Health Care Coalitions Can Effect System Change
Michael Thompson likes to hit the ground running. In his new role as president and CEO of the National Business Coalition on Health for just a few days, he’s already going full steam ahead with an ambitious agenda to tackle many of the challenges facing the health care industry.
He believes, for example, that the administration of occupational and nonoccupational injuries and illnesses should be integrated wherever possible to provide more effective care for patients.
Among his other goals are: fostering an independent system to evaluate returns-on-investment to identify truly effective health care strategies, helping employers generate employee engagement in their own health care decision-making, incorporating community resources into wellness campaigns, and creating a strong infrastructure on the topic of well-being.
“We really want to make sure the focus of NBCH is leveraging the collective efforts of the coalitions,” Thompson said. “This coalition infrastructure is an unbelievable opportunity to accelerate the change that we, as employers, or the country is looking for.”
The National Business Coalition on Health is a 24-year-old not-for-profit company consisting of 51 purchaser-led health care coalitions. Described as a “coalition of coalitions,” the organization “provides expertise, resources, and a voice to its member coalitions across the country and represents each community coalition at the national level,” according to its website.
Thompson, who was named to the top post after spending 20 years with PricewaterhouseCoopers LLP where he was a principal, says that by getting the coalitions to work in a coordinated manner, he hopes to make meaningful inroads in the delivery of health services and reform of the nation’s health care system.
Advancements in the medical delivery system are happening so rapidly it’s difficult for organizations to know what they are, let alone how effective each is. It’s an area where a coordinated effort can allow the coalitions to more easily reveal the strategies that are working best.
“One of the weaknesses in the system today is too often people will tell you what their ROI is, but it’s all self-reported based on their own analysis,” Thompson said. “We need a system that’s more accountable and leads to independent evaluation so we can share that and accelerate the success of those delivering results and cause others to look seriously about making improvements.”
“There’s a lot of movement underway to start to change the way we pay for and deliver and even the way we organize around health care and provide value based care.” — Michael Thompson, president and CEO, National Business Coalition on Health
Such a system would allow the coalitions to support those organizations and strategies that are most effective, and it would help people to become healthier. “What could be healthier to the system than a system that’s accountable?” Thompson said. “We need to develop accountability and improvement that will help us turn the corner in health care.”
Reform of the health care delivery system involves many players, including employers. One of the most pressing issues involved is the affordability of health care — or lack thereof.
“There’s a lot of movement underway to start to change the way we pay for and deliver and even the way we organize around health care and provide value based care,” Thompson said.
“It’s incumbent upon us to figure out how to get the multiple players on the same page. It won’t happen overnight, but you’re already seeing a lot of activity around bundle payments, accountable care organizations in both the public and private sectors. Coalitions become very important to engage stakeholders to rationalize that in the community and NBCH needs to keep that broader picture in mind and facilitate and support the development of that.”
Wellness and Integration
The idea of wellness is being challenged and criticized within the health care industry, Thompson says. He believes the coalitions can help by integrating them into local communities.
“Wellness and population health is a local issue, it’s not limited to the four walls of work,” Thompson said. “Many employers are in multiple communities. We must find a way to help them connect in the communities.”
Along with wellness, Thompson supports what he says is the emerging issue of well-being. Where wellness refers to encouraging people to develop better habits, well-being is a broader concept.
“Well-being is enabling people to be the best they can be so they can thrive in their lives and perform optimally in their chosen work,” Thompson explained. “Well-being is a much higher order conversation, and it doesn’t start and stop with a health risk assessment.”
It also does not necessarily start and stop within the U.S. but can involve any areas of the world. Companies that are global should focus on well-being and integrate it into their cultures, Thompson said.
He endorses the idea of integration overall, including occupational and nonoccupational injuries and illnesses.
“Good health is good health. Good safety is good safety. How do you separate where work ends and life starts? The two are very much intertwined,” Thompson said. “The laws around workers’ compensation are certainly siloed and the processes are siloed, but companies, when they step back, have to deal with the administrative arm on a silo basis but more holistically if they are looking to enhance wellness or health.”
One area that deserves a more holistic approach is mental health. Beyond providing care to people who have mental illnesses are issues related to the stigma associated with it. Increased access to mental health care could help improve employees’ overall health and cut costs for payers.
“What’s even more concerning is in many ways it’s getting worse because we are getting used to the idea that if people want [mental health] services they should go out of network … that’s not sustainable or legal,” Thompson said. “If we can create a system with a more holistic view on treating the whole person, everybody wins, including those paying the bills … it’s one of the areas I’d describe as low hanging fruit.”
Hospitals Struggle with Security Risks
A growing number of health care facilities are foregoing armed security because of insurance carriers’ concerns.
Instead, some facilities are equipping security personnel with intermediate-level weapons, such as handcuffs, TASERs, batons and pepper spray.
“The cost and availability of insurance is almost certainly a factor in the decision,” said Jeff Young, a spokesperson for the International Association of Hospital Security and Safety, and executive director, Lower Mainland Integrated Protection Services in British Columbia.
“Since pepper spray and Tasers are less lethal than firearms, they’re less risky from a liability standpoint … but they’re less effective against an assailant with a gun.” — Michael DuBose, senior vice president, workforce strategies practice, Marsh Risk Consulting
“If insurance coverage isn’t available, the corporation might not be willing to assume the risk on its own.”
Some carriers “take a negative stance on arming staff,” said Michael DuBose, a senior vice president with Marsh Risk Consulting’s workforce strategies practice, particularly internal security staff (as opposed to contracted security personnel, such as off-duty police).
In health care facilities, as in schools, “if you go ahead and arm your staff, you may find out your carrier will drop you or boost your premiums.”
“Since pepper spray and Tasers are less lethal than firearms, they’re less risky from a liability standpoint,” said DuBose.
But there’s a tradeoff. “They imply less liability and require less training, but they’re less effective against an assailant with a gun.”
Shootings at hospitals are, unfortunately, not rare.
In February, an injured man seeking aid fired a bullet into a door at the Reston Hospital Center in Northern Virginia and then fired another bullet once inside the hospital. Medical personnel eventually convinced him to lay down his gun.
In December, a Los Angeles police officer shot and killed a patient at the Harbor- UCLA Medical Center in Torrance, Calif. when he attacked officers and reached for an officer’s gun, according to reports. The patient, arrested earlier in the day, fought ferociously with police at the hospital. Officers tried using a Taser on the patient first to no avail.
That was also a case last summer in Houston, when police were unable to subdue a combative patient with a Taser, according to reports.
The patient, who struggles with mental illness, was shot in the chest by the police, working off-duty as hospital security; that shooting was not fatal.
Determining the Risk
DuBose said many facilities want to equip personnel with some means of protection for themselves and the public.
“They conduct an annual security risk assessment that considers, among other things, the prevalence of gun crime and violence in the neighborhood and the facility’s own history of violence. Then they ask, ‘Is that the right stance for our facility?’ ”
“How many local police officers would feel comfortable pursuing someone into a central sterilization area where there are toxic or flammable gasses?” — Dr. Jeffrey Ho, Hennepin County Medical Center
For example, he said, “firearms may have a role in a Level 1 trauma center that treats victims of violence, mental health patients and inmates. But you have to question very closely the need to arm a small community hospital that doesn’t have that same degree of risk.”
Barry Kramer, senior vice president, Chivaroli & Associates, a health care insurance broker, said that armed security in health care settings is more of a risk management concern than a coverage issue.
“It would be highly unusual for our clients’ liability policies to exclude claims involving security guards, whether or not they’re armed with guns,” he said.
He said many health care risk managers are not equipped to manage exposures associated with licensing and certifying guards or registering the facility’s own firearms.
For facilities that lack the bandwidth to manage, train and track certifications for in-house security staff, Kramer said,third-party vendors, such as local law enforcement or private security companies, can be contracted, since they have firearms experience as well as liability insurance coverage.
Jeffrey Ho, an emergency room physician in a busy Level 1 trauma center at the Hennepin County Medical Center in Minneapolis and a sworn deputy sheriff in neighboring Meeker County, cautioned that armed personnel must be thoroughly trained to work in a health care setting.
“How many local police officers would feel comfortable pursuing someone into a central sterilization area where there are toxic or flammable gasses?” he asked.
“How many would feel comfortable discharging a firearm or Taser, which generates an electric spark? Any weapon can be dangerous in those environments.”
Train for the Worst
“Prevention,” said Young, “is the first line of defense in potentially violent situations. You have only seconds or at most minutes to de-escalate a situation before it can go very wrong.”
Failure to recognize a potentially violent situation and take precautionary steps can lead to tension between security and clinicians.
Training – not just in lockdowns and active shooter drills but in de-escalation techniques and identifying potentially dangerous situations – is essential to preserving safety, said Ho.
Failure to recognize a potentially violent situation and take precautionary steps can lead to tension between security and clinicians, said Ho.
When his facility first undertook a comprehensive violence prevention program nine years ago that included debriefings after forceful intervention, “clinical staff pointed the finger at security and said, ‘How dare you put that patient on the floor, handcuff him, spray him with pepper spray?’ And security would say, ‘The situation was out of hand before we got there. What did you want us to do?’”
Looking back, he said, most situations never should have escalated to violence.
Eventually the entire staff – clinicians, therapists, food service and administrators – were trained to recognize stresses and talk down problems from flash points, which worked well in many but not all situations.
“Maybe the patient was hungry or thirsty or needed a blanket. Failure to recognize a simple problem often led to acting out.”
Greater force may be called for with intoxicated people, he said.
Although security seldom if ever initiates violence but rather responds to aggression, patients may perceive the situation otherwise and pursue litigation, Young said.
“Especially in a psych setting, patients may turn it around,” said Jane Lipscomb, professor at the University of Maryland Schools of Nursing and Medicine, and author of “Workplace Violence in Health Care: Recognized but not Regulated.”
“They can say, ‘I was defending myself because the staff member was being abusive,’ and the staff member is put on administrative leave.”
The most effective environments value staff safety, she said, and see that it’s inextricably linked to patient safety and quality of care.
Compounding: Is it Coming of Age?
The WC managed care market has generally viewed the treatment method of Rx compounding through the lens of its negative impact to cost for treating chronic pain without examining fully the opportunity to utilize “best practice” prescription compounds to help combat the opioid epidemic this nation faces. IPS stands on the front lines of this opioid battle every day making a difference for its clients.
After a shaky start cost-wise, prescription drug compounding is turning the corner in managing chronic pain without the risk of opioid addiction. A push from forward-thinking states and workers’ compensation PBMs who have the networks and resources to manage it is helping, too.
Prescription drug compounding has been around for more than a decade, but after a rocky start (primarily in terms of cost), compounding is finally coming into its own as an effective chronic pain management strategy – and a worthy alternative for costly and dangerous opioids – in workers’ compensation.
According to Greg Todd, CEO and founder of Integrated Prescription Solutions Inc. (IPS), a Costa Mesa, Calif.-based pharmacy benefit manager (PBM) for the workers’ compensation and disability market, one reason compounding is beginning to hit its stride is because some states have enacted laws to manage it more effectively. Another is PBMs like IPS have stepped up and are now managing compound drugs in a much more proactive manner from an oversight perspective.
By definition, compounding is a practice through which a licensed pharmacist or physician (or, in the case of an outsourcing facility, a person under the supervision of a licensed pharmacist) combines, mixes, or alters ingredients of a drug to create a medication tailored to the needs of an individual patient.
During that decade, Todd explains, opioids have filled the chronic pain management needs gap, bringing with them an enormous amount of problems as the ensuing addiction epidemic sweeping the nation resulted in the proliferation and over-consumption of opioids – at a staggering cost to both the bottom line and society at large.
As an alternative, compounded topical cream formulations also offer strong chronic pain management but have limited side effects and require much reduced dosage amounts to achieve effective tissue level penetration. In fact, they have a very low systemic absorption rate.
Bottom line, compounding provides prescribers with an excellent alternative treatment modality for chronic pain patients, both early and late stage, Todd says.
Time for Compounding Consideration
That scenario sets up the perfect argument for compounding, because for one thing, doctors are seeking a new solution, with all the pressure and scrutiny they’re receiving when trying to solve people’s chronic pain problems using opioids.
Todd explains the best news about neuropathic pain treatment using compounded topical analgesic creams is the results are outstanding, both in terms of patient satisfaction in VAS pain reduction but also in reduction potentially dangerous side effects of opioids.
The main issue with some of the early topical creams created via compounding was their high costs. In the early years, compounding, which does not require FDA approval, had little oversight or controls in place. But in the past few years, the workers compensation industry began to take notice of the solid science. At the same time, medical providers also were seeing the same science and began writing more prescriptions for compounding – which also offers them a revenue stream.
This is where oversight and rigor on the part of a PBM can make a difference, Todd says.
“You don’t let that compounded drug get dispensed when you’re going to pay for it without having a chance to approve it,” Todd says.
Education is Critical
At the same time, there is the growing, and genuine, need to start educating the doctors, helping them understand how they can really deliver quality pain management to a patient without gouging the system. A good compounding specialty pharmacy network offering tight, strict rules is fundamental, Todd says. And that means one that really reaches out to work with the doctors that are writing the prescriptions. The idea is to ensure that the active ingredients being chosen aren’t the most expensive sub-components because that unnecessarily will drive the cost of overall compound “through the ceiling.”
IPS has been able to mitigate costs in the last couple years just by having good common sense approach and a lot of physician outreach. Working with DermaTran Health Solutions and its national network of compounding pharmacies, IPS has been successfully impacting the cost while not reducing the effectiveness of a compounded prescription.
In Colorado, which has cracked down on compounding profiteering, Legislative change demanded no compound could be more than $350.00 period. What is notable, in an 18-month window for one client in Colorado, IPS had 38 compound prescriptions come through the door and each had between 4 and 7 active ingredients. Through its physician education efforts, IPS brought all 38 prescriptions down 3 active ingredients or less. IPS also helped patients achieve therapeutic success (and with medical community acceptance). In that case, the cost of compound prescriptions was down to an average of $350, versus the industry average of $788. Nationwide IPS has reduced the average cost of a compound prescription to $478.00.
Todd says. “We’ve still got a way to go, but we’ve made amazing progress in just the past couple of years on the cost and effective use of compound prescriptions.”
For more information on how you can better manage your costs for compound prescriptions, please call IPS at 866-846-9279.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with IPS. The editorial staff of Risk & Insurance had no role in its preparation.