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Course Syllabus

PubH 6564

Private Purchasers of Health Care: Roles of Employers and Health Plans in the U.S. Health Care System

Fall 2012

Credits: 2

Meeting Days: Mondays, September 10 – December 10, 2012

Meeting Time: 1:25 – 3:20 pm

Meeting Place: Moos Tower 2-580

Instructor: Jon B. Christianson

Office Address: 15-225 Phillips Wangensteen Building

Office Phone: 612-625-3849

Fax: 612-624-2196

E-mail: chris001@umn.edu

Office Hours: By Appointment

I. Course Description For health care providers, payments received from private insurance companies, with these funds coming for the most part from employer contributions towards employee health care expenses, are critical to their financial survival. The purpose of this course is to help future health care managers understand the goals of their “best customers” and how health plans and employers pursue these goals. The course examines the role of employers and health plans in the health care system and, specifically, how the “payers of the bills” for health care develop and implement strategies to achieve their organizational and health care system goals.

II. Course Prerequisites

Students must be admitted to the University of Minnesota’s Master in Healthcare Administration Program or have consent of the instructor.

III. Course Goals and Objectives

Specific goals and learning objectives are listed in for each class period.

IV. Methods of Instruction and Work Expectations

Each class will include a didactic presentation on the part of the instructor; significant issues will be identified and discussed, referencing the readings for the class period. There are no “required” readings for the course. The amount that students learn in this course, and their performance on assignments, will depend to a large degree on the time and effort they devote to the readings for each topic. In most class periods, students will present results from individual or group assignments. Students will be expected to prepare for each class by engaging with the readings prior to class, participating in the discussion during class, and completing group

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and individual assignments as scheduled. “Further” readings are provided as starting points for students who wish to explore specific topics in greater depth and to assist in the completion of individual and group assignments.

V. Course Text and Readings

1. To access readings go to www.lib.umn.edu. Click on E-JOURNALS. Type in the name of the journal and click on “search”. Click on journal and then click “full text available via”. Follow the prompts to retrieve the article. For newspaper articles, type in the newspaper name and click search. Click on newspaper and then click on “full text available via ProQuest Newstand Complete.” Click on date of publication and search for article title. Wherever you see “Available at” press the control key on your keyboard and bring the cursor over the link. The cursor should turn into a hand with a pointing finger. Click the left mouse key and you will go directly to the cite. (NOTE: If you have any problems accessing assigned readings online, contact Jane Raasch at raasc001@umn.edu.) If you do not have a University of Minnesota Internet ID and password, call 301-HELP and support staff will help you set up an account (or set up your own account at www.umn.edu/initiate and follow the directions.)

2. Optional background reading for this course: 1) PowerPoint lecture on the basics of health insurance posted on Moodle. 2) Kongstvedt, Peter. Essentials of Managed Care, Aspen Publishers, Gaithersburg, MD. This book is the most frequently used reference in the field. It covers most of the “basics” but may not be current on all topics.

3. For each class session, overheads/PowerPoint slides and/or audio will be posted on the Moodle website for downloading and viewing. To learn more about Moodle, watch Moodle: Online Orientation for Students and/or visit the Moodle support website at http://www1.umn.edu/moodle/, which has a link for “Student support” with user guides, help and FAQs

VI. Course Outline/Weekly Schedule Date Module / Topics

Background

September 10 History and Overview: How Did Employer/Health Plan Strategies Evolve from Managed Care to Facilitated Consumerism?

September 17, 24 Present State of the Health Insurance Industry Presentation of Group Assignment 1 (10 pts.) – September 17

Health Plan/Provider Relationships

October 1 Measuring Provider Performance: The Foundation for Network Management, Provider Payment and Public Reporting Efforts

October 8 Provider Contracting and Network Management Discussion of Individual Assignment 1 (8pts.)

October 15 Fundamentals of Provider Payment: Incentives and Rewards Discussion of Individual Assignment 2 (8 pts.)

October 22 New Payment Arrangements: Bundling/Episode-Based Payment Discussion of Individual Assignment 3 (8 pts.)

October 29 New Payment Arrangements: Comprehensive Gainsharing/Shared Savings Presentation of Group Assignment 2 (10 pts.)

November 5 Utilization: Management Discussion of Individual Assignment 4 (8 pts.)

Health Plan/Enrollee Relationships

November 12 Supporting Consumers in Choosing Providers: Reporting of Provider Performance Presentation of Group Assignment 3 (10 pts.)

November 19 Supporting Consumers in Choosing Treatment Options Discussion of Individual Assignment 5 (14 pts.)

November 26 Supporting Consumers in Maintaining and Improving Their Health

December 3 Supporting Consumers in Managing Chronic Illnesses Discussion of Individual Assignment 6 (8 pts.)

December 10 Putting It All Together: Coordinated Approaches to Supporting Care Management, Improving Quality, and Controlling Costs

Presentation of Group Assignment 4 (10 pts.)

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September 10, 2012 History and Overview: How Did Employer/Health Plan Strategies Evolve from Managed Care to Facilitated Consumerism? The two-decade period from the mid-1970s through the mid-1990s encompassed the ascendancy of a particular style of health plan – the managed care organization in the private health care marketplace and also as a contractor to Medicare and Medicaid. Responding to pressures from employers and government to control health care costs, these organizations (in collaboration with risk-bearing provider systems) instituted a variety of "supply-side" mechanisms, financial and non-financial, to influence provider behavior. Accompanying steps were taken to manage access to care on the part of plan enrollees. The result, eventually, was "managed care backlash" on the part of consumers and providers, precipitated in part by a redefinition of health benefits’ objectives on the part of employers. Since then, payers and health plans have initiated a variety of new approaches directed at restraining cost growth and improving quality. In this first session, we will describe the transition over the past decade towards a new paradigm of “managed” or “facilitated” consumerism, one that has much broader support among significant actors in the health care arena than traditional managed care. We will discuss the challenges faced by this new "facilitated consumerism," and the tools at the disposal of health plans. Learning Objectives Students should be able to:

1. Describe the origins and evolution of managed care organizations. 2. Explain the origins and nature of the "managed care backlash" of the 1990s, and its influence on the ongoing development of the

new facilitated consumerism. 3. Explain the factors influencing present employer demands on the health care system, and the role these demands have played in

changing America’s health care system. Suggested Readings Employer Involvement in Health Care

1. Blumenthal, D. “Employer-sponsored health insurance in the United States – Origins and implications,” New England Journal of Medicine 355(1):82-88, 2006

2. Blumenthal, D. “Employer-sponsored insurance – riding the health care tiger.” New England Journal of Medicine 355(2):195-202, 2006

3. Galvin, R.S., Delbanco, S. “Between a rock and a hard place: understanding the employer mind-set.” Health Affairs 25(6):1548-1555, 2006

Employer Strategies for the Health Care System 1. Kaiser Health News. “Rising health care costs spur policymakers, business leaders to consider shift away from employer-

sponsored system.” November 13, 2007. Available at: http://www.kaiserhealthnews.org/daily-reports/2007/november/13/dr00048826.aspx?referrer=search

2. Christianson, J.B., Ginsburg, P.B., Draper D.A. “The transition from managed care to consumerism: a community-level status report.” Health Affairs 2008;27(5):1362-1370

3. Murphy, T. “Humana CEO preaches power of health care consumer.” Seattle News online, February 24, 2011. Available at: http://seattletimes.nwsource.com/html/businesstechnology/2014319626_apusceointerviewhumana.html

4. Izlar, A.C. “The corporate role in reducing disparities: Initiatives under way at Verizon.” Health Affairs 30(10):1992-1996, 2011 5. PR Newswire. “New study shows lower costs, increased consumer engagement in account-based health plans.” Available at:

http://www.prnewswire.com/news-releases/new-study-shows-lower-costs-increased-consumer-engagement-in-account-based-health-plans-58789467.html

6. Baker, S. “Employers shifting toward high-deductible healthcare plans.” The Hill, July 25, 2012. Available at: http://thehill.com/blogs/healthwatch/health-insurance/240089-employers-shifting-toward-high-deductible-healthcare-plans

7. RAND Corporation. “Expanding consumer-directed health plans could help cut overall health care spending.” May 7, 2012. Available at: http://www.rand.org/news/press/2012/05/07/index1.html

Employer Perspectives on Health Care Reform 1. Darling, H. “Health care reform: perspectives from large employers.” Health Affairs 2010;29(6):1220-1224 2. Overland, D. “Never fear, employer-based insurance will still be here.” FierceHealthPlayer.com, February 11, 2011. Available at:

http://www.fiercehealthpayer.com/story/never-fear-employer-based-insurance-will-still-be-here/2011-02-11 Further Readings

1. Draper, D.A., Hurley, R.E., Lesser, C.S., Strunk, B.C. “The changing face of managed care.” Health Affairs 2002;21(1):11-23. 2. Arnold, S.B. “Improving quality health care: the role of consumer engagement.” Robert Wood Johnson Foundation Issue Brief 1

of 6, AcademyHealth Consumer Engagement Series, October 25, 2007 3. Robinson, J.C., Ginsburg, P.B. “Consumer-driven health care: promise and performance.” Health Affairs 2009;28(2):w272-w281

(published online 27 January 2009)

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4. The Commonwealth Fund. “Can employers really make a difference in health care costs?” June 18, 2009. Available at: http://www.commonwealthfund.org/Content/Newsletters/Purchasing-High-Performance/2009/June-18-2009/Feature-Articles/Can-Employers-Really-Make-a-Difference-in-Health-Care-Costs.aspx

5. Blumberg, A., Davidson, A. “Accidents of history created U.S. health system.” NPR, October 22, 2009. Available at: http://www.npr.org/templates/story/story.php?storyId=114045132

6. Hartocollis, A. “Insurer steps up fight to control health care cost.” The New York Times, January 25, 2010, p.A.1. 7. Chen, P.W. Fueling the anger of doctors. The New York Times, May 4, 2010, p.D.7

September 17, 24, 2012 Present State of the Health Insurance Industry Health plans represent employer interests in the health care system, competing for contracts with employers. They structure their products and actions to gain and retain the business of employer clients, which is critical to their own financial success. In doing so, they provide a wide range of products and services in addition to traditional health insurance. In this session, we trace the development of the health insurance industry and describe its current state. We discuss market concentration, premium setting, and differences among health plan products; describe how plans are evaluated by employers and consumers; and discuss public perceptions of the health insurance industry. Learning Objectives Students should be able to:

1. Describe the structure of the health insurance industry 2. Distinguish among different types of health plans and health plan products. 3. Understand premium cycles in the health insurance industry. 4. Explain how employers assess health plan performance and choose among health plans. 5. Identify the major issues relating to health plan performance from the perspective of employers and the public.

Suggested Readings Overview of the Private Health Insurance Market

1. Wisenberg Brin, D. Blue “Cross plans feeling pressure to consolidate; competition, high costs lead more to weight for-profit conversions.” The Wall Street Journal, August 25, 2008, p.B.7

2. Austin, D.A., Hungerford, T.L. “The market structure of the health insurance industry.” Congressional Research Service Report #R40834, April 8, 2010. Available at: http://www.fas.org/sgp/crs/misc/R40834.pdf

3. Cantlupe, J. “More employers unhappy with health insurers, says PWC study.” HealthLeaders Media, January 19, 2010. Available at: http://healthplans.hcpro.com/content.cfm?topic=HEP&content_id=245127

4. Holahan, J. “The 2007-2009 recession and health insurance coverage.” Health Affairs 2011;20(1):145-152 5. Appleby, J. “Health insurance from both sides: KHN interview of Aetna CEO Bertolini.” Kaiser Health News, April 7, 2011.

Available at: http://www.kaiserhealthnews.org/Stories/2011/April/08/bertolini-aetna-q-and-a.aspx 6. American Medical Association. “New AMA study finds lack of competition among health insurers.” February 1, 2011. Available at:

http://www.ama-assn.org/ama/pub/news/news/competition-health-insurers.page 7. Baker, S. “Businesses predict 7 percent jump in healthcare costs.” The Hill, August 6, 2012. Available at:

http://thehill.com/blogs/healthwatch/health-insurance/242349-businesses-predict-7-jump-in-healthcare-costs 8. Kliff, S. “Businesses think the growth of health insurance premiums is slowing. Yes, really.” Washington Post online, August

6,2012. Available at: http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/08/06/the-growth-of-health-insurance-premiums-is-slowing-yes-really/

9. Overland, D. “Blue Cross $991M surplus draws criticism, feat of monopoly. FierceHealthPayer, August 10, 2012. Available at: http://www.fiercehealthpayer.com/story/blue-cross-991m-surplus-draws-criticism-fear-monopoly/2012-08-10

10. De La Merced, M.J. “Aetna agrees to buy Coventry in $5.7 billion deal.” New York Times online, August 20, 2012. Available at: http://dealbook.nytimes.com/2012/08/20/aetna-is-said-to-strike-deal-for-coventry-health-for-5-7-billion/

11. Boulton, G. “Aurora, Anthem team up with health plan.” JS Online, August 14, 2012. Available at: http://www.jsonline.com/business/aurora-anthem-team-up-with-health-plan-1c6gans-166200326.html

Products Offered by Health Plans 1. Johnson, A. “Reforms prod insurers to diversity.” Wall Street Journal, May 12, 2011, p. B.1 2. Von Bergen, J.M. “Independence Blue Cross and Michigan insurer to expand into Medicaid market.” Philly.com, August 10,

2011. Available at: http://articles.philly.com/2011-08-10/business/29872468_1_medicaid-market-medicaid-business-independence-blue-cross

3. Kulkarni, S.S. “FAQ on HSAs: The basics of health savings accounts.” Kaiser Health News, November 9, 2011. Available at: http://www.kaiserhealthnews.org/stories/2011/november/04/frequently-asked-questions-on-health-savings-accounts.aspx

4. KFF Health Reform Source. “Betting on private insurers.” January 19, 2012. Available at: http://healthreform.kff.org/notes-on-health-insurance-and-reform/2012/january/betting-on-private-insurers.aspx

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5. Blue Cross Blue Shield Minnesota. “No more one size fits all in choosing health care coverage.” March 22, 2012. Available at: http://www.bluecrossmn.com/bc/wcs/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=Latest&dDocName=POST71A_170724

6. Haviland, A.M., Marquis, M.S., McDevitt, R.D., Sood, N. “Growth of consumer-directed health plans to one-half of all employer-sponsored insurance could save $57 billion annually.” Health Affairs 31(5):1009-1015, 2012

7. America’s Health Insurance Plans, Center for Policy and Research. “Health savings accounts and account-based health plans: Research highlights.” July 2012. Available at: https://www.ahip.org/AHIPResearch/

8. Rabin, R.C. “Some hospital networks also become insurers.” Washington Post online, August 25, 2012. Available at: http://www.washingtonpost.com/business/some-hospital-networks-also-become-insurers/2012/08/25/53e90a72-eb1d-11e1-b811-09036bcb182b_story.html

Developing Strategies of Health Plans 1. PR Newswire. “ Anthem Blue Cross and Blue Shield opens Littleton store to sell individuals plans.” July 26, 2010. Available at:

http://www.prnewswire.com/news-releases/anthem-blue-cross-and-blue-shield-opens-littleton-store-to-sell-individual-plans-99260229.html

2. Weaver, C. “Managed care enters the exam room as insurers buy doctor groups.” Kaiser Health News, July 1, 2011. Available at: http://www.kaiserhealthnews.org/daily-reports/2011/july/05/1khn-story.aspx?referrer=search

3. Weaver, C. “Health insurers opening their own clinics to trim costs.” Kaiser Health News, May 4, 2011. Available at: http://www.kaiserhealthnews.org/stories/2011/may/04/insurers-turn-to-clinics-for-cost-control.aspx?referrer=search

4. Vega, T. “Insurers seek to soften their image, no matter how court rules on health act.” New York Times online, June 21, 2012. Available at: http://www.nytimes.com/2012/06/22/us/politics/insurance-companies-are-trying-to-soften-their-image.html?pagewanted=all

5. Overland, D. “Insurers develop next generation of mobile apps.” Fierce Health Player, August 10, 2012. Available at: http://www.fiercehealthpayer.com/story/insurers-develop-next-generation-mobile-apps/2012-08-10

6. Draaghtel, K. “Maximizing your competitive advantage with predictive modeling and consumer data.” Milliman, April 6, 2012. Available at: http://publications.milliman.com/periodicals/rsa/pdfs/rsa-03-2012.pdf

7. iStockAnalyst. “Humana (HUM) purchases Harris, Rothenberg International.” August 9, 2012. Available at: http://www.istockanalyst.com/finance/story/5985690/humana-hum-purchases-harris-rothenberg-international

Issues Relating to Health Plan Behavior and Performance 1. Cohn, J. “How Blue Cross became part of a dysfunctional health care system.” Kaiser Health News, March 8, 2010. Available at:

http://www.kaiserhealthnews.org/columns/2010/march/030810cohn.aspx?referrer=search 2. Scolforo. M. “Pa. regulators probe health insurers’ practices.” The Associated Press, 2010. Available at:

http://www.boston.com/business/healthcare/articles/2010/06/09/pa_regulators_probe_health_insurers_practices/ 3. Krugman, P. “California death spiral.” The New York Times, February 19, 2010 4. Mathews, A.W. “Insurer sets earnings cap” Wall Street Journal, June 8, 2011, p. B.1 5. Drew, L.W. “Finding a path through the health insurance market ‘gobbledygook’” Kaiser health News, April 21, 2011. Available

at: http://www.kaiserhealthnews.org/Stories/2011/April/22/insurance-black-hole.aspx 6. Appleby, J. “Analyst: Nonprofit Blues have huge reserves.” Kaiser Health News, June 29, 2011. Available at:

http://capsules.kaiserhealthnews.org/index.php/2011/06/analyst-nonprofit-blues-have-huge-reserves/?referrer=search 7. Snowbeck, C. “HMO cash cushions at issue in Minnesota legislature.” TwinCities.com, March 10, 2012. Available at:

http://www.twincities.com/localnews/ci_20141316/minnesota-health-care-hmo-cash-cushions-at-issue 8. Lee, D. “Worries grow as healthcare firms send jobs overseas.” Los Angeles Times online, July 25, 2012, Available at:

http://articles.latimes.com/2012/jul/25/business/la-fi-healthcare-offshore-20120725 9. Overland, D. “Excellus defends proposed rate hikes despite big case reserves.” FierceHealthPayer, July 22, 2012. Available at:

http://www.fiercehealthpayer.com/story/excellus-defends-proposed-rate-hikes-despite-big-cash-reserves/2012-07-22 10. United Press International. “Consumers give healthcare plans low marks.” February 20, 2012. Available at:

http://www.upi.com/Health_News/2012/02/20/Consumers-give-healthcare-plans-low-marks/UPI-17301329785602/ 11. BloombergBusinessweek. “Oregon group questions Regence rate-hike proposal.” August 8, 012. 12. Available at: http://www.businessweek.com/ap/2012-08-08/oregon-group-questions-regence-rate-hike-proposal

The Health Insurance Industry and Health Reform 1. Gerencher, K. “Insurers boosting customer service; carriers prepare to compete for millions of new customers starting in 2014.”

The Los Angeles Times, June 24, 2010, p. B.6 2. Mathews, A.W. “Corporate news: Health law puts Cigna in Ad mode.” Wall Street Journal online, September 19, 2011.

Available at: http://online.wsj.com/article/SB10001424053111903374004576578533245560822.html 3. KFF Health Reform Source. “Insurance brokers and the medical loss ratio.” December 8, 2011. Available at:

http://healthreform.kff.org/notes-on-health-insurance-and-reform/2011/december/insurance-brokers-and-the-medical-loss-ratio.aspx

4. Weaver, C. “Health insurers respond to reform by snapping up less-regulated businesses.” Kaiser Health News, March 19, 2011. Available at: http://www.kaiserhealthnews.org/stories/2011/march/20/health-insurers-reform-business.aspx

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5. Emanuel E.J., Liebman, J.F. “The end of health insurance companies.” New York Times online, January 30, 2012. Available at: http://opinionator.blogs.nytimes.com/2012/01/30/the-end-of-health-insurance-companies/

6. Pear, R. “Ambiguity in health law could make family coverage too costly for many.” New York Times online, August 11, 2012. Available at: http://www.nytimes.com/2012/08/12/us/ambiguity-in-health-law-could-make-family-coverage-too-costly.html?pagewanted=all

7. Pear, T. “Obama and insurers join to cut health care fraud.” New York Times online, July 25, 2012. Available at: http://www.nytimes.com/2012/07/26/us/politics/obama-and-insurers-join-to-cut-health-care-fraud.html

8. Henry J. Kaiser Family Foundation. “Transparency and Complexity.” Health Reform Source, August 13, 2012. Available at: http://healthreform.kff.org/notes-on-health-insurance-and-reform/2012/august/transparency-and-complexity.aspx

Further Readings

1. Robinson, J.C. “Use and abuse of the medical loss ratio to measure health plan performance.” Health Affairs 1997;16(4):176-187 2. Robinson, J.C. “Consolidation and the transformation of competition in health insurance.” Health Affairs 2004;23(6):11-24 3. Grossman, J.M., Ginsburg, P.B. “As the health insurance underwriting cycle turns: what next?” Health Affairs 2004;23(6):91-102 4. Rosenblatt, A. “The underwriting cycle: the rule of six.” Health Affairs 2004;23(6):103-106 5. McQueen, M.P. “Health insurers target the individual market; Aetna, WellPoint, others roll out policies that cater to people who

lack employer coverage; stripping out maternity care.” The Wall Street Journal, August 21, 2007, p.D.1 6. Girion, L. “Health insurer tied bonuses to dropping sick policyholders.” The Los Angeles Times, November 9, 2007, p.A.1. 7. Baicker, K., Chandra, A. “Myths and misconceptions about U.S. health insurance.” Health Affairs – Web Exclusive

2008;27(6):w533-w543 (published online 21 October 2008) 8. AIS Health.com. “U.S. health insurers go for the gold in China, but could face hurdles in complex emerging market.” August 15,

2008 9. Meyer, H. “Life with insurance; when a policy is clear as mud; with consumers and critics crying foul, insurers try to strip out the

jargon.” The Los Angeles Times, September 21, 2009, p.E.1 10. Woodward, C. “Fact check: health insurer profits not so fat.” FOX News, October 26, 2009. Available at:

http://www.foxnews.com/politics/2009/10/26/fact-check-health-insurers-profits-fat/ 11. Redig, A.J. “Adventures in (health-insurance-claim) wonderland.” Health Affairs 2009;28(5):1515-1520 12. eValue8 Health Care. “eValue8 2009: Measuring progress toward value-based purchasing.” Available at:

http://www.nbch.org/NBCH/files/ccLibraryFiles/Filename/000000000640/Evalue8%202009%20Annual%20Report.pdf 13. Accenture. “The 7 things your health insurance customers are not telling you and what to do about them.” 2011. Available at:

http://www.accenture.com/SiteCollectionDocuments/PDF/Accenture-7-Things-Health-Insurance-Customers-Not-Telling-You.pdf 14. Dolan, P.L. “Insurer-owned clinics bid to offer more patient care.” Amednews.com, May 16, 2011. Available at: http://www.ama-

assn.org/amednews/2011/05/16/bil20516.htm 15. Jaffe, S. “Consumers may be unaware of their right to a review of health plan decisions.” Kaiser Health News, June 10, 2011.

Available at: http://www.kaiserhealthnews.org/Stories/2011/June/10/external-appeals.aspx 16. Andrews, M. “Appealing an insurer’s denial is often a good strategy.” Kaiser Health News, June 20, 2011. Available at:

http://www.kaiserhealthnews.org/Features/Insuring-Your-Health/Michelle-Andrews-on-appealing-insurers-denial.aspx 17. Mathews, A.W., Adamy, J. “Health-plan buyers get a look under the hood.” Wall Street Journal (online), August 17, 2011.

Available at: http://online.wsj.com/article/SB10001424053111904253204576512494056148396.html 18. Weisman, R. “Blue Cross CEO says providers must control costs, or else.” Boston.com, January 23, 2011. Available at:

http://www.boston.com/business/healthcare/articles/2011/01/23/blue_cross_ceo_says_providers_must_control_health_care_costs_or_else/

October 1, 2012 Measuring Provider Performance: The Foundation for Network Management, Provider Payment and Public Reporting Efforts Efforts on the part of health plans and employers to measure provider performance have intensified over the past decade. Health plans construct measures of performance to: select providers for inclusion in networks; create tiered networks; structure provider incentive payments; and produce provider performance reports for their members. These measures also can be used in public reports of provider performance. The way in which performance measures are constructed and used has been a point of contention between employers/health plans and providers. In this session, we describe methods used by employers and health plans to measure provider performance, common issues in measure construction, and the use of “risk-adjustment” techniques in measure construction. Learning Objectives Students should be able to:

1. Describe and contrast different approaches to performance measurement.

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2. Discuss strengths and weaknesses of these approaches. 3. Discuss the role of risk adjustment techniques in measure construction and how they are applied.

Suggested Readings The Basics of Provider Performance Measurement

1. National Committee on Quality Assurance. “HEDIS measure development process. Desirable attributes of HEDIS. HEDIS life cycle.” Available at: http://www.ncqa.org/tabid/414/Default.aspx

2. National Quality Forum. “The ABCs of measurement.” Available at: http://www.qualityforum.org/Measuring_Performance/ABCs_of_Measurement.aspx

3. Pronovost, P.J., Lilford, R. “A road map for improving the performance of performance measures.” Health Affairs 2011;30(4):569-573.

Challenges in Measuring Provider Quality 1. Neuman, H.B., Michelassi, F., Turner, J.W., Bass, B.L. “Surrounded by quality metrics: what do surgeons think of ACS-NSQIP?”

Surgery 2009;145(1):27-33 2. Nyweide, D.J., Weeks, W.B., Gottlieb, D.J. “Relationship of primary care physicians’ patient caseload with measurement of

quality and cost performance.” Journal of the American Medical Association 2009;302(22)2444-2450 3. Berenson, R. A. “Moving payment from volume to value: What role for performance measurement?” Washington, DC: Urban

Institute, December 2010. Available at: http://www.rwjf.org/files/research/71568full.pdf 4. Cheung, K. “AHA report: Not all readmissions avoidable, ‘ill-suited’ quality indicator.” Fierce Healthcare, September 15, 2011.

Available at: http://www.fiercehealthcare.com/story/aha-report-not-all-readmissions-avoidable-ill-suited-quality-indicator/2011-09-15

Challenges in Measuring Provider Prices, Costs and Efficiency 1. Romley, J.A., Hussey, P.S., de Vries, H., Wang, M.C., Shekelle, P.G., McGlynn, E.A. “Efficiency and its measurement: what

practitioners need to know.” American Journal of Managed Care 2009;15(11):842-845 2. Robinson, R.C., Williams, T., Yanagihara, D. “Measurement of and reward for efficiency in California’s pay-for-performance

program.” Health Affairs 2009;28(5):1438-1447 3. Painter, M.W., Chernew, M.E. “Counting change: Measuring health care prices, costs, and spending.” Robert Wood Johnson

Foundation, March 2012. Available at: http://www.rwjf.org/qualityequality/product.jsp?id=74078 4. Alltucker, K. “Auction website lets patients suggest prices.” azcentral.com, June 16, 2012.

Challenges in Measuring Patient Experience 1. Browne, K., Roseman, D., Shaller, D., Edgman-Levitan, S. “Analysis and Commentary. Measuring patient experience as a

strategy for improving primary care.” Health Affairs 2010;29(5):921-925 Role of Risk Adjustment in Performance Measurement

1. Martin, K.E., Rogal, D.L., Arnold, S.B. “Health-based risk assessment: risk-adjusted payments and beyond.” January 2004. Washington, DC: AcademyHealth. (Available on Moodle Website)

2. Draaghtel, K. “Milliman advanced risk adjuster, MARA.” Milliman, February 2010. Available at: http://publications.milliman.com/periodicals/rsa/pdfs/coming-soon-milliman-advanced.pdf

Further Readings

1. Hoefer, T.P., Hayward, R.A., Greenfield, S., Wagner, E.H., Kaplan, S.H., Manning, W.G. “The unreliability of individual physician ‘report cards’ for assessing the costs and quality of care of a chronic disease.” Journal of the American Medical Association 1999;281(22):2098-2105

2. Landon, B.E., Normand, S-L.T., Blumenthal, D., Daley, J. “Physician Clinical Performance Assessment. Prospects and barriers.” Journal of the American Medical Association 290(9):1183-1189, 2003.

3. Nelson, E.C., Gentry, M.A., Mook, K.H., Spritzer, K.L., Higgins, J.H., Hays, R.D. “How many patients are needed to provide reliable evaluations of individual clinicians?” Medical Care 2004;42(3):259-266

4. Thomas, J.W., Grazier, K.L., Ward, K. “Economic profiling of primary care physicians: consistency among risk-adjusted measures.” HSR: Health Services Research 2004;39(4, Part I):985-1003

5. Scholle, S.H., Roski, J., Adams, J.L., Dunn, D.L., Kerr, E.A., Dugan, D.P., Jensen, R.E. “Benchmarking physician performance: reliability of individual and composite measures.” American Journal of Managed Care 2008;14(12):829-838

6. Greene, R.A., Beckman, H.B., Mahoney, T. “Beyond the efficiency index: finding a better way to reduce overuse and increase efficiency in physician care.” Health Affairs 2008;27(4):w250-w259 (published online 20 May 2008)

7. Mehrotra, A., Adams, J.L., Thomas, J.W., McGlynn, E.A. “Is physician cost profiling ready for prime time?” RAND Research Brief, 2010. Available at: http://www.rand.org/pubs/research_briefs/RB9523/

8. Romano, P., Hussey, P., Ritley, D. “Selecting quality and resource use measures: A decision guide for community quality collaboratives.” ACRQ Publication No. 09(10)-0073, May 2010. Available at: http://www.ahrq.gov/qual/perfmeasguide/

9. Higgins, A., Zeddies, T., Pearson, S.D. “Measuring the performance of individual physicians by collecting data from multiple health plans: The results of a two-state test.” Health Affairs 2011;30(4):673-681

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10. Nelson, B. “Accurate Measures?” The Hospitalist, May 2011. Available at: http://www.the-hospitalist.org/details/article/1056003/Accurate_Measures.html

October 8, 2012 Provider Contracting and Network Management A major factor in health plans’ success in securing employer contracts is their ability to negotiate favorable terms when contracting with providers and to effectively “manage” provider networks. In this session, we will discuss the basics of provider contracting, including the way in which health plans and providers attempt to exert leverage in the contracting process. We also describe steps that health plans are taking to develop products based on subsets of “high performing” providers, and the reasons why this strategy has been controversial. Learning Objectives Students should be able to:

1. Discuss the nature of the contracting process from the health plan and provider perspectives. 2. Describe how provider reimbursement levels are determined. 3. Discuss issues pertaining to tiered provider networks.

Suggested Readings Health Plan/Provider Leverage in the Contracting Process

1. Ginsburg, P.B. “Wide variation in hospital and physician payment rates evidence of provider market power.” Research Brief No. 16, November 2010. Washington, DC: Center for Studying Health System Change. Available at: http://www.hschange.com/CONTENT/1162/1162.pdf

2. Berenson, R.A., Ginsburg, P.B., Kemper, N. “Unchecked provider clout in California foreshadows challenges to health reform.” Health Affairs 2010;29(4):699-705

3. Melnick, G.A., Shen, Y-C., Wu, V.Y. “The increased concentration of health plan markets can benefit consumers through lower hospital practices.” Health Affairs 30(9):1728-1733, 2011

4. Ginsburg, P.B. “Reforming provider payment – The price side of the equation.” New England Journal of Medicine 365:1268-1270, October 12, 2011

5. Merritt, G. “Children’s Hospital, Anthem reaches agreement after two-month standoff.” The CT mirror, June 12, 2012. Available at: http://www.ctmirror.org/story/16625/childrens-hospital-anthem-reach-multi-year-agreement

6. Terhune, C. “Many hospitals, doctors offer cash discount for medical bills.” Los Angeles Times online, May 27, 2012. Available at: http://articles.latimes.com/2012/may/27/business/la-fi-medical-prices-20120527

Tiered Networks, High Performance Networks, and Centers of Excellence 1. Pham, H.H., Ginsburg, P.B., McKenzie, K., Milstein, A. “Redesigning care delivery in response to a high-performance network:

the Virginia Mason Medical Center.” Health Affairs 2007;26(4):w532-w544 (published online 10 July 2007) 2. Draper, D.A., Liebhaber, A., Ginsburg, P.B. “High-performance health plan networks: early experience.” Center for Studying

Health System Change Issue Brief No. 111, May 2007. Available at: http://www.hschange.com/CONTENT/929/ 3. Appleby, J. “Domestic medical travel is taking off for surgery deals.” USA Today, July 9, 2010. Available at:

http://www.usatoday.com/money/industries/health/2010-07-07-travelforhealth07_CV_N.htm 4. Kowalczyk, L. “Insurers may slash rates to hospitals; some patients might have to switch MDs.” The Boston Globe, May 24,

2010, p.B.1 5. Kaiser Health News. “Some heart care costs stay outside insurance coverage, Lowe’s does national comparison shopping for

employees’ heart surgery.” February 17, 2010. Available at: http://www.kaiserhealthnews.org/daily-reports/2010/february/17/cost-of-heart-care.aspx

6. Health Care Financing & Organization. “Finding the Balance in Physician Rankings.” September, 2010. Available at: http://www.hcfo.org/publications/september-hot-topic-finding-balance-physician-rankings

7. Snowbeck, C. “Some insurance companies pushing plans with Mayo Clinic out of network.” Contact Center Solutions Industry News, February 6, 2011. Available at: http://callcenterinfo.tmcnet.com/news/2011/02/06/5292365.htm

8. Andrews, M. “Insurance trade-off: Reducing premiums by eliminating expensive doctors, hospitals.” Kaiser Health News, March 1, 2011. Available at: http://www.kaiserhealthnews.org/features/insuring-your-health/michlle-andrews-on-premiums-and-prices.aspx?referrer=search

9. Mathews, A.W. “Out-of-network rates.” Wall Street Journal (online), June 19, 2011. Available at: http://online.wsj.com/article/SB10001424052702304451504576394103294050580.html

10. Gonzales, A. “Cigna offering lower co-pays at its own clinics in Phoenix.” Phoenix Business Journal, August 9, 2011. Available at: http://www.bizjournals.com/phoenix/news/2011/08/09/cigna-offering-lower-co-pays-at-its.html?page=all

11. Bebinger, M. “’Tiered’ insurance confounds consumers, docs in Mass.” Kaiser Health News, January 17, 2012. Available at: http://www.kaiserhealthnews.org/Stories/2012/January/17/Mass-Tiered-Insurance.aspx

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12. Weaver, C. “Aetna, doctors face off over costs.” Wall Street Journal online, July 4, 2012. Available at: http://online.wsj.com/article/SB10001424052702303933404577505182228232366.html

13. Boulton, G. “Aetna, Aurora to begin offering new health plan.” Equities.com, July 27, 2012. Available at: http://www.equities.com/news/headline-story?dt=2012-07-27&val=315527&cat=hcare

14. Appleby, J. “Consumers hit by higher out-of-network medical costs.” Kaiser Health News, February 8, 2012. Available at: http://www.kaiserhealthnews.org/stories/2012/february/09/consumers-hit-by-higher-out-of-network-medical-costs.aspx

15. Crosby, J. “Medica teams with Fairview on new plan.” StarTribune online, March 8, 2012. Available at: http://www.startribune.com/business/141693483.html?refer=y

16. McGurn, C. “HDMS enables health plans to demonstrate improved quality and outcomes at centers of excellence.” PRWeb, March 13, 2012. Available at: http://www.prweb.com/releases/2012/3/prweb9276605.htm

17. Andrews, M. “Some insurers paying patients who agree to get cheaper care.” Kaiser Health News, March 26, 2012. Available at: http://www.kaiserhealthnews.org/features/insuring-your-health/2012/cash-rewards-for-cheaper-care-michelle-andrews-032712.aspx

Provider Issues Concerning Contracts with Health Plans 1. Fuhrmans, V. “Insurers stop paying for care linked to errors; health plans say new rules improve safety and cut costs; hospitals

can’t dun patients”. The Wall Street Journal, January 15, 2008, p.D.1 2. Associated Press. “AMA, others suing Aetna, Cigna over payments.” February 10, 2009. Available at:

http://blog.cleveland.com/business/2009/02/ama_others_suing_aetna_cigna_o.html 3. Pear, R. “U.S. sues Michigan Blue Cross over pricing.” New York Times, October 19, 2010, p. B.1 4. Reuters. “Aetna ranked tops in connection with doctors.” May 25, 2011. Available at:

http://www.reuters.com/article/2011/05/25/idUS189606+25-May-2011+BW20110525 5. Cheung, K. “AMA blasts insurers for costly 20 percent error rates.” FierceHealthcare, June 20, 2011. Available at:

http://www.fiercehealthcare.com/story/ama-blasts-insurers-costly-20-percent-error-rate/2011-06-20 6. Bernstein, N. “Insurers alter cost formula, and patients pay more.” New York Times online, April 23, 2012. Available at:

http://www.nytimes.com/2012/04/24/nyregion/health-insurers-switch-baseline-for-out-of-network-charges.html?pagewanted=all Further Readings

1. Kaiser Health News. “Cigna agrees to end use of database to determine payments for out-of-network medical services.” February 18, 2009. Available at: http://www.kaiserhealthnews.org/daily-reports/2009/february/18/dr00057024.aspx?referrer=search

2. Casalino, L.P., Nicholson, S., Gans, D.N., Hammons, T., Morra, D., Karrison, T., Levinson, W. “What does it cost physician practices to interact with health insurance plans?” Health Affairs 2009;28(4):w533-w543 (published online 14 May 2009)

3. America’s Health Insurance Plans. “Health plans collaborate on landmark initiative to reduce time, expense for physician office practice ‘paperwork’.” Press Release, February 11, 2010. Available at: http://www.ahip.org/content/pressrelease.aspx?bc=174|29422&pf=true

October 15, 2012 Fundamentals of Provider Payment: Incentives and Rewards During the 1980s through the mid-1990s, most provider payment arrangements employed by health plans were designed to influence providers to reduce unnecessary service utilization. Over the past decade, health plans and purchasers have initiated a variety of new payment approaches that have broader behavioral change goals, including improving quality of care, implementing evidence-based medical practices effectively, and supporting the restructuring of care delivery. Recently, health reform legislation has encouraged Medicare to institute payment reforms with similar objectives. We will discuss traditional methods of provider payment, as well as new payment arrangements, in this session and the two sessions to follow. Learning Objectives Students should be able to:

1. Describe the basic reimbursement approaches used by health plans in contracts with providers, including their strengths and weaknesses.

2. Describe the different types of pay-for-performance initiatives being undertaken by health plans and purchasers. 3. Describe how these approaches differ in their design and the challenges they pose for implementation, in comparison to previous

payment arrangements between health plans and providers.

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Suggested Readings Basics of Provider Payment

1. Robinson, J.C. “Theory and practice in the design of physician payment incentives.” The Milbank Quarterly 2001;79(2):149-177 2. Averill, R.F., Goldfield, N.I., Vertrees, J.C., McCullough, E.C., Fuller, R.L., Eisenbandler, J. “Achieving cost control, care

coordination, and quality improvement through incremental payment system reform.” Journal of Ambulatory Care Management 2010;33(1):2-23

3. Berenson, R.A., Rich, E.C. “US approaches to physician payment: the deconstruction of primary care.” Journal of General Internal Medicine 2010;25(6):613-618

4. Reinhardt, U.E. “The options for payment reform in U.S. health care.” New York Times online, February 17, 2012. Available at: http://economix.blogs.nytimes.com/2012/02/17/the-options-for-payment-reform-in-u-s-health-care/

Use of Provider Payment to Encourage and Reward Quality Improvement 1. Christianson, J.B., Leatherman, S., Sutherland, K. “Lessons from evaluations of purchaser pay-for-performance programs: a

review of the evidence.” Medical Care Research and Review 2008;65(6 suppl):5S-35S 2. Rosenthal, M.E., de Brantes, F.S., Sinaiko, A.D., Frankel, M., Robbins, R.D., Young, S. “Bridges to excellencerecognizing

high-quality care: analysis of physician quality and resource use.” American Journal of Managed Care 2008;14(10):670-677 3. Werner, R.M., Dudley, R.A. “Making the ‘pay’ matter in pay-for-performance: implications for payment strategies.” Health Affairs

2009;28(5):1498-1508 4. Metro, L. “Commercial Blues plans adopting the CMS do-not-pay list policy.” Modern Medicine, April 1, 2010. Available at:

http://license.icopyright.net/user/viewFreeUse.act?fuid=OTIxMDMwMw%3D%3D 5. Werner, R.M., Kolstad, J.T., Stuart, E.A., Polsky, D. “The effect of pay-for-performance in hospitals: Lessons for quality

improvement.” Health Affairs 2011;30(4):690-698. 6. UCare. “Ucare announces details of 2011 pay for performance program that rewards providers for health improvements,” May 2,

2011. Available at: http://www.ucare.org/SiteCollectionDocuments/media/NewsReleases/2011%20P4P%20prog%20details%20rel%20print%205-2-11.pdf

7. PR Newswire. “Harvard Pilgrim awards close to $1 million in quality grants to 14 physician groups.” May 15, 2011. Available at: http://www.prnewswire.com/news-releases/harvard-pilgrim-awards-close-to-1-million-in-quality-grants-to-14-physician-groups-121313819.html

8. Adamy, J. “WellPoint shakes up hospital payments.” Wall Street Journal, online, May 16, 2011. Available at: http://online.wsj.com/article/SB10001424052748704281504576325163218629124.html

9. “Humana’s new provider quality program awarding nearly $10 million in quality awards to primary care physicians across the U.S.” BusinessWire, July 20, 2011. Available at: http://www.businesswire.com/news/home/20110720006098/en/Humana%E2%80%99s-Provider-Quality-Rewards-Program-Awarding-10

10. Kurtzman, E.R., O’Leary, D., Sheingold, B.H., Devers, K.J., Dawson, E.M., Johnson, J.E. “Performance-based payment incentives increase burden and blame for hospital nurses.” Health Affairs 2011;30(2):211-218.

11. Dentzer, S. “One payer’s attempt to spur primary care doctors to form new medical homes.” Health Affairs 31(2):341-349, 2012 12. Rau, J. “Effort to pay hospitals based on quality didn’t cut death rates, study finds.” Kaiser Health News, March 28, 2012.

Available at: http://www.kaiserhealthnews.org/stories/2012/march/28/nejm-study-hospital-quality-and-death-rates.aspx 13. BusinessWire. “Empire BlueCross BlueShield to launch innovative program to enhance primary care by paying physicians more

for quality and cost improvement.” February 2, 2012. Available at: http://www.businesswire.com/news/home/20120202005208/en/Empire-BlueCross-BlueShield-Launch-Innovative-Program-Enhance

14. BusinessWire. “Anthem Blue Cross and Blue Shield launches innovative program to enhance primary care by rewarding physicians for quality and cost improvements.” February 1, 2012. Available at: http://www.businesswire.com/news/home/20120201006036/en/Anthem-Blue-Cross-Blue-Shield-Launches-Innovative

Medicare Payment Reform Initiatives 1. Centers for Medicare & Medicaid Services. “Physician groups earn performance payments for improving quality of care for

patients with chronic illnesses.” Press Release, August 14, 2008. Available at: http://www.cms.gov/apps/media/press/release.asp?Counter=3239&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=false&cboOrder=date

2. Galewitz, P. Tulsa hospital gives “Medicare patients cash back for surgery.” Kaiser Health News, October 26, 2009. Available at: http://www.kaiserhealthnews.org/stories/2009/october/26/tulsa-medicare-hospital-bundling.aspx?referrer=search

3. Guterman, S., Davis, K., Schenbaum, S., Shih, A. “Using Medicare payment policy to transform the health system: a framework for improving performance.” Health Affairs – Web Exclusive 2009;28(2):w238-w250 (published online 27 January 2009)

4. Rau, J. “Medicare to begin basing hospital payments on patient-satisfaction scores.” Kaiser Health News, April 28, 2011. Available at: http://www.kaiserhealthnews.org/Stories/2011/April/28/medicare-hospital-patient-satisfaction.aspx

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5. Rau, J. “Medicare announces rules for quality bonuses to hospitals.” Kaiser Health News, April 29, 2011. Available at: http://www.kaiserhealthnews.org/Stories/2011/April/29/medicare-rules-for-hospital-quality.aspx

6. Pecquet, J., Baker, S. “Medicare proposal links surgical center payments to quality.” The Hill, July 1, 2011. Available at: http://thehill.com/blogs/healthwatch/medicare/169497-medicare-proposes-linking-surgical-center-payments-to-quality

7. VanLare, J.M., Conway, P.H. “Value-based purchasing – National programs to move from volume to value.” New England Journal of Medicine 367:292-295, July 26, 2012

8. Ryan, A.M., Blustein, J., Casalino, L.P. “Medicare’s flagship test of pay-for-performance did not spur more rapid quality improvement among low-performing hospitals.” Health Affairs 31(4):797-805, 2012

Further Readings

1. Kanavos, P., Reinhardt, U. “Reference pricing for drugs: Is it compatible with U.S. Health care?” Health Affairs 22(3):16-30, 2003.

2. Galvin, R. “Pay-for-performance: too much of a good thing? A conversation with Martin Roland.” Health Affairs 2006;25:w412-w419 (published online 5 September 2006)

3. Christianson, J.B., Leatherman , S., Sutherland, K. “Paying for quality: understanding and assessing physician pay-for-performance initiatives.” Robert Wood Johnson Foundation Research Synthesis Report No. 13, December 2007. Available at: http://www.rwjf.org/pr/product.jsp?id=24373

4. Rosenthal, M.B., Dudley, R.A. “Pay-for-performance Will the last payment trend improve care?” Journal of the American Medicine Association 2007;297(7):740-744

5. Nalli, G.A., Scanlon, D.P., “Libby, D. Developing a performance-based incentive program for hospitals: a case study from Maine.” Health Affairs 2007;26(3):817-824

6. Freudenheim, M. “Trying to save by increasing doctors’ fees.” The New York Times, July 21, 2008, p.A.1. 7. BusinessWire. “HealthPartners announces performance bonuses for providers.” November 10, 2008. Available at:

http://www.businesswire.com/portal/site/home/permalink/?ndmViewId=news_view&newsId=20081110006521&newsLang=en 8. Bury, G. “Provider groups receive innovation award from Medica.” Medica Press Release, October 15, 2008. Available at:

http://newscenter.medica.com/press-release/corporate-announcements/provider-groups-receive-innovation-award-medica 9. Abelson, R. “Hospitals pay for cutting costly readmissions.” The New York Times, May 9, 2009, p.B.1 10. Adamy, J. “U.S. news: doctors fight penalty for heavy test use. The Wall Street Journal, October 2, 2009, p.A.5 11. Abelson, R. “For I.B.M., Insurer Reopens Test of Rewarding Doctors for Healthy Patients.” The New York Times, February 7,

2009, p.B.3 12. BlueCross BlueShield Association. “Blue Shield of California awards $29.6 million in pay-for-performance programs in 2009.”

Press release, October 5 2009. Available at: https://www.blueshieldca.com/producer/news/newsletter/shieldspotlight/shieldspotlight_nov09_article.sp#section4

13. Miller, H.D. “From volume to value: better ways to pay for health care.” Health Affairs 2009;28(5):1418-1428 14. Merrell, K., Berenson, R.A. “Structuring payment for medical homes.” Health Affairs 2010;29(5):852-858 15. Howlett, K. “CEOs at Ontario hospitals to face pay-for-performance rules.” The Globe and Mail, April 6, 2010. Available at:

http://www.theglobeandmail.com/news/national/ceos-at-ontario-hospitals-to-face-pay-for-performance-rules/article1525562/ 16. Friedberg, M.R., Safran, D.G., Coltin, K., Dresser, M., Schneider E.C. “Paying for performance in primary care: potential impact

on practices and disparities.” Health Affairs 2010;29(5):926-932 17. Bridges to Excellence. Available at: http://www.bridgestoexcellence.org 18. Abelson, R. “Paying to Cut Health Costs.” New York Times, June 22, 2010 19. Serumaga, B., Ross-Degnan, D., Avery, A.J., Elliott, R.A., Majumdar, S.R., Zhang, F., Soumerai, S.B. “Effect of pay for

performance on the management and outcomes of hypertension in the United Kingdom: Interrupted time series study.” BMJ, 2011. Available at: http://www.bmj.com/content/342/bmj.d108.full.pdf?sid=b6f47b59-d8ba-4dae-9226-b4f8c2800d0f

20. Feder, J.L. “A health plan spurs transformation of primary care practices into better-paid medical homes.” Health Affairs 2011;30(3):397-399

October 22, 2012 New Payment Arrangements: Bundling/Episode-Based Payment Learning Objectives Students should be able to:

1. Describe the basic design features relating to bundled payment. 2. Discuss the obstacles to implementing bundled payment arrangements. 3. Discuss Medicare support for bundled payment.

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Suggested Readings Bundled Payment Approaches

1. Rosenthal, M.B. “Beyond pay for performance emerging models of provider-payment reform.” New England Journal of Medicine 2008;359(12):1197-1200

2. de Brantes, F., D’Andrea, G., Rosenthal, M.B. “Should health care come with a warranty?” Health Affairs – Web Exclusive 2009;29(4):w678-w687 (published online 16 June 2009)

3. Mechanic, R.E., Altman, S.H. “Payment reform options: episode payment is a good place to start.” Health Affairs – Web Exclusive 2009;28(2):w262-w271 (published online 27 January 2009)

4. Golfdield, N.I., Fuller, R.L., Averill, R.F. “Payment for quality and coordination: Aligning provider payments with global goals.” American Journal of Medical Quality 24(6):480-488, 2009

5. Hussey, P.S., Ridgely, M.S., Rosenthal, M.B. “The PROMETHEUS bundled payment experiment: Slow start shows problems in implementing new payment models.” Health Affairs 30(11):2116-2124, 2011

6. Painter, M.W. “Bundled payments: This way toward a challenging yet better place.” Health Care Incentives Issue Brief, 2012. Available at: http://www.hci3.org/sites/default/files/files/HCI-IssueBrief-4-2012.pdf

7. Newcomer, L.N. “Changing physician incentives for cancer care to reward better patient outcomes instead of use of more costly drugs.” Health Affairs 31(4):780-785, 2012

8. Wall Street Journal Market Watch. “BlueCross announces bundled payment agreement with leading orthopedic groups in Tennessee.” Press Release, May 22, 2012. Available at: http://www.marketwatch.com/story/bluecross-announces-bundled-payment-agreements-with-leading-orthopedic-groups-in-tennessee-2012-05-22

9. Cutler, D.M., Ghosh, K. “The potential for cost savings through bundled episode payments.” New England Journal of Medicine 366(12), 1075-1077, 2012

Medicare Payment Reform Initiatives 1. Pecquet, J. “Medicare to bundle dialysis payments, reward facilities for training patients.” The Hill, July 26, 2010. Available at:

http://thehill.com/blogs/healthwatch/medicare/110975-medicare-to-reward-dialysis-facilities-for-training-patients?tmpl=component&print=1&page=

2. Komisar, H.L., Feder, J., Ginsburg, P.B. “’Bundling’ payment for episodes of hospital care. Issues and recommendations for the new pilot program in Medicare.” 2011. Washington, DC: Center for American Progress. Available at: http://www.americanprogress.org/issues/2011/07/pdf/medicare_bundling.pdf

3. Walker, E.P. “CMS testing bundled payments for Medicare.” MedPage Today, August 23, 2011. Available at: http://www.medpagetoday.com/PublicHealthPolicy/Medicare/28172

4. Reuters. “U.S. encourages bundling Medicare payments.” August 23, 2011. Available at: http://www.reuters.com/article/2011/08/23/us-cms-innovation-idUSTRE77M5NR20110823

5. Mechanic, R.E. “Opportunities and challenges for episode-based payment.” New England Journal of Medicine 2011;365:777-779 Further Readings

1. Abelson, R. “In bid for better hospital care, heart surgery with a warranty; health plans: quality control.” New York Times, May 17, 2007

2. Reuters. “Bundled payments a way to cut health costs: study.” November 11, 2009. Available at: http://www.reuters.com/article/idUSTRE5AA4YV20091111

3. Hussey, P.S., Sorbero, M.E., Mehrotra, A., Liu, H., Damberg, C.L. “Episode-based performance measurement and payment: making it a reality.” Health Affairs 2009;28(5):1406-1417

4. Galewitz, P. “Can 'bundled' payments help slash health costs? Effort touts efficiency; critics fear drop in care.” USA Today, October 26, 2009

5. Struijs, J.N., Baan, C.A. “Integrating care through bundled payments – lessons for the Netherlands.” New England Journal of Medicine 2011;364:990-991

6. Adamy, J. “WellPoint shakes up hospital payments.” Wall Street Journal (online), May 16, 2011. Available at: http://proquest.umi.com/pqdlink?index=6&did=2348036301&SrchMode=2&sid=1&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1314044474&clientId=2256

October 29, 2012 New Payment Arrangements: Comprehensive Gainsharing/Shared Savings Learning Objectives Students should be able to:

1. Describe the basic features of comprehensive, gainsharing payment arrangements between health plans and providers. 2. Discuss the obstacles to implementing comprehensive gainsharing arrangements.

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3. Discuss Medicare support for gainsharing payment as evidenced by Alternative Care Organizations. Suggested Readings Gainsharing Payment Approaches

1. Shields, M.C., Patel, P.H., Manning, M., Sacks, L. “A model for integrating independent physicians into accountable care organizations.” Health Affairs 2011;30(1):161-172

2. Berenson, R.A., Burton, R.A. “Accountable care organization in Medicare and the private sector: A status update.” Robert Wood Johnson Foundation/Urban Institute, November 2011. Available at: http://www.rwjf.org/files/research/73470.5470.aco.report.pdf

3. Mechanic, R.E., Santos, P., Landon, B.E., Chernew, M.E. “Medical group responses to global payment: Early lessons from the ‘alternative quality contract’ in Massachusetts.” Health Affairs 30(9):1734-1742, 2011

4. Higgins, A., Stewart, K., Dawson, K., Bocchino, C. “Early lessons from accountable care models in the private sector: Partnerships between health plans and providers.” Health Affairs 30(9):1718-1727, 2011

5. Overland, D. “Cigna ACO pilots are improving quality, cutting costs.” FierceHealthPayer, April 1, 2011. Available at: http://www.fiercehealthpayer.com/story/cigna-aco-pilots-are-improving-quality-cutting-costs/2011-04-01

6. Landon, B.E. “Keeping score under a global payment system.” New England Journal of Medicine 366(5):393-395, 2012 7. Muhlestein, D., Croshaw, A., Merrill, T., Pena, C. “Growth and dispersion of accountable care organizations: June 2012 update.”

Leavitt Partners, 2012. Available at: http://leavittpartners.com/wp-content/uploads/2012/06/Growth-and-Dispersion-of-ACOs-June-2012-Update.pdf

8. BusinessWire. “Lahey Clinic joins Blue Cross Blue Shield of Massachusetts alternative quality contract.” News Release, May 14, 2012. Available at: http://www.businesswire.com/news/home/20120514006575/en/Lahey-Clinic-Joins-Blue-Cross-Blue-Shield

9. Song, Z. Safran, D.G., Landon, B.E., Landrum, M.B., He, Y., Mechanic, R.E., Day, M.P., Chernew, M.E. “The ‘alternative quality contract,’ based on a global budget, lowered medical spending and improved quality.” Health Affairs 31(8)1885-1894, 2012

10. Bailit, M., Hughes, C., Burns, M., Freedman, D.H. “Shared-savings payment arrangement in health care. Six case studies.” Commonwealth Fund, August 2012. Available at: http://www.commonwealthfund.org/Publications/Fund-Reports/2012/Aug/Shared-Savings-Payment-Arrangements.aspx

Medicare Payment Reform Initiatives 1. Berenson, R.A. “Shared savings program for accountable care organizations: A bridge to nowhere?” American Journal of

Managed Care 16(10):721-726, 2010 2. McClellan, M., McKethan, A.N., Lewis, J.L., Roski, J., Fisher, E.S. “A national strategy to put accountable care into practice.”

Health Affairs 29(5):982-990, 2010 3. Meyer, H. “Accountable care organization prototypes: Winners and losers?” Health Affairs 30(7):1227-1231, 2011 4. Haywood, T.T. “The ACO model – A three-year financial loss?” New England Journal of Medicine 364:e27, March 23, 2011 5. Ginsburg, P.B. “Spending to save – ACOs and the Medicare shared savings program.” New England Journal of Medicine

2011;364:2085-2086 6. Crosby, J. “Feds reward Park Nicollet for healthy patients.” StarTribune, August 8, 2011. Available at:

http://www.startribune.com/business/127283643.html 7. Klar, R. “ACO 101: The basics of accountable care.” Health Affairs Blog, August 29, 2011. Available at:

http://healthaffairs.org/blog/2011/08/29/aco-101-the-basics-of-accountable-care/ 8. Gold, J. “FAQ on ACOs: Accountable care organizations, expanded.” Kaiser Health News, October 21, 2011. Available at:

http://www.kaiserhealthnews.org/stories/2011/january/13/aco-accountable-care-organization-faq.aspx 9. Gold, J. “ACO rollout continues with 89 new networks.” Kaiser Health News Blog, July 9, 2012. Available at:

http://capsules.kaiserhealthnews.org/index.php/2012/07/aco-rollout-continues-with-89-new-networks/ Further Readings

1. Elliott, J. “Could health plans derail ACOs?” HealthLeaders Media, October 27, 2010. Available at: http://www.healthleadersmedia.com/page-1/HEP-258288/Could-Health-Plans-Derail-ACOs##

2. Rosenthal, M.B., Cutler, D.M., Feder, J. “The ACO rules – Striking the balance between participation and transformative potential.” New England Journal of Medicine 2011;365:e6.

November 5, 2012 Utilization: Management Reminders, clinical decision-support systems, predictive modeling, guidelines, and rules are all common strategies used by health plans to influence the amount and type of care that providers deliver to their patients. Reminders prompt physicians about a patient's care needs prior to, or at the time of, the treatment visit. Clinical decision-support systems typically involve software designed to assist the physician's clinical decision-making. Predictive modeling uses large claims databases to identify patients who may be at risk of specific illnesses in the

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future and alert clinicians prior to the patient visit. Guidelines, or pathways, assist physicians in taking the appropriate treatment steps, given a patient's condition, and often are applied when treating patients with chronic health problems. Rules are used by health plans to intervene more directly in the care process. This session will address the different ways that health plans attempt to influence the delivery of care by providers, including the manner in which these techniques are being employed and evidence of their effectiveness. Learning Objectives Students should be able to:

1. Describe the most common practices used by health plans to support physicians in the delivery of care. 2. Explain the barriers to their effective implementation. 3. Assess the strength of the evidence supporting their effectiveness. 4. Describe recent trends in their use in conjunction with other efforts to influence physician behavior.

Suggested Readings Utilization Management Challenges Faced by Health Plans

1. The Medical Society of the State of New York. “Survey reveals that doctors feel pressured by health insurers to alter the way they treat patients.” September 10, 2008. Available at: http://www.mssny.org/mssnyip.cfm?c=i&nm=Insurance_Carrier_Rules

2. Paltrow, S.J. “Insurers’ black box.” Center for American Progress, October 23, 2009. Available at: http://www.americanprogress.org/issues/2009/10/black_box.html

3. Gardner, A. “Day of admission dictates length of stay for heart failure.” ABC News, May 22, 2010. Available at: http://abcnews.go.com/Health/Healthday/story?id=4904656&page=1

4. Beckman, H.B. “Lost in translation: Physicians’ struggle with cost-reduction programs.” Annals of Internal Medicine 2011;154(6):430-433.

Overview of Health Plan Efforts 1. Landon, B.E., Rosenthal, M.B., Normand, S-L.T., Frank, R.G., Epstein, A.M. “Quality monitoring and management in commercial

health plans.” American Journal of Managed Care 2008;14(6):377-386 Profiling/Feedback of Information on Treatment Patterns

1. Bindman, A. “Can Physician Profiles Be Trusted?” JAMA 281(22):2142-2143, 1999 2. Greene, R.A., Beckman, H., Chamberlain, J., Partridge, G., Miller, M., Burden, D., Kerr, J. “Increasing adherence to a

community-based guideline for acute sinusitis through education, physician profiling, and financial incentives.” American Journal of Managed Care 10(10):670-678, 2004

Practice Guidelines 1. Lin, K.W., Slawson, D.C. “Identifying and using good practice guidelines.” American Family Physician 2009;80(1):67-69 2. Graham, J. “Mammogram guidelines are sparking a firestorm; Critics hit suggestion that women in 40s may not need routine

screening.” Chicago Tribune, November 17, 2009, p.1 3. Ando, R. “IBM and Aetna tie up to offer clinical support service.” Reuters, August 5, 2010. Available at:

http://www.reuters.com/article/idUSTRE6740EW20100805 4. Boulton, G. “Guidelines met with dose of skepticism. Do they aid doctors or hinder them?” Milwaukee Journal Sentinel, June 27,

2010. Available at: http://www.jsonline.com/business/97280724.html 5. Editorial. “Improving practice guidelines with patient-specific recommendations.” Annals of Internal Medicine 2011;154(9):638-

639 6. Nussbaum, A. “Aetna urges moms to avoid cesareans births to reduce risk.” Bloomberg.com, July 12, 2012. Available at:

http://www.bloomberg.com/news/2012-07-13/aetna-urges-moms-to-avoid-cesareans-births-to-reduce-risk.html 7. Gordon, S. “Diabetes groups issue new guidelines on blood sugar.” HealthDay, April 19, 2012. Available at:

http://consumer.healthday.com/Article.asp?AID=663893 Use of Treatment Reminders

1. Derose, S.F., Dudl, J.R., Benson, V.M., Contreras, R., Nakahira, R.K., Ziel, F.H. “Point-of-service reminders for prescribing cardiovascular medications.” The American Journal of Managed Care 2005;11(5):298-304

2. Mathews, A.W. “WellPoint’s new hire. What is Watson?” Wall Street Journal online, September 12, 2011. Available at: http://online.wsj.com/article/SB10001424053111903532804576564600781798420.html

Managing Imaging Use and Costs: Combining Utilization Management Tools 1. Iglehart, J.K. “The new era of medical imaging progress and pitfalls.” The New England Journal of Medicine 354(26):2822-

2828, 2006 2. Salganik, M.W. “Medical scans zapping insurers.” Baltimore Sun, May 13, 2007. Available at:

http://articles.baltimoresun.com/2007-05-13/business/0705130014_1_pet-scans-emission-tomography-positron-emission 3. Sataline, S. “Doctors may risk overuse of CT scans.” Wall Street Journal, November 29, 2007 4. Landro, L. ”The informed patient: better ways to treat back pain; insurers, employers target excessive scans and surgeries to

improve patient outcomes.” Wall Street Journal, May 16, 2007 5. Mathews, A.W. “Insurers hire radiology police to vet scanning; firms make doctors justify costly CTs, MRIs and PETs; patients

'stuck in the middle'.” Wall Street Journal, November 6, 2008

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6. Tynan, A., Berenson, R.A., Christianson, J.B. “Health plans target advanced imaging services: cost, quality and safety concerns prompt renewed oversight.” Center for Studying Health System Change Issue Brief No. 118, February 2008. Available at: http://www.hschange.com/CONTENT/968/

7. Iglehart, J.K. “Health insurers and medical-imaging policy – a work in progress.” New England Journal of Medicine 360(10):1030-1037, 2009.

8. Kaiser Health News. “Concerns about unnecessary scans and radiation risk prompt reviews by doctors.” March 2, 2010. Available at: http://www.kaiserhealthnews.org/daily-reports/2010/march/02/radiation-and-ct-scans.aspx?referrer=search

9. Tanner, L. “Use of costly scans is climbing in cancer patients.” April 27, 2010. Available at: http://www.msnbc.msn.com/id/36807258/ns/health-cancer/

10. Parashar, A. “In emergency rooms, it’s getting tougher to say ‘no’ to CT scans.” Kaiser Health News, November 29, 2010. Available at: http://www.kaiserhealthnews.org/Stories/2010/November/29/CT-scan-study-short-take.aspx

11. Galewitz, P. “Imaging at the doctor’s: Good thing or transparent ploy?” USAToday, August 23, 2010. Available at: http://www.usatoday.com/yourlife/health/healthcare/doctorsnurses/2010-08-23-Imaging23_ST_N.htm

12. Franklin, C. “Before you get that CT scan…” Chicago Tribune, March 17, 2011, p.21 13. Carey, M.A. “Medical imaging advocates fight proposals requiring advance authorization.” Kaiser Health News, October 18, 2011.

Available at: http://capsules.kaiserhealthnews.org/index.php/2011/10/medical-imaging-advocates-fight-proposals-requiring-advance-authorization/

14. Bardin, J. “Use of imaging tests sores, raising questions on radiation risk.” Los Angeles Times online, June 20, 2012. Available at: http://articles.latimes.com/2012/jun/12/science/la-sci-ct-mri-growth-20120613

15. Lee, D.W., Levy, F. “The sharp slowdown in growth of medical imaging: An early analysis suggests combination of policies was the cause.” Health Affairs 31(8):1876-1884, 2012

Medicare Utilization Initiatives 1. U.S. Government Accountability Office. “Medicare: per capita method can be used to profile physicians and provide feedback on

resource use. Summary.” September 25, 2009. Available at: http://www.gao.gov/products/GAO-09-802 2. Pecquet, J. “Bipartisan duo fights proposals to curb medical imaging.” The Hill, March 31, 2011. Available at:

http://thehill.com/blogs/healthwatch/medicare/163957-bipartisan-duo-fights-proposals-to-curb-medical-imaging 3. Carey, M.A., Serafini, M.W. “Doctors balk at proposal to cut Medicare’s use of imaging.” Kaiser Health News, June 14, 2011. Available

at: http://www.kaiserhealthnews.org/Daily-Reports/2011/June/15/1khnstory.aspx Further Readings on Imaging

1. Watkins, J.B., Choudhury S.R., Wong, E., Sullivan, S.D.” Managing biotechnology in a network-model healthplan: a U.S. private payer perspective”. Health Affairs 2006;25(5):1347-1352

2. Mason, M. “Bargaining down that CT scan is suddenly possible.” New York Times, February 27, 2007 3. Allen, G.P. “Costs escalate, patients suffer when waste, abuse and fraud permeate diagnostic imaging.” May 2007. Available at:

http://www.imakenews.com/seroper/e_article000814532.cfm?x=b11,0,w 4. Phelps, D.” Insurers want 2nd opinion before scans; as their costs rise, insurers want doctors to get consultants to approve CT

scans and MRIs.” Star Tribune, January 4, 2007 5. PR Newswire. “Anthem Blue Cross and Blue Shield of Wisconsin expands transparency of diagnostic imaging.” October 21,

2007. Available at: http://www.prnewswire.com/news-releases/anthem-blue-cross-and-blue-shield-expands-cost-disclosure-tool-to-northcentral-wisconsin-65185497.html

6. Kaiser Health News. “Los Angeles Times examines growing popularity, concerns regarding CT scans.” September 8, 2008. Available at: http://www.kaiserhealthnews.org/daily-reports/2008/september/08/dr00054331.aspx?referrer=search.

7. Steenhuysen, J. “Younger Americans overexposed to radiation risk.” Reuters, August 27, 2009. Available at: http://www.reuters.com/article/idUSTRE57P59Z20090827

8. Bogdanich, W., Ruiz, R.R. “F.D.A. to increase oversight of medical radiation.” The New York Times, February 10, 2010 9. Perrone, M. “Medical scan makers to install radiation controls.” Seattle Times online. February 25, 2010. Available at:

http://seattletimes.nwsource.com/html/businesstechnology/2011184043_apusradiationscanssafety.html 10. Kaiser Health News. “Federal officials focus on radiation practices at Florida clinic; medical scan makers announce new efforts to

prevent mistakes.” February 26, 2010. Available at: http://www.kaiserhealthnews.org/Daily-Reports/2010/February/26/Radiation.aspx

11. Steenhuysen, J. “Doctors work on radiation problem to ease fears.” Reuters, June 7, 2010. Available at: http://www.reuters.com/article/idUSTRE6565Y820100608

12. Marchione, M. “Be wary of radiation overdose from medical tests, doctors say.” TwinCities.com, June 14, 2010. 13. Szabo, L. Cancer risks prompt doctors to try to lower imaging scan radiation. USA Today. Available at:

http://www.usatoday.com/news/health/2010-05-05-radiation05_st_N.htm 14. Holcombe, D. “Oncology management programs for payers and physicians.” American Journal of Managed Care 2011;17:e182-

e186 15. Serafini, M.W., Carey, M.G. “Panel urges crackdown on Medicare’s use of imaging.” Kaiser Health News, June 14, 2011. Available

at: http://www.kaiserhealthnews.org/Stories/2011/June/15/Medicare-imaging.aspx

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16. Bogdanich, W., McGinty, J.C. “Medicare claims showing overuse of CT scanning.” New York Times, June 18, 2011, p. A.1 Further Readings – General

1. Hillman et al. “Physician financial incentives and feedback: failure to increase cancer screening in Medicaid managed care.” American Journal of Public Health 1998;88(11):1699-1701

2. Tierney, W. et al. “Effects of computerized guidelines for managing heart disease in primary care.” Journal of General Internal Medicine 2003;18(12):967-976

3. Juster, I.A. et al. “Use of administrative data to identify health plan members with unrecognized bipolar disorder: a retrospective cohort study.” American Journal of Managed Care 2005;11(9):578-584

4. Preidt, R. “Experts release new asthma care guidelines.” ABC News, 2007. Available at: http://abcnews.go.com/Health/Healthday/story?id=4509375&page=1

5. O’Connor, P.J., Sperl-Hillen, J., Johnson, P.E. “Customized feedback to patients and providers failed to improve safety or quality of diabetes care. A randomized trial.” Diabetes Care 2009;32(7):1158-1163

6. Neergaard, L. “Overtreated: more medical care isn’t always better.” ABC News, July 7, 2010. Available at: http://abcnews.go.com/Health/wireStory?id=10843361

7. Brownlee, S., Lenzer, J. “Can cancer ever be ignored?” New York Times online, October 5, 2011. Available at: http://www.nytimes.com/2011/10/09/magazine/can-cancer-ever-be-ignored.html?pagewanted=all

November 12, 2012 Supporting Consumers in Choosing Providers: Reporting of Provider Performance Providing consumers with timely, useful information about the performance of providers is one way that purchasers hope to engage consumers. Their intent is that consumers will use this information, in combination with financial incentives, to seek out lower cost, higher quality providers. And, it is hoped that providers will improve their quality and reduce their costs when faced with public comparisons with their peers. The present health care system, some argue, does not provide information that is truly useful to consumers in making cost/quality tradeoffs when choosing providers, or that is credible to providers. We will discuss recent efforts to publicly report information comparing providers, as well as the evidence regarding the influence of this information on consumer and provider decisions. Learning Objectives Students should be able to:

1. Describe the recent efforts to increase the amount and quality of information available to health care consumers about providers. 2. Discuss the responses of providers to these efforts. 3. Assess the evidence regarding the impact of comparative provider performance data on consumer decisions, quality of care, and

health care costs. Suggested Readings Public Reports and Their Use by Consumers

1. Rothberg, M.B., Morsi, E., Benjamin, E.M., Pekow, P.S., Lindenauer, P.K. “Choosing the best hospital: the limitations of public quality reporting.” Health Affairs 2008;27(6):1680-1687

2. Harris, K.M. and Buntin, M.B. “Choosing a Health Care Provider: The Role of Quality Information,” Research Synthesis Report No. 14. Princeton, NJ: The Synthesis Project, Robert Wood Johnson Foundation, May 2008. Available at: http://www.rwjf.org/pr/product.jsp?id=29683

3. redOrbit. Blue Cross and Blue Shield of Georgia Launches “Zagat health survey tool.” September 23, 2009. Available at: http://www.redorbit.com/news/health/1758420/blue_cross_and_blue_shield_of_georgia_launches_zagat_health/index.html

4. Christianson, J.B., Volmar, K.M., Alexander, J., Scanlon, D.P. “A report card on provider report cards: Current status of the health care transparency movement.” Journal of General Internal Medicine 2010;25(11):1235-1241

5. Kaiser Health News. “Rating your doctor.” August 3, 2010. Available at: http://www.kaiserhealthnews.org/Features/Insuring-Your-Health/andrews-column-on-physician-ratings.aspx

6. The LeapfrogGroup. “Transparency should not be a luxury; it is a matter of life and death: what purchasers and consumers can do.” February 2, 2010. Available at: http://www.leapfroggroup.org/news/leapfrog_news/4773661

7. Osborne, N.H., Ghaferi, A.A., Nicholas, L.H., Dimick, J.B. “Evaluating popular media and internet-based hospital quality ratings for cancer surgery.” Archives of Surgery 2011;146(5):600-604

8. Cutler, D., Dafney, L. “Designing transparency systems for medical care prices.” New England Journal of Medicine 364:894-895, 2011

9. Hibbard, J.H., Greene, J., Shoshanna, S., Firminger, K., Hirsh, J. “An experiment shows that a well-designed report on costs and quality can help consumers choose high-value health care.” Health Affairs 31(3):560-568, 2012

10. Young, G.J. “Multistakeholder regional collaboratives have been key drivers of public reporting, but now face challenges.”

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Health Affairs 31(3):578-584, 2012 11. Whitney, E. “Attention health care shoppers: Colorado’s new price list for procedures.” Kaiser Health News, May 16, 2012.

Available at: http://www.kaiserhealthnews.org/Stories/2012/May/16/colorado-health-care-price-list-database.aspx 12. Sinaiko, A.D., Eastman, D., Rosenthal, M.B. “How report cards on physicians, physician groups, and hospitals can have greater

impact on consumer choices.” Health Affairs 31(3):602-611, 2012 13. Clark, C. “Consumer reports rates hospital safety.” HealthLeaders Media, July 5, 2012. Available at:

http://www.healthleadersmedia.com/page-1/LED-281969/Consumer-Reports-Rates-Hospital-Safety 14. Fox, M. “People like expensive health care, study finds.” NationalJournal, March 5, 2012. Available at:

http://www.nationaljournal.com/healthcare/people-like-expensive-health-care-study-finds-20120305 15. Friedberg, M.W., Damberg, C.L. “A five-point checklist to help performance reports incentivize improvement and effectively

guide patients.” Health Affairs 31(3):612-618, 2012 Concerns about Public Reports

1. Werner, R., Asch, D. “The unintended consequences of publicly reporting quality information.” JAMA 2005;293(10):1239-1244 2. Kaiser Health News. N.Y. AG, “Cigna reach agreement on physician ranking system.” October 30, 2007. Available at:

http://www.kaiserhealthnews.org/daily-reports/2007/october/30/dr00048525.aspx?referrer=search 3. Anonymous. “Looking for Dr. Right; with more and more websites rating physicians, the question is: Can you trust them?”

Boston, Globe, June 8, 2009, p. G.6 4. Ostrow, N. “Hospitals ranked top based on reputation more than quality, study says.” Bloomberg Businessweek, April 19, 2010.

Available at: http://www.bloomberg.com/news/2010-04-19/hospitals-ranked-top-based-on-reputation-more-than-quality-study-says.html

5. Sullivan, K. “Health care report card was flawed.” November 28, 2010. Available at: http://www.howtoquitsmokingfree.com/quit-smoking/kip-sullivan-health-care-report-card-was-flawed/

6. Sinaiko, A.D., Rosenthan, M.B. “Increased price transparency in health care – challenges and potential effects.” New England Journal of Medicine 2011;364:891-894

7. Reuters. “Hospital ratings miss many high performers: study.” May 18, 2011. Available at: http://www.reuters.com/article/2011/05/18/us-hospital-ratings-idUSTRE74H73F20110518

8. Mehrotra, A., Hussey, P.S., Milstein, A., Hibbard, J.H. “Consumers’ and providers’ responses to public cost reports, and how to raise the likelihood of achieving desired results.” Health Affairs 31(4):843-851, 2012

9. Lieber, R. “The web is awash in reviews, but not for doctors. Here’s why.” New York Times online, March 9, 2012. Available at: http://www.nytimes.com/2012/03/10/your-money/why-the-web-lacks-authoritative-reviews-of-doctors.html?pagewanted=all

10. Rau, J. “Lots of ‘C’s as hospitals get graded for patient safety.” KHN Blog, June 6, 2012. Available at: http://capsules.kaiserhealthnews.org/index.php/2012/06/lots-of-cs-as-hospitals-get-graded-for-patient-safety/

Provider Responses to Public Reporting 1. Hibbard, J., Stockard, Tusler, M. “Does publicizing hospital performance stimulate quality improvement efforts?” Health Affairs

2003;22(2):84-94 2. Associated Press. “Doctors dispute quality rankings.” February 8, 2007. Available at:

http://www.pittsburghlive.com/x/pittsburghtrib/business/s_492216.html 3. Mathews, A.W. “Health care (a special report) --- compare and contrast: when doctors are given a public report card, the

resulting competition can serve patients well.” Wall Street Journal, October 27, 2009, p. R.4 4. Woo, H.E. “The crucible of physician performance reports.” Journal of General Internal Medicine 2010;26(2):226-227 5. CBS News. “Doctors can guard reputation on rating site.” March 3, 2011. Available at:

http://www.cbc.ca/news/health/story/2011/05/03/doctor-rating-websites-reputation.html 6. Chen, P.W. “A report card for doctors.” New York Times, June 16, 2011. Available at:

http://well.blogs.nytimes.com/2011/06/16/a-report-card-for-doctors/ 7. Watts, L.A., de Bocanegra, H.T., Darney, P.D., Hulett, D., Howell, M., Mikanda, J., Zerne, R., Policar, M.S. “In a California

program, quality and utilization reports on reproductive health services spurred providers to change.” Health Affairs 31(4):852-862, 2012

8. Smith, M.A., Wright, A., Queram, C., Lamb, G.C. “Public reporting helped drive quality improvement in outpatient diabetes care among Wisconsin physician groups.” Health Affairs 31(3):570-577, 2012

9. Teleki, S., Shannon, M. “In California, quality reporting at the state level is at a crossroads after hospital group pulls out.” Health Affairs 31(3):642-646, 2012

10. Mehrotra, A. Hussey, P.S., Milstein, A., Hibbard, J.H. “Consumers’ and providers’ responses to public cost reports, and how to raise the likelihood of achieving desired results.” Health Affairs 31(4):843-851, 2012

Further Readings

1. King , J., Henry, E. “Bill Clinton awaits heart surgery next week.” CNN.com, September 4, 2004. Available at: http://www.cnn.com/2004/ALLPOLITICS/09/03/clinton.tests/index.html

2. Hibbard, J.H., Stockard, J., Tusler, M. “Hospital performance reports: impact on quality, market share, and reputation.” Health Affairs 2005;24(4):1150-1160

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3. Ramirez, A. “Attorney general objects to insurer's ranking of doctors by cost and quality.” New York Times, July 14, 2007, p. B.3 4. Robert Wood Johnson Foundation. “Navigating health care: why it’s so hard and what can be done to make it easier for the

average consumer.” Issue Brief 3 of 6, October 2007. Available at: http://www.rwjf.org/pr/product.jsp?id=23073 5. Norton, A. “Hospital report cards get mixed marks.” Reuters, November 18, 2009. Available at:

http://www.reuters.com/article/idUSTRE5AH49920091118 6. Auerbach, A.D., Hilton, J.F., Maselli, J., Pekow, P.S., Rothberg, M.B., Lindenauer, P.K. “Shop for quality or volume? Volume,

quality, and outcomes of coronary artery bypass surgery.” Annals of Internal Medicine 2009;150(10):696-704 7. Graham, J. “Hospital report cards due; consumers can go online to get the scoop on Illinois facilities, such as prices, quality

ratings and much more.” Chicago Tribune, November 19, 2009 8. Andrews, C. “Empire BlueCross Blue Shield and Zagat to survey New Yorkers about doctor accessibility, offices and

communication skills.” Empire BlueCross BlueShield, November 18, 2009. Available at: http://www.empireblue.com/wps/portal/ehpfooter?content_path=shared/noapplication/f1/s0/t0/pw_b139674.htm&label=Empire%20BlueCross%20BlueShield%20and%20Zagat%20To%20Survey%20New%20Yorkers%20About%20Doctor%20Accessibility,%20Offices%20and%20Communication%20Skills

9. Intuit. “UnitedHealthcare expands availability of quicken health expense tracker to nearly 700,000 consumers.” August 3, 2009. Available at: http://about.intuit.com/about_intuit/press_room/press_release/articles/2009/UNITEDHEALTHCAREEXPANDS.html

10. Weaver, C. “Want to know what a hospital charges? Good luck.” Kaiser Health News, June 29, 2010. Available at: http://www.kaiserhealthnews.org/stories/2010/june/29/hospital-prices.aspx?referrer=search

11. Monegain, B. “Study names 100 top-performing hospitals.” Healthcare IT News, March 29, 2010. Available at: http://www.healthcareitnews.com/news/study-names-100-top-performing-hospitals

12. Boulton, G. “Bill would require listing of medical procedure costs.” JSOnline, March 4, 2010. Available at: http://www.jsonline.com/business/86466282.html

13. Stewart, K. “Utah insurer SelectHealth steps up grading providers.” The Salt Lake Tribune, December 21, 2010. 14. Ferraro, M. “Medicine’s big mystery, what does treatment cost?” Bloomberg, July 12, 2011. Available at:

http://www.bloomberg.com/news/2011-07-12/medicine-s-big-mystery-what-does-treatment-cost-mimi-ferraro.html 15. Levey, N. “New website to help patients compare doctors, hospitals.” Los Angeles Times, June 27, 2011. Available at:

http://articles.latimes.com/2011/jun/27/news/la-heb-health-quality-20110628 16. Lansky, D., Findlay, S. “Physician compare site could be ‘game changer,’ but challenges remain.” iHealthBeat, January 12, 2011.

Available at: http://www.ihealthbeat.org/perspectives/2011/physician-compare-site-could-be-game-changer-but-challenges-remain.aspx

17. Barr, S. “Dream of a medical ‘price list’ dies in Florida legislature.” KHN Blog, January 30, 2012. Available at: http://capsules.kaiserhealthnews.org/index.php/2012/01/dream-of-a-medical-price-list-dies-in-florida-legislature/

18. Ryan, A.M., Nallamothu, B.K., Dimick, J.B. “Medicare’s public reporting initiative on hospital quality had modest or no impact on mortality from three key conditions.” Health Affairs 31(3):585-592, 2012

19. Lazar, K. “Federal websites updated with data on hospital imaging, use of antipsychotics in nursing homes.” Boston Globe online, July 19, 2012. Available at: http://www.boston.com/dailydose/2012/07/19/federal-websites-updated-with-data-hospital-imaging-use-antipsychotics-nursing-homes/TtjhhiM8tt0HdP16Q0XQ1M/story.html

November 19, 2012 Supporting Consumers in Choosing Treatment Options There is growing support for the need to provide consumers with information necessary to evaluate treatment options and select the option that is the best fit for their individual circumstances and preferences. Consumer decision aids have been developed with this objective in mind. We will discuss these decision aids, evidence of their effectiveness, and the roles of employers and health plans in encouraging their use. We also will discuss the challenges that low health literacy can pose to informed consumer choice of providers and the use of “shared decision making more generally and specifically relating to treatment options, and how payers and health plans are attempting to address this issue. Learning Objectives Students should be able to:

1. Describe different approaches being used to support consumers in their choice of treatments. 2. Discuss the problems faced by employers and health plans in implementing decision aids. 3. Evaluate the evidence regarding the effectiveness of these decision aids. 4. Assess the challenges that low health literacy poses for informed consumer decision making.

Suggested Readings Shared Decision Making

1. Robert Wood Johnson Foundation. “The current and future role of consumers in making treatment decisions.” Issue Brief 4 of 6,

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October 2007. Available at: http://www.rwjf.org/pr/product.jsp?id=23074 2. Frosch, D.L., May, S.G., Rendle, K.A.S., Tietbohl, C., Elwyn, G. “Authoritarian physicians and patients’ fear of being labeled

‘difficult’ among key obstacles to shared decision making.” Health Affairs 31(5):1030-1038, 2012 3. Lewis, D. “Survey: Patient engagement important, but loosely defined.” FierceHealthcare, March 20, 2012. Available at:

http://www.fiercehealthcare.com/story/survey-patient-engagement-important-loosely-defined/2012-03-20 Decision Aids and Their Use

1. Weinstein, J.N., Clay, K., Morgan, T.S. “Informed patient choice: patient-centered valuing of surgical risks and benefits.” Health Affairs 2007;26(3):726-730

2. Landro. L. “Health & wellness -- the informed patient: weighty choices, in patients' hands.” The Wall Street Journal, August 4, 2009, p. D.2

3. Olson, J. “Sharing of health decisions advocated – clinic gets grant to expand program.” St. Paul Pioneer Press, October 10, 2009

4. Tanner, L. “Hospitals try high-tech to better inform patients.” Daily Herald, November 10, 2010. Available at: http://www.dailyherald.com/article/20101110/entlife/101119961/

5. Healthwise® “Patient response: Giving voice to the patients.” February 21, 2012. Available at: http://www.healthwise.org/Insightsdocs/PressReleases/Patient-Response--Giving-Voice-to-the-Patients.aspx

6. WiserTogether. “Group Health Cooperative of Eau Claire implements WiserTogether’s shared decision support platform.” July 20, 2012. Available at: http://www.wisertogether.com/news/2012/07/20/group-health-cooperative-of-eau-claire/

Issues in the Use of Decision Aids 1. Mullan. R.J., Montori, V.M., Shah, N.D., Christianson, T.J.H., Bryant, S.C., Guyatt, G.H., LPerestelo-Perez, L.I., Stroebel, R.J.,

Yawn, B.P., Yapuncich, V., Breslin, M.A., Pencille, L., Smith, S.A. “The diabetes mellitus medication choice decision aid.” Archives of Internal Medicine 2009;169(17):1560-1568

2. Carman, K.L., Maurer, M., Yegian, J.M., Dardess, P., McGee, J., Evers, M., Mario, K.O. “Evidence that consumers are skeptical about evidence-based health care.” Health Affairs 2010;29(7):1400-1406, 2010

3. Shaw, G. “Does decision support make docs look dumb?” Health Leader Media, April 14, 2011. Available at: http://www.healthleadersmedia.com/page-1/MAG-264919/Does-Decision-Support-Make-Docs-Look-Dumb##

The Importance of Health Literacy and Language Issues to Informed Choice 1. Peters, E., Hibbard, J., Slovic, P., Dieckmann, N. “Numeracy skill and the communication, comprehension, and use of risk-

benefit information.” Health Affairs 2007;26(3):741-748 2. America’s Health Insurance Plans. “New tool available for health care companies to assess their organizations’ health literacy

programs.” Press Release, March 15, 2010. Available at: http://www.ahip.org/content/pressrelease.aspx?bc=174|29744 3. America’s Health Insurance Plans. “AHIP statement on HHS’s national action plan to improve health literacy.” Press Release,

May 27, 2010. Available at: http://www.ahip.org/content/pressrelease.aspx?docid=30599 4. Boodman, S.G. “Helping patients understand their medical treatment.” Kaiser Health News, March 1, 2011. Available at:

http://www.kaiserhealthnews.org/Stories/2011/March/01/Health-Literacy-Understanding-Medical-Treatment.aspx Further Readings

1. Foubister, V. “Issue of the month: health literacy – a quality and patient safety imperative.” The Commonwealth Fund Newsletter, November 16, 2006, Volume 21. Available at: http://www.commonwealthfund.org/Content/Newsletters/Quality-Matters/2006/November-December/Issue-of-the-Month-Health-Literacy-A-Quality-and-Patient-Safety-Imperative.aspx

2. O’Connor, A.M., Wennberg, J.E., Legare, F., Liewellyn-Thomas, H.A., Moulton, B.W., Sepucha, K.R., Sodano, A.G., King. J.S. “Toward the ‘tipping point’: decision aids and informed patient choice.” Health Affairs 2007;26(3):716-725

3. Brownlee, S. “Giving patients a larger voice; more doctors welcome dialogue about tests and procedures.” The Washington Post, October 23, 2007

4. Robert Wood Johnson Foundation. “Choice in medical care: when should the consumer decide?” Issue Brief 5 of 6, October 2007. Available at: http://www.rwjf.org/pr/product.jsp?id=23075

5. Katz, S.J., Howley, S.T. “From policy to patients and back: surgical treatment decision making for patients with breast cancer.” Health Affairs 2007;26(3):761-769

6. Ling, B.S., Trauth, J.M., Fine, M.J., Mor, M.K., Resnick, A., Braddock, C.H., Bereknyei, S., Weissfeld, J.L., Schoen, R.E., Ricci, E.M., Whittle, J. “Informed decision-making and colorectal cancer screening. Is it occurring in primary care?” Medical Care 2008;46(9 Suppl 1):S23-S29

7. Landro. L. “The informed patient: the importance of trying to be a good patient.” Wall Street Journal, April 29, 2009 8. Barclay, E. “Speaking the same language. Medical providers struggle to communicate with immigrant patients.” The Washington

Post, April 21, 2009, p. F.1 9. Brownlee, S., Collins, E.D. “Let women decide on medical tests.” Kaiser Health News, December 15, 2009. Available at:

http://www.kaiserhealthnews.org/Columns/2009/December/121509BrownleeandCollins.aspx 10. Norton, A. “What happens when doctors give patients more power?” Reuters, November 30, 2009. Available at:

http://www.reuters.com/article/idUSTRE5AT3U320091130 11. Health Dialog. “Health Dialog releases testimony on health literacy.” Press Release July 7, 2010. Available at:

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http://www.healthdialog.com/Utility/News/PressRelease/10-07-07/Health_Dialog_Releases_Testimony_on_Health_Literacy 12. Bavley, A. “Health literacy is touted to improve patient roles.” June 3, 2010. Available at:

http://www.computerizedscreening.com/about/news/06-07-2010/health-literacy-is-touted-to-improve-patient-roles 13. Olson, J. “Elective surgery rates all over map.” Star Tribune, February 25, 2011, p. B.3 14. PR Newswire. “Limited health literacy increased safety risk for patients with diabetes.” Available at:

http://www.prnewswire.com/news-releases/limited-health-literacy-increases-safety-risks-for-patients-with-diabetes-94230884.html

November 26, 2012 Supporting Consumers in Maintaining and Improving Their Health Increasingly, employers are instituting programs and financial incentives that support employees in maintaining and improving their health. The expectation is that these efforts will reduce the rate of increase in health care costs overtime by reducing or delaying the onset of chronic illnesses. Payers’ efforts rely both on rewards and negative incentives to encourage healthy behaviors. Employers depend on both health plans and independent vendors for delivering program content. Learning Objectives Students should be able to:

1. Describe the rationale for employer/health plan support for healthy lifestyle programs. 2. Assess the strengths and weaknesses of different program designs. 3. Evaluate the evidence that these programs have been successful in achieving their goals. 4. Discuss the impediments to the successful implementation of these programs.

Suggested Readings Design of Healthy Lifestyle Programs

1. Draper, D.A., Tynan, A., Christianson, J.B. “Health and wellness: the shift from managing illness to promoting health.” Center for Studying Health System Change Issue Brief No. 121, June 2008. Available at: http://www.hschange.com/CONTENT/989/

2. Jauhar, S. “No matter what, we pay for others' bad habits.” New York Times, March 30, 2010. 3. Wall Street Journal. “Survey: employers fret over workers’ poor health habits.” February 22, 2010. Available at:

http://blogs.wsj.com/health/2010/02/22/survey-employers-fret-over-with-workers-poor-health-habits/ 4. National Business Group on Health. “Annual wellness study finds significant jump in incentive dollars as employers report

improved employee participation.” February 8, 2011. Available at: http://www.businessgrouphealth.org/pressrelease.cfm?printPage=1&ID=170

5. Bernstein, L. “Keeping employees, bottom lines in shape.” The Washington Post, July 5, 2011, p. A.1 6. Cigna. “Cigna says health assessment and coaching are key to reducing health risks; extends exclusive license with University

of Michigan.” August 16, 2011. Available at: http://newsroom.cigna.com/NewsReleases/cigna-says-health-assessment-and-coaching-are-key-to-reducing-health-risks--extends-exclusive-license-with-university-of-michigan.htm

7. Press Release. “Dean Health Plan, Healthways partner to introduce comprehensive, integrated total population health programs.” Reuters, February 21, 2012. Available at: http://www.reuters.com/article/2012/02/21/idUS203818+21-Feb-2012+BW20120221

8. HealthPartners. “HealthPartners first in regional market to introduce health and well-being web portal customized to employers.” Press Release, March 19, 2012. Available at: http://www.healthpartners.com/public/newsroom/newsroom-article-list/03-19-12.html

9. Medica. “Medica introduces group health and wellness coaching program.” Corporate Announcement, April 19, 2012. Available at: http://newscenter.medica.com/press-release/products-services/medica-introduces-group-health-and-wellness-coaching-program

Evidence of Program Effectiveness 1. Mattke, S., Serxner, S.A., Zakowski, S.L., Jain, A.K., Gold, D.B. “Impact of 2 employer-sponsored population health management

programs on medical care cost and utilization.” American Journal of Managed Care 2009;15(2):113-120 2. Russell, L.B. “Preventing chronic disease: an important investment, but don’t count on cost savings.” Health Affairs

2009;28(1):42-45 3. Andrews, M. “About That Waistline...” New York Times, October 9, 2009. p. A.19 4. Huskamp, H.A., Rosenthal, M.B. “Health risk appraisals: how much do they influence employees’ health behavior?” Health

Affairs 2009;28(5):1532-1540 5. Goetzel, R.Z. “Do prevention or treatment services save money? The wrong debate.” Health Affairs 2009;28(1):37-41 6. PR Newswire. “Study: Preventive services can save lives, billions of dollars, at little or no cost.” September 7, 2011. Available at:

http://www.prnewswire.com/news-releases/study-preventive-services-can-saves-lives-billions-of-dollars-at-little-or-no-cost-102351314.html

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7. Henke, R.M., Goetzel, R.Z., McHugh, J., Isaac, F. “Recent experience in health promotion at Johnson & Johnson: Lower health spending, strong return on investment.” Health Affairs 2011;30(3):490-499

8. Medica. “Medica health and wellness coaching program improves health, reduces cost.” January 3, 2012. Available at: http://newscenter.medica.com/press-release/products-services/medica-health-and-wellness-coaching-program-improves-health-reduces-

Concerns about Program Incentives 1. Rose, B. “A healthy backlash on benefits incentives; workers, employers clashing over tough wellness programs.” Chicago

Tribune, February 10, 2008, p. 1 2. Lerner, M. “Medica wants to put health coach between you and your bad habits; but critics say the voluntary, no-cost program is

like health care big brother.” Star Tribune, October 1, 2008 3. Knight, V.E. “Treading carefully with wellness programs.” The Wall Street Journal, July 28, 2009. Available at:

http://online.wsj.com/article/SB124880470938287485.html 4. Tuna, C. “Theory and practice: wellness efforts face hurdle --- asking workers about family health history can clash with U.S.

genetics law.” Wall Street Journal, February 1, 2010, p. B.2 5. Sulzberger, A.G. “Hospitals shift smoking bans to smoker ban.” New York Times, February 11, 2011, p. A.1 6. Mincer, J. “Insight: Firms to charge smokers, obese more for healthcare.” Reuters, October 30, 2011. Available at:

http://www.reuters.com/article/2011/10/30/us-penalties-idUSTRE79T2S220111030 7. USA Today. “Not hiring smokers crosses privacy line.” Editorial, January 29, 2012. Available at:

http://www.usatoday.com/news/opinion/editorials/story/2012-01-29/not-hiring-smokers-privacy/52874348/1 8. Koch, W. “Workplaces ban not only smoking, but smokers.” USA Today, January 6, 2012. Available at:

http://www.usatoday.com/money/industries/health/story/2012-01-03/health-care-jobs-no-smoking/52394782/1 Further Readings

1. Sutherland, K., Christianson, J.B., Leatherman, S. “Impact of targeted financial incentives on personal health behavior. A review of the literature.” Medical Care Research and Review 2008;65(Suppl to 6):36S-78S

2. Johnson, A. “Cashing in on healthful lifestyles; State paying its workers to 'take charge, live well'.” Columbus Dispatch, January 17, 2008

3. Slitt, M. “CIGNA earns new accreditation for wellness and health promotion programs from the National Committee for Quality Assurance (NCQA).” News Release, November 9, 2009. Available at: http://newsroom.cigna.com/article_display.cfm?article_id=1126

4. Gold, J. “Corporate wellness programs: healthier employees, lower costs.” Kaiser Health News, October 30, 2009. Available at: http://www.kaiserhealthnews.org/Checking-In-With/fikry-wellness-q-and-a.aspx

5. Cohen, J., Neuman, P. “Cost savings and cost-effectiveness of clinical preventive care.” Robert Wood Johnson Foundation, The Synthesis Project Policy Brief No. 18, September 2009. Available at: http://www.rwjf.org/pr/product.jsp?id=48508

6. Olson, E.G. “New technology is helping elderly patients and those with chronic diseases monitor their condition from the comfort of home.” The Washington Post, November 17, 2009

7. Pearson, S.D., Lieber, S.R. “Financial penalties for the unhealthy? Ethical guidelines for holding employees responsible for their health.” Health Affairs 2009;28(3):845-852

8. Appleby, J. “Firms offer bigger incentives for healthy living.” USA Today, January 20, 2009. Available at: http://www.usatoday.com/news/health/2009-01-19-diabetes_N.htm

9. Business Wire. “Healthways among first organizations to receive NCQA wellness and health promotion accreditation.” December 8, 2009. Available at: http://www.businesswire.com/portal/site/home/permalink/?ndmViewId=news_view&newsId=20091208005353&newsLang=en

10. Stobbe, M. “Dieting for dollars? More US employees trying it.” The Register Citizen, May 28, 2010. Available at: http://www.registercitizen.com/articles/2010/05/28/business/doc4bff41797e90c027843010.txt

11. CIGNA Corporation. “CIGNA Launches Worksite Wellness Program to Help Combat Top Health Risks Facing Americans.” News Release February 22, 2010. Available at: http://newsroom.cigna.com/article_display.cfm?article_id=1175

12. Editors. “Should people be paid to stay healthy?” New York Times, June 14, 2010. Available at: http://roomfordebate.blogs.nytimes.com/2010/06/14/should-people-be-paid-to-stay-healthy/

13. PR Newswire. “Know your numbers campaign a healthy success.” July 21, 2011. Available at: http://www.prnewswire.com/news-releases/know-your-numbers-campaign-a-healthy-success-125946673.html

14. National Institute for Health Care Management. “Building a stronger evidence base for employee wellness programs.” Meeting Brief, May 2011. Available at: http://nihcm.org/images/stories/Wellness_FINAL_electonic_version.pdf

15. Businesswire. “Aetna introduces resources for living, a new approach to engaging members in their emotional and physical health.” June 28, 2011. Available at: http://www.bioportfolio.com/news/article/726997/Aetna-Introduces-Resources-For-Living-A-New-Approach-To-Engaging-Members-In.html

16. PR Newswire. “Medical Mutual of Ohio partners with Linkwell Health to bring can-do wellness program to its members.” May 5, 2011. Available at: http://www.prnewswire.com/news-releases/medical-mutual-of-ohio-partners-with-linkwell-health-to-bring-can-do-wellness-program-to-its-members-121340073.html

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December 3, 2012 Supporting Consumers in Managing Chronic Illnesses Employers are strong supporters of programs that help consumer “self-manage” care for chronic illnesses. The general idea is to place the consumer in a much more central role in medical care treatment. By educating consumers in appropriate treatment methods for their illnesses and supporting their efforts to manage their illnesses, payers and health plans hope that the progression of chronic illnesses can be delayed and the number of acute flare-ups of chronic illnesses can be minimized. This, in turn, would improve the quality of life for employees, reduce emergency room and hospital use, and restrain growth in costs. We will discuss efforts of payers and health plans to support consumers in chronic care management and the context in which they have been successful. Learning Objectives Students should be able to:

1. Explain the concepts of patient self-management and disease management in their different forms. 2. Discuss the various ways in which employers and health plans are supporting employees and plan enrollees in chronic illness

management. 3. Assess the evidence of their effectiveness in various settings. 4. Describe the obstacles to the effective implementation, by payers and health plans, of programs to support chronic illness

management by consumers. Suggested Readings Importance of Developing Effective Approaches to Chronic Illness Management

1. Paez, K.A., Zhao, L., Hwang, W. “Rising out-of-pocket spending for chronic conditions: a ten-year trend.” Health Affairs 2009;28(1):15-25

2. Steenhuysen, J. “U.S. diabetes cases to double, costs triple by 2034.” Reuters, November 27, 2009. Available at: http://www.reuters.com/article/idUSTRE5AQ0C220091127

3. Terhune, C., Weintraub, A. “Take your meds, exerciseand spend billions.” BusinessWeek, February 4, 2010. Available at: http://www.businessweek.com/magazine/content/10_07/b4166046292556.htm

4. Sklaroff, S. “On our own. Why we who struggle to live with diabetes could use a helping hand.” Health Affairs 31(1):236-239, 2012

5. Grens, K. “Half of heart patients don’t stick to their meds.” Reuters, July 25, 2012. Available at: http://www.reuters.com/article/2012/07/25/us-heart-patients-meds-idUSBRE86O16M20120725

Self-Management of Illnesses 1. Bodenheimer, T., Lorig, K., Holman, H., Grumbach K., “Patient self-management of chronic disease in primary care.”JAMA

2002;288(19):2469-2475 2. Jerant, A., Moore-Hill, M., Franks, P. “Home-based, peer-led chronic illness self-management training: findings from a 1-year

randomized controlled trial.” Annals of Family Medicine 2009;7(4):319-327 Disease Management Programs – Structure and Effectiveness

1. Mays, G.P., Au, M., Claxton, G. “Convergence and dissonance: evolution in private-sector approaches to disease management and care coordination.” Health Affairs 2007;26(6):1683-1691

2. McQueen, M.P. “Look who's watching your health expenses; employers increasingly turn to 'care managers' to control medical costs, but some wonder if patients always benefit.” Wall Street Journal, September 25, 2007, p. D.1

3. Conklin, A., Nolte, E. “Disease management evaluation. A comprehensive review of current state of the art.” RAND Technical Report, December 2010. Available at: http://www.rand.org/content/dam/rand/pubs/technical_reports/2011/RAND_TR894.pdf

4. Bernstein, J., Chollet D., Peterson, G.G. “Disease management: does it work?” Mathematica Policy Research Inc. Issue Brief No. 4, May 2010. (PDF on Moodle Website)

5. Draaghtel, K. “Using predictive modeling to identify patients for disease management.” Milliman White Paper, April 2010. (PDF on Moodle Website)

6. Feder, J.L. “Predictive modeling and team care for high-need patients at HealthCare Partners.” Health Affairs 2011;30(3):416-418

7. Vojta, D., De Sa, J., Prospect, T., Stevens, S. “Effective interventions for stemming the growing crisis of diabetes and prediabetes: A national payer’s perspective. Health Affairs 31(1):20-26, 2012

Further Readings

1. Nakashima, E. “Prescription data used to assess consumers.” The Washington Post, August 4, 2008, p. A.1 2. Mattke, S. “Is there a disease management backlash?” American Journal of Managed Care 2008;14(6):349-350 3. Preidt, R. “Simple case management cuts pulmonary disease admissions.” ABC News, May 22, 2008. Available at:

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http://abcnews.go.com/Health/Healthday/story?id=4901415&page=1 4. Reuters. “Incentives and pharmacist coaches lead to improved health and lower health care costs for diabetic patients.” May 7,

2009. Available at: http://www.reuters.com/article/2009/05/07/idUS158325+07-May-2009+PRN20090507 5. Aizenman, N.C. “Insurers want the calls to go through; Health-care overhaul may threaten popular disease management

programs.” The Washington Post, July 20, 2010. p. E.1 6. Agency for Healthcare Research and Quality, USDHHS. “Asthma Return-on-Investment Calculator. User’s guide.” Available at:

http://statesnapshots.ahrq.gov/asthma/UserGuide.jsp 7. PR Newswire. “Capital BlueCross receives inaugural national award for developing oncology case management program.” July

12, 2011. Available at: http://www.prnewswire.com/news-releases/capital-bluecross-receives-inaugural-national-award-for-developing-oncology-case-management-program-125428503.html

8. Motheral, B.R. “Telephone-based disease management: Why it does not save money.” American Journal of Managed Care 2011;17(1):e10-e16

December 10, 2012 Putting It All Together: Coordinated Approaches to Supporting Care Management, Improving Quality, and Controlling Costs Employers and health plans are introducing comprehensive approaches, including new benefit designs, that they hope will encourage and reward consumers for healthy living, effective self-management of their chronic illnesses, and choice of cost effective treatments and providers. These strategies are in the early stages of implementation, and evidence on their impact to date is limited. Learning Objectives Students should be able to:

1. Describe value-based benefit strategies and how they are being implemented. 2. Assess the strengths and weaknesses of these strategies from the perspectives of employers and consumers. 3. Describe recent collaborative approaches to control community health care costs and improve health.

Suggested Readings Collaborative Initiatives

1. Blackmore, C.C., Mecklenburg, R.S., Kaplan, G.S. “At Virginia Mason, collaboration among providers, employers, and health plans to transform care cut costs and improved quality.” Health Affairs 30(9):1680-1687, 2011

2. Tomek, I.M., Sabel, A.L., Froimson, M.I., Muschler, G., Jevsevar, D.S., Koenig, K.M., Lewallen, D.G., Naessens, J.M., Savitz, L.A., Westrich, J.L., Weeks, W.B., Weinstein, J.N. “A collaborative of leading health systems finds wide variations in total knee replacement delivery and takes steps to improve value. Health Affairs 31(6):1329-1338, 2012

3. Meyer, H. “Collaborative efforts can save money and improve care.” Kaiser Health News, January 5, 2012. Available at: http://www.kaiserhealthnews.org/stories/2012/january/06/collaborative-efforts-can-save-money-and-improve-care.aspx

Structure of Value-Based Benefit Design 1. Hibbard, J.H., Greene, J., Tusler, M. “Plan design and active involvement of consumers in their own health and healthcare.”

American Journal of Managed Care 2008;14(11):729-736 2. Fendrick, A.M., Chernew, M.E. “Value based insurance design: maintaining a focus on health in an era of cost containment.”

American Journal of Managed Care 2009;15(6):338-343 3. Health Care Financing & Organization. “Making the value proposition in benefit design.” HCFO, June 2010. Available at:

http://www.hcfo.org/publications/making-value-proposition-benefit-design 4. Neumann, P.J., Auerbach, H.R., Cohen, J.T., Greenberg, D. “Low-value services in value-based insurance design.” American

Journal of Managed Care 2010;16(4):280-286 5. Alliance for a Healthier Generation. “Anthem Blue Cross and Blue Shield in Virginia teams with the Alliance for a Healthier

Generation to offer comprehensive health benefits to combat childhood obesity.” Press Release, May 18, 2010. Available at: http://www.healthiergeneration.org/media.aspx?id=4583

6. Appleby, J. “Carrot-and-stick health plans aim to cut costs.” USA Today/Kaiser Health News, March 11, 2010. Available at: http://www.kaiserhealthnews.org/stories/2010/march/11/value-based-health-insurance.aspx?referrer=search

Experience with Value-Based Benefit Design 1. Chernew, M.E., Shah, M.R., Wegh, A, Rosenberg, S.N., Juster, I.A., Rosen, A.B., Sokol, M.C., Yu-Isenberg, K., Fendrick, A.M.

“Impact of decreasing copayments on medication adherence within a disease management environment.” Health Affairs 2008;27(1):103-112

2. The Free Library. “Center for Health Value Innovation releases white paper: value-based design manages costs, improves health for public sector employers.” September 21, 2009. Available at: http://www.thefreelibrary.com/Center+for+Health+Value+Innovation+Releases+White+Paper%3A+Value-Based+...-

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a0208090928 3. Gibson, T.B., Wang, S., Kelly, E., Brown, C., Turner, C., Frech-Tamas, F., Doyle, J., Mauceri, E. “A value-based insurance

design program at a large company boosted medication adherence for employees with chronic illnesses.” Health Affairs 2011;30(1):109-117

Addressing Obesity: Challenges in Designing a Coordinated Approach 1. Rundle, R.L. “Obesity surgery is called cost-effective.” The Wall Street Journal, September 8, 2008 2. Finkelstein, E.A., Trogdon, J.G., Cohen, J.W., Dietz, W. “Annual medical spending attributable to obesity: payer-and service-

specific estimates.” Health Affairs 2009;28(5):w822-w831 (published online 27 July 2009) 3. Steenhuysen, J. “Hospital label no guarantee of better weight surgery.” Reuters, April 20, 2009. Available at:

http://www.reuters.com/article/idUSTRE53J5WL20090421 4. Pollack, A. “FDA studies band surgery for less obese.” New York Times, December 2, 2010, p. A.1 5. Gardner, A. “Gastric bypass best for weight loss, study finds.” Health.com, February 21, 2011. Available at:

http://news.health.com/2011/02/21/gastric-bypass-best-for-weight-loss-study-finds/ 6. Pollack, A. “Hoping to avoid the knife.” New York Times, March 17, 2011, p. B.1 7. Pittman, G. “Bariatric surgery doesn’t reduce long-term costs.” Reuters Health Information, July 16, 2012. Available at:

http://www.nlm.nih.gov/medlineplus/news/fullstory_127291.html 8. Graham, J. “Doctors and Insurers are key to fighting obesity.” Kaiser Health News, May 12, 2012. Available at:

http://www.kaiserhealthnews.org/stories/2012/may/13/obesity-and-doctors.aspx Further Readings

1. Kane, D. “Overweight N.C. workers may pay a price.” News & Observer, February 20, 2009. Available at: http://www.newsobserver.com/2009/02/20/94051/overweight-nc-workers-may-pay.html#storylink=misearch

2. IBM. “IBM to provide employees with 100% primary health care coverage, new wellness rebate.” Press Release, October 29, 2009. Available at: http://www-03.ibm.com/press/us/en/pressrelease/28728.wss

3. National Business Coalition on Health. “Value-based benefit design: a purchaser guide.” 2009. Available at: http://www.nbch.org/NBCH/files/ccLibraryFiles/Filename/000000000222/VBBD%20Purchaser%20Guide.pdf

4. PR Newswire. “Harvard Pilgrim launches social networking e-community to inspire people to be well.” November 23, 2009. Available at: http://www.prnewswire.com/news-releases/harvard-pilgrim-launches-social-networking-e-community-to-inspire-people-to-be-well-71527682.html

5. Johnson, A. “Health & wellness -- Heart beat: the do-it-yourself house call --- insurer-endorsed remote-monitoring technology leads heart patients to take their readings at home.” Wall Street Journal, July 27, 2010. p. D.2

6. Intel. “Aetna, Intel effort signals importance of early intervention, remote health management.” News Release June 10, 2010. Available at: http://www.intel.com/pressroom/archive/releases/20100610corp.htm

7. Nucci, C. “Insurers curbing hospital admissions, remotely.” HealthLeaders Media, January 13, 2011. Available at: http://www.healthleadersmedia.com/page-1/MAG-260996/Insurers-Curbing-Hospital-Admissions-Remotely

8. Galewitz, P. “Insurers embrace ‘virtual’ doctor visits.” Kaiser Health News, May 6, 2012. Available at: http://www.kaiserhealthnews.org/stories/2012/may/07/telemedicine.aspx

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VII. Evaluation and Grading Grades will be determined based on four group assignments (total of 40 points) and six individual assignments (total 60 points) The student will receive a grade of zero if an assignment is not submitted as scheduled, unless prior arrangements have been made for late submission. Grading Scale An A/F letter grade will be determined based on the following:

A=93-100% Represents outstanding achievement relative to the level necessary to meet course requirements

A- = 90-92.99%

B+ = 87-89.99%

B = 83-86.99% Represents achievement that is significantly above the level necessary to meet course requirements

B- = 80-82.99%

C+ = 77-79.99%

C = 73-76.99% Represents achievement that meets the minimum course requirements

C- = 70-72.99%

D+ = 65-69.99%

D = 60-64.99%

F = < 59.99% No credit. Signifies work was below level of achievement that represents minimum threshold to obtain credit or work was not completed and there was no agreement between instructor and student that the student would be awarded an I.

The instructor reserves the right to adjust final grades “upward” based on the overall distribution of points for the class. That is, students may receive a higher grade than expected based on their overall point total, but not a lower grade. Course Evaluation Beginning in fall 2008, the SPH will collect student course evaluations electronically using a software system called CoursEval: www.sph.umn.edu/courseval. The system will send email notifications to students when they can access and complete their course evaluations. Students who complete their course evaluations promptly will be able to access their final grades just as soon as the faculty member renders the grade in SPHGrades: www.sph.umn.edu/grades. All students will have access to their final grades through OneStop two weeks after the last day of the semester regardless of whether they completed their course evaluation or not. Student feedback on course content and faculty teaching skills are an important means for improving our work. Please take the time to complete a course evaluation for each of the courses for which you are registered.

Incomplete Contracts A grade of incomplete “I” shall be assigned at the discretion of the instructor when, due to extraordinary circumstances (e.g., documented illness or hospitalization, death in family, etc.), the student was prevented from completing the work of the course on time. The assignment of an “I” requires that a contract be initiated and completed by the student before the last official day of class, and signed by both the student and instructor. If an incomplete is deemed appropriate by the instructor, the student in consultation with the instructor, will specify the time and manner in which the student will complete course requirements. Extension for completion of the work will not exceed one year (or earlier if designated by the student’s college). For more information and to initiate an incomplete contract, students should go to SPHGrades at: www.sph.umn.edu/grades. University of Minnesota Uniform Grading and Transcript Policy A link to the policy can be found at onestop.umn.edu.

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VIII. Other Course Information and Policies Grade Option Change (if applicable) For full-semester courses, students may change their grade option, if applicable, through the second week of the semester. Grade option change deadlines for other terms (i.e. summer and half-semester courses) can be found at onestop.umn.edu. Course Withdrawal Students should refer to the Refund and Drop/Add Deadlines for the particular term at onestop.umn.edu for information and deadlines for withdrawing from a course. As a courtesy, students should notify their instructor and, if applicable, advisor of their intent to withdraw. Students wishing to withdraw from a course after the noted final deadline for a particular term must contact the School of Public Health Student Services Center at sph-ssc@umn.edu for further information. Student Conduct, Scholastic Dishonesty and Sexual Harassment Policies Students are responsible for knowing the University of Minnesota, Board of Regents' policy on Student Conduct and Sexual Harassment found at www.umn.edu/regents/polindex.html. Students are responsible for maintaining scholastic honesty in their work at all times. Students engaged in scholastic dishonesty will be penalized, and offenses will be reported to the SPH Associate Dean for Academic Affairs who may file a report with the University’s Academic Integrity Officer. The University’s Student Conduct Code defines scholastic dishonesty as “plagiarizing; cheating on assignments or examinations; engaging in unauthorized collaboration on academic work; taking, acquiring, or using test materials without faculty permission; submitting false or incomplete records of academic achievement; acting alone or in cooperation with another to falsify records or to obtain dishonestly grades, honors, awards, or professional endorsement; or altering, forging, or misusing a University academic record; or fabricating or falsifying of data, research procedures, or data analysis.” Reference: “a mention or citation of a source of information in a book or article” (Compact Oxford English Dictionary, 2012) Citation: “a quotation from or reference to a book, paper, or author, especially in scholarly work” (Compact Oxford English Dictionary, 2012) Quotation: “a group of words taken from a text or speech and reported by someone other than the original author or speaker” (Compact Oxford English Dictionary, 2012) Plagiarism: “the process of taking another person’s work, ideas, or words, and using them as if they were your own” (Macmillan Dictionary, 2012) You will be asked to review a variety of sources of information when completing assignments for this course. It is important that you acknowledge these sources of information appropriately in your written assignments and verbal presentations. If you are quoting a source directly (using the words in the source, not your words) you must indicate this by using quotation marks, as in the definitions above, and by including a citation to the reference from which the quote was extracted. There is nothing wrong with including quotes in your assignments, but you are expected to put them in quotation marks and cite them appropriately. If you use the words of someone else, but do not put them in quotation marks, this is called plagiarism (even if you include a citation), and it violates the University’s academic code. Essentially, you are saying that you wrote these words, when that isn’t true, so you are lying to your instructor and classmates. In addition to using citations for quotations, you should use citations in the text to indicate instances where you have drawn on specific works of others in framing your answer or arguments. In using citations for this purpose, you acknowledge that the thoughts are not entirely yours, even though you may have expressed them in your own words. You should include a reference list at the end of your assignment. This list should include a complete description of all citations included in the text. References 1. Compact Oxford English Dictionary, Oxford University Press, 2012, http://oxforddictionary.com/definition/english (accessed on

August 21, 2012). 2. MacMillan Dictionary, 2012, http://www.macmillandictionary.com/dictionary/american (accessed on August 21, 2012). Plagiarism is an important element of this policy. It is defined as the presentation of another's writing or ideas as your own. Serious, intentional plagiarism will result in a grade of "F" or "N" for the entire course. For more information on this policy and for a helpful discussion of preventing plagiarism, please consult University policies and procedures regarding academic integrity: http://writing.umn.edu/tww/plagiarism/.

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Students are urged to be careful that they properly attribute and cite others' work in their own writing. For guidelines for correctly citing sources, go to http://tutorial.lib.umn.edu/ and click on “Citing Sources”. In addition, original work is expected in this course. Unless the instructor has specified otherwise, all assignments, papers, reports, etc. should be the work of the individual student. It is unacceptable to hand in assignments for this course for which you receive credit in another course unless by prior agreement with the instructor. Building on a line of work begun in another course or leading to a thesis, dissertation, or final project is acceptable. Disability Statement It is University policy to provide, on a flexible and individualized basis, reasonable accommodations to students who have a documented disability (e.g., physical, learning, psychiatric, vision, hearing, or systemic) that may affect their ability to participate in course activities or to meet course requirements. Students with disabilities are encouraged to contact Disability Services to have a confidential discussion of their individual needs for accommodations. Disability Services is located in Suite180 McNamara Alumni Center, 200 Oak Street. Staff can be reached by calling 612/626-1333 (voice or TTY). Mental Health Services: As a student you may experience a range of issues that can cause barriers to learning, such as strained relationships, increased anxiety, alcohol/drug problems, feeling down, difficulty concentrating and/or lack of motivation. These mental health concerns or stressful events may lead to diminished academic performance or reduce a student’s ability to participate in daily activities. University of Minnesota services are available to assist you with addressing these and other concerns you may be experiencing. You can learn more about the broad range of confidential mental health services available on campus via www.mentalhealth.umn.edu

ADDENDUM

*The MHA program uses the National Center for Healthcare Leadership (NCHL) Health Leadership Competency Model (v 2.1). Copyright 2006. NCHL. All rights reserved.

The number following the decimal indicates the level to which that competency is addressed, as further described in the Competency Model, available here: http://www.nchl.org/Documents/NavLink/NCHL_Competency_Model-full_uid892012226572.pdf.

    Addendum Page 1 of 3 

PubH 6564 (Private Purchasers of Health Care) NCHL* Competencies

Based on the course objectives listed in the Self-Study Year syllabus, the following competencies have been addressed by this course:

3 – Analytical Thinking 5 – Collaboration 6 – Communication Skills 7 – Community Orientation

11 – Information Seeking 17 – Performance Measurement 24 – Strategic Orientation

The course objectives are listed here with the corresponding NCHL competencies:

Learning Objectives – Lesson 1 Students should be able to:

1. Describe the origins and evolution of managed care organizations. 2. Explain the origins and nature of the "managed care backlash" of the 1990s, and

its influence on the ongoing development of the new facilitated consumerism. 3. Explain the factors influencing present employer demands on the health care

system, and the role these demands have played in changing America’s health care system.

NCHL 3.2; 3.3; 11.3 

Learning Objectives – Lesson 2 Students should be able to:

1. Describe the structure of the health insurance industry 2. Distinguish among different types of health plans and health plan products. 3. Understand premium cycles in the health insurance industry. 4. Explain how employers assess health plan performance and choose among health

plans. 5. Identify the major issues relating to health plan performance from the perspective

of employers and the public.

NCHL 5.1; 6.3; 11.3 

Learning Objectives – Lesson 3 Students should be able to:

1. Describe and contrast different approaches to performance measurement. 2. Discuss strengths and weaknesses of these approaches. 3. Discuss the role of risk adjustment techniques in measure construction and how

they are applied.

NCHL 5.1; 6.3; 11.3; 17.1 

Learning Objectives – Lesson 4 Students should be able to:

1. Discuss the nature of the contracting process from the health plan and provider perspectives.

NCHL 3.2; 3.3; 5.1; 6.3; 

11.3; 24.1 

    Addendum Page 2 of 3  

2. Describe how provider reimbursement levels are determined. 3. Discuss issues pertaining to tiered provider networks.

Learning Objectives – Lesson 5 Students should be able to:

1. Describe the basic reimbursement approaches used by health plans in contracts with providers, including their strengths and weaknesses.

2. Describe the different types of pay-for-performance initiatives being undertaken by health plans and purchasers.

3. Describe how these approaches differ in their design and the challenges they pose for implementation, in comparison to previous payment arrangements between health plans and providers.

NCHL 3.2; 3.3; 5.1; 6.3; 

11.3; 24.1 

Learning Objectives – Lesson 6 Students should be able to:

1. Describe the basic design features relating to bundled payment. 2. Discuss the obstacles to implementing bundled payment arrangements. 3. Discuss Medicare support for bundled payment.

NCHL 3.2; 3.3; 5.1; 6.3; 

11.3; 24.1 

Learning Objectives – Lesson 7 Students should be able to:

1. Describe the basic features of comprehensive, gainsharing payment arrangements between health plans and providers.

2. Discuss the obstacles to implementing comprehensive gainsharing arrangements.

3. Discuss Medicare support for gainsharing payment as evidenced by Alternative Care Organizations.

NCHL 3.2; 3.3; 5.1; 6.3; 

11.3; 24.1 

Learning Objectives – Lesson 8 Students should be able to:

1. Describe the most common practices used by health plans to support physicians in the delivery of care.

2. Explain the barriers to their effective implementation. 3. Assess the strength of the evidence supporting their effectiveness. 4. Describe recent trends in their use in conjunction with other efforts to influence

physician behavior.

NCHL 3.2; 3.3; 5.1; 6.3; 

11.3; 24.1 

Learning Objectives – Lesson 9 Students should be able to:

1. Describe the recent efforts to increase the amount and quality of information available to health care consumers about providers.

2. Discuss the responses of providers to these efforts. 3. Assess the evidence regarding the impact of comparative provider performance

data on consumer decisions, quality of care, and health care costs.

NCHL 5.1; 6.3; 11.3 

Learning Objectives – Lesson 10 Students should be able to:

1. Describe different approaches being used to support consumers in their choice of treatments.

2. Discuss the problems faced by employers and health plans in implementing decision aids.

3. Evaluate the evidence regarding the effectiveness of these decision aids. 4. Assess the challenges that low health literacy poses for informed consumer

decision making.

NCHL 5.1; 6.3; 7.1; 11.3; 

17.2 

Learning Objectives – Lesson 11 Students should be able to:

1. Describe the rationale for employer/health plan support for healthy lifestyle

NCHL 5.1; 6.3; 11.3; 17.1 

    Addendum Page 3 of 3  

programs. 2. Assess the strengths and weaknesses of different program designs. 3. Evaluate the evidence that these programs have been successful in achieving

their goals. 4. Discuss the impediments to the successful implementation of these programs.

Learning Objectives – Lesson 12 Students should be able to:

1. Explain the concepts of patient self-management and disease management in their different forms.

2. Discuss the various ways in which employers and health plans are supporting employees and plan enrollees in chronic illness management.

3. Assess the evidence of their effectiveness in various settings. 4. Describe the obstacles to the effective implementation, by payers and health

plans, of programs to support chronic illness management by consumers.

NCHL 5.1; 6.3; 11.3 

Learning Objectives – Lesson 13 Students should be able to:

1. Describe value-based benefit strategies and how they are being implemented. 2. Assess the strengths and weaknesses of these strategies from the perspectives

of employers and consumers. 3. Describe recent collaborative approaches to control community health care costs

and improve health.

NCHL 5.1; 6.3; 11.3