As an employer are you educating your employees about the appropriate use of the Emergency Room, Urgent Care and Telemedicine?

One in five Americans will visit the Emergency Room (ER) at least once a year. Between one-third and one-half of all ER visits are for non-urgent matters.

Many conditions can be treated at Urgent Care centers. A recent review of the top 100 diagnosis codes from a self-insured employer revealed that 83 percent of them were in the top 100 diagnoses seen at a nearby urgent care center.

Unnecessary and inappropriate use of the ER causes multiple systemic issues and wastes scarce resources. The average cost for an ER visit is $1400 — compared to $125 for an urgent care visit.

Chronic conditions — which affect 45 percent of Americans — account for 75 percent of health care expenditures in the US. Diabetes, heart disease, asthma, and other chronic illnesses are also responsible for a large portion of ER visits. Asthma alone precipitated 1.8 million ER visits in 2004.  The ER visits resulting from unmanaged chronic conditions are avoidable. Proactive disease management, effective patient and caregiver education and simple lifestyle changes, can reduce ER usage for this group by up to 69%.

Appropriate use of the ER could save the U.S. healthcare system more than $18 billion a year. Patients with avoidable or non-urgent conditions who use urgent care centers, primary care physicians, or a telemedicine service can contribute significantly to creating a sustainable healthcare system.

How do you divert your employees to Urgent Care or Telemedicine?

An effective ER diversion program begins and ends with employee education. If you, as an employer, are serious about reducing your health care spend you need to think about the following;

Education Campaigns: Educational messaging creates an awareness of cost consciousness, reinforcing how to use urgent care, emergency room care, telemedicine and primary care. Campaigns leverage long-standing trusted relationships in order to have the greatest impact in changing the behavior of inappropriate ER use. If you partner with a Telemedicine service make sure your employees know how to use this benefit – provide examples, maybe a wallet-sized card with the 1-800 number, a list of appropriate ailments etc. Provide an online map to the nearest Urgent Care.

Member Engagement through Incentives: It may take the use of incentives to encourage members to change their behavior about the correct use of the ER. To reinforce behavior change, a great way to keep people engaged is to provide incentives to employees who seek appropriate care, including gift cards, coupons, and vouchers for dining, entertainment, and other goods and services.

The use of good data is the key to success.

It is essential to use Data to define the Initiatives: Use data analytics to establish a baseline reading of ER, Urgent Care, Telemedicine and primary care use. This information guides initiatives revealing the hotspots for intervention. Your data analytics should measure the impact of initiatives and allow for adjustments as needed. Use claims analysis to alert employees about a previous ER visit and show them the financial advantage of that visit when compared to using Urgent Care or Telemedicine. The employee will be forever grateful – particularly if they are responsible for large ‘out of pocket’ costs.

Take the time to explain all the benefits to your employees

Employees who manage their health and seek Urgent Care treatment instead of ER services (when appropriate) can expect to enjoy several benefits:

·      Save Time: The average wait time in urgent care centers is a door through door time of 45 minutes. Walk-in patients receive high-quality treatment quickly and efficiently. Very often issues can be addressed via Telemedicine in less than 10 minutes.

·      Save Money: Compare the $140 price tag of an urgent care visit to the $1400 price tag of the average ER visit. Even if a member’s insurance covers these costs completely, members learn that inappropriate use of the ER drives up the cost of healthcare and inevitably the consumer will pay for it. Employers are known to cover the cost of a Telemedicine consult 100%.

·      Reduce stress: Using an urgent care center when an illness or injury strike relieves the stress of handling an unscheduled crisis. When families have easy access to affordable, high-quality and convenient care when they need it, they go home happier and satisfied.

The Obeo Health Organizer module can help you reduce your ER costs – take a test drive of this module today.

Obeo Health featured in Gartner report

The following article is taken from the recent Gartner report – Hype Cycle for U.S. Healthcare Payers, 2016, published: 1 July 2016.


Smart Health Plan Selector Tools – Analysis By Constance Sjoquist

Smart health plan selector tools apply advanced analytics, such as machine learning
and cognitive computing, to large and diverse datasets to assist consumers in shopping for a
suitable health plan based on factors such as their health risk, financial risk tolerance, current
prescriptions and physicians, and experience preferences. These tools are in contrast to simple plan
selection tools that use rule-based scoring to sort and filter health plans.

Position and Adoption Speed Justification: Smart health plan selector tools are advancing to aid individuals in picking health plans that most closely align with their personal, financial, and health risk tolerance and goals, and are being adopted in response to the increase in:


■ Use of enrollment portals where individuals go through the plan selection process alone — with minimal knowledge of plan designs and little human support


■ Number of health plan designs that individuals choose from on enrollment portals, making the decision process for individuals overwhelming


■ Number of employers switching to defined contribution benefit designs to cap their benefit
costs and shift costs onto individual employees, with the assumption that more choices will
make up for higher individual out-of-pocket costs


■ The government’s, employer’s and payer’s desire to align an individual’s health plan selection
with their health history to determine the health plan that will result in the best health outcomes
Most health plan selection tools are embryonic and not truly “smart,” but rely on decision workflows and Excel worksheets to facilitate individual plan selection. Smart health plan selector tools are often coupled with online or mobile enrollment solutions. Expect their velocity along the Hype Cycle to closely align to the velocity of private exchange technologies and other online and mobile enrollment solutions.


Health plan selector tools are often integrated into payer, broker or group enrollment, or private
exchange portals. The limitations of Generation 1 (rule-based) plan selector tools are triggering
Generation 2 plan selector tool development and adoption. With the addition of smart technologies, such as virtual consumer assistants and recommendation algorithms, we expect the rate of adoption of smart health plan selector tools to increase.


User Advice: Healthcare payer CIOs and chief marketing officers (CMOs) should understand that
there are few vendors who actually use smart technologies — the use of data analytics and
algorithms — in their health plan selector tools. Most representative vendors we listed are largely
aspirational. Look for vendors whose solutions can perform perceptual tasks — classifying large
and variant data input streams in nonobvious ways — to inform decision making at a greater depth than using only member-, payer-, provider-, or employer-specific data. By combining health and financial data with behavioral, social, demographic, and other nonhealth data, payers can expect to more closely align individual plan preferences with health outcomes.


Payer CIOs and CMOs should:

■ Drive awareness and quantitative analysis of the growing impact of plan selector tools on payer revenue.
■ Track emerging vendors in this space, paying special attention to evidence of their incremental
growth in efficacy compared with Generation 1 tools.
■ Assess the opportunities for internally built cognitive solutions in this market. This begins with
an inventory of the structured and unstructured data available to train against, including claims,
products, provider network, member profitability, member satisfaction, and renewal.


Use the data from smart health plan selection tools as early in the enrollment phase as possible —beginning with post enrollment data from current plan years. Review how well individuals were
matched to plan selection and what modifications can be made for the next enrollment cycle.
Following the member’s health journey, look for over- or underutilization of benefits, customer
complaints or confusion of how to use their benefits.


Business Impact: All areas of the payer are impacted by the use of smart health plan selector tools.While the decision to implement these tools may reside with sales and marketing leaders, benefits derived will be evident beyond the enrollment stage of the member life cycle, as the payer’s success depends on members who understand how to choose and use their health benefits. Smart health plan selector tools help payers provide members with the optimal health plan that addresses members’ particular health and financial interests in a way that paper- or rule-based health plan selection tools cannot.


By incorporating data analytics and algorithms into the plan selection process, payers can go
beyond simple workflows and lead members along an enrollment path that is more personal and
results in a more suitable health plan match. Substantial consumer value can be unlocked using
cognitive approaches to match consumers to plans that improve their health outcomes and
experience, and lower their health costs. While payers may take a near-term hit on profitability, as enlightened members choose “skinnier” plans, their value will accrue value through improved
competitiveness, sales effectiveness, and member loyalty.


As this space matures and tools incorporate more cognitive capabilities, payers should expect to
improve product placement for desirable members, similar to search engine optimization. Cognitive plan selector tool algorithms can be used in the aggregate to determine whether a payer or an exchange vendor’s product portfolio has an appropriate mix of appealing and beneficial products for their prospective members.


Benefit Rating: High

Market Penetration: Less than 1% of target audience

Maturity: Embryonic

Sample Vendors: Array Health; ConnectedHealth; Obeo Health; Picwell
Recommended Reading:


“Predicts 2016: U.S. Healthcare Payers Are Challenged to Become Digital Health Payers”

“Industry Vision: Mass Personalization of Consumer Healthcare Engagement”


Study Quantifies The Value Of Health Plan Member Engagement

Employers and health plans have long sought after a clear understanding of the benefits derived from engagement. It is widely understood that engagement results in positive business outcomes for both types of entities; however, some would argue that too much engagement is a bad thing. Regardless, few studies have been published that quantify the financial impact of engaging employees and members…until now. A new report shows the value of consumer engagement in health plans.

Through an analysis of 14 years of consumer health insights, more than a billion interactions with consumers, and an extensive amount of academic and industry research, the study revealed that health plans can generate significant short- and long-term value by engaging members in their health. In fact, the report suggests that engaging healthcare consumers can be one of the highest value activities a health plan can undertake.

According to the analysis, health plans could potentially double their net income by engaging an additional 10% of consumers with their health. “For example, a one million-member commercial health plan in the individual marketplace could produce over $130 million in new value by engaging just 10% more members. This value is comprised of key medical and administrative cost reductions and revenue increases, resulting from an array of specific actions that consumers take in response to being more engaged. The report also revealed an even higher value of engagement among Medicare Advantage ($302 per member per year) and Managed Medicaid ($157 per member per year) populations.”

The key takeaway is that small increases in engagement can have big impacts on financial outcomes. The silver lining is that most employees and health plan members are woefully disengaged, which means the opportunity to achieve small increases in engagement are certainly attainable. With 60% of human resource leaders viewing wellness as an engagement tool and health plans focusing on engaging members in wellness, technologies and solutions that can engage users effectively and affordably will be highly valuable to these entities.

It is also important to note that this analysis considers a broad range of benefits that result from engagement. Traditionally, employers and health plans tried to constrict the gains from engagement through an analysis of hard savings, or return on investment (ROI), rather than considering all the benefits, often referred to as value on investment (VOI). Employers are beginning to shift their perspective to VOI as noted by a survey suggesting the majority of employers now consider VOI.

This post has been reproduced from the Wellable Blog.

Expensive combination medications – a costly problem.

Have you ever heard of a prescription medication called Duexis ? It’s a prescription drug that contains 2 different medications combined in one pill – Ibuprofen and Famotidine. Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID). It is used for arthritis pain. Famotidine is a type of antihistamine that blocks the release of stomach acid. It is used to prevent stomach problems from the ibuprofen. Sounds good – right ? Not so fast – 90 pills of Duexis costs about $2,200.00 per month!

But what if I were to take the medications separately – i.e. one Ibuprofen pill and one Famotidine pill ? According to, 90 pills of Ibuprofen 800mg can be had for $10.00 per month. 90 pills of Famotidine 20mg can also be obtained for $10.00 per month. And you probably don’t need to use your insurance for these 2 medications!

So, $2,200.00 per month or $20.00 per month!
To the makers of Duexis (Horizon Pharma) please tell me how you can justify this price discrepancy. On their web site they claim you can get a coupon to help with the cost. Coupons are just a way for pharma to hike their prices – check this article which I posted earlier.

There are many more examples like the one cited above. Time to stop this shenanigans.

A generic drug strategy is essential for cost savings

Generic drugs are an essential part of any solution to sustaining our health system and are central to efforts that increase patient access and generate savings for patients, taxpayers, employers, payers, providers and others.

Nearly 3.8 billion of the total 4.3 billion prescriptions dispensed in the U.S. in 2014 were filled using generic drugs. This means that generic drugs now account for nearly nine out of every 10 (88%) prescriptions dispensed in the United States. Yet generic prescriptions account for only 28% of total drug spending. Generic drugs were responsible for $254 billion in health system savings in 2014, bringing the total savings over the last 10 years to $1.68 trillion. Generic drug manufacturers can proudly point to a legacy of savings and access that brings expensive treatments within reach for millions of people. It is important to note that savings are growing and are expected to continue to grow.


• A May 2015 report from AARP notes that RETAIL PRICES FOR GENERIC DRUGS FELL AN AVERAGE OF 4% IN 2013, marking nearly a decade of consecutive years of decreasing generic drug costs. That report also notes that 73% OF GENERIC DRUGS in the study EXPERIENCED PRICE DECREASES.

• An August 2015 Drug Channels blog noted that in the SECOND QUARTER OF 2015 ALMOST HALF (44%) OF GENERIC DRUGS EXPERIENCED A DECLINE IN COST.

As an employer in the ‘self-insured’ space it is essential to adopt a comprehensive strategy with respect to the use of generic drugs. This involves providing education on this topic for employees and suggesting generic alternatives. Having access to prescribing data can be used to assess generic usage and illustrate possible cost savings. For more information on this topic please contact a team member at Obeo Health.

8 questions to ask prior to a planned surgical procedure.

Prior to undergoing a planned procedure such as a knee replacement or gall bladder removal there are questions you can ask to help with calculating your out-of-pocket costs.

1. What is the exact name of the procedure?  Ask your doctor to clearly print the name of the procedure. Correct spelling is important and many surgery names sound similar.

2. What ICD-10 codes will be used? Your health plan pays healthcare providers based on these diagnosis codes, which the doctor’s office or hospital will provide to them. The coding system was recently updated from ICD-9 to ICD-10, which is much more detailed than ICD-9.

3. What is the CPT® code for this procedure? One or more five-digit CPT codes are the billing codes that are used by providers—usually for physician services—throughout the United States.

4. What tests will I need before the surgery? Blood tests, diagnostic imaging tests, such as a CT scan or ultrasound?  Ask for specifics about which blood tests will be ordered. Ask the doctor if you have a choice of facilities for getting these tests done. Check with your health plan before you have the test to find out where your out-of-pocket cost will be lowest.

5. Will other doctors be involved in my care and bill me for their services? A pathologist, a radiologist, and an anesthesiologist may be involved in your care. Even if your surgeon and the hospital are in your health plan’s network, other doctors involved in your hospital care may not be.

6. What kind of anesthesia will I receive? Many surgeries will involve care by an anesthesiologist and other doctors who may or may not be part of your health plan’s network.

7. After my surgery, will I go right home from the hospital? What medications and follow-up care will I need? After you are discharged from the hospital, you should be able to go directly home. After some operations, you may need care in a rehabilitation unit or skilled nursing facility for a while. Or you may need home health care. Your health plan can provide information about coverage and prices.

8. What else should I know about—such as potential complications—that might affect the cost of the procedure? For example a minimally invasive (laparoscopic) gall bladder surgery has to be changed to an “open” cholecystectomy, which may or may not be more expensive. You and your doctor should already have discussed this when you talked about the risks and benefits of the surgery. If not, be sure to ask questions about the open procedure before the day of surgery. Having a different procedure (or an additional procedure) is likely to change the cost. And if you need to stay overnight in the hospital for any reason, that is generally more expensive than an outpatient procedure.

Ultimately you may to call your insurance company (groan) or set up an online account on their web site (further groan). This may or may not give you an answer.  You could also wait for that Explanation of Benefits (EOB) statement in the mail – good luck with making sense of that document !

All of the above can entail a lot of time and effort on your part. The good news is that the whole process is a lot easier with new electronic tools that are now available. These tools do the math for you and calculate these costs. They also make your medical bills easier to read and decipher those confusing EOBs. Check to see if your employer offers these tools to their employees.

For more information on the tools offered by Obeo Health please watch the video on the home page.

The Risks of the 15-Minute Doctor’s Appointment

How would you react if you sent your sputtering car to the auto mechanic, and they stopped trying to diagnose the problem after 15 minutes? You would probably revolt if they told you that your time was up and gave back the keys.

Yet in medicine, it’s common for practices to schedule patient visits in 15-minute increments — often for established patients with less complex needs. Physicians face pressure to mind the clock while they examine you.

That’s not to say that your physician “clocks out” as soon as your 1 p.m. appointment hits 1:15, or that all appointments last that long. What it does mean is that patients and doctors may be deprived of the opportunity for more meaningful discussions about the underlying causes of their problems and plans to improve them. A woman in her 50s who presents with high blood pressure and obesity might need medicine. But a longer conversation about the stresses of being the primary caregiver to her father, who has Alzheimer’s, could help provide strategies to help her look after herself.

When you see a new patient every quarter hour, there is often scant time to get to these root causes, to make accurate diagnoses, and develop the best treatment plans. And there is the danger that you miss a major diagnosis altogether.

The 15-minute appointment arose not out of evidence that it improves patient outcomes but out of production pressures — both the need to meet patient demand and to see enough patients to stay profitable.

Unpopular among patients, these production pressures have few fans among physicians either. A Mayo Clinic report stated that 54 percent of physicians meet the criteria for burnout in 2014 — up nearly 10 percent from three years earlier. Running on a treadmill all day in 15-minute sprints likely contributes to this phenomenon. Onerous documentation requirements and other pressures don’t help, either.

Some patient problems could be solved in 5, 10 or 15 minutes, but others cannot. What if health care trusted its physicians enough to take the time they need with patients and no more — and then monitored and paid for results? Could we realize better care while reducing costs, because patients are getting the right diagnosis sooner, and not coming back after their problem has been missed and their condition has worsened?

It’s not clear whether alternative payment models will achieve this. Concierge practices, in which patients pay a hefty annual fee in exchange for greater access to their physicians, may work well for those who can afford it. While this model is beyond the financial reach of many, a related model called direct primary care — or “concierge care for the masses” — is more accessible. Patients pay a monthly fee of anywhere from $25 to $85 to cover their primary care services, according to a Health Affairs report in December, and are encouraged to have insurance to cover more serious health issues. Patients and physicians might have 45 minutes to spend in an appointment. Because direct primary care usually does not bill insurance, it results in less checking boxes and more conversation.

A criticism of these models is that they may exacerbate the larger physician shortage, because physicians are responsible for significantly fewer patients than in a typical practice. Yet we need to evaluate their impact and see if their lessons might help us reclaim the patient-physician encounter.

This post first appeared in The Wall Street Journal’s blog, The Experts.

Did you pick the right health insurance plan?

Selecting a health insurance plan can cause considerable angst for a consumer and his/her family. Insurance plans are complex and there is a wide variety available on the market. Let’s try to simplify the decision making process. There are basically four areas that the consumer needs to assess for each plan offering;

1. The deductible.

2. The co-payment.

3. The co-insurance.

4. Out-of-pocket spending limits.

The complexity of plan choice arises in part from wide variation among plans across these four features that determine how health costs are shared between the insurer and consumer. And so consumers are faced with a dizzying number of permutations when trying to balance these four areas.

Lack of health literacy also plays a part in the process. A study done in 2013 found that only 14% of consumers could answer four simple multiple choice questions regarding the definition of these four cost sharing features. Also when presented with a simplified plan, most respondents were unable to accurately estimate the cost of their medical services. To confuse things further employees need to know if the plan covers their medications (formulary status) and whether their physicians are in or out of network.

The Affordable Care Act (ACA) organized plans were segregated into four ‘metal’ tiers – platinum, gold, silver and bronze. One investigation of hypothetical plan choices with plan menus designed to mimic those of the exchanges found that metal labels, rather than facilitating better decisions, worsened choices compared with generic labels (eg, plan A, plan B, plan C). This study also found that alternative plan labels that encouraged consumers to forecast how much care they anticipated needing did have a modestly beneficial effect, suggesting that participants may have misinterpreted metal labels as signals of quality, or the breadth of services covered, rather than the degree of cost sharing.

To make a financially efficient choice, employees, most of whom lack extensive prior experience with insurance, have to carefully consider the complicated relationship between plan cost, cost sharing, and their expected health risk. So what can be done to help employees navigate through these complex scenarios? I would like to suggest some possible solutions;

1. Provide decision aids. These may be scenario based examples or so called “people like me” illustrations.

2. The utilization of consumer historical data (claims, pharmacy etc) to help predict future costs should be encouraged. Prescriptive analytics tools can now help perform this task.

3. A more aggressive approach may be the use of plan “defaults” or restricted menus tailored to each consumer.

4. A more long term solution would be to simplify health insurance – period. Insurance products free of the complex features that consumers are least able to understand, such as deductibles and co-insurance,would more likely help consumers make informed decisions regarding plan choice and utilization.

Offering multiple plans seems like a good idea – the typical ACA enrollee is offered an average of 47 plans. One would hope that this large number of choices would help the consumer find an appropriate plan and may stimulate competition among insurers, leading to improvements in plan price and quality. However, these benefits are unlikely to emerge if consumers are not given the right tools and education.

To sign up for a free demo of the tools on offer at Obeo Health please click here.