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Companies launch their own healthcare reform

Having given up on Congress, dozens of companies have launched an initiative called the Health Transformation Alliance to change how their employees get healthcare.

Robert Andrews discusses the initiative in a piece in The New York Times. Among his comments:

“Rather than having individual companies contract with benefit managers, we worked with CVS and OptumRx on an approach under which we gain more access to drug companies’ pricing structures, strengthening our position in cost negotiations. That results in lower prices for the same medicines and allows the alliance members to achieve considerable savings. We also are working to ensure that formularies, the lists of prescription medicines covered by insurers, are the right ones for patients, not just the most profitable ones. This can increase the use of lower-cost generic drugs.”

“We and our employees spend more than $5 billion each year on four procedures and ailments: knee replacements, hip replacements, back pain and diabetes. These common problems account for 20 percent of the money our companies spend on treatment. Starting next year, we will create new medical networks in three major cities that will focus on delivering better results for these ailments and procedures at better prices. Our new networks are likely to compete with some doctors and hospitals that don’t have as good a treatment record. The health care arena needs more competition, and we will encourage it.’

To read this important piece, please hit this link.

Manic marketing of premature flu shots




For Kaiser Health News

The pharmacy chain pitches started in August: Come in and get your flu shot.

Convenience is touted. So are incentives: CVS offers a 20-percent-off shopping pass for everyone who gets a shot, while Walgreens donates toward international vaccination efforts.

The start of flu season is still weeks — if not months — away. Yet marketing of the vaccine has become an almost year-round effort, beginning when the shots become available in August and hyped as long as the supply lasts, often into April or May.

Not that long ago, most flu-shot campaigns started as the leaves began to turn in October. But the rise of retail medical clinics inside drug stores over the past decade — and state laws allowing pharmacists to give vaccinations — has stretched the flu-shot season.

The stores have figured out how “to deliver medical services in an on-demand way” which appeals to customers, particularly millennials, said Tom Charland, founder and CEO of Merchant Medicine, which tracks the walk-in clinic industry. “It’s a way to get people into the store to buy other things.”

But some experts say the marketing may be overtaking medical wisdom since it’s unclear how long the immunity imparted by the vaccine lasts, particularly in older people.

Federal health officials say it’s better to get the shot whenever you can. An early flu shot is better than no flu shot at all. But the science is mixed when it comes to how long a flu shot promoted and given during the waning days of summer will provide optimal protection, especially because flu season generally peaks in mid-winter or beyond. Experts are divided on how patients should respond to such offers.

“If you’re over 65, don’t get the flu vaccine in September. Or August. It’s a marketing scheme,” said Laura Haynes, an immunologist at the University of Connecticut Center on Aging.

That’s because a combination of factors makes it more difficult for the immune systems of people older than age 65 to respond to the vaccination in the first place. And its protective effects may wear off faster for this age group than it does for young people.

When is the best time to vaccinate? It’s a question even doctors have.

“Should I wait until October or November to vaccinate my elderly or medically frail patients?” That’s one of the queries on the website of the board that advises the Centers for Disease Control and Prevention on immunizations. The answer is that it is safe to make the shots available to all age groups when the vaccine becomes available, although it does include a caution.

The board says antibodies created by the vaccine decline in the months following vaccination “primarily affecting persons age 65 and older,” citing a study done during the 2011-2012 flu season. Still, while “delaying vaccination might permit greater immunity later in the season,” the CDC notes that “deferral could result in missed opportunities to vaccinate.”

How long will the immunity last?

“The data are very mixed,” said. John J. Treanor, a vaccine expert at the University of Rochester medical school. Some studies suggest vaccines lose some protectiveness during the course of a single flu season. Flu activity generally starts in the fall, but peaks in January or February and can run into the spring.

“So some might worry that if [they] got vaccinated very early and flu didn’t show up until very late, it might not work as well,” he said.

But other studies “show you still have protection from the shot you got last year if it’s a year when the strains didn’t change, Treanor said.

In any given flu season, vaccine effectiveness varies. One factor is how well the vaccines match the virus that is actually prevalent. Other factors influencing effectiveness include the age and general health of the recipient. In the overall population, the CDC says studies show vaccines can reduce the risk of flu by about 50 to 60 percent when the vaccines are well matched.

Health officials say it’s especially important to vaccinate children because they often spread the disease, are better able to develop antibodies from the vaccines and, if they don’t get sick, they won’t expose grandma and grandpa. While most people who get the flu recover, it is a serious disease responsible for many deaths each year, particularly among older adults and young children. Influenza’s intensity varies annually, with the CDC saying deaths associated with the flu have ranged from about 3,300 a year to 49,000 during the past 31 seasons.

To develop vaccines, manufacturers and scientists study what’s circulating in the Southern Hemisphere during its winter, which is our summer. Then — based on that evidence — forecast what flu strains might circulate here to make vaccines that are generally delivered in late July.

For the upcoming season, the vaccines will include three or four strains, including two A strains, an H1N1 and an H3N2, as well as one or two B strains, according to the CDC. It recommends that everyone older than 6 months get vaccinated, unless they have health conditions that would prevent it.

The vaccines can’t give a person the flu because the virus is killed before it’s included in the shot. This year, the nasal vaccine is not recommended for use, as studies showed it was not effective during several of the past flu seasons.

But when to go?

“The ideal time is between Halloween and Thanksgiving,” said Haynes at UConn. “If you can’t wait and the only chance is to get it in September, then go ahead and get it. It’s best to get it early rather than not at all.”

Rise of partnerships in ‘convenient care’

A post in the New England Journal of Medicine’s Catalyst blog reports that the rise of “convenient care” in the hospital sector is driving a wave of partnerships, including joint ventures, nonexclusive arrangements and telehealth alliances.

The piece looks at such partnerships as:

  • Non-exclusive agreements with the likes of  such nonhospital enterprises as CVS MinuteClinics, with their big customer bases and low financial risk.
  • Joint ventures that may appeal to providers willing to make a capital investment in return for more ownership and equal representation on boards of directors.
  • Leased-space arrangements in which  hospital systems operate convenient-care clinics themselves, but within a retail space.
  • Telemedicine partnerships that might include healthcare providers paying a fee for provide services and technology in return for branding and referrals.

CVS plowing ahead in medicine on demand


Andrew Sussman, M.D., executive vice president and associate chief medical officer of CVS Health, discusses how the huge drugstore chain will continue to expand in an age of retail medical care as provided in its MinuteClinics.

As this Hospitals & Health Networks piece reports:

“Telehealth is one growth area that CVS is warming to as a way to provide low-cost services, and consumers are, too. Oliver Wyman’s study estimates that 57 percent of consumers are now familiar with the concept of a health and wellness visit conducted remotely via voice or video chat. Some 95 percent of CVS customers said they thought a telehealth visit was ‘just as good’ or ‘better’ than the traditional model, Dr. Sussman added.”

“CVS has partnered with three players in the telehealth space — Doctor on Demand, American Well and Teladoc — aiming to build out its capabilities. Pilots tied to those partnerships include making telehealth services available through the CVS app, having one company beam its doctors into CVS telehealth clinics to look at rashes and other superficial ailments or sending patients from a telehealth provider’s app into MinuteClinic if further in-person consultation is required.”

Retail clinics might be adding to nation’s medical costs



For Kaiser Health News

Retail clinics, long seen as an antidote to more expensive doctor offices and emergency rooms, may actually boost medical spending by leading consumers to get more care, a new study shows.

Rather than substituting for a physician office visit or trip to the hospital, 58 percent of retail clinic visits for minor conditions represented a new use of medical services, according to the study published Monday in the journal Health Affairs. Those additional visits led to a modest increase in overall health care spending of $14 per person per year.

“This challenges the conventional wisdom that retail clinics save the healthcare system money,” said Dr. Ateev Mehrotra, a co-author of the study and an associate professor of healthcare policy at Harvard Medical School. “The increase in spending from new utilization trumps the savings we saw from replacing doctor visits and the emergency department.”

There are more than 2,000 in-store clinics nationwide, and they handle about 6 million patient visits annually, the study said.

They are popular with many consumers who like strolling in for care with no appointment, as opposed to waiting hours elsewhere, and they are open seven days a week. These small clinics are typically run by nurse practitioners and treat infections, mild sprains and handle other preventive care such as immunizations.

CVS Health Corp.’s MinuteClinic is the industry leader with more than 1,100 locations. Many health insurers and employers encourage people to use these clinics, in some cases waiving co-payments.

But Mehrotra said policymakers and health insurers should realize that promoting more convenient options, from retail clinics to online doctor visits, may spur more use and higher costs.

“As we make things more convenient people will use it a lot more,” said Mehrotra, also a researcher at Rand Corp., a nonprofit think tank in Santa Monica, Calif.

The study doesn’t contradict earlier research that found retail clinics provide care that costs 30 to 40 percent less than similar care provided at a physician’s office and that the treatment for routine illnesses was of similar quality. But it suggests those savings are more than offset by increased use of medical services.

Dr. Andrew Sussman, president of the MinuteClinic unit at CVS, criticized the study as “flawed” and too reliant on old data. He said about half of MinuteClinic patients don’t have a regular family physician and his clinics are able to prevent minor conditions from becoming major illnesses requiring costlier care.

The study “is not an accurate assessment of retail clinic cost savings and value,” Sussman said. “It is a step backward to think of people who did not have a primary-care physician and get care as excess utilization.”

The study’s authors couldn’t assess the impact retail clinics have on overall medical use and total spending because they didn’t have data on inpatient care or prescription drug use — two large components of healthcare spending.

The researchers looked at data on 3 million Aetna Inc. members from 2010 to 2012 and their medical use tied to 11 low-acuity conditions, such as sinusitis and urinary-tract infections. The patients were divided between users of retail clinics and people who did not visit them.

Aetna, the nation’s third-largest health insurer, said it remains supportive of retail clinics and looks forward to further studies examining the longer-term impact on costs and patient outcomes. In particular, Aetna and other health care purchasers want to know if retail clinics can help diabetics and others battling costly chronic illnesses.

“Retail clinics are a convenient and flexible option that are available during extended hours, while traveling, and for minor health needs,” the company said in a statement. “They are also a good option for consumers who do not have a primary-care physician.”

In this latest study, researchers found that much of the new use was for ailments that typically cleared up on their own, such as a fever, cough or runny nose. But Mehrotra said he doesn’t want the study to be seen as criticizing people for seeking medical help. Rather, he wants to emphasize that convenience is going to increase utilization.

“If the retail clinics wouldn’t have been around, people would have stayed home,” he said. “New utilization accounts for most retail clinic visits.”

The researchers noted some limitations to the study. It was confined to the commercial insurance population, excluding people on Medicare, Medicaid or the uninsured. It didn’t factor in benefits such as the time saved by going to a retail clinic.

And Mehrotra said this study focused on the initial visit. It looked at whether it was new utilization or replaced a more expensive option. Among visits deemed to be substitution, 93 percent replaced a doctor visit and 7 percent were in place of going to an emergency room.

Tom Charland, an industry analyst and chief executive of research firm Merchant Medicine, said retailers have had mixed results with these in-store clinics. CVS and Kroger continue to open new locations while Wal-Mart Stores Inc. and Target Corp. pulled back on the business after lackluster results, he said.

These clinics have been seen as one way to address a lack of primary-care doctors in some areas of the country as the federal health law expands insurance coverage to millions of Americans. Some major health systems, including the Cleveland Clinic and UCLA, have partnered with retail clinics to help meet the increased demand.

Sussman said about half of MinuteClinic patients are seen on weekends or during evening hours when most physician offices are closed. “The Affordable Care Act is bringing millions of new patients into the system, and it’s necessary to provide alternate types of care,” Sussman said.

But Mehrotra said health plans and employers should carefully consider how they cover care at retail clinics. “If the goal is to lower costs,” he said, “then encouraging use of retail clinics may not be a successful strategy.”


Bigger clinic competitor


Walgreens’s plan to buy Rite Aid for about $9.4 billion means that CVS will have a more powerful competitor to deal with. The would-be merger partners together have about 13,000 U.S. stores.

If antitrust regulators approve the deal, it means that hospital systems and physician groups will have both a stronger collaborator and a stronger competitor — the latter given the big push by drugstore chains to open many more clinics in their stores with some services competing with those  of hospitals and physicians.

Further, the chain would have more bargaining power with the drug companies.









Open your mouth for the dental therapists


Text and WGBH podcast:

What has been happening with  the rise of such non-physician clinicians as nurse practitioners and physician assistants is now  happening in dental care, too, with the appearance of “dental therapists”. They work in the space between dentists and dental hygienists.

It’s a matter of healthcare access and cost.

Many middle-class patients forgo dental care because it is very expensive, in part because dentists have demanded and gotten very high incomes. Consider that the average net income for a general dentist exceeds $180,000 — more than the average of around $170,000 for primary-care physicians. In some places poorer people on Medicaid can get dental care, though such access can vary quite a bit across America.

Further hurting access is that dental insurance, if you have it, usually provides very skimpy coverage, forcing most patients to make very large out-of-pocket payments. It’s enough to scare a lot of people away from getting the treatment they need. And course poor dental care can lead to other health problems, including heart disease.

So  some states,  although often opposed by dentist organizations fearful of reduced incomes for their members, are authorizing a new classification called “dental therapists” to provide routine care at considerably lower prices than those charged by dentists.

We’d bet that pressure from payers will lead to a rapid expansion in the number of this new kind of dental practitioner. We may even see them soon in retail clinics run by CVS and other drugstore chains.


The importance of knowing when/how to stop



Tamara Rosin, writing in Becker’s Hospital Review, reports on how various healthcare organizations stopped things to improve patient care and other operations.

Her examples include:

Cleveland Clinic removing  McDonald’s from its cafeteria; three prominent academic medical centers  moving to ban low-volume surgeries; New York City hospitals agreeing to ban reality TV filming without patient approval; Mayo Clinic stopping requiring an outmoded dress code for women, and CVS stopping its sale of  tobacco products.

She notes: “Stopping one thing doesn’t just have to be an effect of starting something else. Rather, the deliberate departure from existing approaches, systems and norms should be given equal consideration as healthcare organizations look for ways to innovate and improve the care they provide. Stopping something might be the best innovation for a hospital, even if it is uncomfortable to break from the norm.”

“Change requires that you break from habit,” Manuel Hernandez, M.D., MBA, practicing emergency physician and leader of CannonDesign’s Health Advisory Services, told Ms. Rosin. “Many of the steps and processes people are engaged in — in any industry — can become almost automatic and oppressive.”






Partners invading urgent-care-clinic business



Prestigious Partners HealthCare,  whose flagship is the Massachusetts General Hospital, will  open as many as a dozen urgent-care clinics over the next three years, in Massachusetts, in a move that helps highlight the more general moves in U.S, healthcare from inpatient to outpatient services and from the use of very expensive physicians to cheaper nurses, nurse practitioners and physician assistants.

It also poses a threat to nearby, Rhode Island-based CVS, whose drugstores are rapidly adding urgent-care centers. The prestige of Partners’  famous hospitals may take some business away from CVS’s urgent-care centers, which it calls MinuteClinics. It may also lighten the load a bit in some area hospitals’ emergency rooms.

Partners is late to urgent care in Massachusetts. Steward Health Care System, Beth Israel Deaconess Medical Center, Lahey Health, and others are already in the business, either directly or with partners, The Boston Globe reports.

But, The Globe reports, “Partners has advantages in its size and reputation. It is the parent of 10 hospitals, including Massachusetts General and Brigham and Women’s, and has 6,000 doctors, the largest network in the state. It also is planning more urgent care locations than most of its competitors.”

“This is more than a pilot for us,” said Dr. Gregg S. Meyer, chief clinical officer of Partners, told The Globe.  “These are meant to be extensions of availability and convenience for patients. We know we are not always as available as possible for our patients.”







Will retail clinics transform primary care?



A story in the Providence Business News investigates whether retail clinics  set up in drugstores by CVS and other pharmacy chains will transform primary care. That Rhode Island is also the headquarters of CVS adds a certain piquancy to the issue in the tiny state.

“It’s the latest iteration of easy-access care that’s forcing doctors, hospitals and insurers in Rhode Island and across the country to take notice, as they brace for federally mandated changes designed to stem the ever-rising costs of health care delivery,” noted the newspaper.

“The retail clinics are filling a market void, and they will continue to be relatively successful until the primary care physicians are able to fill that void,”  Augustine Manocchia,  M.D., chief medical officer of Blue Cross & Blue Shield of Rhode Island, told the paper.

Michael Fine, M.D., a former Rhode Island state health director, said  easy-access care  offered by CVS MinuteClinics and similar outlets, is cutting into primary-care physicians’ “bread and butter.”

“[Physicians’] economic survival depends on their ability to treat the sore throats and rashes. The more complicated conditions – they’re not well-paid for,” Dr. Fine told the publication. “The danger is that from a business-model perspective, we’re peeling away their margins.”

But Steven R. DeToy, director of government and public affairs at the Rhode Island Medical Society, says retail clinics could be a “great help” to providers if they stick with basic services .  But he’s wary that clinics might try to become something more. The paper said that “He says that could further fragment an already disjointed system of care.”

“I think hospitals are going to be the most challenged health care organization of the next 20 years,” Dr. Fine predicted to the paper. “If the rest of us are good at what we’re doing, hospital [visits] should drop by 40-50 percent and their volume will diminish. If it doesn’t diminish then we’re going to be a collaborative failure.” •

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