The Health Insurance Broker as Risk Manager some slides from July 25 lecture in Westborough, MA

1. The Health Insurance Brokeras Risk Managersome slides from July 25 lecture in Westborough, MA Gary Fradin gfradin@HealthInsuranceCE.com 508-878-3785

2. Lecture outlinePutting consumerism into Consumer Driven 1. The need to manage healthcare risks 2. Utilization risks (today’s focus) • Which tests? Preference-sensitive decisions 3. Employee risks • Who gets sick? Disease patterns by income, status 4. One tool for managing test and Rx risks • Out of 100 people like me…. 5. Treatment variation risks 6. Conclusion: the high deductible / self insured world

3. Our point of departure: Wennberg, Tracking Medicine, page 117 It is not the prices, it is the use of care – the volume – that matters more

4. Consumer DrivenPhysician Driven Government Driven 85% of medicine involves choices. Whose? Different risk management tools for each type • Consumer driven = consumer decides • Facilities … also treatments, tests, medications etc • Management tool: teach consumers how to decide • Test: sometimes disagree with your doc, gov’t recommendations • Fact / Value distinction • Fact: Vitamin D strengthens bones & stresses kidneys • Value: how to weigh facts. Risk averse? Conservative? Which effect more important to you?

5. Different risk management toolsNot today’s lecture • Physician driven: physician decides • Management tool: alter physician behavior • Managed care / Kaiser Permanente • Government driven: gov’t decides • VHA: excellent outcomes at lower costs • Mandates: e.g. free cancer screening ($ incentive) • Process: USPSTF, expert committee recommends, Medicare funds, private carriers follow Physician and Government Driven: Someone decides for you

6. Part 1:Americans spend more on healthcare than anyone else

7. Americans Get More of Almost EverythingOECD Health at a Glance 2011, OECD Health Data 2012

12. But Americans aren’t more satisfied‘Not feeling the benefits of high spending’ Khoury and Brown, 3/31/09, Gallup.com

13. Americans don’t enjoy better outcomes:Infant mortality ratesDeaths/1000 live births, OECD Health Data 2012

14. Life Expectancy at Birthibid

15. Life expectancy age 65, malesibid

16. Summary iJohn Wennberg, Dartmouth Med School, Tracking Medicine, page 4 Much of healthcare is of questionable value For example

17. Stress TestsFrom the American College of Cardiologychoosingwisely.org • 1. Don’t perform stress cardiac imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present. • 2. Don’t perform annual stress cardiac as part of routine follow-up in asymptomatic patients. • This practice may lead to unnecessary invasive procedures without any proven impact on patients’ outcomes. 

18. Back MRIsfrom American Academy of Family Physicians106,000 members; choosingwisely.org • Don’t do imaging for low back pain within the first six weeks, unless red flags are present. • …Imaging of the lower spine before six weeks does not improve outcomes, but does increase costs. Low back pain is the fifth most common reason for all physician visits.

19. And many more… ChoosingWisely has • 5 recommendations from each of • 26 medical societies = • 130 medical tests and procedures that patients should not get… According to the medical society whose members provide those services!

20. Part 2Utilization risksin a Consumer Driven world Preference-sensitive decision makingthe essence of consumer driven Which medical risks concern you? Which medical interventions appeal to you? How to make an informed decision? Ask the right questions and get useful information

21. Noise vs. Useful InfoWhat is this car’s gas mileage?(how many lives/1000 screened does this test save over 10 years?) Noise Useful Info 28 miles highway / 22 miles city • Very good gas mileage • 30% better than competitors • Highly rated for gas mileage • Most buyers recommend • Autobuyer.com rates ‘buy’ • > 350 miles on a tank of gas • Owners average less than $1000 in gas per year * • * compared to national average of $1800

22. Background • 1 million internal substances, functions or chemicals that we can measure, analyze and test Newman, Hippocrates’ Shadow, page 202 20,000/week Which to worry about? Which to get screened for? Which to take meds for?

23. Different kinds of tests • Screening: asymptomatic people, according to a calendar • Diagnostic: symptomatic people • Also public (population) health vs. individual decision: different perspectives

24. Some potential tests partial list of ‘A’ from WebMD • Abdominal MRI (look for tumors) • Abdominal Tap (screen for liver cancer) • Abdominal Ultrasound (liver, gallbladder, liver evaluation) • Acoustic reflect test (screening for hearing problems) • Activated Partial Thromboplastin Time (test of blood clotting) • Adrenocorticotropic Hormone test (check for problems in pituitary or adrenal glands)

25. Some cancer risksNational Cancer Institute and SEER Stat Fact Sheets40 different cancers listed Cancer TypeNew cases/yearDeaths/year Vulva 4,700 990 Testicular 7,920 370 Cervix 12,340 4,030 Stomach 21,600 10,990 Pancreatic 45,220 38,460 Thyroid 60,220 1,850 Kidney and renal pelvis 65,150 13,680 Colon 142,820 50,830

26. Some medical risks(thousands more) • Ankylosing Spondylitis • Osgood-Schlatter's disease • Dercum's disease • Uterine leiomyosarcoma • Tardive Dyskinesia • Lupus (various forms) • Gaucher’s disease • Male breast cancer 

27. Just because a test or treatment exists doesn’t mean you should have it!* * Even if free! Consumer Driven vs. Physician Driven vs. Government Driven

28. How to decideA 4-step programUseful info vs. Noise • Determine Starting Risk • Chance of a specific bad event without medical care • Determine Modified Risk • Chance of same specific event with medical care • Determine Treatment Benefit * (next slide) • Impact of medical care: Starting Risk – Modified Risk • Determine Treatment Risk(s) / Harms • Harms caused by the medical care

29. * 3 potential reasons for treatment benefits: • Better treatments • Earlier treatment of symptomatic people (due to more widespread education) • Early treatment of asymptomatic people, from screening

30. Starting Risk • Why you don’t wear a bike helmet when you walk

31. Case study #1Would you have this test?

32. Modified Risk:Does the test work well enough to have?

33. Treatment Benefits:Does the test work well enough to have?

34. Treatment Harms:Is the test too dangerous for you?

35. Summary:Would you have this test?

36. What is this test and condition? • Mammography for breast cancer • Benefit and risk data for 50 year old woman over 10 years

37. References • Starting Risk: Risk Charts, Woloshin, Journal National Cancer Institute, June 5, 2002 • Mammography Benefit: Otis Brawley est that mammography + better breast awareness reduces breast cancer mortality by 15 – 30%, various articles, American Cancer Society website, How We Do Harm • Mammography risks: US Preventive Services Task Force, Woloshin, JAMA, 2010

38. ‘big’ or ‘small’ impact‘good’ gas mileage • 1 in 100 - 150 heart attacks prevented is ‘major’, ‘significant’ or ‘big benefit’ • But .6 in 100 - 150 diabetes caused is ‘rare’, ‘infrequent’ or ‘minor’

39. Get numbers! But you need to ask the right questions to get the right numbers

40. Downsideof bad decision making, failure to get numbers (1) • Vioxx , painkiller ‘as good as aspirin with fewer stomach bleeds’ 1999 - 2005 • Merck settled, 2010, for • 20,000 heart attacks • 12,000 strokes • 3,500 deaths Voreacos, Merck paid 3,468 death claims, Bloomberg, 7/27/10 • May have caused up to 140,000 heart attacks Bhattacharya, Up to 140,000 heart attacks linked to Vioxx, New Scientist, January 2005

41. Downsideof bad decision making, failure to get numbers (2)Harris, Research ties diabetes drug to heart woes, NY Times, 2/19/10 • Avandia, $3.2 billion sales 2006 • US gov’t report: if all people taking Avandia switched to a safer drug, would avoid • 500 heart attacks per month • 300 heart failures per month • 304 people died during 3rd quarter, 2009 alone

42. Part 3: Modifying starting riskwho’s most likely to need medical care? • The impact of income / status / class • Whitehall ‘status’ • NEJM ‘class’ • Issue: focus risk management education and wellness programs at the people most likely to get sick • Not only the conditions most likely to cause illness

43. Sir Michael MarmotDirector of the Whitehall studiesglobetrotter.berkeley.edu/people2/marmot • Firstly, just looking at heart disease, it was not the case that people in high stress jobs had a higher risk of heart attack, rather it went exactly the other way: people at the bottom of the hierarchy had a higher risk of heart attacks. • Secondly, it was a social gradient. The lower you were in the hierarchy, the higher the risk. So it wasn't top versus bottom, but it was graded. • And, thirdly, the social gradient applied to all the major causes of death.

44. Marmot’s exampleRemember – this study was from 1970s – early 2000s • How many times have you called the telephone company, and, in exasperation, asked to speak to the person's supervisor? You do this because the discretion of the lower-status [and lower paid] person to make decisions is limited • Boss derides secretary for making mistakes, destroys her self confidence • ‘Underling’ given instructions by manager that are inefficient ‘I like reports this way’ – even if underling has better way to do it • Cleaner gets reprimanded for washing floors incorrectly… But bank president doesn’t get fired for making a bad loan!

45. Class – the ignored determinant of the nation’s healthNEJM, Sept 9, 2004 • Differences in rates of premature death, illness and disability are closely tied to socio-economic status • Unhealthy behavior and lifestyle alone do not explain the poor health of those in lower classes • There is something about lower socioeconomic status itself that increases the risk of premature death

46. Other examplesDrexler, The People’s Epidemiologists, Harvard Magazine, March 2006 • Smoking cessation attempts same for working class and higher class people. Success rates vary. Will power? Social supports? • Or because job so boring that lighting up only way to break the tedium?

47. Breast cancer survival ratesBouchardy et al, Social class is an important and independent prognostic factor of breast cancer mortality, International Journal of Cancer, Vol 119, Issue 5, March 2006 • In this study, we clearly demonstrate that breast cancer patients of low Socio-Economic Status have a significantly increased risk of dying as a result of breast cancer compared to the risk in patients of high SES. • Low SES patients were diagnosed at a later stage, had different tumor characteristics and more often received suboptimal treatment. • However, these important prognostic factors explained less than 50% of the overmortality linked to low SES.

48. ibid. Even after adjusting for all these factors, the risk of dying of breast cancer remained 70% higher among patients of low SES than that among patients of high SES.

49. Summary observationsDrexler, Harvard Magazine • ‘an individual’s health can’t be torn from context and history. We are both social and biological beings…. • and the social is every bit as real as the biological’

50. Back to Michael Marmot • The social gradient applied to all the major causes of death -- to cardiovascular disease, to gastrointestinal disease, to renal disease, to stroke, to accidental and violent deaths, to cancers that were not related to smoking as well as cancers that were related to smoking -- all the major causes of death.