Tag Archives: Employee Health Insurance

What the Walmart Decision to Send all Spine Surgeries to Centers of Excellence Really Says

Walmart announced this past year that they were modifying their Centers of Excellence (COE) program and requiring employees to travel to one of their eight approved COEs for Spine Surgery. That raised a lot of eyebrows and interest among other self-insured employers, benefits consultants and of course the healthcare system itself. Walmart did this after finding that perhaps 40 percent of those referred to a COE after having a recommendation for surgery by their local physicians, were not recommended for surgery by the COE.

There are 650,000 to 700,000 spine surgeries performed per year, with around 280,000 to 300,000 being done in an outpatient setting and (https://www.beckersasc.com/outpatient-spine/10-things-to-know-about-spine-surgery-in-ascs.html) spine surgery is the most highly reimbursed subspecialty within orthopedics. (https://www.beckersspine.com/lists-and-statistics/item/739-11-statistics-and-facts-about-orthopedics-and-orthopedic-practices).

Amazingly, 90% of Americans live within 10 miles of a Walmart and they employ about 1.5 million people in the United States (https://corporate.walmart.com/newsroom/company-facts). Think about that! I would assume that somewhere close to 90% of the spine surgeons also live within 10 miles of those Walmart’s’, many of whom Walmart has deemed were potentially doing unnecessary surgeries on 40% of the employees they referred to the COEs with spine issues. BTW the hospitals I’m sure were doing well by these referrals too.Becker’s said they did this to save money (https://www.beckershospitalreview.com/finance/walmart-will-require-workers-to-travel-for-surgery-in-effort-to-cut-healthcare-costs.html), not mentioning that 40% of the cases were reviewed by the COE and determined to not need the surgery that had been recommended by the local doctor, sure that saved money, but what about quality of life for the patients, and quality in general . Should they just go ahead and let those surgeries be done?

Here are some other outcomes as reported by Beckers Spine Review

1. About 2,300 employees — around half of the Walmart employees who underwent spine surgery or evaluation without surgery from 2015 to 2018 — utilized a center of excellence. During that time, 46 percent of patients underwent surgery and 54 percent received other forms of treatment.

2. The employees who underwent care at center of excellence sites reported shorter hospital stays; the COE employees stayed in the hospital for 2.5 days, compared to 2.9 days for the non-COE employees. Then, 0.6 percent of the COE patients were discharged to skilled nursing facilities, far lower than 4.9 percent of the non-COE patients.

3. Over the past three years, the readmission rate per 1,000 patients in the program was three for COE patients, compared to 65 for non-COE patients.

4. On average, patients who received care at a center of excellence returned to work after 10.6 weeks, which was 2.6 weeks sooner than the non-COE patients.

5. Cost for care was 8 percent higher at the center of excellence — $32,177 on average — compared to $29,770 at the non-COE, but the lower readmission rates, earlier discharge and lower skilled nursing facility use was a “payoff” of the COE model.

So now getting back to something I have seen little attention paid to, what does that say about the state of spine surgery around the United States? Its not as if Walmart has a little footprint around the country.

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Looking to the Validation Institute and Validated Programs as an Employer

Disclosure – I serve as an Advisor to the Validation Institute.

Costs for their employees’ health care have continued to rise even as employers have implemented numerous programs and benefit changes, from raising employees’ deductibles and co-pays, to implementing wellness programs.  While employers pay most of the premiums, which now exceed $20,000 for family coverage, employees now shoulder $6,000 per year on average, a heavy burden.

Here is a look at premiums growth over the years from the Kaiser Family Foundation Employer Health Benefits Survey..

Image result for employer healthcare costs continue to rise

So, what’s an employer to do?

That’s where the Validation Institute comes in.  The Validation Institute or VI does three things:

  • Validate
  • Educate, and
  • Connect

This post will discuss Validation and its importance.

No doubt employers have been looking at their health benefits and listening to their brokers or consultants explain how this program or that health plan is the best way to go and will result in better employee health and lower costs or a lower growth in costs. But how do they know? While most have heard these statements year after year, their costs have continued to rise.

The good news is there are solutions that deliver better clinical outcomes and/or reduced costs. Finding and validating the claims being made has been the hard part. The marketing of health care services has been fraught with all sorts of performance claims and many of the studies and white papers used to support them are just plain wrong.

The VI, through its Validation process, handles that process for you. It rigorously looks at claims being made by companies throughout heath care. 

For a company to be validated, it must submit its data.  The source, measures, analysis and results are reviewed to determine whether the claim being made stands up to a rigorous evaluation. Only after a thorough review can a company place the Validation Institute seal on its website and use the VI certification in its marketing materials.

There are four different “levels” of Validation. They are, in ascending order of rigor:

Calculators

Many companies develop calculators to show prospects their expected savings or outcomes.  If the calculator has been validated, that means  it uses reliable and linked data sources, reasonable parameters and estimates, but allows the users to change certain assumptions. It also means that the calculator produces credible estimates of an intervention’s impact and the intervention has been shown in published literature to be correlated with the impact.

The company may  not have produced a study showing these results, but based upon their calculator and other research, the calculator is likely a credible estimate.

Program Impact – Metrics

In this case the vendor has a credible measure (either from a published source or modeled closely to a standard measure) of the program impact, but the measure has yet to be applied to data from a population receiving the program. The intervention has been shown in published literature to be correlated with the impact.

So, the program has been shown in other cases to be correlated with creating the outcome, they are measuring and doing something similar, but have not yet measured their own results to the satisfaction of the VI.

Program Impact – Outcomes

The vendor has used credible data about a population receiving the program and reliable measures (either from a published source or modeled closely to standard measures) to estimate impact.  The intervention has been shown in published literature to be strongly correlated with the impact.

The program being reviewed by the VI has been shown to strongly correlate with creating the outcomes, and the company has obtained these outcomes on a population with credible data and reliable measures.

Program Impact – Savings

This is the big one. The program has been shown to the Validation Institute’s satisfaction to produce savings.

As a health care purchaser, you want the best for your employees and your company. Look to the Validation Institute and their certified companies to know that what you are implementing for your employees is based on sound studies, measures and/or outcomes and is more likely to do the same for you.

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PopHealth Week – Annual Medicare Wellness Visit,Value Based Care and Employers

Gregg and I had an interesting discussion on this week’s episode of PopHealth Week. We covered the Annual Medicare Wellness Visit and how it came to be, as well as value based care and some interesting moves by employers (Walmart and the Utah State Employee Health Plan) and providers (Oschner and their ACO).  Listen in:

PopHealthWeek-logo-TWTTR-sq PopHealth Week – The Medicare Annual Wellness Visit, Oschner and Walmart, Utah Employees and high Cost Pharmaceuticals, a new approach.

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Filed under Health Innovation Media, Interviews of Fred, Legislation, PopHealth Week, Population Health

The Health Value Awards -My Interview at WHCC 18.

This past spring I was interviewed at the World Health Care Congress 2018 by Mabel Jong.  We discussed the Health Value Awards.

 

The Health Value Awards recognizes health care vendors, brokers and purchasers who consistently deliver high value that can be replicated throughout the continuum of clinical and financial risk management. Validated categories are evaluated by the Validation Institute, an independent certifier for performance and methodologies and all categories are then reviewed by a panel of nationally prominent judges for market viability, impact and innovation. The Health Value Team: World Congress, Validation Institute and Health Rosetta Institute, showcase these organizations based on their performance and illumination of issues of national importance.

I’m honored to serve as a judge again for the 2019 Awards. You can learn more about the Health Value Awards and apply here.

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Casino Healthcare – An Interview with Dan Munro

PopHealthWeek-logo-50

I recently interviewed Dan Munro on PopHealth Week and we discussed his book Casino Healthcare. dan-munro-picWe all know about the high costs and poorer outcomes associated with American Healthcare.  In Casino Healthcare Dan explains his view of how our system, one built with Selective Health Coverage is like a casino; or really three casino’s, the insurer casino, provider casino and pharmaceutical casino.

Dan explores each of these areas and explains how they work to maximize revenue through a system of complex transactions and systems.

As an example, on the Provider side Dan explains a little known group called the AMA/Relative Value Scale Update Committee  or “RUC” as its more affectionately known.   Continue reading

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