes.com/2010/06/22/business/22geisinger.html?pagewanted=all
Adamy, J. “WellPoint shakes up hospital payments.” Wall Street Journal, online, May 16, 2011. Available at:
http://online.wsj.com/article/SB10001424052748704281504576325163218629124.html
BlueCross BlueShield Association. “Blue Shield of California awards $29.6 million in pay-for-performance programs in 2009.”
Press release, October 5 2009. Available at:
https://www.blueshieldca.com/producer/news/newsletter/shieldspotlight/shieldspotlight_nov09_article.sp#section4
Bridges to Excellence. Available at: http://www.bridgestoexcellence.org
Bury, G. “Provider groups receive innovation award from Medica.” Medica Press Release, October 15, 2008. Available at:
http://newscenter.medica.com/press-release/corporate-announcements/provider-groups-receive-innovation-award-medica
BusinessWire. “HealthPartners announces performance bonuses for providers.” November 10, 2008. Available at:
http://www.businesswire.com/portal/site/home/permalink/?ndmViewId=news_view&newsId=20081110006521&newsLang=en
Christianson, J.B., Leatherman , S., Sutherland, K. “Paying for quality: understanding and assessing physician pay-forperformance initiatives.” Robert Wood Johnson Foundation Research Synthesis Report No. 13, December 2007. Available at:
http://www.rwjf.org/pr/product.jsp?id=24373
Dentzer, S. “One payer’s attempt to spur primary care doctors to form new medical homes.” Health Affairs 2012;31(2):341-349.
Available at: http://online.wsj.com/article/SB125444082517257805.html
Friedberg, M.R., Safran, D.G., Coltin, K., Dresser, M., Schneider E.C. “Paying for performance in primary care: potential impact
on practices and disparities.” Health Affairs 2010;29(5):926-932. Available at:
http://content.healthaffairs.org/content/29/5/926.full.pdf+html
Kurtzman, E.R., O’Leary, D., Sheingold, B.H., Devers, K.J., Dawson, E.M., Johnson, J.E. “Performance-based payment
incentives increase burden and blame for hospital nurses.” Health Affairs 2011;30(2):211-218. Available at:
http://content.healthaffairs.org/content/30/2/211.full.pdf+html
Miller, H.D. “From volume to value: better ways to pay for health care.” Health Affairs 2009;28(5):1418-1428. Available at:
http://content.healthaffairs.org/content/28/5/1418.full.pdf+html
PR Newswire. “Harvard Pilgrim awards close to $1 million in quality grants to 14 physician groups.” May 15, 2011. Available at:
http://www.prnewswire.com/news-releases/harvard-pilgrim-awards-close-to-1-million-in-quality-grants-to-14-physician-groups121313819.html
Rosenthal, M.B., Dudley, R.A. “Pay-for-performance  Will the last payment trend improve care?” Journal of the American
Medicine Association 2007;297(7):740-744. Available at:
http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=5110&direction=P
Serumaga, B., Ross-Degnan, D., Avery, A.J., Elliott, R.A., Majumdar, S.R., Zhang, F., Soumerai, S.B. “Effect of pay for
performance on the management and outcomes of hypertension in the United Kingdom: Interrupted time series study.” BMJ,
2011. Available at: http://www.bmj.com/content/342/bmj.d108.full.pdf?sid=b6f47b59-d8ba-4dae-9226-b4f8c2800d0f
UCare. “Ucare announces details of 2011 pay for performance program that rewards providers for health improvements,” May 2,
2011. Available at:
http://www.ucare.org/SiteCollectionDocuments/media/NewsReleases/2011%20P4P%20prog%20details%20rel%20print%205-211.pdf
October 21, 2013
New Payment Arrangements: Bundled/Episode-Based Payment
Learning Objectives
Students should be able to:
1. Understand the basic design features relating to bundled payment.
2. Discuss the obstacles to implementing bundled payment arrangements.
3. Discuss Medicare support for bundled payment.
Suggested Readings
Bundled Payment in Concept
1. Aligning Forces for Quality. “Bundled payment: The quest for simplicity in pricing and tying payment to quality.” Robert Wood
Johnson Foundation, June 2013. Available at: http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/06/bundledpayment--the-quest-for-simplicity-in-pricing-and-tying-p.html
2. Silversmith, J. “Five payment models: The pros, the cons, the potential.” Minnesota Medicine, February 2011. Available at:
http://www.minnesotamedicine.com/PastIssues/PastIssues2011/February2011.aspx
15
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
Rosenthal, M.B. “Beyond pay for performance  emerging models of provider-payment reform.” New England Journal of
Medicine 2008;359(12):1197-1200. Available at: http://www.nejm.org/doi/pdf/10.1056/NEJMp0804658
4. de Brantes, F., D’Andrea, G., Rosenthal, M.B. “Should health care come with a warranty?” Health Affairs – Web Exclusive
2009;29(4):w678-w687 (published online 16 June 2009). Available at:
http://content.healthaffairs.org/content/28/4/w678.full.pdf+html
5. Mechanic, R.E., Altman, S.H. “Payment reform options: episode payment is a good place to start.” Health Affairs – Web
Exclusive 2009;28(2):w262-w271 (published online 27 January 2009). Available at:
http://content.healthaffairs.org/content/28/2/w262.full.pdf+html
6.* Painter, M.W. “Bundled payments: This way toward a challenging yet better place.” Health Care Incentives Issue Brief, 2012.
Available at: http://www.hci3.org/sites/default/files/files/HCI-IssueBrief-4-2012.pdf
7. Cutler, D.M., Ghosh, K. “The potential for cost savings through bundled episode payments.” New England Journal of Medicine
2012;366(12):1075-1077. Available at: http://www.nejm.org/doi/pdf/10.1056/NEJMp1201853
8.* Berenson, R.A., DeBrantes, F., Burton, R. Payment reform: Bundled episodes vs. global payments. Urban Institute, September
2012. Available at: http://www.urban.org/publications/412655.html
9. Bach, P.B. “Reforming the payment system for medical oncology.” Journal of the American Medical Association 2013;310(3):261262. Available at: http://jama.jamanetwork.com/issue.aspx?journalid=67&issueid=927287&direction=P
Field of Practice:
1) Mitchell, R. “Slow progress on efforts to pay docs, hospitals for ‘value,’ not volume.” Kaiser Health News, March 26,
2013. Available at: http://www.kaiserhealthnews.org/stories/2013/march/26/employers-value-volume-purchasing.aspx
Examples of Bundled Payment
1. Bailit, M., Burns, M., Houy, M. “Bundled payments one year later: An update on the status of implementations and operational
findings.” Health Care Incentives Improvement institute, May 30, 2013. Available at:
http://www.hci3.org/sites/default/files/files/IB.BundledPayment-June2013-L3_0.pdf
2. Hussey, P.S., Ridgely, M.S., Rosenthal, M.B. “The PROMETHEUS bundled payment experiment: Slow start shows problems in
implementing new payment models.” Health Affairs 2011;30(11):2116-2124. Available at:
http://content.healthaffairs.org/content/30/11/2116.full.pdf+html
Field of Practice:
1) Wall Street Journal Market Watch. “BlueCross announces bundled payment agreement with leading orthopedic
groups in Tennessee.” Press Release, May 22, 2012. Available at: http://www.marketwatch.com/story/bluecrossannounces-bundled-payment-agreements-with-leading-orthopedic-groups-in-tennessee-2012-05-22
2) Klukarni, S.S. Eyes turn to Arkansas’ bold effort to cut Medicaid costs, add transparency. Kaiser Health News October 1,
2012. Available at: http://www.kaiserhealthnews.org/Daily-Reports/2012/October/01/2khnstory.aspx?print=1
3) Emanuel, E.J. The Arkansas innovation. The New York Times, September 5, 2012. Available at:
http://opinionator.blogs.nytimes.com/2012/09/05/the-arkansas-innovation/
Medicare Payment Reform Initiatives
1. Chernew, M., Goldman D. “Proposal 1: Transitioning to bundled payments in Medicare.” Brookings, The Hamilton Project, 2013.
Available at:
http://www.brookings.edu/~/media/research/files/papers/2013/02/thp%20budget%20papers/thp_15waysfedbudget_prop1.pdf
2. Pecquet, J. “Medicare to bundle dialysis payments, reward facilities for training patients.” The Hill, July 26, 2010. Available at:
http://thehill.com/blogs/healthwatch/medicare/110975-medicare-to-reward-dialysis-facilities-for-trainingpatients?tmpl=component&print=1&page=
3. Komisar, H.L., Feder, J., Ginsburg, P.B. “’Bundling’ payment for episodes of hospital care. Issues and recommendations for the
new pilot program in Medicare.” 2011. Washington, DC: Center for American Progress. Available at:
http://www.americanprogress.org/issues/2011/07/pdf/medicare_bundling.pdf
4. Mechanic, R.E. “Opportunities and challenges for episode-based payment.” New England Journal of Medicine 2011;365(9):777779. Available at: http://www.nejm.org/doi/pdf/10.1056/NEJMp1105963
Field of Practice:
1) Minich-Pourshadi, K. “CMS bundled payment changes untenable?” HealthLeaders Media, December 10, 2013.
Available at: http://www.healthleadersmedia.com/page-1/FIN-287297/CMS-Bundled-Payment-Changes-Untenable
2) Walker, E.P. “CMS testing bundled payments for Medicare.” MedPage Today, August 23, 2011. Available at:
http://www.medpagetoday.com/PublicHealthPolicy/Medicare/28172
3.
Further Readings
1.
2.
Abelson, R. “In bid for better hospital care, heart surgery with a warranty; health plans: quality control.” New York Times, May 17,
2007. Available at: http://www.nytimes.com/2007/05/17/business/17quality.html?pagewanted=all&_r=0
Adamy, J. “WellPoint shakes up hospital payments.” Wall Street Journal (online), May 16, 2011. Available at:
http://proquest.umi.com/pqdlink?index=6&did=2348036301&SrchMode=2&sid=1&Fmt=3&VInst=PROD&VType=PQD&RQT=309
&VName=PQD&TS=1314044474&clientId=2256
16
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
3.
4.
5.
6.
7.
8.
9.
Galewitz, P. “Can 'bundled' payments help slash health costs? Effort touts efficiency; critics fear drop in care.” USA Today,
October 26, 2009. Available at: http://usatoday30.usatoday.com/news/health/2009-10-25-bundle-payments_n.htm
Hussey, P.S., Sorbero, M.E., Mehrotra, A., Liu, H., Damberg, C.L. “Episode-based performance measurement and payment:
making it a reality.” Health Affairs 2009;28(5):1406-1417. Available at:
http://content.healthaffairs.org/content/28/5/1406.full.pdf+html
Newcomer, L.N. “Changing physician incentives for cancer care to reward better patient outcomes instead of use of more costly
drugs.” Health Affairs 2012;31(4):780-785. Available at: http://content.healthaffairs.org/content/28/5/1406.full.pdf+html
Reuters. “Bundled payments a way to cut health costs: study.” November 11, 2009. Available at:
http://www.reuters.com/article/idUSTRE5AA4YV20091111
Reuters. “U.S. encourages bundling Medicare payments.” August 23, 2011. Available at:
http://www.reuters.com/article/2011/08/23/us-cms-innovation-idUSTRE77M5NR20110823
Struijs, J.N., Baan, C.A. “Integrating care through bundled payments – lessons from the Netherlands.” New England Journal of
Medicine 2011;364(11):990-991. Available at: http://www.nejm.org/doi/pdf/10.1056/NEJMp1011849
TriZetto Press Release. QualChoice Health Insurance chooses TriZetto’s payment-bundling solution to help improve cost and
quality of care for members. August 22, 2012. Available at:
http://www.trizetto.com/NewsEvents/PressReleases/PressRelease.aspx?id=4243
October 28, 2013
New Payment Arrangements: Comprehensive Gainsharing/Total Cost of Care (TCOC)
Learning Objectives
Students should be able to:
1. Describe the basic features of comprehensive, TCOC payment arrangements between health plans and providers.
2. Discuss the obstacles to implementing TCOC arrangements.
3. Discuss Medicare support for TCOC payment as evidenced by Alternative Care Organizations.
Suggested Readings
TCOC Payment Approaches
1. Klar, R. “Saving the shared savings program (ACOs): Specific suggestions for success—part one.” Health Affairs Blog, May 17,
2011. Available at: http://healthaffairs.org/blog/2011/05/17/saving-the-shared-savings-program-acos-specific-suggestions-forsuccess-part-one/
2. Lieberman, S.M., Bertko, J.M. “Building regulatory and operational flexibility into accountable care organizations and ‘shared
savings’.” Health Affairs 30(1):23-31, 2011. Available at: http://content.healthaffairs.org/content/30/1/23.full.pdf+html
3. Shields, M.C., Patel, P.H., Manning, M., Sacks, L. “A model for integrating independent physicians into accountable care
organizations.” Health Affairs 2011;30(1):161-172. Available at: http://content.healthaffairs.org/content/30/1/161.full.pdf+html
4. Berenson, R.A., Burton, R.A. “Accountable care organization in Medicare and the private sector: A status update.” Robert
Wood Johnson Foundation/Urban Institute, November 2011. Available at:
http://www.rwjf.org/files/research/73470.5470.aco.report.pdf
5. Mechanic, R.E., Santos, P., Landon, B.E., Chernew, M.E. “Medical group responses to global payment: Early lessons from the
‘alternative quality contract’ in Massachusetts.” Health Affairs 2011;30(9):1734-1742. Available at:
http://content.healthaffairs.org/content/30/9/1734.full.pdf+html
6*. Higgins, A., Stewart, K., Dawson, K., Bocchino, C. “Early lessons from accountable care models in the private sector:
Partnerships between health plans and providers.” Health Affairs 2011;30(9):1718-1727. Available at:
http://content.healthaffairs.org/content/30/9/1718.full.pdf+html
7. Landon, B.E. “Keeping score under a global payment system.” New England Journal of Medicine 366(5):393-395, 2012
8. Muhlestein, D., Croshaw, A., Merrill, T., Pena, C. “Growth and dispersion of accountable care organizations: June 2012 update.”
Leavitt Partners, 2012. Available at: http://leavittpartners.com/wp-content/uploads/2012/06/Growth-and-Dispersion-of-ACOsJune-2012-Update.pdf
9*. Song, Z. Safran, D.G., Landon, B.E., Landrum, M.B., He, Y., Mechanic, R.E., Day, M.P., Chernew, M.E. “The ‘alternative quality
contract,’ based on a global budget, lowered medical spending and improved quality.” Health Affairs 2012;31(8)1885-1894.
Available at: http://content.healthaffairs.org/content/31/8/1885.full.pdf+html
10. Bird, J. “Physician-led ACOs outnumber hospital counterparts.” FierceHealthcare, April 15, 2013. Available at:
http://www.fiercehealthcare.com/story/physician-led-acos-outnumber-hospital-counterparts/2013-04-15
11. Christensen, C., Flier, J., Vijayaraghavan, V. Opinion: “The coming failure of ‘accountable care’.” The Wall Street Journal,
February 18, 2013. Available at: http://online.wsj.com/article/SB10001424127887324880504578296902005944398.html
12. Muhlestein, D. “Continued growth of public and private accountable care organizations.” Health Affairs Blog, February 19, 2013.
Available at: http://healthaffairs.org/blog/2013/02/19/continued-growth-of-public-and-private-accountable-care-organizations/
17
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
Field of Practice:
1) Betbeze, P. “Incentives, motivations clash under ACOs.” HealthLeaders Media, April 26, 2013. Available at:
http://www.healthleadersmedia.com/content/LED-291569/Incentives-Motivations-Clash-Under-ACOs##
2) Bailit, M., Hughes, C., Burns, M., Freedman, D.H. “Shared-savings payment arrangement in health care. Six case
studies.” Commonwealth Fund, August 2012. Available at: http://www.commonwealthfund.org/Publications/FundReports/2012/Aug/Shared-Savings-Payment-Arrangements.aspx
3) McCann, E. “Bon Secours, Aetna ink big ACO Deal.” Healthcare IT News, June 25, 2013. Available at:
http://www.healthcareitnews.com/news/bon-secours-aetna-ink-big-aco-deal
4) Geist, R.W. “Minnesota’s health care merger proposals.” Star Tribune, April 15, 2013. Available at:
http://www.startribune.com/opinion/commentaries/203112301.html
5) Lowrey, A. “A health provider finds success in keeping hospital beds empty.” The New York Times, April 23, 2013.
Available at: http://www.nytimes.com/2013/04/24/business/accountable-care-helping-hospitals-keep-medical-costsdown.html?pagewanted=all&_r=0
6) Betbeze, P. “ACO or not, Fairview builds shared savings into all payer contracts.” HealthLeaders Media, May 23, 2011.
Available at: http://www.healthleadersmedia.com/page-1/HEP-266457/ACO-or-Not-Fairview-Builds-Shared-Savingsinto-All-Payer-Contracts
7) HealthPartners. “HealthPartners among first to receive accountable care organization accreditation from NCQA.” News
Release, February 14, 2013. Available at: http://www.healthpartners.com/public/newsroom/newsroom-article-list/2-1413.html
8) Crosby, J. “UnitedHealth expands efforts to link cost, quality.” Star Tribune, July 10, 2013. Available at:
http://www.startribune.com/business/215007791.html
9) UnitedHealthcare. “UnitedHealthcare expects to more than double industry-leading accountable care contracts to $50
billion by 2017.” July 10, 2013. Available at: http://finance.yahoo.com/news/unitedhealthcare-expects-more-doubleindustry-120000393.html
Medicare Payment Reform Initiatives
1. Wayne, A. “Obamacare shows hospital savings as patient make gains.” Bloomberg, June 12, 2013. Available at:
http://www.bloomberg.com/news/2013-06-12/obamacare-shows-hospital-savings-as-patients-make-gains.html
2. Centers of Medicare and Medicaid Services. “Pioneer accountable care organization model.” General Fact Sheet, September 12,
2012. Available at: http://innovation.cms.gov/Files/fact-sheet/Pioneer-ACO-General-Fact-Sheet.pdf
3. Klar, R. “Overweight and out of shape: ACO regs need a major makeover.” Health Affairs Blog, April 7, 2011. Available at:
http://healthaffairs.org/blog/2011/04/07/overweight-and-out-of-shape-aco-regs-need-a-major-makeover/
4. Lieberman, S. “Proposed CMS regulation kills ACOs softly.” Health Affairs Blog, April 6, 2011. Available at:
http://healthaffairs.org/blog/2011/04/06/proposed-cms-regulation-kills-acos-softly
5. Correia, E.W. “Accountable care organizations: The proposed regulations and the prospects for success.” American Journal of
Managed Care 2011;17(8):560-568. Available at: http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=3&sid=68ac2d733f7a-4fdf-890c-00fee61d722d%40sessionmgr111&hid=128
6. Berwick, D.M. “Making good on ACOs’ promise — The final rule for the Medicare shared savings program.” New England
Journal of Medicine 2011;365(19):1753-1756. Available at: http://www.nejm.org/doi/pdf/10.1056/NEJMp1111671
7. Berenson, R.A. “Shared savings program for accountable care organizations: A bridge to nowhere?” American Journal of
Managed Care 2010;16(10):721-726. Available at: http://www.ajmc.com/publications/issue/2010/2010-10-vol16n10/AJMC_10oct_Berenson_721to726/
8. McClellan, M., McKethan, A.N., Lewis, J.L., Roski, J., Fisher, E.S. “A national strategy to put accountable care into practice.”
Health Affairs 2010;29(5):982-990. Available at: http://content.healthaffairs.org/content/29/5/982.full.pdf+html
9. Meyer, H. “Accountable care organization prototypes: Winners and losers?” Health Affairs 2011;30(7):1227-1231. Available at:
http://content.healthaffairs.org/content/30/7/1227.full.pdf+html
10*. Ginsburg, P.B. “Spending to save – ACOs and the Medicare shared savings program.” New England Journal of Medicine
2011;364(22):2085-2086. Available at: http://www.nejm.org/doi/pdf/10.1056/NEJMp1103604
11. Klar, R. “ACO 101: The basics of accountable care.” Health Affairs Blog, August 29, 2011. Available at:
http://healthaffairs.org/blog/2011/08/29/aco-101-the-basics-of-accountable-care/
12. Gold, J. “FAQ on ACOs: Accountable care organizations, expanded.” Kaiser Health News, October 21, 2011. Available at:
http://www.kaiserhealthnews.org/stories/2011/january/13/aco-accountable-care-organization-faq.aspx
13. Binder, J. “Doctors should be rewarded for quality care – not for cutting corners.” Health Affairs Blog, July 19, 2013. Available at:
http://healthaffairs.org/blog/2013/07/19/doctors-should-be-rewarded-for-quality-care-not-for-cutting-corners/
Field of Practice:
1) BCBS of Illinois. “Blue Cross and Blue Shield of Illinois and OSF HealthCare team to create accountable care
organization to improve quality of care and reduce costs.” News Release, May 17, 2013. Available at:
http://www.bcbsil.com/company_info/newsroom/press_releases/2013/2013_05_17.html
18
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
2)
Torres, C. “32 ‘pioneers’ selected to test new health care model for seniors.” Kaiser Health News Blog, December 19,
2011. Available at: http://capsules.kaiserhealthnews.org/index.php/2011/12/32-pioneers-selected-to-test-newhealthcare-model-for-seniors/
Further Readings
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
BusinessWire. “Lahey Clinic joins Blue Cross Blue Shield of Massachusetts alternative quality contract.” News Release, May
14, 2012. Available at: http://www.businesswire.com/news/home/20120514006575/en/Lahey-Clinic-Joins-Blue-Cross-BlueShield
Crosby, J. “Feds reward Park Nicollet for healthy patients.” StarTribune, August 8, 2011. Available at:
http://www.startribune.com/business/127283643.html
Elliott, J. “Could health plans derail ACOs?” HealthLeaders Media, October 27, 2010. Available at:
http://www.healthleadersmedia.com/page-1/HEP-258288/Could-Health-Plans-Derail-ACOs##
Gold, J. “ACO rollout continues with 89 new networks.” Kaiser Health News Blog, July 9, 2012. Available at:
http://capsules.kaiserhealthnews.org/index.php/2012/07/aco-rollout-continues-with-89-new-networks/
Goodnough, A. New medical care networks show savings. The New York Times, September 11, 2012. Available at:
http://www.nytimes.com/2012/09/12/health/policy/medical-care-networks-show-savings-study-finds.html
Haywood, T.T. “The ACO model – A three-year financial loss?” New England Journal of Medicine 364:e27, March 23, 2011.
Available at: http://www.nejm.org/doi/pdf/10.1056/NEJMp1100950
NCQA Press Release. NCQA releases HEDIS for ACOs. September 11, 2012. Available at:
http://www.ncqa.org/Newsroom/2012NewsArchive/NewsReleaseSeptember112012.aspx
Overland, D. Medica launches private exchange to sell ACO projects. FierceHealthPayer, October 16, 2012. Available at:
http://www.fiercehealthpayer.com/story/medica-launches-private-exchange-sell-aco-products/2012-10-16
Parmar, A. Mayo, Medica partner to create alternative to fee-for-service health insurance. MedCity News, June 14, 2012. Available
at: http://medcitynews.com/2012/06/mayo-clinic-cements-new-collaboration-with-minnesota-health-plan/
Rosenthal, M.B., Cutler, D.M., Feder, J. “The ACO rules – Striking the balance between participation and transformative
potential.” New England Journal of Medicine 2011;365:e6. Available at: http://www.nejm.org/doi/pdf/10.1056/NEJMp1106012
Snowbeck, C. From HMOs to ACOs: Meet the newest model in health care management. TwinCities.com, September 24, 2012.
Available at: http://www.twincities.com/ci_21602399
The New York Times. How insurers can help. September 30, 2012. Available at: http://www.nytimes.com/2012/10/01/opinion/howinsurers-can-help.html
Weisman, R. Harvard Pilgrim, partners agree on 4-year contract. The Boston Globe, October 25, 2012. Available at:
http://www.bostonglobe.com/business/2012/10/25/partners-harvard-pilgrim-reach-new-four-year-contract-that-limits-annualpayment-increases/BpoapJk1S48xuiUo4p6QFK/story.html
November 4, 2013
Utilization Management
Reminders, clinical decision-support systems, predictive modeling, guidelines, and rules are all used by health plans to influence the
amount and type of care that providers deliver to their patients. Reminders prompt physicians about a patient's care needs prior to, or at
the time of, the treatment visit. Clinical decision-support systems typically involve software designed to assist the physician's clinical
decision-making. Predictive modeling uses large claims databases to identify patients who may be at risk of specific illnesses in the future
and alert clinicians prior to the patient visit. Guidelines, or pathways, assist physicians in taking the appropriate treatment steps, given a
patient's condition, and often are applied when treating patients with chronic health problems. Rules are used by health plans to intervene
more directly in the care process. This session will address the different ways that health plans attempt to influence the delivery of care by
providers, including the manner in which these techniques are being employed and evidence of their effectiveness.
Learning Objectives
Students should be able to:
1. Describe the most common practices used by health plans to support physicians in the delivery of care.
2. Explain the barriers to their effective implementation.
3. Assess the strength of the evidence supporting their effectiveness.
4. Describe recent trends in their use in conjunction with other efforts to influence physician behavior.
Suggested Readings
Utilization Management Challenges Faced by Health Plans
1*. The Medical Society of the State of New York. “Survey reveals that doctors feel pressured by health insurers to alter the way
they treat patients.” September 10, 2008. Available at: http://www.mssny.org/mssnyip.cfm?c=i&nm=Insurance_Carrier_Rules
2. Paltrow, S.J. “Insurers’ black box.” Center for American Progress, October 23, 2009. Available at:
http://www.americanprogress.org/issues/2009/10/black_box.html
19
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
3.
Beckman, H.B. “Lost in translation: Physicians’ struggle with cost-reduction programs.” Annals of Internal Medicine
2011;154(6):430-433. Available at: http://annals.org/issue.aspx?journalid=90&issueID=20228&direction=P
4. Goldberger, J.J., Buston, A.E. “Personalized medicine vs guideline-based medicine.” Journal of the American Medical Association
2013;309(24):2559-2560. Available at: http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=927181&direction=P
Field of Practice:
1) Gardner, A. “Day of admission dictates length of stay for heart failure.” ABC News, May 22, 2010. Available at:
http://abcnews.go.com/Health/Healthday/story?id=4904656&page=1
Overview of Health Plan Efforts
1*. Landon, B.E., Rosenthal, M.B., Normand, S-L.T., Frank, R.G., Epstein, A.M. “Quality monitoring and management in commercial
health plans.” American Journal of Managed Care 2008;14(6):377-386. Available at:
http://www.ajmc.com/publications/issue/2008/2008-06-vol14-n6/Jun08-3301p377-386/
2. Goodell, S., Bodenheimer, T., Berry-Millet, R. “Care management of patients with complex health care needs.” Policy Brief No. 19.
Robert Wood Johnson Foundation Synthesis Project, December 2009. Available at: http://www.rwjf.org/en/researchpublications/find-rwjf-research/2009/12/care-management-of-patients-with-complex-health-care-needs.html
Field of Practice:
1) MedeAnalytics. “Blue Cross Blue Shield of Vermont slects MedeAnalytics’ medical management analytics.” April 30,
2013. Available at: http://www.medeanalytics.com/news-events/blue-cross-blue-shield-of-vermont-selectsmedeanalytics-medical-management-analytics
2) MedSolutions. “MedSolutions launches comprehensive post-acute care management project.” March 28, 2013. Available
at: http://www.medsolutions.com/news/3-28-13.html
3) Keim, B. Paging Dr. Watson: Artificial intelligence as a prescription for health care. Wired. October 16, 2012. Available
at: http://www.wired.com/wiredscience/2012/10/watson-for-medicine/
Profiling/Feedback of Information on Treatment Patterns
1. Bindman, A. “Can Physician Profiles Be Trusted?” JAMA 1999;281(22):2142-2143. Available at:
http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=4646&direction=P
2. Greene, R.A., Beckman, H., Chamberlain, J., Partridge, G., Miller, M., Burden, D., Kerr, J. “Increasing adherence to a
community-based guideline for acute sinusitis through education, physician profiling, and financial incentives.” American Journal
of Managed Care 2004;10(10):670-678. Available at: http://www.ajmc.com/publications/issue/2004/2004-10-vol10-n10/Oct041901p670-678/
Practice Guidelines
1. Goldberger, J.J., Buxton, A.E. “Personalized medicine vs. guideline-based medicine.” Journal of the American Medical Association
2013;309(24):2559-2560. Available at: http://jama.jamanetwork.com/issue.aspx?journalid=67&issueid=927181&direction=P
2*. Lin, K.W., Slawson, D.C. “Identifying and using good practice guidelines.” American Family Physician 2009;80(1):67-69. Available
at: https://www.clinicalkey.com/#!/BrowserCtrl/doBrowseTo/journalIssue/{"facet":["1-s2.0S0002838X09X60156"],"issn":"0002838X","contentType":"Journals"}
3. Editorial. “Improving practice guidelines with patient-specific recommendations.” Annals of Internal Medicine 2011;154(9):638639. Available at: http://annals.org/issue.aspx?journalid=90&issueID=20231&direction=P
Field of Practice:
1) Graham, J. “Mammogram guidelines are sparking a firestorm; Critics hit suggestion that women in 40s may not need
routine screening.” Chicago Tribune, November 17, 2009, p.1. Available at: http://articles.chicagotribune.com/2009-1117/news/0911160603_1_routine-mammograms-annual-mammograms-breast-cancer
2) Ando, R. “IBM and Aetna tie up to offer clinical support service.” Reuters, August 5, 2010. Available at:
http://www.reuters.com/article/idUSTRE6740EW20100805
3) Boulton, G. “Guidelines met with dose of skepticism. Do they aid doctors or hinder them?” Milwaukee Journal Sentinel,
June 27, 2010. Available at: http://www.jsonline.com/business/97280724.html
4) Nussbaum, A. “Aetna urges moms to avoid cesareans births to reduce risk.” Bloomberg.com, July 12, 2012. Available
at: http://www.bloomberg.com/news/2012-07-13/aetna-urges-moms-to-avoid-cesareans-births-to-reduce-risk.html
5) Gordon, S. “Diabetes groups issue new guidelines on blood sugar.” HealthDay, April 19, 2012. Available at:
http://consumer.healthday.com/Article.asp?AID=663893
Use of Treatment Reminders
1. Derose, S.F., Dudl, J.R., Benson, V.M., Contreras, R., Nakahira, R.K., Ziel, F.H. “Point-of-service reminders for prescribing
cardiovascular medications.” The American Journal of Managed Care 2005;11(5):298-304. Available at:
http://www.ajmc.com/publications/issue/2005/2005-05-vol11-n5/May05-2027p298-304/
Field of Practice:
1) Mathews, A.W. “WellPoint’s new hire. What is Watson?” Wall Street Journal online, September 12, 2011. Available at:
http://online.wsj.com/article/SB10001424053111903532804576564600781798420.html
Managing Imaging Use and Costs: Combining Utilization Management Tools
1. Tynan, A., Berenson, R.A., Christianson, J.B. “Health plans target advanced imaging services: cost, quality and safety concerns
prompt renewed oversight.” Center for Studying Health System Change Issue Brief No. 118, February 2008. Available at:
20
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
http://www.hschange.com/CONTENT/968/
Iglehart, J.K. “Health insurers and medical-imaging policy – a work in progress.” New England Journal of Medicine
2009;360(10):1030-1037. Available at: http://www.nejm.org/doi/pdf/10.1056/NEJMhpr0808703
3. Rao, V.M., Levin, D.C. The overuse of diagnostic imaging and the choosing wisely initiative. Annals of Internal Medicine. Available
at: http://annals.org/article.aspx?articleid=1355170
4*. Lee, D.W., Levy, F. “The sharp slowdown in growth of medical imaging: An early analysis suggests combination of policies was
the cause.” Health Affairs 2012;31(8):1876-1884. Available at: http://content.healthaffairs.org/content/31/8/1876.full.pdf+html
Field of Practice:
1) Seaman, A.M. “Many lower back MRI scans may be unnecessary.” Reuters, March 25, 2013. Available at:
http://www.reuters.com/article/2013/03/25/us-lower-back-mri-idUSBRE92O0XV20130325
2) Mathews, A.W. “Insurers hire radiology police to vet scanning; firms make doctors justify costly CTs, MRIs and PETs;
patients 'stuck in the middle'.” Wall Street Journal, November 6, 2008. Available at:
http://online.wsj.com/article/SB122591900516802409.html
3) Kaiser Health News. “Concerns about unnecessary scans and radiation risk prompt reviews by doctors.” March 2,
2010. Available at: http://www.kaiserhealthnews.org/daily-reports/2010/march/02/radiation-and-ctscans.aspx?referrer=search
4) Parashar, A. “In emergency rooms, it’s getting tougher to say ‘no’ to CT scans.” Kaiser Health News, November 29,
2010. Available at: http://www.kaiserhealthnews.org/Stories/2010/November/29/CT-scan-study-short-take.aspx
5) Galewitz, P. “Imaging at the doctor’s: Good thing or transparent ploy?” USAToday, August 23, 2010. Available at:
http://www.usatoday.com/yourlife/health/healthcare/doctorsnurses/2010-08-23-Imaging23_ST_N.htm
6) Carey, M.A. “Medical imaging advocates fight proposals requiring advance authorization.” Kaiser Health News, October
18, 2011. Available at: http://capsules.kaiserhealthnews.org/index.php/2011/10/medical-imaging-advocates-fightproposals-requiring-advance-authorization/
7) Hancock, J. Pressure from insurers, government cuts radiology use and spending. KHN Blog, September 10, 2012.
Available at: http://capsules.kaiserhealthnews.org/index.php/2012/09/pressure-from-insurers-government-cuts-radiologyuse-and-spending/
8) Bardin, J. “Use of imaging tests sores, raising questions on radiation risk.” Los Angeles Times online, June 20, 2012.
Available at: http://articles.latimes.com/2012/jun/12/science/la-sci-ct-mri-growth-20120613
Medicare Utilization Initiatives
1. U.S. Government Accountability Office. “Medicare: per capita method can be used to profile physicians and provide feedback on
resource use. Summary.” September 25, 2009. Available at: http://www.gao.gov/products/GAO-09-802
2*. Pecquet, J. “Bipartisan duo fights proposals to curb medical imaging.” The Hill, March 31, 2011. Available at:
http://thehill.com/blogs/healthwatch/medicare/163957-bipartisan-duo-fights-proposals-to-curb-medical-imaging
3. Matlock, D.D., Groeneveld, P.W., Sidney, S., et al. “Geographic variation in cardiovascular procedure use among Medicare fee-forservice vs Medicare advantage beneficiaries.” Journal of the American Medical Association 2013;310(2):155-162. Available at:
http://jama.jamanetwork.com/issue.aspx?journalid=67&issueid=927264&direction=P
Field of Practice:
1) Carey, M.A., Serafini, M.W. “Doctors balk at proposal to cut Medicare’s use of imaging.” Kaiser Health News, June 14, 2011.
Available at: http://www.kaiserhealthnews.org/Daily-Reports/2011/June/15/1khnstory.aspx
2.
Further Readings on Imaging
1.
2.
3.
4.
5.
6.
7.
8.
Allen, G.P. “Costs escalate, patients suffer when waste, abuse and fraud permeate diagnostic imaging.” May 2007. Available at:
http://www.imakenews.com/seroper/e_article000814532.cfm?x=b11,0,w
Bogdanich, W., McGinty, J.C. “Medicare claims showing overuse of CT scanning.” New York Times, June 18, 2011, p. A.1.
Available at: http://www.nytimes.com/2011/06/18/health/18radiation.html?pagewanted=all
Bogdanich, W., Ruiz, R.R. “F.D.A. to increase oversight of medical radiation.” The New York Times, February 10, 2010.
Available at: http://www.nytimes.com/2010/02/10/health/policy/10radiation.html
Franklin, C. “Before you get that CT scan…” Chicago Tribune, March 17, 2011, p.21. Available at:
http://articles.chicagotribune.com/2011-03-17/opinion/ct-oped-0317-scanner-20110317_1_future-cancers-ct-scans-ctcolonography
Holcombe, D. “Oncology management programs for payers and physicians.” American Journal of Managed Care 2011;17:e182e186. Available at: http://www.ajmc.com/publications/issue/2011/2011-5-vol17-n5/AJMC_11JOPmayHolcombe_e182to6
Iglehart, J.K. “The new era of medical imaging  progress and pitfalls.” The New England Journal of Medicine
2006;354(26):2822-2828. Available at: http://www.nejm.org/doi/pdf/10.1056/NEJMhpr061219
Kaiser Health News. “Federal officials focus on radiation practices at Florida clinic; medical scan makers announce new efforts to
prevent mistakes.” February 26, 2010. Available at: http://www.kaiserhealthnews.org/DailyReports/2010/February/26/Radiation.aspx
Kaiser Health News. “Los Angeles Times examines growing popularity, concerns regarding CT scans.” September 8, 2008.
Available at: http://www.kaiserhealthnews.org/daily-reports/2008/september/08/dr00054331.aspx?referrer=search.
21
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Landro, L. ”The informed patient: better ways to treat back pain; insurers, employers target excessive scans and surgeries to
improve patient outcomes.” Wall Street Journal, May 16, 2007. Available at:
http://online.wsj.com/article/SB117926943880204067.html
Marchione, M. “Be wary of radiation overdose from medical tests, doctors say.” TwinCities.com, June 14, 2010. Available at:
http://www.twincities.com/alllistings/ci_15296869?source=rss
Perrone, M. “Medical scan makers to install radiation controls.” Seattle Times online. February 25, 2010. Available at:
http://seattletimes.nwsource.com/html/businesstechnology/2011184043_apusradiationscanssafety.html
Phelps, D.” Insurers want 2nd opinion before approving scans.” MPR News, January 4, 2007. Available at:
http://minnesota.publicradio.org/display/web/2007/01/04/scans
PR Newswire. “Anthem Blue Cross and Blue Shield of Wisconsin expands transparency of diagnostic imaging.” October 21,
2007. Available at: http://www.prnewswire.com/news-releases/anthem-blue-cross-and-blue-shield-expands-cost-disclosure-toolto-northcentral-wisconsin-65185497.html
Salganik, M.W. “Medical scans zapping insurers.” Baltimore Sun, May 13, 2007. Available at:
http://articles.baltimoresun.com/2007-05-13/business/0705130014_1_pet-scans-emission-tomography-positron-emission
Sataline, S. “Doctors may risk overuse of CT scans.” Wall Street Journal, November 29, 2007. Available at:
http://online.wsj.com/article/SB119627836509306828.html
Serafini, M.W., Carey, M.G. “Panel urges crackdown on Medicare’s use of imaging.” Kaiser Health News, June 14, 2011. Available
at: http://www.kaiserhealthnews.org/Stories/2011/June/15/Medicare-imaging.aspx
Steenhuysen, J. “Doctors work on radiation problem to ease fears.” Reuters, June 7, 2010. Available at:
http://www.reuters.com/article/idUSTRE6565Y820100608
Steenhuysen, J. “Younger Americans overexposed to radiation risk.” Reuters, August 27, 2009. Available at:
http://www.reuters.com/article/idUSTRE57P59Z20090827
Szabo, L. Cancer risks prompt doctors to try to lower imaging scan radiation. USA Today. Available at:
http://www.usatoday.com/news/health/2010-05-05-radiation05_st_N.htm
Tanner, L. “Use of costly scans is climbing in cancer patients.” April 27, 2010. Available at:
http://www.msnbc.msn.com/id/36807258/ns/health-cancer/
Bodenheimer, T., Berry-Millet, R. “Care management of patients with complex health care needs.” Research Synthesis Report No.
19. Robert Wood Johnson Foundation Synthesis Project, December 2009. Available at: http://www.rwjf.org/en/researchpublications/find-rwjf-research/2009/12/care-management-of-patients-with-complex-health-care-needs.html
Further Readings – General
1.
2.
3.
Juster, I.A. et al. “Use of administrative data to identify health plan members with unrecognized bipolar disorder: a retrospective
cohort study.” American Journal of Managed Care 2005;11(9):578-584. Available at:
http://www.ajmc.com/publications/issue/2005/2005-09-vol11-n9/Sep05-2123p578-584/
Neergaard, L. “Overtreated: more medical care isn’t always better.” ABC News, July 7, 2010. Available at:
http://abcnews.go.com/Health/wireStory?id=10843361
O’Connor, P.J., Sperl-Hillen, J., Johnson, P.E. “Customized feedback to patients and providers failed to improve safety or quality of
diabetes care. A randomized trial.” Diabetes Care 2009;32(7):1158-1163. Available at:
http://care.diabetesjournals.org/content/32/7/1158.full.pdf+html
November 11, 2013
Supporting Employees/Enrollees in Choosing Providers: Reporting of Provider Performance
Providing consumers with timely, useful information about the performance of providers is one way that purchasers hope to engage
consumers. Their intent is that consumers will use this information, in combination with financial incentives, to seek out lower cost, higher
quality providers. And, it is hoped that providers will improve their quality and reduce their costs when faced with public comparisons with
their peers. The present health care system, some argue, does not provide information that is truly useful to consumers in making
cost/quality tradeoffs when choosing providers, or that is credible to providers. We will discuss recent efforts to publicly report information
comparing providers, as well as the evidence regarding the influence of this information on consumer and provider decisions.
Learning Objectives
Students should be able to:
1. Describe the recent efforts to increase the amount and quality of information available to health care consumers about providers.
2. Discuss the responses of providers to these efforts.
3. Assess the evidence regarding the impact of comparative provider performance data on consumer decisions, quality of care, and
health care costs.
22
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
Suggested Readings
Private Entities Producing Public Reports
1. Young, G.J. “Multistakeholder regional collaboratives have been key drivers of public reporting but now face challenges.” Health
Affairs 2012;31(3):578-584. Available at: http://content.healthaffairs.org/content/31/3/578.full.pdf+html
2.* Christianson, J.B., Volmar, K.M., Alexander, J., Scanlon, D.P. “A report card on provider report cards: Current status of the
health care transparency movement.” Journal of General Internal Medicine 2010;25(11):1235-1241. Available at:
http://link.springer.com/content/pdf/10.1007%2Fs11606-010-1438-2.pdf
Public Reports and Their Use by Consumers
1. Kullgren, J.T., Duey, K.A., Werner, R.M. “A census of state health care price transparency websites.” Journal of the American
Medical Association 2013;309(23):2437-2438. Available at:
http://jama.jamanetwork.com/issue.aspx?journalid=67&issueid=927128&direction=P
2. Reinhardt. U.E. “Health care payers push back against costs.” The New York Times, February 3, 2012. Available at:
http://economix.blogs.nytimes.com/2012/02/03/health-care-payers-push-back-against-costs/
3. Rothberg, M.B., Morsi, E., Benjamin, E.M., Pekow, P.S., Lindenauer, P.K. “Choosing the best hospital: the limitations of public
quality reporting.” Health Affairs 2008;27(6):1680-1687. Available at:
http://content.healthaffairs.org/content/27/6/1680.full.pdf+html
4. Harris, K.M. and Buntin, M.B. “Choosing a Health Care Provider: The Role of Quality Information,” Research Synthesis Report
No. 14. Princeton, NJ: The Synthesis Project, Robert Wood Johnson Foundation, May 2008. Available at:
http://www.rwjf.org/pr/product.jsp?id=29683
5. The LeapfrogGroup. “Transparency should not be a luxury; it is a matter of life and death: what purchasers and consumers can
do.” February 2, 2010. Available at: http://www.leapfroggroup.org/news/leapfrog_news/4773661
6. Osborne, N.H., Ghaferi, A.A., Nicholas, L.H., Dimick, J.B. “Evaluating popular media and internet-based hospital quality ratings
for cancer surgery.” Archives of Surgery 2011;146(5):600-604. Available at:
http://archsurg.jamanetwork.com/Issue.aspx?journalid=76&issueID=5406&direction=P
7. Cutler, D., Dafney, L. “Designing transparency systems for medical care prices.” New England Journal of Medicine
2011;(10):364:894-895. Available at: http://www.nejm.org/doi/pdf/10.1056/NEJMp1100540
8.* Hibbard, J.H., Greene, J., Shoshanna, S., Firminger, K., Hirsh, J. “An experiment shows that a well-designed report on costs
and quality can help consumers choose high-value health care.” Health Affairs 2012;31(3):560-568. Available at:
http://content.healthaffairs.org/content/31/3/560.full.pdf+html
9.* Sinaiko, A.D., Eastman, D., Rosenthal, M.B. “How report cards on physicians, physician groups, and hospitals can have greater
impact on consumer choices.” Health Affairs 2012:31(3):602-611. Available at:
http://content.healthaffairs.org/content/31/3/602.full.pdf+html
10.* Friedberg, M.W., Damberg, C.L. “A five-point checklist to help performance reports incentivize improvement and effectively
guide patients.” Health Affairs 2012;31(3):612-618. Available at: http://content.healthaffairs.org/content/31/3/612.full.pdf+html
11. Minnesota HealthScores. “Understanding the cost of your care.” Available at:
http://www.mnhealthscores.org/?p=cost_landing&category=all&sf=group
Field of Practice:
1) Kaiser Health News. “Rating your doctor.” August 3, 2010. Available at:
http://www.kaiserhealthnews.org/Features/Insuring-Your-Health/andrews-column-on-physician-ratings.aspx
2) redOrbit. Blue Cross and Blue Shield of Georgia Launches “Zagat health survey tool.” September 23, 2009. Available
at:
http://www.redorbit.com/news/health/1758420/blue_cross_and_blue_shield_of_georgia_launches_zagat_health/index.
html
3) McCann, E. “The price transparency argument.” Healthcare Finance News, May 23, 2013. Available at:
http://www.healthcarepayernews.com/content/price-transparency-argument
4) Soltas, E. “How to make the health-care market work better.” Bloomberg, March 28, 2013. Available at:
http://www.bloomberg.com/news/2013-03-28/how-to-make-the-health-care-market-work-better.html
5) Mitchell, R. Employers, unions jointly demand health care price transparency. KHN Blog, November 1, 2012. Available
at: http://capsules.kaiserhealthnews.org/index.php/2012/11/employers-unions-jointly-demand-health-care-pricetransparency/
6) Commins, J. “Consumer reports expands hospital ratings list.” HealthLeaders Media, April 19, 2013. Available at:
http://www.healthleadersmedia.com/page-1/QUA-291310/Consumer-Reports-Expands-Hospital-Ratings-List
7) Betbeze, P. “Managing physicians may be impossible.” HealthLeaders Media, April 19, 2013. Available at:
http://www.healthleadersmedia.com/page-1/LED-291313/Managing-Physicians-May-Be-Impossible
8) MN Community Measurement. The Measurement Minute, February 2013. Available at: http://mncm.org/wpcontent/uploads/2013/05/February-2013-MNCM-Measurement-Minute.pdf
9) Rau, J. “Hospital ratings are in the eye of the beholder.” Kaiser Health News, March 18, 2013. Available at:
http://www.kaiserhealthnews.org/stories/2013/march/18/expanding-number-of-groups-offer-hospital-ratings.aspx
23
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
10) Bebinger, M. “How much for an MRI? $500? $5,000? A reporter struggles to find out.” Kaiser Health News, December
9, 2012. Available at: http://www.kaiserhealthnews.org/stories/2012/december/09/mri-cost-price-comparison-healthinsurance.aspx
11) Betbeze, P. “Get ready for price transparency.” HealthLeaders Media, November 30, 2012. Available at:
http://www.healthleadersmedia.com/page-1/LED-287017/Get-Ready-for-Price-Transparency
Concerns about Public Reports
1. Williams, D. “The state of online doctor ratings: It’s still early.” KevinMD.com, April 24, 2013. Available at:
http://www.kevinmd.com/blog/2013/04/state-online-doctor-ratings-early.html
2. Ubel, P. “How price transparency could end up increasing health-care costs.” The Atlantic, April 9, 2013. Available at:
http://www.theatlantic.com/health/archive/2013/04/how-price-transparency-could-end-up-increasing-health-care-costs/274534/
3. Ginsburg, P. “Most health costs data of little use: Opposing view.” USA Today, March 5, 2013. Available at:
http://www.usatoday.com/story/opinion/2013/03/05/health-care-price-transparency-center-for-studying-health-systemchange/1966039/
4. Werner, R., Asch, D. “The unintended consequences of publicly reporting quality information.” Journal of the American Medical
Association 2005;293(10):1239-1244. Available at:
http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=4967&direction=P
5*. Sinaiko, A.D., Rosenthan, M.B. “Increased price transparency in health care – challenges and potential effects.” New England
Journal of Medicine 2011;364(10):891-894. Available at: http://www.nejm.org/doi/pdf/10.1056/NEJMp1100041
6. Reuters. “Hospital ratings miss many high performers: study.” May 18, 2011. Available at:
http://www.reuters.com/article/2011/05/18/us-hospital-ratings-idUSTRE74H73F20110518
7. Mehrotra, A., Hussey, P.S., Milstein, A., Hibbard, J.H. “Consumers’ and providers’ responses to public cost reports, and how to
raise the likelihood of achieving desired results.” Health Affairs 2012;31(4):843-851. Available at:
http://content.healthaffairs.org/content/31/4/843.full.pdf+html?sid=90f9112a-49f3-4748-ba50-8d6ce5cf3343
Field of Practice:
1) Associated Press. “ACPE survey finds most physician leaders skeptical of online ratings.” January 16, 2013. Available
at: http://www.ereleases.com/pr/acpe-survey-finds-physician-leaders-skeptical-online-ratings-97316
2) BusinessWire. “U.S. news best hospitals rankings may be misleading, according to Comparion.” May 7, 2013.
Available at: http://www.businesswire.com/news/home/20130507005013/en/U.S.-News-Hospitals-RankingsMisleading-Comparion
3) Minnesota Medicine. “MMA finds significant errors in Medica’s physician ratings.” February 2011. Available at:
http://www.minnesotamedicine.com/PastIssues/PastIssues2011/February2011/MMANewsFeb2011.aspx
4) Mitchell, R. “29 states get ‘F’ for price transparency laws.” Kaiser Health News Blog, March 18, 2013. Available at:
http://capsules.kaiserhealthnews.org/?p=17815
5) Ostrow, N. “Hospitals ranked top based on reputation more than quality, study says.” Bloomberg Businessweek, April
19, 2010. Available at: http://www.bloomberg.com/news/2010-04-19/hospitals-ranked-top-based-on-reputation-morethan-quality-study-says.html
6) Lieber, R. “The web is awash in reviews, but not for doctors. Here’s why.” New York Times online, March 9, 2012.
Available at: http://www.nytimes.com/2012/03/10/your-money/why-the-web-lacks-authoritative-reviews-ofdoctors.html?pagewanted=all
Provider Responses to Public Reporting
1. Frisch, S. “Pricing problem. Hospitals and clinics struggle to tell patients what things cost.” Minnesota Medicine, April 2013.
Available at: http://www.minnesotamedicine.com/Portals/mnmed/April%202013/Pricingproblem1304.pdf
2. Woo, H.E. “The crucible of physician performance reports.” Journal of General Internal Medicine 2010;26(2):226-227. Available
at: http://link.springer.com/content/pdf/10.1007%2Fs11606-010-1498-3.pdf
3*. Watts, L.A., de Bocanegra, H.T., Darney, P.D., Hulett, D., Howell, M., Mikanda, J., Zerne, R., Policar, M.S. “In a California
program, quality and utilization reports on reproductive health services spurred providers to change.” Health Affairs
2012;31(4):852-862. Available at: http://link.springer.com/content/pdf/10.1007%2Fs11606-010-1498-3.pdf
4. Smith, M.A., Wright, A., Queram, C., Lamb, G.C. “Public reporting helped drive quality improvement in outpatient diabetes care
among Wisconsin physician groups.” Health Affairs 2012;31(3):570-577. Available at:
http://content.healthaffairs.org/content/31/4/843.full.pdf+html
5*. Teleki, S., Shannon, M. “In California, quality reporting at the state level is at a crossroads after hospital group pulls out.” Health
Affairs 2012;31(3):642-646. Available at: http://content.healthaffairs.org/content/31/3/642.full.pdf+html
6. Mehrotra, A. Hussey, P.S., Milstein, A., Hibbard, J.H. “Consumers’ and providers’ responses to public cost reports, and how to
raise the likelihood of achieving desired results.” Health Affairs 2012;31(4):843-851. Available at:
http://content.healthaffairs.org/content/31/4/843.full.pdf+html
7. Seabrook, G.R. “Does rigorous quality process reporting guarantee superior-quality health care?” Journal of the American
Medical Association 2013;310(3):316-317. Available at:
http://jama.jamanetwork.com/issue.aspx?journalid=67&issueid=927287&direction=P
24
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
Field of Practice:
1) Associated Press. “Doctors dispute quality rankings.” February 8, 2007. Available at:
http://www.pittsburghlive.com/x/pittsburghtrib/business/s_492216.html
2) Mathews, A.W. “Compare and contrast when doctors are given a public report card, the resulting competition can
serve patients well.” Wall Street Journal, October 27, 2009, p. R.4. Available at:
http://online.wsj.com/article/SB10001424052970204488304574431741881361528.html
3) CBS News. “Doctors can guard reputation on rating site.” March 3, 2011. Available at:
http://www.cbc.ca/news/health/story/2011/05/03/doctor-rating-websites-reputation.html
4) Chen, P.W. “A report card for doctors.” New York Times, June 16, 2011. Available at:
http://well.blogs.nytimes.com/2011/06/16/a-report-card-for-doctors/
Medicare Reporting
1. Hostetter, M., Klein, S. “Quality matters. In focus: Medicare data helps fill in picture of health care performance.” The
Commonwealth Fund, April/May 2013. Available at: http://www.commonwealthfund.org/Newsletters/Quality-Matters/2013/AprilMay/In-Focus.aspx
2. Klein, S. “Quality matters. Q&A: Building an all-payer claims database—The Wisconsin model.” The Commonwealth Fund,
April/May 2013. Available at: http://www.commonwealthfund.org/Newsletters/Quality-Matters/2013/April-May/QA.aspx
Further Readings
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Andrews, C. “Empire BlueCross Blue Shield and Zagat to survey New Yorkers about doctor accessibility, offices and
communication skills.” Empire BlueCross BlueShield, November 18, 2009. Available at:
http://www.empireblue.com/wps/portal/ehpfooter?content_path=shared/noapplication/f1/s0/t0/pw_b139674.htm&label=Empire%2
0BlueCross%20BlueShield%20and%20Zagat%20To%20Survey%20New%20Yorkers%20About%20Doctor%20Accessibility,%2
0Offices%20and%20Communication%20Skills
Auerbach, A.D., Hilton, J.F., Maselli, J., Pekow, P.S., Rothberg, M.B., Lindenauer, P.K. “Shop for quality or volume? Volume,
quality, and outcomes of coronary artery bypass surgery.” Annals of Internal Medicine 2009;150(10):696-704. Available at:
http://annals.org/issue.aspx?journalid=90&issueID=20182&direction=P
Barr, S. “Dream of a medical ‘price list’ dies in Florida legislature.” KHN Blog, January 30, 2012. Available at:
http://capsules.kaiserhealthnews.org/index.php/2012/01/dream-of-a-medical-price-list-dies-in-florida-legislature/
Boulton, G. “Bill would require listing of medical procedure costs.” JSOnline, March 4, 2010. Available at:
http://www.jsonline.com/business/86466282.html
Clark, C. “Consumer reports rates hospital safety.” HealthLeaders Media, July 5, 2012. Available at:
http://www.healthleadersmedia.com/page-1/LED-281969/Consumer-Reports-Rates-Hospital-Safety
Ferraro, M. “Medicine’s big mystery, what does treatment cost?” Bloomberg, July 12, 2011. Available at:
http://www.bloomberg.com/news/2011-07-12/medicine-s-big-mystery-what-does-treatment-cost-mimi-ferraro.html
Fox, M. “People like expensive health care, study finds.” NationalJournal, March 5, 2012. Available at:
http://www.nationaljournal.com/healthcare/people-like-expensive-health-care-study-finds-20120305
Hibbard, J., Stockard, Tusler, M. “Does publicizing hospital performance stimulate quality improvement efforts?” Health Affairs
2003;22(2):84-94. Available at: http://content.healthaffairs.org/content/22/2/84.full.pdf+html
Hibbard, J.H., Stockard, J., Tusler, M. “Hospital performance reports: impact on quality, market share, and reputation.” Health
Affairs 2005;24(4):1150-1160. Available at: http://content.healthaffairs.org/content/24/4/1150.full.pdf+html
Intuit. “UnitedHealthcare expands availability of quicken health expense tracker to nearly 700,000 consumers.” August 3, 2009.
Available at: http://about.intuit.com/about_intuit/press_room/press_release/articles/2009/UNITEDHEALTHCAREEXPANDS.html
Kaiser Health News. N.Y. AG, “Cigna reach agreement on physician ranking system.” October 30, 2007. Available at:
http://www.kaiserhealthnews.org/daily-reports/2007/october/30/dr00048525.aspx?referrer=search
King , J., Henry, E. “Bill Clinton awaits heart surgery next week.” CNN.com, September 4, 2004. Available at:
http://www.cnn.com/2004/ALLPOLITICS/09/03/clinton.tests/index.html
Lansky, D., Findlay, S. “Physician compare site could be ‘game changer,’ but challenges remain.” iHealthBeat, January 12, 2011.
Available at: http://www.ihealthbeat.org/perspectives/2011/physician-compare-site-could-be-game-changer-but-challengesremain.aspx
Lazar, K. “Federal websites updated with data on hospital imaging, use of antipsychotics in nursing homes.” Boston Globe
online, July 19, 2012. Available at: http://www.boston.com/dailydose/2012/07/19/federal-websites-updated-with-data-hospitalimaging-use-antipsychotics-nursing-homes/TtjhhiM8tt0HdP16Q0XQ1M/story.html
Levey, N. “New website to help patients compare doctors, hospitals.” Los Angeles Times, June 27, 2011. Available at:
http://articles.latimes.com/2011/jun/27/news/la-heb-health-quality-20110628
Monegain, B. “Study names 100 top-performing hospitals.” Healthcare IT News, March 29, 2010. Available at:
http://www.healthcareitnews.com/news/study-names-100-top-performing-hospitals
Norton, A. “Hospital report cards get mixed marks.” Reuters, November 18, 2009. Available at:
http://www.reuters.com/article/idUSTRE5AH49920091118
25
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
18. Rau, J. “Lots of ‘C’s as hospitals get graded for patient safety.” KHN Blog, June 6, 2012. Available at:
http://capsules.kaiserhealthnews.org/index.php/2012/06/lots-of-cs-as-hospitals-get-graded-for-patient-safety/
19. Robert Wood Johnson Foundation. “Navigating health care: why it’s so hard and what can be done to make it easier for the
average consumer.” Issue Brief 3 of 6, October 2007. Available at: http://www.rwjf.org/pr/product.jsp?id=23073
20. Ryan, A.M., Nallamothu, B.K., Dimick, J.B. “Medicare’s public reporting initiative on hospital quality had modest or no impact on
mortality from three key conditions.” Health Affairs 2012;31(3):585-592. Available at:
http://content.healthaffairs.org/content/31/3/585.full.pdf+html
21. Sullivan, K. “Health care report card was flawed.” November 28, 2010. Available at: http://www.howtoquitsmokingfree.com/quitsmoking/kip-sullivan-health-care-report-card-was-flawed/
22. Sun, L.H. Johns Hopkins, other major area hospitals left off top-performer list. The Washington Post, September 20, 2012.
Available at: http://articles.washingtonpost.com/2012-09-20/national/35497303_1_stroke-patients-hospitals-joint-commission
23. Weaver, C. “Want to know what a hospital charges? Good luck.” Kaiser Health News, June 29, 2010. Available at:
http://www.kaiserhealthnews.org/stories/2010/june/29/hospital-prices.aspx?referrer=search
24. Whitney, E. “Attention health care shoppers: Colorado’s new price list for procedures.” Kaiser Health News, May 16, 2012.
Available at: http://www.kaiserhealthnews.org/Stories/2012/May/16/colorado-health-care-price-list-database.aspx
25. Young, G.J. “Multistakeholder regional collaboratives have been key drivers of public reporting, but now face challenges.”
Health Affairs 2012;31(3):578-584. Available at: http://content.healthaffairs.org/content/31/3/578.full.pdf+html
November 18, 2013
Supporting Employees/Enrollees in Choosing Treatment Options
There is growing support for the need to provide consumers with information necessary to evaluate treatment options and select the option
that is the best fit for their individual circumstances and preferences. Consumer decision aids have been developed with this objective in
mind. We will discuss these decision aids, evidence of their effectiveness, and the roles of employers and health plans in encouraging their
use. We also will discuss the challenges that low health literacy can pose to informed consumer choice of providers and the use of “shared
decision making more generally and specifically relating to treatment options, and how payers and health plans are attempting to address
this issue.
Learning Objectives
Students should be able to:
1. Describe different approaches being used to support consumers in their choice of treatments.
2. Discuss the problems faced by employers and health plans in implementing decision aids.
3. Evaluate the evidence regarding the effectiveness of these decision aids.
4. Assess the challenges that low health literacy poses for informed consumer decision making.
Suggested Readings
Shared Decision Making in Concept
1. RWJF Aligning Forces for Quality. “Shared decision-making and benefit design: Engaging employees and reducing costs for
preference-sensitive conditions.” April 2013. Available at: http://www.rwjf.org/en/research-publications/find-rwjfresearch/2013/04/shared-decision-making-and-benefit-design.html
2*. Robert Wood Johnson Foundation. “The current and future role of consumers in making treatment decisions.” Issue Brief 4 of 6,
October 2007. Available at: http://www.rwjf.org/pr/product.jsp?id=23074
3*. Frosch, D.L., May, S.G., Rendle, K.A.S., Tietbohl, C., Elwyn, G. “Authoritarian physicians and patients’ fear of being labeled
‘difficult’ among key obstacles to shared decision making.” Health Affairs 2012;31(5):1030-1038. Available at:
http://content.healthaffairs.org/content/31/5/1030.full.pdf+html
4. Weinstein, J.N., Clay, K., Morgan, T.S. “Informed patient choice: patient-centered valuing of surgical risks and benefits.” Health
Affairs 2007;26(3):726-730. Available at: http://content.healthaffairs.org/content/26/3/726.full.pdf+html
5. Seaman, A.M. “Patient communication has room to grow: Studies.” Reuters, May 27, 2013. Available at:
http://www.reuters.com/article/2013/05/27/us-patient-communication-idUSBRE94Q0KN20130527
6. Brown, E. “Patients who helped with medical choices had higher bills: Study.” Los Angeles times, May 27, 2013. Available at:
http://articles.latimes.com/2013/may/27/science/la-sci-sn-patient-decisions-higher-bills-20130528
7. Tanner, L. “Hospitals try high-tech to better inform patients.” Daily Herald, November 10, 2010. Available at:
http://www.dailyherald.com/article/20101110/entlife/101119961/
8. Healthwise® “Patient response: Giving voice to the patients.” February 21, 2012. Available at:
http://www.healthwise.org/Insightsdocs/PressReleases/Patient-Response--Giving-Voice-to-the-Patients.aspx
9. WiserTogether. “Group Health Cooperative of Eau Claire implements WiserTogether’s shared decision support platform.” July
20, 2012. Available at: http://www.wisertogether.com/news/2012/07/20/group-health-cooperative-of-eau-claire/
10. Brownlee, S., Colucci, J. The cost of assuming doctors know best. The Atlantic, September 28, 2012. Available at:
http://www.theatlantic.com/health/archive/2012/09/the-cost-of-assuming-doctors-know-best/262993/
26
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
11. Health Dialog. Health dialog makes decision aid available for national hospice and palliative care month. November 15, 2012.
Available at: http://www.healthdialog.com/Utility/News/PressRelease/12-1116/Health_Dialog_Makes_Decision_Aid_Available_for_National_Hospice_and_Palliative_Care_Month
Field of Practice:
1) Landro. L. “Weighty choices, in patients' hands.” The Wall Street Journal, August 4, 2009, p. D.2. Available at:
http://online.wsj.com/article/SB10001424052970203674704574328570637446770.html
2) Lewis, D. “Survey: Patient engagement important, but loosely defined.” FierceHealthcare, March 20, 2012. Available
at: http://www.fiercehealthcare.com/story/survey-patient-engagement-important-loosely-defined/2012-03-20
3) Kenen, J. ACA boosts ‘shared decision-making.’ Politico, November 29, 2012. Available at:
http://www.politico.com/story/2012/11/84356.html
4) Weiner, S.J., Schwartz, A., Sharma, G., et al. “Patient-centered decision making and health care outcomes. An
observational study.” Annals of Internal Medicine 2013;158(8):573-579. Available at:
http://annals.org/issue.aspx?journalid=90&issueID=926759&direction=P
5) Rao, A. Study: Decision aids show promise in reducing medical procedures. KHN Blog, September 5 ,2012. Available
at: http://capsules.kaiserhealthnews.org/index.php/2012/09/study-decision-aids-show-promise-in-reducing-medicalprocedures/
Issues in Shared Decision Making and the Use of Decision Aids
1. Frosch, D.L., May, S.G., Rendle, K.A.S., Tietbohl, C., Elwyn, G. “Authoritarian physicians and patients’ fear of being labeled
‘difficult’ among key obstacles to shared decision making.” Health Affairs 2012;31(5):1030-1038. Available at:
http://content.healthaffairs.org/content/31/5/1030.full.pdf+html
2. Mullan. R.J., Montori, V.M., Shah, N.D., Christianson, T.J.H., Bryant, S.C., Guyatt, G.H., LPerestelo-Perez, L.I., Stroebel, R.J.,
Yawn, B.P., Yapuncich, V., Breslin, M.A., Pencille, L., Smith, S.A. “The diabetes mellitus medication choice decision aid.”
Archives of Internal Medicine 2009;169(17):1560-1568. Available at:
http://archinte.jamanetwork.com/Issue.aspx?journalid=71&issueID=5741&direction=P
3. Carman, K.L., Maurer, M., Yegian, J.M., Dardess, P., McGee, J., Evers, M., Mario, K.O. “Evidence that consumers are skeptical
about evidence-based health care.” Health Affairs 2010;29(7):1400-1406. Available at:
http://content.healthaffairs.org/content/29/7/1400.full.pdf+html
4. Krumholz, H.M. “Variations in health care, patient preferences, and high-quality decision making.” Journal of the American
Medical Association 2013;310(2):151-152. Available at:
http://jama.jamanetwork.com/issue.aspx?journalid=67&issueid=927264&direction=P
Field of Practice:
1) Shaw, G. “Does decision support make docs look dumb?” Health Leader Media, April 14, 2011. Available at:
http://www.healthleadersmedia.com/page-1/MAG-264919/Does-Decision-Support-Make-Docs-Look-Dumb##
The Importance of Health Literacy and Language Issues to Informed Choice
1*. Peters, E., Hibbard, J., Slovic, P., Dieckmann, N. “Numeracy skill and the communication, comprehension, and use of riskbenefit information.” Health Affairs 2007;26(3):741-748. Available at:
http://content.healthaffairs.org/content/26/3/741.full.pdf+html
3. America’s Health Insurance Plans. “AHIP statement on HHS’s national action plan to improve health literacy.” Press Release,
May 27, 2010. Available at: http://www.ahip.org/content/pressrelease.aspx?docid=30599
Field of Practice:
1) America’s Health Insurance Plans. “New tool available for health care companies to assess their organizations’ health
literacy programs.” Press Release, March 15, 2010. Available at:
http://www.ahip.org/content/pressrelease.aspx?bc=174|29744
2) Boodman, S.G. “Helping patients understand their medical treatment.” Kaiser Health News, March 1, 2011. Available
at: http://www.kaiserhealthnews.org/Stories/2011/March/01/Health-Literacy-Understanding-Medical-Treatment.aspx
Further Readings
1.
2.
3.
4.
5.
Barclay, E. “Speaking the same language. Medical providers struggle to communicate with immigrant patients.” The Washington
Post, April 21, 2009, p. F.1. Available at: http://www.washingtonpost.com/wpdyn/content/article/2009/04/20/AR2009042002466.html
Bavley, A. “Health literacy is touted to improve patient roles.” June 3, 2010. Available at:
http://www.computerizedscreening.com/about/news/06-07-2010/health-literacy-is-touted-to-improve-patient-roles
Brownlee, S. “Giving patients a larger voice; more doctors welcome dialogue about tests and procedures.” The Washington Post,
October 23, 2007. Available at: http://www.washingtonpost.com/wp-dyn/content/article/2007/10/19/AR2007101902620.html
Brownlee, S., Collins, E.D. “Let women decide on medical tests.” Kaiser Health News, December 15, 2009. Available at:
http://www.kaiserhealthnews.org/Columns/2009/December/121509BrownleeandCollins.aspx
Foubister, V. “Issue of the month: health literacy – a quality and patient safety imperative.” The Commonwealth Fund Newsletter,
November 16, 2006, Volume 21. Available at: http://www.commonwealthfund.org/Content/Newsletters/QualityMatters/2006/November-December/Issue-of-the-Month-Health-Literacy-A-Quality-and-Patient-Safety-Imperative.aspx
27
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
6.
7.
8.
9.
10.
11.
12.
13.
Health Dialog. “Health Dialog releases testimony on health literacy.” Press Release July 7, 2010. Available at:
http://www.healthdialog.com/Utility/News/PressRelease/10-07-07/Health_Dialog_Releases_Testimony_on_Health_Literacy
Katz, S.J., Howley, S.T. “From policy to patients and back: surgical treatment decision making for patients with breast cancer.”
Health Affairs 2007;26(3):761-769. Available at: http://content.healthaffairs.org/content/26/3/761.full.pdf+html
Landro. L. “The informed patient: the importance of trying to be a good patient.” Wall Street Journal, April 29, 2009
Ling, B.S., Trauth, J.M., Fine, M.J., Mor, M.K., Resnick, A., Braddock, C.H., Bereknyei, S., Weissfeld, J.L., Schoen, R.E., Ricci,
E.M., Whittle, J. “Informed decision-making and colorectal cancer screening. Is it occurring in primary care?” Medical Care
2008;46(9 Suppl 1):S23-S29. Available at: http://ovidsp.tx.ovid.com/sp3.8.1a/ovidweb.cgi?WebLinkFrameset=1&S=MEIDFPGIPFDDEEFINCOKEGMCIOAEAA00&returnUrl=ovidweb.cgi%3f%26TOC
%3dS.sh.18.19.23.27%257c5%257c50%26FORMAT%3dtoc%26FIELDS%3dTOC%26S%3dMEIDFPGIPFDDEEFINCOKEGMC
IOAEAA00&directlink=http%3a%2f%2fgraphics.tx.ovid.com%2fovftpdfs%2fFPDDNCMCEGFIPF00%2ffs047%2fovft%2flive%2fg
v024%2f00005650%2f00005650-200809001-00005.pdf&filename=Informed+DecisionMaking+and+Colorectal+Cancer+Screening%3a+Is+it+Occurring+in+Primary+Care%3f&link_from=S.sh.18.19.23.27%7c5&pdf_
key=B&pdf_index=S.sh.18.19.23.27
O’Connor, A.M., Wennberg, J.E., Legare, F., Liewellyn-Thomas, H.A., Moulton, B.W., Sepucha, K.R., Sodano, A.G., King. J.S.
“Toward the ‘tipping point’: decision aids and informed patient choice.” Health Affairs 2007;26(3):716-725. Available at:
http://content.healthaffairs.org/content/26/3/716.full.pdf+html
Olson, J. “Elective surgery rates all over map.” Star Tribune, February 25, 2011, p. B.3. Available at:
http://www.startribune.com/lifestyle/health/116782593.html
PR Newswire. “Limited health literacy increased safety risk for patients with diabetes.” May 19, 2012. Available at:
http://www.prnewswire.com/news-releases/limited-health-literacy-increases-safety-risks-for-patients-with-diabetes94230884.html
Robert Wood Johnson Foundation. “Choice in medical care: when should the consumer decide?” Issue Brief 5 of 6, October
2007. Available at: http://www.rwjf.org/pr/product.jsp?id=23075
November 25, 2013
Supporting Employees/Enrollees in Maintaining and Improving Their Health
Increasingly, employers are instituting programs and financial incentives that support employees in maintaining and improving their health.
The expectation is that these efforts will reduce the rate of increase in health care costs overtime by reducing or delaying the onset of
chronic illnesses. Employers also hope that they will reduce absenteeism and increase worker productivity. Payers’ efforts rely both on
rewards and negative incentives to encourage healthy behaviors. Employers depend on both health plans and independent vendors for
delivering program content.
Learning Objectives
Students should be able to:
1. Describe the rationale for employer/health plan support for healthy lifestyle programs.
2. Assess the strengths and weaknesses of different program designs.
3. Evaluate the evidence that these programs have been successful in achieving their goals.
4. Discuss the impediments to the successful implementation of these programs.
Suggested Readings
Design of Healthy Lifestyle Programs
1.* Volpp, K.G., Asch, D.A., Galvin, R., Loewenstein, G. “Redesigning employee health incentives — Lessons from behavioral
economics.” New England Journal of Medicine 2011;365(5):388-390. Available at:
http://www.nejm.org/doi/pdf/10.1056/NEJMp1107285
2. Draper, D.A., Tynan, A., Christianson, J.B. “Health and wellness: the shift from managing illness to promoting health.” Center for
Studying Health System Change Issue Brief No. 121, June 2008. Available at: http://www.hschange.com/CONTENT/989/
3. Jauhar, S. “No matter what, we pay for others' bad habits.” New York Times, March 30, 2010. Available at:
http://www.nytimes.com/2010/03/30/health/30risk.html?_r=0
4*. Wall Street Journal. “Survey: employers fret over workers’ poor health habits.” February 22, 2010. Available at:
http://blogs.wsj.com/health/2010/02/22/survey-employers-fret-over-with-workers-poor-health-habits/
5.* Appleby, J. Workers’ poor health costs employers $344 billion, study finds. KHN Blog, September 14, 2012. Available at:
http://capsules.kaiserhealthnews.org/index.php/2012/09/workers-poor-health-costs-employers-344-billion-study-finds/
6. National Business Group on Health. “Annual wellness study finds significant jump in incentive dollars as employers report
improved employee participation.” February 8, 2011. Available at:
http://www.businessgrouphealth.org/pressrelease.cfm?printPage=1&ID=170
7. Bernstein, L. “Keeping employees, bottom lines in shape.” The Washington Post, July 5, 2011, p. A.1 (posted on Moodle)
28
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
Field of Practice:
1) Health Net. “Health Net urges men to be proactive when it comes to their health.” News Release, June 4, 2013.
Available at: http://newsroom.healthnet.com/press-release/health-net-urges-men-be-proactive-when-it-comes-theirhealth
2) Midwest Business Group on Health. “New employer survey finds growing use of outcomes-based incentives, majority
using either carrot or stick to motivate healthy employee behaviors.” PRNewswire, May 7, 2013. Available at:
http://www.prnewswire.com/news-releases/new-employer-survey-finds-growing-use-of-outcomes-based-incentivesmajority-using-either-carrot-or-stick-to-motivate-healthy-employee-behaviors-206394381.html
3) Cigna. “Cigna says health assessment and coaching are key to reducing health risks; extends exclusive license with
University of Michigan.” August 16, 2011. Available at: http://newsroom.cigna.com/NewsReleases/cigna-says-healthassessment-and-coaching-are-key-to-reducing-health-risks--extends-exclusive-license-with-university-of-michigan.htm
4) Press Release. “Dean Health Plan, Healthways partner to introduce comprehensive, integrated total population health
programs.” Reuters, February 21, 2012. Available at: http://www.reuters.com/article/2012/02/21/idUS203818+21Feb-2012+BW20120221
5) HealthPartners. “HealthPartners first in regional market to introduce health and well-being web portal customized to
employers.” Press Release, March 19, 2012. Available at:
http://www.healthpartners.com/public/newsroom/newsroom-article-list/03-19-12.html
6)* Medica. “Medica introduces group health and wellness coaching program.” Corporate Announcement, April 19, 2012.
Available at: http://newscenter.medica.com/press-release/products-services/medica-introduces-group-health-andwellness-coaching-program
Evidence of Program Effectiveness
1. Minnesota Medicine. “The healthy workplace.” September 2007. Available at:
http://www.minnesotamedicine.com/PastIssues/PastIssues2007/September2007/PulseYogaSeptember2007.aspx
2.* Horwitz, J.R., Kelly, B.D., DiNardo, J.E. “Wellness incentives in the workplace: Cost savings through cost shifting to unhealthy
workers.” Health Affairs 2013;32(3):468-476. Available at: http://content.healthaffairs.org/content/32/3/468.full.pdf+html
3. Mattke, S., Serxner, S.A., Zakowski, S.L., Jain, A.K., Gold, D.B. “Impact of 2 employer-sponsored population health management
programs on medical care cost and utilization.” American Journal of Managed Care 2009;15(2):113-120. Available at:
http://www.ajmc.com/publications/issue/2009/2009-02-vol15-n2/Feb09-3916p113-120/
4. Russell, L.B. “Preventing chronic disease: an important investment, but don’t count on cost savings.” Health Affairs
2009;28(1):42-45. Available at: http://content.healthaffairs.org/content/28/1/42.full.pdf+html
5. Huskamp, H.A., Rosenthal, M.B. “Health risk appraisals: how much do they influence employees’ health behavior?” Health
Affairs 2009;28(5):1532-1540. Available at: http://content.healthaffairs.org/content/28/5/1532.full.pdf+html
6. Goetzel, R.Z. “Do prevention or treatment services save money? The wrong debate.” Health Affairs 2009;28(1):37-41. Available
at: http://content.healthaffairs.org/content/28/5/1532.full.pdf+html
7)* Goodell, S., Cohen, J., Neumann, P. “Cost savings and cost-effectiveness of clinical preventive care.” Policy Brief No. 18. Robert
Wood Johnson Foundation Synthesis Project, September 2009. Available at:
http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2009/rwjf46045
Field of Practice:
1) Thomas, K. “Companies get strict on health of workers.” The New York Times, March 25, 2013. Available at:
http://www.nytimes.com/2013/03/26/business/companies-offer-workers-more-incentives-for-health-changes.html?_r=0
2) PR Newswire. “Study: Preventive services can save lives, billions of dollars, at little or no cost.” September 7, 2011.
Available at: http://www.prnewswire.com/news-releases/study-preventive-services-can-saves-lives-billions-of-dollarsat-little-or-no-cost-102351314.html
3) Henke, R.M., Goetzel, R.Z., McHugh, J., Isaac, F. “Recent experience in health promotion at Johnson & Johnson:
Lower health spending, strong return on investment.” Health Affairs 2011;30(3):490-499. Available at:
http://content.healthaffairs.org/content/30/3/490.full.pdf+html
4) Medica. “Medica health and wellness coaching program improves health, reduces cost.” January 3, 2012. Available
at: http://newscenter.medica.com/press-release/products-services/medica-health-and-wellness-coaching-programimproves-health-reducesConcerns about Program Incentives
1. Pearson, S.D., Lieber, S.R. “Financial penalties for the unhealthy? Ethical guidelines for holding employees responsible for their
health.” Health Affairs 2009;28(3):845-852. Available at: http://content.healthaffairs.org/content/28/3/845.full.pdf+html
Field of Practice:
1) Kwoh, L. “When your boss makes you pay for being fat.” The Wall Street Journal, April 5, 2013. Available at:
http://online.wsj.com/article/SB10001424127887324600704578402784123334550.html
2) Lerner, M. “Medica wants to put health coach between you and your bad habits; but critics say the voluntary, no-cost
program is like health care big brother.” Star Tribune, October 1, 2008. Available at:
http://www.startribune.com/lifestyle/29981699.html
3) Knight, V.E. “Treading carefully with wellness programs.” The Wall Street Journal, July 28, 2009. Available at:
29
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
http://online.wsj.com/article/SB124880470938287485.html
Tuna, C. “Theory and practice: wellness efforts face hurdle --- asking workers about family health history can clash with
U.S. genetics law.” Wall Street Journal, February 1, 2010, p. B.2. Available at:
http://online.wsj.com/article/SB10001424052748703822404575019790731232312.html
5) Mincer, J. “Insight: Firms to charge smokers, obese more for healthcare.” Reuters, October 30, 2011. Available at:
http://www.reuters.com/article/2011/10/30/us-penalties-idUSTRE79T2S220111030
6)* USA Today. “Not hiring smokers crosses privacy line.” Editorial, January 29, 2012. Available at:
http://www.usatoday.com/news/opinion/editorials/story/2012-01-29/not-hiring-smokers-privacy/52874348/1
7)* Koch, W. “Workplaces ban not only smoking, but smokers.” USA Today, January 6, 2012. Available at:
http://www.usatoday.com/money/industries/health/story/2012-01-03/health-care-jobs-no-smoking/52394782/1
Health Reform and Wellness
1. Lewis, A., Khanna, V. “Here comes ObamaCare’s ‘workplace wellness’.” The Wall Street Journal, June 20, 2013. Available at:
http://online.wsj.com/article/SB10001424127887323501004578389673547444046.html
2. Jost, T. “Implementing health reform: Workplace wellness programs.” Health Affairs Blog, May 29, 2013. Available at:
http://healthaffairs.org/blog/2013/05/29/implementing-health-reform-workplace-wellness-programs/
3. Madison, K., Schmidt, H., Volpp, K.G. “Smoking, obesity, health insurance, and health incentives in the Affordable Care Act.”
Journal of the American Medical Association 2013;310(2):143-144. Available at:
http://jama.jamanetwork.com/issue.aspx?journalid=67&issueid=927264&direction=P
4. Lewis, A., Khanna, V. “The million-dollar workplace wellness heart attack screen.” Health Affairs Blog, April 29, 2013. Available
at: http://healthaffairs.org/blog/2013/04/29/the-million-dollar-workplace-wellness-heart-attack-screen/
4)
Further Readings
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Appleby, J. “Firms offer bigger incentives for healthy living.” USA Today, January 20, 2009. Available at:
http://www.usatoday.com/news/health/2009-01-19-diabetes_N.htm
Businesswire. “Aetna introduces resources for living, a new approach to engaging members in their emotional and physical
health.” June 28, 2011. Available at: http://www.bioportfolio.com/news/article/726997/Aetna-Introduces-Resources-For-Living-ANew-Approach-To-Engaging-Members-In.html
CIGNA Corporation. “CIGNA Launches Worksite Wellness Program to Help Combat Top Health Risks Facing Americans.” News
Release February 22, 2010. Available at: http://newsroom.cigna.com/article_display.cfm?article_id=1175
Cohen, J., Neuman, P. “Cost savings and cost-effectiveness of clinical preventive care.” Robert Wood Johnson Foundation, The
Synthesis Project Policy Brief No. 18, September 2009. Available at: http://www.rwjf.org/pr/product.jsp?id=48508
Editors. “Should people be paid to stay healthy?” New York Times, June 14, 2010. Available at:
http://roomfordebate.blogs.nytimes.com/2010/06/14/should-people-be-paid-to-stay-healthy/
Gold, J. “Corporate wellness programs: healthier employees, lower costs.” Kaiser Health News, October 30, 2009. Available at:
http://www.kaiserhealthnews.org/Checking-In-With/fikry-wellness-q-and-a.aspx
Johnson, A. “Cashing in on healthful lifestyles; State paying its workers to 'take charge, live well'.” Columbus Dispatch, January
17, 2008. Available at: http://www.dispatch.com/content/stories/local/2008/01/17/PAID_TO_BE_HEALTHY.ART_ART_01-1708_B1_EI9342R.html
National Institute for Health Care Management. “Building a stronger evidence base for employee wellness programs.” Meeting
Brief, May 2011. Available at: http://nihcm.org/images/stories/Wellness_FINAL_electonic_version.pdf
PR Newswire. “Know your numbers campaign a healthy success.” July 21, 2011. Available at: http://www.prnewswire.com/newsreleases/know-your-numbers-campaign-a-healthy-success-125946673.html
PR Newswire. “Medical Mutual of Ohio partners with Linkwell Health to bring can-do wellness program to its members.” May 5,
2011. Available at: http://www.prnewswire.com/news-releases/medical-mutual-of-ohio-partners-with-linkwell-health-to-bring-cando-wellness-program-to-its-members-121340073.html
Slitt, M. “CIGNA earns new accreditation for wellness and health promotion programs from the National Committee for Quality
Assurance (NCQA).” News Release, November 9, 2009. Available at:
http://newsroom.cigna.com/article_display.cfm?article_id=1126
Stobbe, M. “Dieting for dollars? More US employees trying it.” The Register Citizen, May 28, 2010. Available at:
http://www.registercitizen.com/articles/2010/05/28/business/doc4bff41797e90c027843010.txt
Sutherland, K., Christianson, J.B., Leatherman, S. “Impact of targeted financial incentives on personal health behavior. A review
of the literature.” Medical Care Research and Review 2008;65(Suppl to 6):36S-78S. Available at:
http://mcr.sagepub.com/content/65/6_suppl/36S.full.pdf+html
Cohen, J.T., Neumann, P.J. “The cost savings and cost-effectiveness of clinical preventive care.” Research Synthesis Report
No. 18. Robert Wood Johnson Foundation, September 2009. Available at:
http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2009/rwjf46045/subassets/rwjf46045_1
30
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
December 2, 2013
Supporting Employees/Enrollees in Managing Chronic Illnesses
Employers are strong supporters of programs that help employees “self-manage” care for chronic illnesses. The general idea is to place
the consumer in a much more central role in medical care treatment. By educating consumers in appropriate treatment methods for their
illnesses and supporting their efforts to manage their illnesses, payers and health plans hope that the progression of chronic illnesses can
be delayed and the number of acute flare-ups of chronic illnesses can be minimized. This, in turn, would improve the quality of life for
employees, reduce emergency room and hospital use, and restrain growth in costs. We will discuss efforts of payers and health plans to
support consumers in chronic care management and the contexts in which they have been successful.
Learning Objectives
Students should be able to:
1. Explain the concepts of patient self-management and disease management in their different forms.
2. Discuss the various ways in which employers and health plans are supporting employees and plan enrollees in chronic illness
management.
3. Assess the evidence of their effectiveness in various settings.
4. Describe the obstacles to the effective implementation, by payers and health plans, of programs to support chronic illness
management by consumers.
Suggested Readings
Importance of Developing Effective Approaches to Chronic Illness Management
1*. Steenhuysen, J. “U.S. diabetes cases to double, costs triple by 2034.” Reuters, November 27, 2009. Available at:
http://www.reuters.com/article/idUSTRE5AQ0C220091127
2. Terhune, C., Weintraub, A. “Take your meds, exerciseand spend billions.” BusinessWeek, February 4, 2010. Available at:
http://www.businessweek.com/magazine/content/10_07/b4166046292556.htm
3*. Sklaroff, S. “On our own. Why we who struggle to live with diabetes could use a helping hand.” Health Affairs 31(1):236-239,
2012. Available at: http://content.healthaffairs.org/content/31/1/236.full.pdf+html
4. Grens, K. “Half of heart patients don’t stick to their meds.” Reuters, July 25, 2012. Available at:
http://www.reuters.com/article/2012/07/25/us-heart-patients-meds-idUSBRE86O16M20120725
Self-Management of Illnesses
1.* Health Affairs. Patient engagement. People actively involved in their health and health care tend to have better outcomes—and,
some evidence suggests, lower costs. Health Policy Brief, February 14, 2013. Available at:
http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_86.pdf
2*. Bodenheimer, T., Lorig, K., Holman, H., Grumbach K., “Patient self-management of chronic disease in primary care.”JAMA
2002;288(19):2469-2475. Available at: http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=4856&direction=P
3. Jerant, A., Moore-Hill, M., Franks, P. “Home-based, peer-led chronic illness self-management training: findings from a 1-year
randomized controlled trial.” Annals of Family Medicine 2009;7(4):319-327. Available at:
https://www.clinicalkey.com/#!/BrowserCtrl/doBrowseTo/journalIssue/{"facet":["1-s2.0S1544170909X6004X"],"issn":"15441709","contentType":"Journals"}
Disease Management Programs – Structure and Effectiveness
1. PR Web. “New study shows coaching to patient activation levels improves disease management outcomes.” June 10, 2009.
Available at: http://www.prweb.com/releases/Insignia_Health/LifeMasters/prweb2510184.htm
2. Lin, W.C., Chien, H.L., Willis, G., et al. “The effect of a telephone-based health coaching disease management program on
Medicaid members with chronic conditions.” Medical Care 2012;50(1):91-98. Available at: http://ovidsp.tx.ovid.com/sp3.8.1a/ovidweb.cgi?WebLinkFrameset=1&S=KIAOFPEMJODDDCAANCOKIHJCIEPOAA00&returnUrl=ovidweb.cgi%3f%26TOC
%3dS.sh.18.19.23.27%257c12%257c50%26FORMAT%3dtoc%26FIELDS%3dTOC%26S%3dKIAOFPEMJODDDCAANCOKIHJ
CIEPOAA00&directlink=http%3a%2f%2fgraphics.tx.ovid.com%2fovftpdfs%2fFPDDNCJCIHAAJO00%2ffs047%2fovft%2flive%2fg
v031%2f00005650%2f00005650-201201000-00012.pdf&filename=The+Effect+of+a+Telephonebased+Health+Coaching+Disease+Management+Program+on+Medicaid+Members+With+Chronic+Conditions.&link_from=S.sh.
18.19.23.27%7c12&pdf_key=B&pdf_index=S.sh.18.19.23.27
3. Bernstein, J., Chollet D., Peterson, G.G. “Disease management: does it work?” Mathematica Policy Research Inc. Issue Brief
No. 4, May 2010. http://www.mathematica-mpr.com/publications/PDFs/health/reformhealthcare_IB4.pdf
4*. Vojta, D., De Sa, J., Prospect, T., Stevens, S. “Effective interventions for stemming the growing crisis of diabetes and
prediabetes: A national payer’s perspective. Health Affairs 31(1):20-26, 2012. Available at:
http://content.healthaffairs.org/content/31/1/20.full.pdf+html
5. Joelving, F. Drop in hospital visits seen with lower drug copay. Reuters, October 3, 2012. Available at:
http://www.reuters.com/article/2012/10/03/us-drop-drug-idUSBRE8921AP20121003
6*. Mullainathan, S. “When a co-pay gets in the way of health.” The New York Times, August 10, 2013. Available at:
http://www.nytimes.com/2013/08/11/business/when-a-co-pay-gets-in-the-way-of-health.html?pagewanted=all&_r=0
31
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
Field of Practice:
1) Andrews, M. “Group appointments with doctors: When three isn’t a crowd.” Kaiser Health News, March 19, 2013.
Available at: http://www.kaiserhealthnews.org/features/insuring-your-health/2013/031913-michelle-andrews-on-grouppatient-appointments.aspx
2) Calandra, R. “The doctor will see you now – in a group.” The Inquirer, May 13, 2013. Available at:
http://articles.philly.com/2013-05-13/news/39231077_1_dietary-fiber-group-appointments-family-physicians
3) Independence Blue Cross. “Independence Blue Cross’s nurse coaches are just a phone call away.” Press Release,
May 16, 2013. Available at:
http://www.ibx.com/company_info/news/press_releases/2013/05_16_IBCs_nurse_coaches_are_j.html
4) Ramsey, M. “Ford adopts health management program.” The Wall Street Journal, June 24, 2013. Available at:
http://online.wsj.com/article/SB10001424127887324183204578565503660688878.html
5) McQueen, M.P. “Look who's watching your health expenses; employers increasingly turn to 'care managers' to control
medical costs, but some wonder if patients always benefit.” Wall Street Journal, September 25, 2007, p. D.1. Available
at: http://online.wsj.com/article/SB119067896298438111.html
6) Feder, J.L. “Predictive modeling and team care for high-need patients at HealthCare Partners.” Health Affairs
2011;30(3):416-418. Available at: http://content.healthaffairs.org/content/30/3/416.full.pdf+html
7) Draaghtel, K. Predicting participation and savings. Using predictive modeling to identify patients for disease
management. Milliman White Paper. Available at: http://publications.milliman.com/periodicals/rsa/pdfs/predictingparticipation-and-savings.pdf
Further Readings
1.
Agency for Healthcare Research and Quality, USDHHS. “Asthma Return-on-Investment Calculator. User’s Guide.” Available at:
http://statesnapshots.ahrq.gov/asthma/UserGuide.jsp
2. Conklin, A., Nolte, E. “Disease management evaluation. A comprehensive review of current state of the art.” RAND Technical
Report, December 2010. Available at: http://www.rand.org/content/dam/rand/pubs/technical_reports/2011/RAND_TR894.pdf
3. Draaghtel, K. Hit or miss? Using risk scores to decide. Milliman, March 7, 2011. Available at:
http://publications.milliman.com/periodicals/rsa/pdfs/hit-or-miss-using-risk.pdf
4. Healthways well-being improvement solution. Available at: http://www.healthways.com/solution/default.aspx?id=91
5. Mattke, S. “Is there a disease management backlash?” American Journal of Managed Care 2008;14(6):349-350. Available at:
http://www.ajmc.com/publications/issue/2008/2008-06-vol14-n6/Jun08-3297p349-350/
6. Motheral, B.R. “Telephone-based disease management: Why it does not save money.” American Journal of Managed Care
2011;17(1):e10-e16. Available at: http://www.ajmc.com/publications/issue/2011/2011-1-vol17n1/AJMC_11jan_Motheral_WebX_e10/
7. Nakashima, E. “Prescription data used to assess consumers.” The Washington Post, August 4, 2008, p. A.1. Available at:
http://articles.washingtonpost.com/2008-08-04/business/36810357_1_prescription-drug-federal-health-ingenix
8. Paez, K.A., Zhao, L., Hwang, W. “Rising out-of-pocket spending for chronic conditions: a ten-year trend.” Health Affairs
2009;28(1):15-25. Available at: http://content.healthaffairs.org/content/28/1/15.full.pdf+html
9. PR Newswire. “Capital BlueCross receives inaugural national award for developing oncology case management program.” July
12, 2011. Available at: http://www.prnewswire.com/news-releases/capital-bluecross-receives-inaugural-national-award-fordeveloping-oncology-case-management-program-125428503.html
10. Preidt, R. “Simple case management cuts pulmonary disease admissions.” ABC News, May 22, 2008. Available at:
http://abcnews.go.com/Health/Healthday/story?id=4901415&page=1
11. Reuters. “Incentives and pharmacist coaches lead to improved health and lower health care costs for diabetic patients.” May 7,
2009. Available at: http://www.reuters.com/article/2009/05/07/idUS158325+07-May-2009+PRN20090507
December 9, 2013
What’s on the Horizon for Purchasers and Health Plans
Employers and health plans are introducing comprehensive approaches, including new benefit designs, that they hope will encourage and
reward consumers for healthy living, effective self-management of their chronic illnesses, and choice of cost effective treatments and
providers. Some of these strategies, especially as they pertain to obesity reduction, move employers and health plans into what has
historically been the purview of “public health” while others appear to provide a basis for scaling down employer involvement in health care.
These strategies are in the early stages of implementation, and evidence on their impact to date is limited.
Learning Objectives
Students should be able to:
1. Describe value-based benefit strategies and how they are being implemented.
2. Assess the strengths and weaknesses of these strategies from the perspectives of employers and consumers.
3. Describe recent collaborative approaches to control community health care costs and improve health.
32
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
Suggested Readings
Collaborative Initiatives
1*. Blackmore, C.C., Mecklenburg, R.S., Kaplan, G.S. “At Virginia Mason, collaboration among providers, employers, and health
plans to transform care cut costs and improved quality.” Health Affairs 2011;30(9):1680-1687. Available at:
http://content.healthaffairs.org/content/30/9/1680.full.pdf+html
2. Tomek, I.M., Sabel, A.L., Froimson, M.I., Muschler, G., Jevsevar, D.S., Koenig, K.M., Lewallen, D.G., Naessens, J.M., Savitz,
L.A., Westrich, J.L., Weeks, W.B., Weinstein, J.N. “A collaborative of leading health systems finds wide variations in total knee
replacement delivery and takes steps to improve value. Health Affairs 2012;31(6):1329-1338. Available at:
http://content.healthaffairs.org/content/31/6/1329.full.pdf+html
Field of Practice:
1) Center for Value-Based Insurance Design. “The state innovation models initiative: An opportunity to align payer and
consumer incentives.” V-BID Center Brief, May 2013. Available at:
http://www.sph.umich.edu/vbidcenter/publications/pdfs/V-BID%20Brief%20SIMS%20May13.pdf
2) Aetna News Hub. “Aetna, Carolinas HealthCare System advance more collaborative care in Charlotte.” April 25, 2013.
Available at: http://newshub.aetna.com/press-release/health-care-professionals-and-networks/aetna-carolinashealthcare-system-advance-more3) Meyer, H. “Collaborative efforts can save money and improve care.” Kaiser Health News, January 5, 2012. Available
at: http://www.kaiserhealthnews.org/stories/2012/january/06/collaborative-efforts-can-save-money-and-improvecare.aspx
Value-Based Benefit Designs
1. Availity Research Study. “Health plan readiness to operationalize value-based payment models.” April, 2013. Available at:
http://www.nbch.org/nbch/files/ccLibraryFiles/Filename/000000002854/Availity_Study_on_Plan_Readiness_to_Operationalize_N
ew_Payt_Models.pdf
2. Thomson, S., Schang, L., Chernew, M.E. “Value-based cost sharing in the United States and elsewhere can increase patients’
use of high-value goods and services.” Health Affairs 2013;32(4):704-712. Available at:
http://content.healthaffairs.org/content/32/4/704.full.pdf+html
3. Hibbard, J.H., Greene, J., Tusler, M. “Plan design and active involvement of consumers in their own health and healthcare.”
American Journal of Managed Care 2008;14(11):729-736. Available at:
http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=3&sid=305e43bb-34cc-45e0-b3b0f8d8288d48fa%40sessionmgr111&hid=127
4*. Fendrick, A.M., Chernew, M.E. “Value based insurance design: maintaining a focus on health in an era of cost containment.”
American Journal of Managed Care 2009;15(6):338-343. Available at:
http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=3&sid=305e43bb-34cc-45e0-b3b0f8d8288d48fa%40sessionmgr111&hid=127
5. Health Care Financing & Organization. “Making the value proposition in benefit design.” HCFO, June 2010. Available at:
http://www.hcfo.org/publications/making-value-proposition-benefit-design
6. Neumann, P.J., Auerbach, H.R., Cohen, J.T., Greenberg, D. “Low-value services in value-based insurance design.” American
Journal of Managed Care 2010;16(4):280-286. Available at:
http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=3&sid=305e43bb-34cc-45e0-b3b0f8d8288d48fa%40sessionmgr111&hid=127
7*. Gibson, T.B., Wang, S., Kelly, E., Brown, C., Turner, C., Frech-Tamas, F., Doyle, J., Mauceri, E. “A value-based insurance
design program at a large company boosted medication adherence for employees with chronic illnesses.” Health Affairs
2011;30(1):109-117. Available at: http://content.healthaffairs.org/content/30/1/109.full.pdf+html
Field of Practice:
1) Appleby, J. “Carrot-and-stick health plans aim to cut costs.” USA Today/Kaiser Health News, March 11, 2010.
Available at: http://www.kaiserhealthnews.org/stories/2010/march/11/value-based-healthinsurance.aspx?referrer=search
2) Chernew, M.E., Shah, M.R., Wegh, A, Rosenberg, S.N., Juster, I.A., Rosen, A.B., Sokol, M.C., Yu-Isenberg, K.,
Fendrick, A.M. “Impact of decreasing copayments on medication adherence within a disease management
environment.” Health Affairs 2008;27(1):103-112. Available at:
http://content.healthaffairs.org/content/27/1/103.full.pdf+html
3) The Free Library. “Center for Health Value Innovation releases white paper: value-based design manages costs,
improves health for public sector employers.” September 21, 2009. Available at:
http://www.thefreelibrary.com/Center+for+Health+Value+Innovation+Releases+White+Paper%3A+Value-Based+...a0208090928
Private Health Insurance Exchanges
Field of Practice:
1) Mercer. “Mercer signs first group of insurance carriers to Mercer marketplace private exchange.” Press Release, April
33
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
15, 2013. Available at: http://www.mercer.com/press-releases/1521295
Japsen, B. “Insurers flock to private exchanges while states grapple with Obamacare marketplace.” Forbes, April 15,
2013. Available at: http://www.forbes.com/sites/brucejapsen/2013/04/15/insurers-flock-to-private-exchanges-whilestates-grapple-with-obamacare-marketplace/
3) Overland, D. “Will private exchanges become the new Travelocity?” FierceHealthPayer, May 29, 2012. Available at:
http://www.fiercehealthpayer.com/story/will-private-exchanges-become-new-travelocity/2012-05-29
4) Overland, D. “UnitedHealth, Cigna, HCSC to sell plans on Aon Hewitt exchange.” FierceHealthPayer, September 27,
2012. Available at: http://www.fiercehealthpayer.com/story/unitedhealth-cigna-hcsc-sell-plans-aon-hewittexchange/2012-09-27
5) Overland, D. “Medica launches private exchange to sell ACO products.” FierceHealthPayer, October 16, 2012.
Available at: http://www.fiercehealthpayer.com/story/medica-launches-private-exchange-sell-aco-products/2012-10-16
6) Overland, D. “10 insurers to sell plans on Mercer’s private exchange.” FierceHealthPayer, April 17, 2013. Available at:
http://www.fiercehealthpayer.com/story/aetna-cigna-unitedhealth-sell-plans-mercers-private-exchange/2013-04-17
Supporting Customized Care
Field of Practice:
1) Dishman, E. “How big data can revolutionize health care.” Politico, June 26, 2013. Available at:
http://www.politico.com/story/2013/06/how-big-data-can-revolutionize-health-care-93449.html
Addressing Public Health Problems: The Case of Obesity
1. Weiner, J.P., Goodwin, S.M., Chang, H-Y., et al. “Impact of bariatric surgery on health care costs of obese persons.” JAMA
Surgery 2013;148(6):555-561. Available at: http://archsurg.jamanetwork.com/article.aspx?articleid=1653574
2. Ignagni, K. “Health plan innovations in delivery system reforms.” American Journal of Managed Care 2013;19(4):260-262.
Available at: http://www.ajmc.com/publications/issue/2013/2013-1-vol19-n4/Health-Plan-Innovations-in-Delivery-SystemReforms/
3. Alliance for a Healthier Generation. “Anthem Blue Cross and Blue Shield in Virginia teams with the Alliance for a Healthier
Generation to offer comprehensive health benefits to combat childhood obesity.” Press Release, May 18, 2010. Available at:
http://www.healthiergeneration.org/media.aspx?id=4583
4. Finkelstein, E.A., Trogdon, J.G., Cohen, J.W., Dietz, W. “Annual medical spending attributable to obesity: payer-and servicespecific estimates.” Health Affairs 2009;28(5):w822-w831 (published online 27 July 2009). Available at:
http://content.healthaffairs.org/content/28/5/w822.full.pdf+html
Field of Practice:
1) America’s Health Insurance Plans. “Health plans leading efforts to reduce and prevent obesity.” June 19, 2013.
Available at: http://www.ahipcoverage.com/2013/06/19/health-plans-leading-efforts-to-reduce-and-prevent-obesity/
2) Varney, S. “Obamacare insurance won’t cover weight-loss surgery in many states.” Kaiser Health News, May 27, 2013.
Available at: http://www.kaiserhealthnews.org/stories/2013/may/27/bariatric-surgery-obesity-exchange-marketplacemississippi.aspx
3) Alliance for a Healthier Generation. “Anthem Blue Cross and Blue Shield in Virginia teams with the Alliance for a
Healthier Generation to offer comprehensive health benefits to combat childhood obesity.” Press Release, May 18,
2010. Available at: http://www.healthiergeneration.org/media.aspx?id=4583
4) Steenhuysen, J. “Hospital label no guarantee of better weight surgery.” Reuters, April 20, 2009. Available at:
http://www.reuters.com/article/idUSTRE53J5WL20090421
5) Pollack, A. “FDA studies band surgery for less obese.” New York Times, December 2, 2010, p. A.1. Available at:
http://www.nytimes.com/2010/12/02/business/02obese.html?pagewanted=all&_r=0
6) Gardner, A. “Gastric bypass best for weight loss, study finds.” Health.com, February 21, 2011. Available at:
http://news.health.com/2011/02/21/gastric-bypass-best-for-weight-loss-study-finds/
7) Pittman, G. “Bariatric surgery doesn’t reduce long-term costs.” Reuters Health Information, July 16, 2012. Available
at: http://www.nlm.nih.gov/medlineplus/news/fullstory_127291.html
8) Graham, J. “Doctors and Insurers are key to fighting obesity.” Kaiser Health News, May 12, 2012. Available at:
http://www.kaiserhealthnews.org/stories/2012/may/13/obesity-and-doctors.aspx
9) Rundle, R.L. “Obesity surgery is called cost-effective.” The Wall Street Journal, September 8, 2008. Available at:
http://online.wsj.com/article/SB122082794026608293.html
2)
Further Readings
1.
2.
3.
4.
Kane, D. “Overweight N.C. workers may pay a price.” News & Observer, February 20, 2009. Available at:
http://www.newsobserver.com/2009/02/20/94051/overweight-nc-workers-may-pay.html#storylink=misearch
IBM. “IBM to provide employees with 100% primary health care coverage, new wellness rebate.” Press Release, October 29,
2009. Available at: http://www-03.ibm.com/press/us/en/pressrelease/28728.wss
National Business Coalition on Health. “Value-based benefit design: a purchaser guide.” 2009. Available at:
http://www.nbch.org/NBCH/files/ccLibraryFiles/Filename/000000000222/VBBD%20Purchaser%20Guide.pdf
PR Newswire. “Harvard Pilgrim launches social networking e-community to inspire people to be well.” November 23, 2009.
34
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
5.
6.
7.
8.
Available at: http://www.prnewswire.com/news-releases/harvard-pilgrim-launches-social-networking-e-community-to-inspirepeople-to-be-well-71527682.html
Johnson, A. “Health & wellness -- Heart beat: the do-it-yourself house call --- insurer-endorsed remote-monitoring technology
leads heart patients to take their readings at home.” Wall Street Journal, July 27, 2010. p. D.2. Available at:
http://online.wsj.com/article/SB10001424052748704700404575391262635170370.html
Intel. “Aetna, Intel effort signals importance of early intervention, remote health management.” News Release June 10, 2010.
Available at: http://www.intel.com/pressroom/archive/releases/20100610corp.htm
Nucci, C. “Insurers curbing hospital admissions, remotely.” HealthLeaders Media, January 13, 2011. Available at:
http://www.healthleadersmedia.com/page-1/MAG-260996/Insurers-Curbing-Hospital-Admissions-Remotely
Galewitz, P. “Insurers embrace ‘virtual’ doctor visits.” Kaiser Health News, May 6, 2012. Available at:
http://www.kaiserhealthnews.org/stories/2012/may/07/telemedicine.aspx
VII. Evaluation and Grading
Grades will be determined based on two group assignments (total of 25 points) and five individual
assignments (total 75 points) The student will receive a grade of zero if an assignment is not submitted as
scheduled, unless prior arrangements have been made for late submission.
Grading Scale
An A/F letter grade will be determined based on the following:
A=93-100%
Represents outstanding achievement relative to the level necessary to meet
course requirements
A- = 90-92.99%
B+ = 87-89.99%
B = 83-86.99%
Represents achievement that is significantly above the level necessary to meet
course requirements
B- = 80-82.99%
C+ = 77-79.99%
C = 73-76.99%
Represents achievement that meets the minimum course requirements
C- = 70-72.99%
D+ = 65-69.99%
D = 60-64.99%
F = < 59.99%
No credit. Signifies work was below level of achievement that represents minimum
threshold to obtain credit or work was not completed and there was no agreement
between instructor and student that the student would be awarded an I.
The instructor reserves the right to adjust final grades “upward” based on the overall distribution of points for
the class. That is, students may receive a higher grade than expected based on their overall point total, but
not a lower grade.
Course Evaluation
Beginning in fall 2008, the SPH will collect student course evaluations electronically using a software system
called CoursEval: www.sph.umn.edu/courseval. The system will send email notifications to students when
they can access and complete their course evaluations. Students who complete their course evaluations
promptly will be able to access their final grades just as soon as the faculty member renders the grade in
SPHGrades: www.sph.umn.edu/grades. All students will have access to their final grades through OneStop
two weeks after the last day of the semester regardless of whether they completed their course evaluation or
not. Student feedback on course content and faculty teaching skills are an important means for improving our
work. Please take the time to complete a course evaluation for each of the courses for which you are
35
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
registered.
Incomplete Contracts
A grade of incomplete “I” shall be assigned at the discretion of the instructor when, due to extraordinary
circumstances (e.g., documented illness or hospitalization, death in family, etc.), the student was prevented
from completing the work of the course on time. The assignment of an “I” requires that a contract be initiated
and completed by the student before the last official day of class, and signed by both the student and
instructor. If an incomplete is deemed appropriate by the instructor, the student in consultation with the
instructor, will specify the time and manner in which the student will complete course requirements.
Extension for completion of the work will not exceed one year (or earlier if designated by the student’s
college). For more information and to initiate an incomplete contract, students should go to SPHGrades at:
www.sph.umn.edu/grades.
University of Minnesota Uniform Grading and Transcript Policy - A link to the policy can be found at
onestop.umn.edu.
VIII. Other Course Information and Policies
Grade Option Change (if applicable)
For full-semester courses, students may change their grade option, if applicable, through the second week of
the semester. Grade option change deadlines for other terms (i.e. summer and half-semester courses) can
be found at onestop.umn.edu.
Course Withdrawal
Students should refer to the Refund and Drop/Add Deadlines for the particular term at onestop.umn.edu for
information and deadlines for withdrawing from a course. As a courtesy, students should notify their
instructor and, if applicable, advisor of their intent to withdraw.
Students wishing to withdraw from a course after the noted final deadline for a particular term must contact
the School of Public Health Office of Admissions and Student Resources at sph-ssc@umn.edu for further
information.
Student Conduct Code
The University seeks an environment that promotes academic achievement and integrity, that is protective of
free inquiry, and that serves the educational mission of the University. Similarly, the University seeks a
community that is free from violence, threats, and intimidation; that is respectful of the rights, opportunities,
and welfare of students, faculty, staff, and guests of the University; and that does not threaten the physical or
mental health or safety of members of the University community.
As a student at the University you are expected adhere to Board of Regents Policy: Student Conduct Code.
To review the Student Conduct Code, please see:
http://regents.umn.edu/sites/default/files/policies/Student_Conduct_Code.pdf.
Note that the conduct code specifically addresses disruptive classroom conduct, which means "engaging in
behavior that substantially or repeatedly interrupts either the instructor's ability to teach or student learning.
The classroom extends to any setting where a student is engaged in work toward academic credit or
satisfaction of program-based requirements or related activities."
Use of Personal Electronic Devices in the Classroom
Using personal electronic devices in the classroom setting can hinder instruction and learning, not only for
the student using the device but also for other students in the class. To this end, the University establishes
the right of each faculty member to determine if and how personal electronic devices are allowed to be used
in the classroom. For complete information, please reference:
http://policy.umn.edu/Policies/Education/Education/STUDENTRESP.html.
Scholastic Dishonesty
You are expected to do your own academic work and cite sources as necessary. Failing to do so is
scholastic dishonesty. Scholastic dishonesty means plagiarizing; cheating on assignments or examinations;
engaging in unauthorized collaboration on academic work; taking, acquiring, or using test materials without
faculty permission; submitting false or incomplete records of academic achievement; acting alone or in
cooperation with another to falsify records or to obtain dishonestly grades, honors, awards, or professional
36
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
endorsement; altering, forging, or misusing a University academic record; or fabricating or falsifying data,
research procedures, or data analysis. (Student Conduct Code:
http://regents.umn.edu/sites/default/files/policies/Student_Conduct_Code.pdf) If it is determined that a student has
cheated, he or she may be given an "F" or an "N" for the course, and may face additional sanctions from the
University. For additional information, please see:
http://policy.umn.edu/Policies/Education/Education/INSTRUCTORRESP.html.
The Office for Student Conduct and Academic Integrity has compiled a useful list of Frequently Asked
Questions pertaining to scholastic dishonesty: http://www1.umn.edu/oscai/integrity/student/index.html. If you
have additional questions, please clarify with your instructor for the course. Your instructor can respond to
your specific questions regarding what would constitute scholastic dishonesty in the context of a particular
class-e.g., whether collaboration on assignments is permitted, requirements and methods for citing sources,
if electronic aids are permitted or prohibited during an exam.
Makeup Work for Legitimate Absences
Students will not be penalized for absence during the semester due to unavoidable or legitimate
circumstances. Such circumstances include verified illness, participation in intercollegiate athletic events,
subpoenas, jury duty, military service, bereavement, and religious observances. Such circumstances do not
include voting in local, state, or national elections. For complete information, please see:
http://policy.umn.edu/Policies/Education/Education/MAKEUPWORK.html.
Appropriate Student Use of Class Notes and Course Materials
Taking notes is a means of recording information but more importantly of personally absorbing and
integrating the educational experience. However, broadly disseminating class notes beyond the classroom
community or accepting compensation for taking and distributing classroom notes undermines instructor
interests in their intellectual work product while not substantially furthering instructor and student interests in
effective learning. Such actions violate shared norms and standards of the academic community. For
additional information, please see: http://policy.umn.edu/Policies/Education/Education/STUDENTRESP.html.
Sexual Harassment
"Sexual harassment" means unwelcome sexual advances, requests for sexual favors, and/or other verbal or
physical conduct of a sexual nature. Such conduct has the purpose or effect of unreasonably interfering with
an individual's work or academic performance or creating an intimidating, hostile, or offensive working or
academic environment in any University activity or program. Such behavior is not acceptable in the
University setting. For additional information, please consult Board of Regents Policy:
http://regents.umn.edu/sites/default/files/policies/SexHarassment.pdf
Equity, Diversity, Equal Opportunity, and Affirmative Action
The University will provide equal access to and opportunity in its programs and facilities, without regard to
race, color, creed, religion, national origin, gender, age, marital status, disability, public assistance status,
veteran status, sexual orientation, gender identity, or gender expression. For more information, please
consult Board of Regents Policy: http://regents.umn.edu/sites/default/files/policies/Equity_Diversity_EO_AA.pdf.
Disability Accommodations
The University of Minnesota is committed to providing equitable access to learning opportunities for all
students. Disability Services (DS) is the campus office that collaborates with students who have disabilities to
provide and/or arrange reasonable accommodations.
If you have, or think you may have, a disability (e.g., mental health, attentional, learning, chronic health,
sensory, or physical), please contact DS at 612-626-1333 to arrange a confidential discussion regarding
equitable access and reasonable accommodations.
If you are registered with DS and have a current letter requesting reasonable accommodations, please
contact your instructor as early in the semester as possible to discuss how the accommodations will be
applied in the course.
For more information, please see the DS website, https://diversity.umn.edu/disability/.
37
https://docs.google.com/a/umn.edu/file/d/0B7LWJ83cOEeeVUhpa1gzNG9iVlE/edit
Mental Health and Stress Management
As a student you may experience a range of issues that can cause barriers to learning, such as strained
relationships, increased anxiety, alcohol/drug problems, feeling down, difficulty concentrating and/or lack of
motivation. These mental health concerns or stressful events may lead to diminished academic performance
and may reduce your ability to participate in daily activities. University of Minnesota services are available to
assist you. You can learn more about the broad range of confidential mental health services available on
campus via the Student Mental Health Website: http://www.mentalhealth.umn.edu.
Academic Freedom and Responsibility: for courses that do not involve students in research
Academic freedom is a cornerstone of the University. Within the scope and content of the course as defined
by the instructor, it includes the freedom to discuss relevant matters in the classroom. Along with this
freedom comes responsibility. Students are encouraged to develop the capacity for critical judgment and to
engage in a sustained and independent search for truth. Students are free to take reasoned exception to the
views offered in any course of study and to reserve judgment about matters of opinion, but they are
responsible for learning the content of any course of study for which they are enrolled.*
Reports of concerns about academic freedom are taken seriously, and there are individuals and offices
available for help. Contact the instructor, the Department Chair, your adviser, the associate dean of the
college, or the Vice Provost for Faculty and Academic Affairs in the Office of the Provost. [Customize with
names and contact information as appropriate for the course/college/campus.]
* Language adapted from the American Association of University Professors "Joint Statement on Rights and
Freedoms of Students".
Template update 9/2013
38