2018 Company Members

Transcription

1 2018 Company Members

2 2018 Company Members

3 2018 Company Members

4 The leading resource for Houston employers dedicated to providing health care at a sustainable cost while improving the quality and experience in their delivery

5 LinkedIn Social Media Search Houston Business Coalition on Health; Request to join group; Approval in 1 day Benefits: HBCH info, relevant news and articles input & output, upcoming events Twitter Find Articles & links in healthcare and benefits Local and national info HBCH news, events

6 Thank You to Our Sponsors

7 Agenda 8:30-8:40 Welcome & Introductions 8:40-9:15 Obesity as a Disease Impact & Implications 9:15-9:30 A Physician's Perspective 9:30-9:50 A Health Plan s Perspective 9:50-10:05 Break 10:05-10:25 A Need to Improve ICD-10 Coding 10:25-11:00 Provider Panel Discussion 11:00-11:30 Employer Panel Q&A 11:30-11:50 Houston NDPP Update

8 Collective Influence evalue8 Health Plan Benchmarking Leapfrog Group Health System Benchmarking Specialty Pharmacy SWAT Houston Employer NDPP

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10 Obesity as a Disease vs. a Condition: Employer Impact and Implications BRUCE SHERMAN, MD CHIEF MEDICAL OFFICER NATIONAL ALLIANCE OF HEALTHCARE PURCHASER COALITIONS

11 Obesity trends among US adults

12 Obesity-related comorbidities Nearly 21% of healthcare costs are spent on obesity-related conditions

13 Annual healthcare costs by BMI and diabetes with diabetes without diabetes Cawley J, et al. Pharmacoeconomics 2015

14 Condition-related medical cost drivers actual client data Clinical Condition Enrolled population >71,000 individuals How well does this report capture obesity-related healthcare costs??? Client Incurred Jan Dec. 2017; paid thru Mar. 2018

15 Obesity adds to Workers Compensation costs Dollars per claim Lost workdays per claim Indemnity claims costs Medical claims costs Lost workdays 0 < Obese employees have twice the number of WC claims than non-obese WC component costs are higher for obese individuals and increase with higher BMI OSTBYE T, ET AL. OBESITY AND WORKERS COMPENSATION COSTS. ARCH INT MED,

16 Obesity employer total cost analysis Henke RM, et al. J Occ Environ Med,

17 Employer costs of obesity include more than healthcare Workplace accommodations for overweight/obese individuals Hiring concerns related to physical work capabilities Turnover issues for individuals in physically demanding jobs 17

18 Recognition will likely help support: reimbursement for anti-obesity treatment implementation of weight loss strategies efforts to reduce risk of CV disease, diabetes and other obesity-associated comorbidities

19 Smoking vs. obesity an intriguing comparison Smoking Obesity Behavior or disease? Behavior with addiction potential Behavior with addiction potential Stress as a mediator Potentially significant Potentially significant Social component Yes Yes Associated medical complications Yes Manufacturer s role Significant contributor Significant contributor Physician s role Employer s role Guidance resource and pharmacotherapy support Benefits offerings / workplace considerations Yes Guidance resource and pharmacotherapy support Benefits offerings / workplace considerations Community role Significant Opportunities exist

20 Employer benefits approach to obesity As BMI increases so does the eligibility for intervention methods 1,2 BMI Category > 40 Disease Risk Low Increased High High Very High Very High Extremely High Nutrition Counseling Ensure Appropriate Physical Activity Behavioral Weight Management Medication Surgery 1. American Gastroenterological Association. 2002; 2. Wadden and Stunkard, eds

21 Most employers feel that current obesity management practices haven t been particularly effective 50% Employer perceptions of the overall effectiveness of their obesity management strategy 40% 30% 20% 10% 0% Not at all effective Somewhat effective Extremely effective Don t know Source: ACTION Study,

22 and employees seem to feel the same way Source: ACTION Study,

23 Weight management is a community issue needing a community-level focus 23

24 What can employers do? The main points of leverage for employer impact: Implement supportive benefit designs that encourage healthy behaviors and address well-being priorities Promote a culture of health at work Provide workplace environment support for healthy lifestyles Support community and family connections 24

25 Factors that stress people most intensely Financial Situation Work Changes Work Schedule Work Relationship Influence/Control Over Work Personal/Family Commitments Health Condition of Family Personal Health Condition Family Changes 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% What does this mean for prioritization of personal health issues? The Consumer Health Mindset Survey. Aon/NBGH/the futures co.,

26 Summary Is obesity a disease or a condition? The debate continues Irrespective of categorization, the health impact is significant Employers can derive benefit by providing meaningful resource support for weight management This is not an individual problem it a major societal concern

27 Resources Centers for Disease Control and Prevention: American Heart Association: Resources for Success State of Obesity-Texas (RWJF): Novo Nordisk: Obesity Action Coalition:

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29 By Gary J. Sheppard, M.D. Houston Academy of Medicine Vice President

30 There is no single or simple solution to the obesity epidemic. It s a complex problem and there has to be a multifaceted approach. Policy makers, state and local organizations, business and community leaders, school, childcare and healthcare professionals, and individuals must work together to create an environment that supports a healthy lifestyle.

31 Corpulence is not only a disease itself, but a harbinger of others Hippocrates 400 BC

32 Definitions Obesity: Body Mass Index (BMI) of 30 or higher. Body Mass Index (BMI): A measure of an adult s weight in relation to his or her height, calculated by using the adult s weight in kilograms divided by the square of his or her height in meters.

33 Prevalence estimates reflect BRFSS methodological changes started in These estimates should not be compared to prevalence estimates before *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) 30%.

34 Summary No state had a prevalence of obesity less than 20%. 3 states and the District of Columbia had a prevalence of obesity between 20% and <25%. 22 states and Guam had a prevalence of obesity between 25% and <30%. 20 states, Puerto Rico, and Virgin Islands had a prevalence of obesity between 30% and <35%. 5 states (Alabama, Arkansas, Louisiana, Mississippi, and West Virginia) had a prevalence of obesity of 35% or greater. Prevalence estimates reflect BRFSS methodological changes started in These estimates should not be compared to prevalence estimates before

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37 What do they need? Peer support- Weight Watchers, TOPS Convenient food choices- Jenny Craig, NutriSystem Low-calorie, limited food options- Meal replacement (OPTIFAST, HMR, Medifast, Robard)

38 Treatments BMI BMI BMI BMI BMI 40+ Diet, PA, & Behavioral Therapy With Comorbidities With Co-morbidities Pharmacotherapy With Co-morbidities Weight Loss Surgery With Comorbidities With Comorbidities Consider pharmacotherapy only if a patient has not lost 1 pound per week after 6 months of combined lifestyle therapy. The + represents the use of indicated treatment regardless of comorbidities.

39 Listen to patient cues about hunger, satiety, and side effects to drive weight management. Continue to encourage healthy lifestyle behaviors as weight loss medications should serve an adjunct to these. If a patient has a superior response to medication (5-10% of total body weight loss), continue medications indefinitely. Advise women of childbearing age about discontinuing medication prior to conception.

40 Just because we have an ICD-10 code, obesity treatment hasn t been made easier. Decrease in obesity can prevent or enhance treatment of other serious cardiovascular, metabolic and musculoskeletal conditions. Management of obesity is a multi-factorial, chronic, individualized treatment. Surgery is not the answer for all patients, but can be beneficial in some patients. Insurance coverage for nutrition consultation, medications, weight programs and surgery is needed. Always think Team Approach for obesity therapy.

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42 A Health Plan s Perspective on Obesity Challenges & Opportunities JUNE 12, 2018 ROBERT MORROW, MD, MBA MARKET PRESIDENT, HOUSTON AND SOUTHEAST TEXAS A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield

43 43 THE STATISTICS ARE DRAMATIC Health care spending in the United States now tops lives with a chronic condition that is largely preventable 2 $2.9 trillion annually 1 1 in 2 Americans Chronic conditions account for 3 out of 4 U.S. dollars spent on health care 3 In one study, more than 60% of patients said they had no idea about the cost of their care until they received a bill 4 1 Centers for Medicare and Medicaid Services Office of the Actuary, September Centers for Disease Control and Prevention, : 17th Annual Towers Watson/National Business Group on Health Employer Survey on Purchasing Value in Health Care 4 Institute of Medicine, September

44 Top 5 Most Expensive Chronic Conditions Oncology Diabetes Musculoskeletal Health Conditions Respiratory

45 Challenges Workplace environments can pose challenges. Weight is a private and sensitive matter, which can make outreach difficult. Lack of obesity awareness and education can hinder engagement levels. Weight loss is challenging to accomplish which requires long-term coaching and engagement. Few physicians formally diagnose obesity through CPT codes. Chronic health conditions receive a greater emphasis than obesity 45

46 Opportunities Proactive: Health Risk Assessments Biometric screenings Wellness coaching Incentives / Disincentives Onsite clinical nurse Workplace assessment Reactive: Weight loss programs Bariatric 46

47 Identifying Members Through Claims A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

48 Proactive Identification of Members < < < Supported by Clinical Intelligence Rules > > > 1 2 Collect Claim History with Predictive Modeling Historical claims data is included in a scheduled predictive modeling run Identify Current Member Activity using real time referrals initiated by: Emergency room visits Preauthorization/notification Self referral Provider referrals Human Resources staff Pharmacy Data 24/7 Nurseline 3 Member Stratification Complex Catastrophic Care High-Risk Multiple Diseases Moderate-Risk Low-Risk Well

49 ALL GAPS MATTER Just some of the hundreds of gaps Preventive Gaps Lifestyle Gaps Lack of immunizations, mammograms, cervical screenings, colonoscopies Physical inactivity / poor nutrition / BMI>=25 Tobacco use Abnormal cholesterol Psychosocial Gaps Positive depression screen Inadequate financial, family or other resources Cultural or religious barriers Knowledge Gaps Condition-Specific Gaps No emergency action plan in place for asthma, or conditionspecific screenings done Member not following physician's treatment plan Medication Compliance Member does not understand need to track blood pressure readings or how to read No beta blocker use with Coronary Artery Disease diagnosis Member does not know how to use peak flow meter Diabetic not taking diabetic meds Asthmatic not on controller meds

50 Proactive Approaches for Employers A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

51 What is the most clinically and financially effective way to manage an illness? To prevent

52 A Suite of Wellness Options ENGAGING EVERYONE Blue Points SM ondemand client website Healthy Worksite consultation* Personalized member communications** Fitness device integration CLIENT REPORTING Weekly utilization reporting Aggregate and member-level reporting WORKSITE WELLNESS Events and seminars* Health fairs* Monthly Challenge competitions** Wellness coordinators* WELLNESS COACHING Dedicated coaching Goal-setting tools Online and telephonic support MEMBER WEB PORTAL Well ontarget portal AlwaysOn mobile app Self-directed courses Trackers Health articles Interactive Symptom Checker Fitness Program Social networking Text messaging ASSESSING HEALTH Health Assessment Personal Wellness Report Biometric screenings* One-on-one coaching *Buy-up dependent **Available with BCC EnhancedSM Blue Points Program Rules are subject to change without prior notice. See the Program Rules on the Well ontarget Member Wellness Portal at wellontarget.com for further information 52

53 Solving for Obesity in the Workplace A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

54 The Mug Experiment Class A Given a coffee mug at the beginning of class, and then at the end of class, offered to switch mug for a bar of Swiss chocolate. 89% Chose Coffee Mug Class B Given a bar of Swiss chocolate at the beginning of class, and then at the end of class, offered to switch for the mug. 10% Chose Coffee Mug Class C Offered the choice between a coffee mug and a bar of Swiss chocolate at the beginning of class. 59% Chose Coffee Source: Kahneman, Thinking Fast and Slow, 2011

55 Incentive Research People feel loss twice as much as they feel gain. Reframing a question in terms of a loss instead of a gain changes the 55

56 Incentives are

57 Chocolate vs Radish Experiment The set up: a room full of recently baked chocolate chip cookies, and a basket of radishes. Group A: Eat Radishes (while not eating cookies) Group B: Eat Cookies Try to solve an unsolvable tracing puzzle

58 Results Time before giving up Radishes: 8 minutes Cookies: 19 minutes Attempts before giving up Radishes: 19 attempts Cookies: 34

59 Diets Don t Work. Lifestyle Changes Do. The Science of Ego 59

60 Weight Loss Program Airline Client Results NS Classes 21,786 Participants 80%+ Completion Rate >155,000 lbs Lost So Far 9 lbs Avg 10-Week Weight Loss >10,000 participants lost more than 5% body weight 65% Lowered Diabetes Risk 39% Metabolic Syndrome (MetS)

61 Weight Loss Program Success at a University System ( ) 45,000+ lbs Lost and counting. Participants averaged a 10 lb. weight loss at 10 weeks in the program. 60% 5,000+ Participants MetS

62 Weight Loss Program Real world clinical results with employers, published in two peer-reviewed journals Journal of Metabolic Syndrome and Related Disorders 1 Journal of Occupational and Environmental Medicine 2 Metabolic Syndrome -50.7% Type II Diabetes Risk -55% Blood Pressure Risk -50% Losing 5%+ of bodyweight -44% 1. Evaluation of a Voluntary Work Site Weight Loss Program on Metabolic Syndrome. Conrad P. Earnest, PhD; Timothy S. Church, MPH, MD, PhD. October Issue 2015 (N=3880) 2. Evaluation of a Voluntary Work Site Weight Loss Program on Hypertension. Conrad P. Earnest, PhD; Timothy S. Church, MPH, MD, PhD. December Issue 2016 (N=5988)

63 Quality Bariatric Surgery 32% lower ER visit rate 21% lower Readmission rate 48-73% lower Surgical site infection rate 29% savings overall $4,300 savings gastric banding $3,200 savings gastric sleeve $4,900 savings gastric roux-en-y All savings results, BCBSA data; BDC+ eligible facilities vs. relevant comparison group. Results based on most recent designation cycle for each specialty. Savings based on total episode cost. To learn more about Blue Distinction Centers for Specialty Care, please visit or contact your Local Plan. 1. All quality results, BCBSA data; BDC/BDC+ eligible facilities vs. relevant comparison group; results based on most recent designation cycle for each specialty. 2. AHRQ-sponsored Health Cost and Utilization Project (HCUP), 2014 (reflects all privately insured).

64 Consider Covering Bariatric Surgery Total diabetes medication costs decreased significantly among surgery patients. Courcoulas, JAMA Surgery 2015 Bariatric surgery with lowlevel lifestyle intervention resulted in more disease remission than did lifestyle intervention Klein, obesity VOLUME 19 NUMBER 3 March

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67 INSIDE Obesity Management Houston Business Coalition on Health Luigi Meneghini, MD, MBA Professor, UT Southwestern Medical Center Executive Director, Global Diabetes Program, Parkland Health & Hospital System

68 INSIDE Quality Improvement Project Program Overview: Improve the clinical management of patients with obesity Baseline data collection & analysis from EMR Quality Improvement (QI) training & education Three regional CME/CE conducted by ADA, KOL & clinical site faculty Patient education Ongoing data collection & analysis Publications & presentations

69 Agreed with sponsoring partners to focus attention on overweight/obese patients with pre-diabetes RATIONALE Intervention on weight directly impacts risk of developing type 2 diabetes Diabetes Prevention Program (DPP) proven intervention for delaying type 2 diabetes through weight loss & lifestyle modifications Delaying type 2 diabetes can have beneficial impact on morbidity & fiscal burden of disease Challenge: Most patients with pre-diabetes have not been identified

70 Baseline data collection & analysis

71 Care Quality: EHR Landscape Survey Analyzed 91,574 patients with 454k encounters over 36 months Age, gender Medications Population sample: Age with PCP visit < 18 months AND BMI c/w overweight OR Age 45 HbA1c, glucose, OGTT Nephropathy screening Height, weight, BMI ICD codes BP, lipid panel, LFTs Ethnicity/race, education Limitations Lack data on Diet, exercise, patient adherence Some data/exclusion criteria incomplete, unhelpful, or un-curated

72 Population Demographics 35% Male / 65% Female Max: 90+ Seen: for 1-65 visits, median 4 56% Hispanic white, 27% Black, 10% Non- Hispanic white, 4% Asian Age Median: 53 Mean: 52 65% Insurance 14% 8% 7% 5% Min: 19 Charity Medicare Medicaid Commercial Self Pay

73 ICD Diagnoses Associated with Obesity (BMI 30) 43% 29% 28% have prediabetes by lab tests 28% 23% 65% 35% Only 6% have ICD obesity codes 6% Only 5% have ICD prediabetes codes 5% 2%

74 ADA Criteria for Prediabetes/Diabetes Testing in Undiagnosed Adults 79% 97% of undiagnosed sample eligible for testing; 79% tested 23% of undiagnosed sample meets ADA criteria for prediabetes 21% 23% 14,598 65% 35% % testing in undiagnosed, eligible patients % prediabetes in all undiagnosed patients

75 Diabetes Screening at Parkland Approximately 61% of Parkland COPC patients without diagnosed diabetes/prediabetes have been screened in the past 2 years We are doing BETTER than the National average (53%) Of Parkland patients screened Diabetes: 49% normal glycemic status 38% Prediabetes 13% Diabetes Although we are doing a good job, nearly half (46%) of COPC patients we have not screened in clinical practice have either prediabetes or diabetes Determined by inviting COPC patients in for a screening study

76 PHHS EPIC Population 1 Is patient part of Diabetes Registry? NO 2 Glycemic Risk Surveillance (Bowen Risk Tool) LOW RISK Pool HIGH RISK Pool 3 Does patient have pre-dm by labs (A1C/FPG) & is not on anti- DM meds* &/or obesity by BMI? Glycemic Risk Surveillance/ Re-screening (Bowen Tool) YES DIABETES REGISTRY 6 PRE- DIABETES REGISTRY Alert COPC provider & staff Assign appropriate ICD10 code (R73.09 for PDM) (E66.x for obesity) [automated] to Problem List OBESITY REGISTRY Diabetes Pre-DM No further action Automated result reporting to ordering provider Normal Diabetes Prevention Program Intervention (Education materials, local COPC intervention, community program [YMCA]) Population Health DM Screening (Vickery) Screening Outreach by Population Health Team Visit-Based DM Screening BPA (Garland) Provider Order Order screening test (Random A1C or fasting plasma glucose) * With the exception of metformin, GLP-1 RA, pioglitazone or acarbose 4

77 Challenges with ICD coding of obesity & prediabetes population No automated option for patients identified with condition ICD code entry would need to be manually entered Pre-diabetes & overweight/obesity are dynamic conditions Will probably change over time making the prior ICD code incorrect Establishing registries for the condition based on A1C scores (prediabetes) and BMI category makes sense Registries can be periodically updated to add/remove patients

78 Preliminary Pre-Diabetes Registry Stand-Up Laboratory-based A1C within past 2 years ( %) Exclude use of FPG or OGTT Exclude anyone in the diabetes registry No antidiabetic medications with exception of metformin

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80 OBESITY REGISTRY Has patient had PCP visit in past 18 months? YES Is patient part of Diabetes Registry? NO MODIFIED OBESITY REGISTRY Alert COPC provider & staff No further action Identify high DM risk patients (EPIC tool, ADA questionnaire, Bowen study) Diabetes Normal Assign appropriate ICD10 code (R73.09) Pre-DM Interpret test result Order screening test (Random A1C or fasting plasma glucose) YES Is patient at high risk for DM or pre- DM? PRE-DIABETES REGISTRY Diabetes Prevention Program Intervention (Education materials, local COPC intervention, community program [YMCA])

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82 Houston Employer DPP 2018 Pilot

83 TOP 10 REASONS FOR PARTICIPATING IN THE HOUSTON EMPLOYER DIABETES PREVENTION PROGRAM (DPP) PILOT

84 TOP 10 REASONS FOR PARTICIPATING IN THE HOUSTON EMPLOYER DIABETES PREVENTION PROGRAM (DPP) PILOT

85 CDC Diabetes Prevention Program Curriculum Eligibility 35% BMI & Blood Test, 65% BMI & CDC Screening Evaluation Initial 6-month phase, 16 sessions over weeks Second 6-month phase, 6 sessions delivered monthly Regular opportunities for direct, individual or group interaction Body weight collected at in-person sessions & data elements recorded Body weights objectively obtained for virtual sessions Providers evaluated on objective criteria, e.g. sessions attended, body weights obtained, physical activity, weight loss obtained, etc.

86 CDC Diabetes Prevention Program- Curriculum Weeks 1-26 Weeks Welcome to the DPP Welcome to the Second Phase Self-monitoring weight and food intake Healthy eating: taking it one meal at a time Eating less Making active choices Healthy eating Balancing thoughts for long-term maintenance Intro to physical activity Healthy eating with variety & balance Overcoming barriers to physical activity Handling holidays, vacations, and special events Balancing calorie intake and output More volume, fewer calories Environmental cues to eating and physical activity Dietary fats Problems solving Stress and time management Strategies for healthy eating out Healthy cooking Reversing negative thoughts Physical activity barriers Dealing with slips in lifestyle change Preventing stress Mixing up physical activity: aerobic fitness Heart health Social cues Life with type 2 diabetes Managing stress Looking back and looking forward Staying motivated

87 Houston DPP Participants Employer Employees City of Houston 22,000 DOW Chemical Friedkin Group KBR 3000 Harris Health 9300 Harris County 16,000 Latham & Watkins Noble Energy 1100 Rice University 3400 Total Lives Covered