Don Hall, MPH

home

authors

don-hall-mph

When most people think about epidemics, they think of Ebola, SARS, and now, especially, the new coronavirus. But until COVID-19, when healthcare executives had thought about epidemics, they should also be thinking about diabetes, because it is growing, expensive - and deadly. 

The impact of diabetes on the lives of patients can be absolutely devastating. It is the underlying cause of serious complications, such as heart disease and stroke. Many people with diabetes are afflicted with chronic pain; it is also the leading cause of kidney failure, blindness, and amputations. Diabetes, and the complications resulting from it, ranks third behind heart disease and cancer as a cause of death in this country.  

Over 34 million Americans have been diagnosed with diabetes, mostly with the type 2 variety that is linked with being overweight or obese. Another 88 million Americans have prediabetes: They have blood sugar levels and other risk factors that could put them on the road to having full-blown diabetes. Nearly $250 billion is spent on healthcare costs related to diabetes, with an average medical expenditure of $15,000 per person with the disease. As far as drug costs are concerned, diabetes is the most expensive traditional therapeutic class on a per-member, per-month basis. 

21st Century-Style Diabetes Disease Management: Coaches and Tech-Enabled

The causal factors of the type 2 diabetes epidemic are well characterized: poor diet, obesity, lack of exercise, and aging. Diabetes also occurs more frequently in some groups because of social determinants of health, such as unsafe neighborhoods with a lack of access to recreation.

The good news is that managed healthcare can have a significant impact on all aspects of diabetes prevention and management. Through analytics and health risk appraisals, health plans can identify members with diabetes and those who are prediabetic. Focused disease management programs, combined with value-based provider contracts, can encourage engagement of members and incentivize providers to improve outcomes. Health plans can help by, among other things,  covering smartpens that can monitor injections. The same goes for stick-free glucose monitoring, which improves adherence to blood testing and insulin management. Health plans are also well positioned to work with community organizations to support efforts to educate people about proper nutrition, exercise habits, and weight management. 

When and how is difficult to say, but COVID-19 will recede. Diabetes will not. It will continue to grow as our society struggles to control the impacts of poor lifestyle habits. However, managed healthcare plans continue to play an important part in ensuring that members receive the most impactful information and care possible to manage and ultimately stop this epidemic.

Don Hall, MPH, and Sherry Rohlfing are principals of DeltaSigma, a consulting firm that specializes in strategic problem solving for managed care.

Articles

Americans have been diagnosed with diabetes, mostly with the type 2 variety linked with being overweight or obese.

Diabetes: The Quiet Epidemic That Is Not Going Away

We recently returned from an educational summit of the Swedish healthcare system sponsored by the TPG International Health Academy. The group of 25 was made up of healthcare executives from Canadian and the U.S. organizations including Kaiser Permanente, LA Care, National Indian Health Board, Centene, Cigna, Affinity Health Plan, and others. We studied a number of aspects of Sweden’s universal, government-sponsored system including its organization, financing, access-to-care, and current challenges.

While there were a number of key points learned from the study, two things stood out to us.

First, their focus is on care delivered in a primary care setting. In the Swedish system, primary care, which does not include pediatricians or internal medicine, accounts for over 20% of all healthcare costs. As a comparison, in the United States we spend about 5% (including pediatricians and some internal medicine and non-delivery OB-GYN). Primary care in the Swedish system is largely delivered in clinic settings that include general practitioners, nurse practitioners, nutritionists, psychologists, and physiotherapists in a holistic approach to patient and family care.

Through this approach, more comprehensive care is provided in the primary care clinics and fewer referrals to specialty and other care are required. In addition, an emphasis is put on patient education and self-care. The result is lower cost and better healthcare results, which demonstrates that primary care medical homes work.
	
	The takeaway is that health plans should improve efforts to create more robust medical homes for their members to improve outcomes and lower overall healthcare costs.

Second, Swedish leadership incorporates an interesting management approach that takes an old Swedish practice called a fika (pronounced fee-ka) and turns it into a communication channel with their teams. Fika is much like our concept of a coffee break, taking time away from work to relax with a hot beverage and some food. Managers take traditional fika further by making it a time for everyone to get together for a break-management and staff. During this time, leaders have the ability to informally hear from their employees and get to know them on a more personal level. It’s like an informal focus group every day.

The takeaway is that executives should develop a similar mechanism, whether a break or lunches, to spend time with more than just the management team to better understand their employees and how to make their company a better place to work and more aligned with their customers.

As we strive to improve healthcare in the United States, it’s useful to travel to other countries to learn about their cultures and healthcare systems. Sweden’s approaches provide useful insights.

Don Hall, MPH, and Sherry Rohlfing are principals of DeltaSigma, a consulting firm that specializes in strategic problem solving for managed care organizations. They work with the TPG International Health Academy on Educational Summits and will study healthcare in Columbia and Italy in 2020. 

U.S. health executives can glean useful insight from studying how other countries approach healthcare.

Learning From Others

It’s that time of the year when organizations begin developing their budgets for the coming year by projecting membership growth, medical loss ratio, administrative expenses as well as the investment in new initiatives. Most of these costs can and will be developed based on past trends that are adjusted incrementally for competitor, product, and market changes.

Beyond this, executives in the most successful organizations will also take a step back to think about what could go wrong and what could prevent their organization from reaching its goals. Aside from the inherent risk that all organizations have of unexpected staffing changes or poor sales performance, what are some of the biggest potential disruptors looming in 2020?

As personalized approaches to cancer treatment like CAR T-cell therapy become more applicable to wider a range of malignancies, oncology centers will face significant pressure to incorporate these therapies in addition to surgery, chemotherapy, and radiation.

Because CAR T can, in specific malignancies, deliver such dramatic and rapid results, it has the potential to be a major disruptor, forcing providers and managed care organizations to include it as a first line therapy. At a total cost ranging from $700,000 to well over $1 million, CAR T therapies could have a great impact on the cost of cancer treatment as well.

The use of integrated, distributed systems of recording, storing, and viewing information critical to providers, payers, and regulators has the potential to address problems inherent in keeping provider directories up-to-date, tracking member prescription use from multiple pharmacies, integrating patient medical records in real time, and eliminating redundant diagnostic tests.

Many of the major managed care organizations have begun efforts to employ blockchain powered approaches to provider data management, including credentialing and directories. Challenges with trusting data, lacking ownership of information, and violating HIPAA requirements will reshape how managed care organizations approach this major disruptor.

Applications for machine learning, or artificial intelligence (AI) in managed care organizations range from claims review for fraud or manipulative billing to identification of high-risk members and the development of care plans, to viewing and approving authorizations, to data quality review and interface with electronic medical records.

In short, AI has the potential to change virtually every area of a healthcare organization and have a tremendous impact on staffing skillsets managed care organizations require.

Nine Reasons Health Execs Are Excited for the Future

Social determinants of health (SDoH) are the conditions in which people are born, live, and work and have been found to have a significantly greater impact on an individual's health than any clinical or genetic factor.

For most health plans, the SDoH conditions affecting their members are related to adequate housing, access to healthy food, and lack of transportation. Addressing these conditions on a member-by-member basis can have a dramatic impact on healthcare cost-but requires a new set of tools and employee skills and a transformation on how an organization defines itself and deploys its resources.

While Apple, Google, and Amazon have discussed their interest in the healthcare market, most of their activities have been relatively modest to date. That could change very rapidly.

These data-obsessed behemoths have the resources, technological capabilities, and loyal customers to be major disruptors when they enter the market in a larger way. Amazon’s purchase of PillPack is already raising significant concerns at large pharmacy chains and among PBM companies. Amazon’s Haven joint venture with Berkshire Hathaway and J.P. Morgan is starting to take form as a new intermediary focusing on outcomes-based reimbursement.

How much impact each of these or other potential disruptors will have in 2020 remains to be seen. But organizations that don’t take the time and effort to prepare for disruptors-do so at their own peril.

Don Hall, MPH, is principal of DeltaSigma LLC, a consulting practice specializing in strategic problem solving for managed care organizations. He most recently served as president and chief executive officer of a nonprofit, provider-sponsored health plan. 

From personalized therapies to new technologies, the line items you shouldn’t overlook next year.

5 Items to Include in Your 2020 Budget 

If you ignore the Sword of Damocles hanging over the industry in the form of a Texas federal judge’s ruling the entire ACA unconstitutional, 2019 could shape up as a relatively chaos-free year with little chance of legislative or regulatory upheaval. Despite the fact that the number one issue on voters’ minds during the 2018 election was healthcare, it’s unlikely that the extremely divided Congress will be able to address it in any meaningful way. Cue the 2020 election. 

The biggest issues healthcare industry leaders foresee include: 

Although it’s become clear that a person’s zip code has more impact on their health than their DNA, dealing with the 

 (or social drivers) of health that relate to where a person lives are often far outside of the scope of most health plans’ operations. That’s rapidly changing. Whether it’s food or housing insecurity, economic stability, social or environmental safety or literacy, the impacts these social drivers have on health outcomes and costs are significant. Spurred by state Medicaid agencies and CMS, finding and deploying tools to measure and address the underlying issues that drive much of the cost and utilization in healthcare will be a focus during the year. 

As hospital systems extend their reach with acquisitions, mergers and alliances (for example the $28 billion 

Catholic Health Initiatives and Dignity Health merger

), health plans will be faced with much less leverage in rate negotiation and greater challenges in establishing competitive product differentiation as providers will have more power to dictate terms for products and rates. On the other hand, plans aligned with providers will face a more favorable environment and may see significant growth over their unaligned competition. 

Opinion: Top Two Ways the CVS-Aetna Merger Will Shake Up Healthcare

Adding work requirements for “able-bodied adults” to Medicaid expansion waivers has allowed Republican states that opted out of this ACA option (and the significant federal dollars that go with it) to find a way to participate that aligns with their stated conservative values. 

Unfortunately, work requirements are much easier to put in place than to administer as some of the early-implementing states like Arkansas are finding out. Expect more non-expansion states to use this mechanism to expand their Medicaid coverage and for the health plans involved to be inundated with a whole new set of administrative requirements and challenging enrollment issues. 

The Dick Tracy watches are here and are way 

. Measuring pulse and blood sugar, breathing rate, simple ECGs, and providing emergency alerts for falls are only the beginning of what appears to be a host of clinical monitoring and alerts coming from these personal technologies. Whether and how health plans address and incorporate the application of these new capabilities to their membership will make a significant difference in the MCO’s market presence and competitive stance. 

While these were a some of the more frequently mentioned challenges, obviously other issues resonated a higher level for some execs based on their geography and product lines. Here’s hoping that 2019 sees the industry better serve the diverse healthcare needs of the country by meeting consumers’ demands for quality, affordability, and access. 

Don Hall, MPH, is principal of DeltaSigma LLC, a consulting practice specializing in strategic problem solving for managed care organizations. He most recently served as president and chief executive officer of a nonprofit, provider-sponsored health plan

Healthcare industry leaders share the biggest issues they foresee for their organizations. What can we expect in 2019?

The 4 Biggest New Areas to Focus on in 2019

A change is occurring, and it’s not the type of change we typically talk about in the shifting healthcare landscape. It is a change requiring us, as healthcare leaders, to acquire new skills, talents, and capabilities as we lead new and expanded teams of people in the treatment of patients.

Physician leaders, in particular, are trained well to do many things. We perform highly technical skills and complicated procedures. We manage multiple needs at the same time. We take an unstructured human narrative, break it down into individual components, and develop an entire care plan-determining if and when others are needed. We are trained well for one-to-one interactions with our patients. This training has made us very good at a certain type of leadership-one that is based on hierarchy and a top-down approach.

Unfortunately, this team dynamic and leadership style is not effective in a value-based reimbursement model, where better health outcomes for chronically-ill patients is the measure of success.

In the managed healthcare market, words like logical, predictable, or stable are seldom used anymore. Instead, for healthcare executives, disruption is the norm. The usual change drivers-an aging population dealing with more chronic illness and the increasing problems of affordability and government regulation-are coupled with other disrupters that make it even more difficult for healthcare executives to find the right course. These include:

While the federal government has long been a disruptive force in healthcare, this has generally been related to new policies, programs, or approaches. We’ve entered an era with no clear federal policy except eliminating and destabilizing previous approaches such as the ACA.

Due to the lack federal direction on healthcare, some states are considering new approaches to cover their residents, including Medicaid buy-in programs and even Medicaid for all. Others are evaluating moving from Medicaid capitation to fee-for-service, increasing emphasis on value-based contracts, and expanding their focus on quality and outcomes.

Many new states are pursuing Medicaid expansion. This includes work and other requirements that force health plans into roles beyond their expertise. These new requirements are sometimes not included in rate calculations, thus resulting in rates that are not actuarially sound.

The awareness that a person’s social conditions has a greater impact on their health than their genetics has emerged as a significant driver for how health plans approach member services. Lack of food security, housing, transportation, or a safe environment are enormous contributors to preventable morbidity and mortality and are beginning to be incorporated into care plans and health plans’ outreach efforts and community initiatives. In addition, insurers are forging new partnerships with community partners to ensure access to these services.

This rapidly emerging approach to treating disease considers individual genetic, environmental, and lifestyle variability and is reshaping how many medical conditions are treated. While usually more effective than previous approaches, precision medicine is often more expensive and has fewer provider network options. While many health plans aren’t covering precision medicine, clinical studies demonstrating effectiveness will push consumer demand for its coverage.



With Amazon’s announcement of its intent to purchase PillPack and its partnership with JP Morgan Chase and Berkshire Hathaway to establish a disruptive new healthcare enterprise, Jeff Bezos is clearly eyeing healthcare as a market open to business opportunities. Apple and Google also have investments in healthcare initiatives. Even unintentionally, ebusiness is disrupting healthcare as demonstrated by Uber’s impact on reducing traditional ambulance services.

At $3.5 trillion, the healthcare industry comprises 21% of the U.S. economy. Despite investing far more in Americans’ healthcare than any other country does, the United States delivers poor results in terms of affordability, quality, access, and outcomes. Until there’s a balance between the dollars invested in healthcare and the results obtained, significant changes in products, strategies, competitors, and federal and state regulation will continue. For healthcare executives, trying to achieve this balance should be their consuming focus. Disruption is not going away, it will only become even more frequent and rapid.

Don Hall, MPH, is principal of DeltaSigma LLC, a consulting practice specializing in strategic problem solving for managed care organizations. He most recently served as president and chief executive officer of a nonprofit, provider-sponsored health plan.

In the managed healthcare market, words like logical, predictable, or stable are seldom used anymore. Instead, for healthcare executives, disruption is the norm.

Five Disruptors Healthcare Executives Must Watch 

 recognizes the 2018 top 10 emerging leaders in the industry, as selected by our editorial advisory board. These remarkable individuals include leaders who have demonstrated their expertise in areas such as the human genome, opioid risk management, innovative cloud solutions, care management technology, and mental healthcare. They demonstrate the key attributes that define up-and-coming leaders: vision, drive, confidence, resourcefulness, and tenacity. 

Emerging leaders, as represented by this group, are often the product of organizations that actively encourage and develop their capabilities and acknowledge their contributions, as exemplified by the vast number of nominations we received this year.  

There are many different ways to cultivate emerging leaders, but the most successful organizations incorporate these five critical aspects:

While there are a number of analytical assessment tools available to identify prospective leaders, perhaps the best tool is a management team engaged in the identification, formal and informal, of team members demonstrating leadership potential. Once identified, having a process that includes regular updates on how their skills are evolving, offering appropriate training, and establishing meaningful career paths can set a trajectory for growth for these individuals.

One of the most valuable tools for grooming emerging leaders is providing a trusted resource that can be a sounding board for their ideas, provide feedback on how they are approaching projects and issues, and serve as a source of support and encouragement. In the best case, mentors should be drawn from the ranks of upper management and outside of a direct reporting relationship to the candidate.

Putting prospective leaders to the test with opportunities that require creativity, goal setting, resourcefulness, and getting buy-in from various departments within the organization is an important step in determining how successful these individuals will be as leaders. Often, emerging leaders will exceed expectations on these types of opportunities, reinforcing their selection as future leader.

When management positions open up, look first to your pool of emerging leaders. Even better, give them opportunities to build out new products or services and take their skills to whole new level.

Recognition is important but needs to be personalized. Monetary rewards only go so far. Conference participation, appointment to community boards, and nomination to regional and national recognition programs are a few ways to let emerging leaders feel the love.

These individuals are not only the future of their organizations, but even more important, they are the future of our industry. Their importance cannot be overstated.

Healthcare in the U.S. is at a critical point. Rising costs, governmental indecision, aging, sicker populations, high deductibles, and a high level of consumer dissatisfaction create a rich environment for new and disruptive approaches. Savvy organizations understand this environment and are making the investment in finding and developing their next crop of leaders that can lead us all into the future.

While there are different ways that healthcare organizations can nurture emerging leaders, most incorporate these five critical aspects.