Successful three way sharing requires constant communication, clear expectations, an awareness of the different motivations and expectations of all of the interested parties. It is tough to manage communication, expectations and experiences so everyone has a happy ending where all parties want to do it again in the near future.
That might be why the dominant form of health care gain sharing is a two way split between the payer and a provider group without taking into consideration the individual patient. The most common form of gain sharing will have a provider group contract with a payer entity (Medicare, Medicaid, or a private insurer) to care for a certain population. The contract will be written so that the provider group gets a certain amount of money to care for the group. That pot of money may be risk adjusted prospectively or retrospectively, but it is deemed to be sufficient to take care of the patient group.
The gain share works when the provider group is able to meet quality and outcome metrics of the patient group for less than the total pot of money. The provider group gets a bonus based on how much money they save and how well they do on the quality metrics. The payer saves the portion of money that is the wedge between the original pot of money minus the amount actually spent on care plus the provider bonuses plus the incremental administrative costs of running a complex program. But in these models, patients and individuals are by products of the decision making process where they are hopefully directed, probably diverted and financially coerced and cajoled onto desired paths.
There is good evidence that financial incentives to patients significantly increases adherence to treatment regimes. It is common for managed care organizations to use member level incentives to encourage basic preventative behaviors and utilization. Some of the more common incentive programs will be rewards for people getting flu shots, appropriate screenings if individuals are in high risk groups, and regular dental visits. More targeted programs may give rewards to diabetics who meet with a nutrition counselor.
Gains flow to provider groups although a successful intervention that increases health while reducing costs is often a set of services and interventions that are far broader than strict medical interventions. Emmy Ganos of the Robert Wood Johnson Foundation makes this point in relation to social service system referrals:
Fantastic point: if you rely on social service referrals to help make $ targets, shouldn’t you share savings w/ social service? #get2value15
— Emmy Ganos (@emmyganos) November 9, 2015
But one thing that I have not seen a lot of conversation about is three way gain sharing between the payer, the provider and the patient who has the most inherent reason to get well. I’m spitballing an idea here, so this will be rough as we go below the fold:
Most of the schemes are two way schemes. The insurer either pays a provider group for systemic results through global budgets, capitation models or gain sharing models where the providers are given a target medical expense ratio for a population pool and they get bonuses if they meet quality metrics plus keep costs underneath the benchmark. The other model is a direct payment by the insurer to the individual person for process goals. A person might get a $25 gift card if they have a cancer screening, or the work wellness program will knock $100 off the deductible if they got a flu shot.
My idea that I’m playing with is a hybridization of the traditional gain-share model where the insurer pays bonuses for the combination of cost control and quality goals to the provider groups and micro-finance solidarity lending where individuals and small groups are part of the gain sharing process.
For instance, if a provider group has a traditional gain-sharing arrangement where providers get a third of the first three points of MER below 87% risk adjusted Medical Expense Ratio for the covered population once quality metrics are met, and then providers receive 50% of the gain of the next five points and two thirds of all gains below 79% MER, the members are treated as widgets to manage. The goal is to improve health while also lowering costs, but the individual is fundamentally an object acted upon and not a subject with agency.
My tweak is that small groups of projected high cost utilizers would be grouped together. If a group of five people with similar conditions were expected to have an annual cost of $150,000, they could split some of the gain if total actual costs for that particular condition came in at $135,000. The $15,000 could be split three ways, with one third going to the insurer, one third going to the provider, and one third being split five ways to the members of the solidarity group each getting $1,000. The gain would be incumbent on the conditions staying stable or improving instead of being the result of someone being non-compliant with care.
I think the member group portion would be important for a few reasons. First, it reduces volatility. Secondly, there is good evidence that quite a few environmental risk factors such as obesity and activity levels are influenced strongly by local norms within social networks. Creating a local cluster of people who are motivated to motivate the other members of the group could influence behaviors. For instance, if the members of a group are Type 2 diabetics, it is harder for a member to decide that they don’t want to go for a three mile walk along the river on a misty night when three other people have already committed to joining them for the walk. Peer pressure could be leveraged for positive behavioral changes.
This model would focus more attention and agency on the people whose behaviors and outcomes have to change the most to bend the cost and quality curves in the United States. There are a couple of big problems with the model. The first is that there are dozens of confounding factors I have not thought about yet. Secondly, the optics of the program look really bad as insurers would be cutting fairly large checks to people who the rest of society judge as having made potentially bad choices. This is especially true if we include substance abuse as a costly chronic condition which it is. Finally, this system would be extremely vulnerable to gaming by people opting out of medically necessary care and the providers would still have the incentive to under-treat. This final problem is greater in the three way model as everyone gets paid more for lower expenses while in the two way model of the traditional payer-provider gain share, the patient has no reason not to advocate for more treatment. I am not sure how to resolve that particular problem right now.
BGinCHI
Based on the title I thought Balloon Juice had finally gotten the Sex Advice post it had always dreamed of.
Baud
@BGinCHI:
I think that was the intent.
Stupid, sexy health insurance.
MomSense
Green balloons!
Baud
Manage(d Care)-a-trois.
BGinCHI
@Baud: Right there you have the tag for Baud Care:
I think you can win this thing.
Baud
@BGinCHI:
That fits nicely with my free condom proposal in the last thread.
BGinCHI
@Baud: A car in every garage, a condom in every wallet, a progressive income tax on every fatcat.
I’m going to have to start charging you for this.
Gin & Tonic
Oh, so this wasn’t about soccer refereeing post-gaming. I am disappoint.
WereBear
If health care could be seen as a cooperative effort, instead of a capitalistic endeavor, I think the savings sharing plan would work well.
I agree that incentives and peer pressure are effective ways to nudge people towards more healthy practices. My big problem is that what do we do (shades of the last Mayhew thread) when the health advice is not helpful, or even harmful?
My total cholesterol is considered “too high” from the last round of statin-driven guidelines. But my doctor tells me it is actually a very good profile, with low triglycerides, which seem to be the only real indicator of trouble. The previous cholesterol theory is getting torn to tatters with new research that the insurance companies still aren’t applying to their requirements. So I could go on an expensive statin to drive a number down, my company’s insurance would pay for it, driving up the total healthcare costs for my company, I risk serious side effects, and I get a bit of a bump to my deductible for being a Good Patient.
Doesn’t make any sense.
Don’t think such scenarios don’t happen. A friend’s father has been getting excellent blood sugar numbers from controlling his carbohydrates (he eats to his meter) and his doctor was thrilled, and sent him on to the nutritionist, who scolded him for not eating enough carbohydrates. He says he is able to use very little medication by controlling his carb intake, and she says he has to eat his required amounts and can use extra medication to keep his blood sugar under worse parameters than the ones he is accomplishing on his own!
That’s the issue. The insurance companies need to be up on the latest. And from what I can see… they are not.
WereBear
This is a possible duplicate, since I have been randomly chosen for moderation.
If health care could be seen as a cooperative effort, instead of a capitalistic endeavor, I think the savings sharing plan would work well.
What do we do (shades of the last Mayhew thread) when the health advice is not helpful, or even harmful? A nice walk does everyone some good, but I pounded my knees into jelly following the health advice of the 1980’s, and no one is giving me sweeteners on my deductible for that. If my knees turn arthritic in the future, I suffer and my company’s insurance gets dinged.
I think people would do far better with lifestyle interventions… but which ones?
WereBear
In the future, historians will crown you as the first Bumper Sticker Strategist.
Baud! Because.
WereBear
Oh! It was farmAsooticals.
WereBear
Repeated because I figured out my moderation trigger:
I agree that incentives and peer pressure are effective ways to nudge people towards more healthy practices. My big problem is that what do we do (shades of the last Mayhew thread) when the health advice is not helpful, or even harmful?
A friend’s father has been getting excellent blood sugar numbers from controlling his carbohydrates (he eats to his meter) and his doctor was thrilled, and sent him on to the nutritionist, who scolded him for not eating enough carbohydrates. He says he controls his carb intake, and she says he has to eat his required amounts of carbs and should use insulin to keep his blood sugar under worse parameters than the ones he is accomplishing on his own!
That’s the issue. The insurance companies need to be up on the latest. And from what I can see… they are not.
FlyingToaster (tablet)
@WereBear: Massive suckiness.
Back when I had gestational diabetes, I was lucky enough to have a teaching hospital nurse-practitioner as the person monitoring my meter. She and my ob/gyn talked weekly after I uploaded my numbers so that all three of us could stay on the same page. I was able to stay away from insulin and reduced my likelihood of developing Type II diabetes 28 years later. And ended up with an insanely healthy WarriorGirl.
WereBear
@FlyingToaster (tablet): Good for you! And WarriorGirl.
People in more advanced health situations are aghast at my little diabetes story, and yet, for every person online who is appalled, there is another who gets told the exact same stupid thing as my friend’s father.
Nutella
As WereBear said, these have to be carefully structured to avoid punishing sick people. Workplace health incentive programs are notorious for that. Losing weight, for example, is often rewarded in those yet some people (who are naturally skinny or sick) would be worse off if they lost weight. Incentives for exercise are good for many people but not for those of us with conditions that limit exercise.
Routing the incentives through health insurance rather than salaries helps a bit but you still need to be careful in designing any incentive plans.
Richard Mayhew
@Nutella: I agree, there would need to be a massive amount of careful thought put into this.
Right now it is a spitball of an idea, slightly better developped than an argument made at 1:00 AM after a six pack with some buddies in my sophomore year dorm… it has been sticking in my head for a while that the gain sharing methods that I see treat the patients as objects and not the subjects of their own stories.
Richard Mayhew
@BGinCHI: I would be slightly scared to see what the Balloon Juice sex column would look like (and no I am not volunteering to write one)
Villago Delenda Est
“Pass the savings on to you!” is right up there with “I’ll respect you in the morning” and “The check is in the mail” in the pantheon of great lies.
Villago Delenda Est
@WereBear: That’s the main problem with health care in this country…it’s a capitalistic endeavor first, and once that mantle is assumed, it rapidly becomes strictly about the benjamins and the original idea…to keep people healthy and productive…is totally lost because it’s much more difficult for bean counting fuckheads to comprehend healthy and productive as opposed to numbers in Excel.
WereBear
@Villago Delenda Est: As someone who remembers crawling around on the floor doing giant projections using a pencil and an adding machine, I love Excel.
On the other hand, it has made it entirely too easy for pin-headed MBAs to shorten the screws in all their furniture and present their bosses with PROFITS while the people who purchase the resulting furniture have to assemble it AGAIN with proper hardware.
BGinCHI
@Richard Mayhew: It would, I dare say, go to waste.
Brachiator
This is very interesting, thought provoking stuff. But in California, maybe elsewhere as well, there are a lot of the basics that need addressing.
The California insurers are doing fairly well, but while people can get insurance, they still have problems getting doctors.
I notice that urgent care centers are getting more crowded and emergency rooms are doing good business. I wonder whether people are having trouble getting to doctors for checkups and spot care, and having even more trouble going in for follow-up visits. The problems could be access, transportation problems, who knows.
But this dovetails with the main subject of this post. It is far more difficult to craft any intermediate to long term strategy of intervention and maintenance if people cannot or do not want to schedule follow-up visits with a primary care physician.
Jackie
Unfortunately it looks like a giant hipaa violation to me. Wouldn’t it require sharing health information about your partners?
FlyingToaster
@Brachiator: Under RomneyCare, it took years to work out the “getting a PCP” problem. A lot of people ended up at local clinics as practices ramped up to add physicians and therefore patients.
HerrDoktor & I go to a PCP group, which has grown from 3 doctors and an NP in 2002 to 6 doctors, 1 NP, and a locum, plus a daily specialist-on-call (the podiatrist is in on Wednesday). Upstairs in the same building is my ob/gyn.
My daughter’s pediatric primary care practice has 4 doctors, 1 PNP; it’s been stable since 2007.
All of these are teaching practices, affiliated with teaching hospitals and Harvard Medical School. I’d have been just as happy with Tufts Med or BU Med; the advantage to having all of these med students going through the practice(s) is that some of them end up coming there to work after their residencies.
From the stats I remember (which was via Brad at Sadly, No), we had full pediatric coverage — every kid could find a pediatrician — by 2007. Adults took longer, but I think we were at full coverage around 2009-10.
So I suspect California has a serious ramp-up period, along with the rest of the nation; and the whole “don’t go to a teaching practice because it’s more expensive” advice from insurers needs to be examined for “how expensive is the outcome?”
It’s like the ROI on equipment; BCBS spent a lot on me during my pregnancy, but almost nothing on me and WarriorGirl since. Taking a capital hit up front (teaching hospital, best practices, pediatric allergist, etc.) to reduce the long-term expenditures (fewer and cheaper scrips, fewer childhood illnesses, no inherited dietary allergies) means that they’re back to making money off of our family.
Mnemosyne (iPhone)
The Giant Evil Corporation I work for is self-insured, which means that they hire an insurance company to administer the network, but the GEC pays the bills, not the insurance company. That means they have a lot of incentive to try and bend the cost curve since unlike an insurance company, they want to keep employees for as long as possible.
The main incentive program gives $100 for meeting each of three benchmarks: getting a checkup, having blood pressure within the normal range, and having a BMI less than 27. If you’re off the BMI scale because of muscle mass, you can have your doctor write you a note and still get your $100. If your spouse or domestic partner is on your insurance and meet the same benchmarks, you can get another $300.
They seem to be trying some other programs as well. One of my coworkers was offered a free FitBit Zip pedometer, and since it was free, he accepted it. So they definitely seem to be focusing on carrots over sticks.
J R in WV
@WereBear:
I’m so not surprised by strangeness surrounding eating – diet – and diabetes and other health problems. Nutritionists seem to have a one size fits all perspective from a book, and I don’t fit into that picture very well.
I have a good friend and former co-worker who got into an HMO back when insurance was changing a lot. Pretty quickly he was diagnosed with pre-diabetes, and his HMO doctor put him on a med to “help”. He also enrolled in a diet control program at the local big hospital, and changed how he ate a lot.
About 6 weeks later, he got a call from the HMO, and they told him to double his dose of the med, without any blood test, appointment, questions about any self-control efforts, nothing. He raised hell and demanded an appointment with the DOCTOR before accepting any change to his meds. They were appalled at his ignorance and arrogance thinking that he knew better than the policy of the HMO, to assume that all patients are going to eat more after starting meds.
At the appointment, after the blood work was done, they were pretty embarrassed to have to tell him to stop taking the med, and to admit that if he had blindly followed their malpractice based instructions to double his dose, he would have dropped into a coma, and very possibly died. He lost a lot of weight at the time, and has gained a little back over 20 years, but remains med-free with stable glucose levels.
So doctors and HMOs can “gang oft agley” [Burns, I think], just like regular people groping in the dark.
I hate running, and have only done it on wet sand at the beach, years ago. I used to ride a bike a lot, but then I got hit by a car, T-boned on the left, and took quite a beating. I did get back on a bike (not the same one, it was trashed!) for a while, but where I live now the roads are twisty and narrow, no one rides bikes so drivers are totally unaware, and the hills are really steep, so I never really took it up again in the same way I did it before the collision.
My joints seem to be failing rapidly. I’ve had both shoulders replaced, and now my legs seem to be going. Would using a stationary bike be a good thing, or would I just wear the remaining cartilage out faster? Hard to say. I used my shoulders a lot with heavy tools, gathering fire wood, build things, hammering bedrock, so I’m thinking that high impact exercise would definitely be bad, while low impact stationary bike might not be bad… I’ll try to remember to ask the doc next week.
I will ask my physical therapist tomorrow, he’s easy to talk to while I submit to the torture. He will probably say he doesn’t know, which will at least be honest.
J R in WV
Richard,
If you would volunteer to host the sex advice post once a week, I bet you would get lots of other folks anxious to chip in and help! This blog is full of people ready to provide good advice!
Like mclaren, svr, ReadytoRise, etc, etc! People with real emotional maturity and social skillz… what you need to give folks advice, right? Right?
;-)
Richard Mayhew
@Jackie: Insurer to provider is a covered relationship for HIPAA, provider to patient is covered as well. Patient to patient could be the problem. It is not a HIPAA violation if individuals self-disclose their information, so maybe make it a voluntary program that is made attractive through the potential of a pay-off and HIPAA is resolved? Thinking this one through and looking for major problems like HIPAA.
Brachiator
@FlyingToaster:
Very good information. This makes a lot of sense. Thanks very much for taking the time to respond.