Health for life

Check out the three page article on "U.S. Health Cares Future" in the Marketplace section of the December 12 Wall Street Journal. Using personal stories of a doc, hospital CEO, insurance executive, human resources manager and a patient, the news piece portrays the blurring business lines between insurers, buyers and providers.  Mainstream readers of the Journal are likely to think the topic is both timely and novel.  Regular readers of the Disease Management Care Blog learned about his months ago.

Who are these five canaries in the health care coal mine, these bellwethers of the insurance business, these oracles of management and what are they telling us?

1. Dr. McCullough, a salaried physician with 28% of his income contingent on quality and satisfaction.  Some measures were imposed by the local Blues plan, which was passed through to the him by his employer.

Message: Purchaser and buyer control of physician reimbursement is already big and its growing.

2. Jim Taylor, a hospital CEO who cannot buy an electronic record system unless he merges with two other hospital systems.  If the merger is approved, the hospital will also be able to take on "warranty-style" payments from insurers.

Message: "Bigger is better" for capital-constrained hospitals.

3. Chris Day, an Aetna executive who got an Arizona health system to share insurance risk.  The main sticking point was the two-way mutual sharing of internal cost and contracting data.

Message: If insurers are willing to share internal pricing data, they must really mean it and think its an important success factor.

4.Robert Jacobs, the HR person, who linked about $10 per week of employees health insurance premiums to healthy behaviors (like tobacco) and quality test results (like blood cholesterol levels).

Message:  "Dont just stand there," say the employers, "do something."

5. Louis Kandor, an 86 year old man with advanced diabetes, who is being visited by a nurse who, in turn, is employed by a care management service provider under contract by his Medicare Advantage insurer.

Message: One key to mitigating risk for every insurer (except fee-for-service Medicare) is to use nurse-led care management.

While the Journal article doesnt spell it out, the DMCB believes the anecdotes can be distilled down into three useful insights:

1. Stakeholders are scrambling to demonstrate measurable outcomes to an increasingly educated and  skeptical public.  Thats the basis for physician pay-for-performance and premium surcharges.

2) Sharing proprietary insurance data is important.  Is information the secret ingredient that was lacking during the similar - and mostly unsuccessful - insurer-provider collaborations back in the 1990s?  Well see. 

3) For those hospitals that cannot or will not take risk, the next best answer is to merge.  That will mean economies of scale, access to capital and negotiating leverage.

Just a quick rant today. Ive been thinking a lot lately about the concept of "voting with your food dollar". Voting with your food dollar is just what it sounds like... when you buy a particular food, youre essentially "voting" for it. Youre telling producers that you like it and you want more of it. But beyond that, youre supporting the entire process that made that food available to you at your local grocery store. This is obviously true of anything you buy in a free market system. You have the opportunity to vote every time you buy anything. Anything at all. Whether its fitness equipment, a new leather purse, or the new Justin Timberlake album, your dollar essentially votes for what you buy. Just think of the consequences if nobody bought JTs new album (which I know isnt true since I already bought it)... Justin would end up a complete failure. Hed likely enter a downward spiral involving drugs, Taylor Swift, and his first emo album, until hes finally relegated to neighborhood bar gigs opening for Good Charlotte.  But worst of all, nobody would adopt his new hairstyle.

Okay a little off topic there.  Where was I?  Oh yes, when you buy a food at the store, you support everything that went into putting that food on your grocery store shelf.  In addition to supporting the food itself, you support the production methods, the processing, and the transportation costs.  Id like to take this opportunity to go through a few different food options and talk about what it means when you choose to buy them.

1) Doritos
One of my favorite childhood foods.  I could eat an entire bag of this stuff as a teen.  Of course theyre yummy, but lets talk about where Doritos come from.  Heres an ingredients list...


Now I dont have time to go through all of these or else Id be here all day.  The corn is genetically modified, along with the corn oil and soybean oil.  Theres partially hydrogenated oil in there (trans fat), theres MSG (monosodium glutamate), and therere artificial colors (yellow 6, yellow 5, and red 40).  I know you buy Doritos because they taste good, and that is the ONLY reason the food manufacturers want you to buy them, because looking any deeper at the product would scare you off. Thats why they hide all of the scary information in the ingredients list; and youd need some training in nutrition to even interpret it.  Thats why Im here.

So unfortunately, when you buy Doritos because they taste good, youre also supporting GMOs, trans fat, MSG, and artificial colors, many of which are banned in Europe because, unlike Americans, they actually care about the quality of their food and the health of their children.  See example here. There are more natural options available, you just have to look for them, and yes they DO taste good. And when youre cocky-ass friend makes fun of you for buying organic chips, just tell him to fuck off.

2) A Grocery Store Chicken
On to some real food.  To the lay person, a roaster chicken may seem harmless.  At least its a real food, not some packaged, processed corn chip like Doritos.  But nevertheless, when you spend your food dollar on a grocery store chicken, there are some unsavory consequences. Factory farmed chickens typically spend all of their lives indoors.  Theyre genetically bred to have oversized breasts because consumers, like men, per breasts.  As a result of these large breasts and the fact that they may never leave their cage, they often cant even stand up.  Not to mention the fact that nearly their entire diet is made up of genetically modified corn and soy.

Not to freak everyone out, but I think its important to know what youre dollar is supporting.  When you buy chicken at a grocery store, you vote for this system, whether you mean to or not.  Free range chicken is just a little better, and organic may be a little better on top of that.  Unfortunately, though, your best option is to find a local farmer producing chicken the right way.  I know its time-consuming and inconvenient, but the option is there.  But hey, if we vote for this kind of chicken more often, we might start seeing it in our grocery stores!

3) Blueberries in the Winter
Or oranges in the summer.  Same difference.  Blueberries are in-season in July.  Oranges are in-season in December.  Yet we still see both available year-round.  Why?  Because in the winter, blueberries are shipped in from Chile; same with oranges in the summer.  And it costs a lot of money, and wastes a lot of gas, to fly those blueberries from Chile to the United States.  The distance from Santiago, Chile to New York City is about 5,125 miles.  Thats far.


This blogger here did some calculations to figure out how much energy it takes to transport one package of blueberries... ONE PACKAGE... and I quote, "You would have to run your blender for 11 hours, continuously, to use the same amount of energy."  Thats just insane, and completely unsustainable.

Sad but true, even our healthiest, seemingly most natural of options can put our money in the wrong place.  Its nice to have the option of fresh blueberries in the winter, but the implications on the environment are pretty strong.  Local, in-season fruits and vegetables are always a more sustainable choice.


And another quick rant turns into a long-winded one!  Sorry if I just ruined your life with education. But this is important to me.  Most Americans are ignorant of what their money is truly supporting, and the food industry would love to keep it that way.  But we have the power to change things, if only we all understood where our food comes from.  I know the barriers to this stuff go far beyond education; its often much more expensive to put your food dollar in the right place.  But even a little bit helps.  You dont have to go all out and buy 100% of your food from a farmers market... Maybe start by leaving the name-brand snacks on the shelf and opting for a more natural, organic option with fewer ingredients.  See where that takes you.

If you take away nothing else from this post, I hope youll at least now take the time to think about what youre buying.  Every time you put something in your grocery cart youre taking a vote; I think its important you know what youre voting for.

This week, it’s a hypothetical question that came up during a lovely, bacon-soaked Valentine’s brunch.

Q: You can only eat three dishes for the rest of your life. They’re dishes, not single foods; this means you can choose bananas, but you can also opt for Spaghetti Bolognese. You must consider proper nutrition. Side dishes are not allowed. Which three do you choose?

A: This took both of us (me and Husband-Elect) a surprisingly long time to answer. If we were just choosing our favorite foods, it would have been easy, but the nutritional aspect is such a killer. After much discussion, we finally came up with:

Husband-Elect: vegetarian burrito, bean chili, and fruit salad.
Me: vegetable stir-fry over rice, chicken fajitas, and Sausage, Apple, and Cranberry Stuffing.

Leaving out macaroni & cheese was one of the hardest things I’ve ever had to do, and that includes that time I burnt all my fingers at Wendy’s and kept working the register.

Readers, how ‘bout you? Three dishes from here TO ETERNITY.

Want to ask the interweb a question? Post one in the comment section, or write to Cheaphealthygood@gmail.com. Then, tune in next Tuesday for an answer/several answers from the good people of the World Wide Net.

Researchers reporting in the July 17 issue of the New England Journal of Medicine published results of their two-year investigation into three popular diets: A low-carbohydrate diet (based on Atkins guidelines), a Mediterranean diet, and a low-fat diet (based on American Heart Association guidelines).

The full study can be found at:

Weight Loss with a Low-Carbohydrate, Mediterranean, or Low-Fat Diet

Weight Loss

For weight loss, the low-carbohydrate and Mediterranean diets performed best, and were just about tied at 2 years:

• Low-carbohydrate Diet: 4.7 kg (approximately 10 pounds)
  
• Mediterranean Diet: 4.4 kg (approximately 10 pounds)
  
• American Heart Association (AHA) Diet: 2.9 kg (approximately 6 pounds)

Women did better on the Mediterranean diet, while men did better on the low-carbohydrate diet.

Diabetes

There was an unexpected finding that applied specifically to participants with diabetes. Fasting blood glucose of people with diabetes who followed the Mediterranean dropped an average of 32.8 mg/dl; while the fasting glucose of diabetics in the other groups increased by 1.2 mg/dl in the low-carb group and 12.1 mg/dl in the AHA group.

People with diabetes who followed the Mediterranean diet also had the lowest fasting insulin and lowest insulin resistance (HOMA-IR).

Differences Between Diets

All participants reduced their intake from baseline and were eating about the same amount of calories, 1500/day for women and 1800/day for men, regardless of group assignment. Physical activity also increased from baseline but was not different between groups.

The low-fat AHA diet derived about 30% of its calories from fat and 50% from carbohydrate. "The participants were counseled to consume low-fat grains, vegetables, fruits, and legumes and to limit their consumption of additional fats, sweets, and high-fat snacks."

The Mediterranean diet derived about 33% of its calories from fat and 50% from carbohydrate. This group had the highest ratio of monounsaturated-to-saturated fat, probably owing to olive oil and nut consumption: "the main sources of added fat were 30 to 45 g of olive oil and a handful of nuts (five to seven nuts, <20 g) per day." It was a diet "rich in vegetables and low in red meat, with poultry and fish replacing beef and lamb." Members also consumed the greatest amount of dietary fiber.

The low-carbohydrate diet derived about 39% of its calories from fat and 40% from carbohydrate. Members consumed the least amount of carbohydrates (consuming about 120 g/day after the first 2 months and throughout) and the most amount of fat, protein, and cholesterol. It diverged from Atkins protocol by advising vegetarian sources of fat and protein. This was the only diet that was unrestricted in calories. However, participants averaged about the same amount of calories as the other groups. Notably, even though limits were not placed on how much members of this group could eat, the low-carb group had the highest drop-out rate.

Conclusion

"Mediterranean and low-carbohydrate diets may be effective alternatives to low-fat diets. The more favorable effects on lipids (with the low-carbohydrate diet) and on glycemic control (with the Mediterranean diet) suggest that personal perences and metabolic considerations might inform individualized tailoring of dietary interventions."

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While the prescient Disease Management Care Blog was among the earliest to identify the threat of an Obamacare-induced insurance "death spiral," it missed spotting the potential fallout from a delay of the individual mandate.

As shrewdly pointed out in this Politico article, health insurance timelines require at least three months of claims experience to inform future rate setting.  Once that actuarial work is done, it then has to go through the states Insurance Departments for approval.

In other words, if large numbers of Obamacare customers are allowed to sign up after March 31, 2014, insurance companies wont know what to charge their customers on January 1, 2015. 

While overcharging can be remedied by customer rebates, it remains to be seen how accommodating Washington DC will be if the insurers undercharge. That means negative cash flows, raiding surpluses and facing the ire of their investors and Boards of Directors.

Its baseball season, so think of the death spiral as a potential strike one, and inaccurate rate setting as a potential strike two.

Which brings the DMCB to a dreaded strike three. If it happens, the health orm brand could be irretrievably tarnished.  It could also and sink the current version of Obamacare.

Strike three would be a critical mass of inaccurate insurance policies.

If reports like this and this are even remotely representative of the back-end of Obamacare enrollment, the relative trickle of individuals who are successfully navigating the exchanges are getting commercial polices that depend on a very vulnerable reconciliation process involving many moving parts.  That includes information from the "hub" as well as user-based data entry. As noted in this report, commercial insurers are being forced to manually "clean up" the information prior to issuing their exchange-generated policies.

The DMCB suspects that a "garbage in, garbage out" adage may apply. Thanks to sheer number of inputs, clean-up mistakes are going to be inevitable.  And it will get a whole lot worse if the healthcare.gov web site gets only partially fixed. 

While a few mistakes are acceptable in large risk pools, more than a few could be huge problem at three levels:

1. At a business level, where a core competency of insurance companies is to cover their enrollees and only their enrollees. Insurance companies are really good at knowing who is and who isnt insured for a covered or non-covered service with or without a variety of co-insurance arrangements.  Its more than just getting it right, it goes to the core of their business model. If enough policies are inaccurate, it could bring the finances of some smaller health insurers to their knees.

2. At national health policy-making level, where a critical mass of insured customers with premiums and subsidies mismatched to the risk could destabilize the market and distract our political leaders. Think about the customers who assume a service is covered, providers who expect to get paid accurately, balance sheets that dont lect the truth about claims expense as well as IBNR and regulators who will need to sort it all out.

3. At an Obamacare "brand" level.  Think about all those unfriendly and anecdotal news reports about vulnerable patients who ended up legitimately - if mistakenly - paying more out of pocket for care, or persons mysteriously lacking insurance, or hospitals and doctors being unable to get paid. It could ultimately track back to the HealthCare.gov web site that everyone will loves to hate.

The worst part is that the White House has done such a masterful job of bullying the insurers that its unlikely that theyll want to rock the boat by going public with any notification that their enrollment data is corrupted.  Mr. Obama will naturally claim that he wasnt in the loop and his loyal aides will deflect blame elsewhere.

Strike three, and we may not even see it coming.