THCB Spotlights: Arcadia Health Solutions

Arcadia Health Solutions is a population health company that helps providers and insurers in their transition to a value-based care model. Arcadia is working with several of the Blues, Cigna, Beth Israel, and more. While it started as a consulting firm, in recent years Arcadia has raised over $40m from Merck, GE, and other corporate venture funds.

Listen to Matthew Holt’s interview with Sean Carroll, CEO of Arcadia Health below.

from The Health Care Blog

The “Back Story” of the JAMA Wellness Smackdown (Part 2)


Part 2 picks up where Part 1 left off, as coincidence would have it.

Soeren Mattke (as mentioned in the last installment) and I were quite relentless in trying, quixotically, to get Professor Baicker to explain her results. Its popularity could have landed her many profitable speaking and consulting gigs, but she evinced no interest in cashing in, or even in defending her position. Indeed, the four times she spoke publicly on the topic, she didn’t do herself, or her legions of sycophants in the wellness industry, any favors. In each interview, she distanced herself more and more from her previous conclusion. Here are her four takeaways from her own study “proving” wellness has precisely a 3.27-to-1 ROI:

  1. It’s too early to tell (um, after 30 years of workplace wellness?)
  2. She has no interest in wellness anymore
  3. People aren’t reading her paper right (Shame on us readers! We’re only reading the headline, the data, the findings and the conclusion, apparently)
  4. “There are few studies with reliable data on the costs and the benefits”(um, then how were you able to reach a conclusion with two significant digits?)

Individually or in total, these comments sounded an awful lot like retractions, but she (and her co-author and instigator, David Cutler) claimed those comments didn’t constitute retractions. Whatever they were, she wasn’t exactly doubling down on this 3.27-to-1 conclusion.

The industry at this time — 2013 and 2014 — came under a lot of criticismfor basically being somewhere between hilariously worthless and a fraud. (Here is some comprehensive documentation of the fraudulent and harmful activity in the wellness industry. Wellness is a classic example of the observation that every cause starts out as a movement, becomes a business, and degenerates into a racket, the poster company for the last being Interactive Health.)

Here’s where it gets interesting. Due to this relentless criticism, instigated and sometimes written by me (most of which is catalogued here) with credit to Soeren Mattke and Jon Robison as well (with Pulitzer Prize-winning LA Times columnist Michael Hiltzik piling on multiple times), Ron Goetzel and his colleagues urged Professor Baicker — who had previously claimed to have no more interest in wellness — to get a grant from Ron’s friends at the Robert Wood Johnson Foundation and do an actual controlled study of workplace wellness to set the record straight. As a strategic gambit, this showed a level of professional judgment worthy of Gary Hart.*

Obviously if you are perpetrating a fraud and you know it, you don’t urge people to investigate it. Mr. Goetzel at this point (or at least shortly thereafter) knew that his industry was a fraud, going so far as to erase some accurate data and disown inconveniently accurate conclusions he had forgotten to suppress.

He even forged a letter from the governor of Nebraska to cover his tracks. (To be completely accurate, he did not forge the signature on the letter. He merely doctored the wording in a letter that was already signed to say something much different than the letter said when it was actually signed. Maybe that’s not technically forgery. Who knows?)

And yet that’s exactly what Mr. Goetzel did. Maybe he thought she was as corrupt as he is, but she has an excellent reputation in this industry. My suspicion is that she accepted his offer for exactly the opposite reason that he made it — to clear her name after her ill-considered 2010 meta-analysis.

Way back in 2016, I predicted how this gambit would turn out — that Katherine Baicker was not going to mail it in this time but rather do a high-quality study of the type she is known for.

Her now-famous outcome was preordained for four reasons:

  1. In this industry, as Michael O’Donnell pointed out in the trade journal where he formally served as Prevaricator-in-Chief, the higher quality the study, the lower the ROI, to the point where RCTs invariably show negative ROIs. (Owing to the embarrassing accuracy of this unintended finding, Mr. O’Donnell walked it back in a subsequent editorial.)
  2. Kate Baicker was not going to sully her legacy by being known as the Typhoid Mary of wacky wellness programs, just to please her sycophants.
  3. She picked the most clueless vendor imaginable to carry their water. This selection couldn’t have been an accident.
  4. No wellness study since Johnson & Johnson (which was probably also wrong–just not obviously from the data presented) had shown even a remotely positive outcome. This list includes PepsiCoBarnes Hospital, NebraskaVitalityNewtopiaHealth Fitness CorpHealth Fitness Corp again, Boise School District/Wellsteps, McKessonConnecticut, and the University of Illinois. All were epic fails, according to their own data. Not to mention that the wellness trade association itself published a case study showing wellness loses money and then ran away from it.

Where does the wellness industry go from here?  They’re hoping for Tiger Woods, wiser souls are channeling Gary Hart, and probably what we’ll get instead is Harold Stassen. (Look it up.)

*For those of you who aren’t old enough to remember, here’s what happened. Dogged by rumors of philandering, the front-running Democratic presidential candidate urged reporters to follow him around. It took about a day for reporters to discover he was indeed philandering. It only took another few weeks for him to withdraw from the presidential race.

Al Lewis, the originator of risk-based population health contracting and outcomes measurement, is founder and President of the Disease Management Purchasing Consortium International, Inc. This article originally appeared on Dismgmt here.

from The Health Care Blog

The “Back Story” of the JAMA wellness smackdown (Part 1)


Let’s climb into the WABAC Machine (and, yes, that’s the way it’s spelled) and set the dial for 2008.

Then-candidate Barack Obama, campaigning on the promise of universal health coverage, enlisted Harvard professor David Cutler as his key adviser on that topic. Business lobbying associations were not thrilled about their members having to cover all their full-time employees and incorrectly assumed, then as now, that the major drivers of healthcare cost were employees smoking, overeating, and not exercising. Prof. Cutler suggested, quite correctly, that one way to assuage that concern would be to allow employers to spend less money covering employees with those three health habits.

Fast-forward to 2009, when it appeared that — with enough concessions to enough vested interests — the Affordable Care Act (ACA) could become a reality. Business lobbying groups were, then as now, powerful entities. Using Prof. Cutler’s suggestion, they were pacified by allowing businesses to tie up to 30% of total premium dollars to employee health (in practice, largely employee weight). Generally, the business lobbying groups engineered this withhold in the shadows. It wasn’t until 2015 that one of those business groups, the Business Roundtable, publicly admitted that the 30% withholdwas the main reason they bought into the ACA.

Since this 30% was basically a giveaway to corporations, the Obama Administration needed to justify it as a cost-savings measure. On the one hand, they had the Safeway experience “proving” that wellness could save money in practice. This alleged proof was met with open arms by both parties. Safeway’s CEO became a “rock star” on Capitol Hill.  (Of course, Safeway’s wellness program, like virtually every other great-sounding success in wellness, turned out to be a scam. In retrospect, just reading the Safeway CEO’s Wall Street Journal op-ed* announcing these results, it’s amazing how the mind-blowingly fallacious statistics didn’t get called out back then, by me or anyone else.)

What the Administration needed in addition to the Safeway experience was some academic support. It happens there is an old joke among economists that the definition of “economist” is someone who, upon finding that something works in practice, wonders whether it will work in theory. Enter Professor Cutler again. He enlisted the then-little-known Katherine Baicker, of the Harvard School of Public Health, who had no background or apparent interest in wellness, to lead-author a meta-analysis to prove that wellness works (he was the second author).

She “proved” the theory that wellness works by citing basically every research study ever published. In those days, like today, essentially every published study — virtually all published by wellness promoters in wellness trade journals — showed savings, thanks to three rather transparent fabrications:

  1. Comparing participants to non-participants, which specifically the recent study did not do, nor did the NBER study in 2018.
  2. Looking only at the decline in high-risk members and not the increase in risk by the low-risk members
  3. Drawing a trendline straight up and saying how much cost was “avoided” because expenses didn’t rise that fast.

The resulting meta-analysis, Workplace Wellness Programs Can Generate Savings, was raced into publication in Health Affairs, peer review be damned. (Indeed it was published so quickly that Prof. Cutler didn’t have time to disclose his conflict of interest.)

The finding was quite definitive, to two significant digits: wellness produced a 3.27-to-1 ROI on cost savings alone. This is an almost unheard-of level of precision and conclusiveness in a population health analysis. Plus, an additional precise 2.73-to-1 on productivity.

The game was supposed to be over. That article was supposed to be the cherry on top of the ACA, academically blessing the one aspect of ACA which both parties supported. It was billed as a true win-win, saving money by getting employees to be healthier.  This article became the single most influential article in Health Affairs history, with 935 academic citations alone, plus an untold number of start-ups, corporate program implementations, and references in lay publications.

Unfortunately, when you attract that much attention with a finding that is basically fabricated, someone is bound to notice. In this case, the someone was me. (I also encouraged RAND’s ace wellness researcher, Soeren Mattke, to take part in the effort, which he expertly did.)  It turns out that most if not all of the studies in this meta-analysis never should have made it to peer review, let alone passed it.  One researcher credited wellness programs with a reduction in spending on blood-borne ailments — like hemophilia, Von Willebrand’s Disease, and cat-scratch fever. Another found that you could save millions within six months by encouraging diabetics to eat more carbs. A third found that annual mammograms for women under 40 and low-fat diets saved Procter & Gamble 29%.

Part 2 will cover how Prof. Baicker distanced herself from this result to the point of disowning it…and how withering criticism from myself and others (notably The Incidental Economist) created a chain of events which got her back in the game despite saying she had “no interest.”

*Safeway’s CEO, Stephen Burd, eventually got tired of wellness and focused his efforts on another shiny new object: Theranos. He has subsequently retired from Safeway to become the honorary chairman of Mensa. (not)

Al Lewis, the originator of risk-based population health contracting and outcomes measurement, is founder and President of the Disease Management Purchasing Consortium International, Inc. This article originally appeared on Dismgmt here.

from The Health Care Blog

Health in 2 Point 00, Episode 78 | FBI, FDIC and Funding, oh my!

Today, we’ve got another episode of Health in 2 Point 00—airport edition. On Episode 78, Jess is spending the last few moments before her vacation interviewing me from the airport. She asks me about lots of big raises: Redox raised $33 million for their interoperability platform; EverlyWell, which offers direct-to-consumer lab testing, raised $50 million, and Ro raised another $85 million just a year after raising $88 million. In other news, SureScripts is getting sued by the FDIC for monopolizing the e-prescriptions market and the FBI just raided uBiome for double-billing insurers. —Matthew Holt

from The Health Care Blog

Race-Based Medicine Can Blind Doctors from Social Injustice


Fifteen years ago, as a medical student, I learned a
terrifying lesson about blindly using race-based medicine. I was taking care of
Mr. Smith, a thin man in his late 60s, who entered the hospital with severe
back pain and a fever. As the student on the hospital team, I spent over an
hour interviewing him, asking relevant questions about his medical and social history,
the medications he took, and the details of his symptoms. I learned Mr. Smith
was a veteran who ran into tough times that left him chronically homeless,
uninsured, and suffering from hypertension and diabetes. I performed a complete
physical exam, paying particularly close attention to his back. Upon reviewing
his blood tests and kidney function, I read the computer’s report: “normal.”

I felt confident as I presented Mr. Smith’s treatment plan
to my attending physician: I recommended a CT scan, ibuprofen for pain, blood
pressure lowering medication, and an antibiotic. My attending listened quietly,
reviewed the labs herself, and then firmly corrected every aspect of my
treatment proposal. “His kidney function is NOT
normal. What you want to do for him can further damage his kidneys. The lab
reported his creatinine as ‘normal’ because it has an algorithm that makes
faulty assumptions based on race.” Mr. Smith, according to the medical record,
was African American.

I almost harmed Mr. Smith because I hadn’t realized that the exact same creatinine level (the key metric for kidney function) yields two different reports based on whether you’re African American or not. The logic goes that because black people supposedly have higher muscle mass on average, healthy creatinine levels for those who check the “black” box is different from those who check other boxes. Physicians around the country continue to rely on this metric even when the black patient is thin, like Mr. Smith. This example of race-based creatinine levels to determine kidney function is a symptom of race-based medicine in general: (poorly defined) racial categories are often used as proxies to explain discrepancies in health outcomes by race, which is a potentially dangerous analysis. Mr. Smith’s case forced me to consider why race-based medicine is problematic and where our attention as healthcare providers should be directed instead.

What is certain is that health inequities persist along racial lines. African Americans and Hispanics have higher rates of diabetes, hypertension, and heart disease than other groups (Figure 1).[1] American Indians and Alaskan Natives are 2.1 times as likely to be diagnosed with diabetes as white individuals and the prevalence of obesity in this population is higher than any other group. While it would be convenient to attribute these disparities to genetic difference, this is simply not the case.

Figure 1. Source: Centers for Disease Control

Using race to predict different health outcomes is
problematic for more reasons than one. Let’s start with why it’s bad science
and bad medicine. Because racial categories have been socially constructed, the
definitions and qualifications for each race are dependent on location and time.

These racial categories have been proven time and time again to mean very little genetically, yet medicine continues to assume that innate biological difference among races explains racial disparities in health. Why would we test race to predict muscle mass to then predict kidney function when instead we can just test muscle mass to predict kidney function? That would avoid crude metrics like race and use more scientifically-justified criteria to predict health outcomes.

Figure 2. Source: Center for American Progress
Figure 3. Source: Kaiser Family Foundation

The second problem with race-based medicine is that it detracts clinicians from the social determinants of health disparities. If we really want to know why the above statistics hold true, let’s start by looking at insurance rates among these groups (Figures 2-3). Eighty-eight percent of whites have health insurance while only 79% of African Americans and 68% of Hispanics and Native Americans do. One in five Latinos reported not seeking medical care due to a language barrier. Forty-six percent of nonelderly blacks without health insurance report having one or more chronic health condition. High rates of incarceration among communities of color (Figure 4), exposure to environmental toxins, underfunded schools, food deserts, and the daily stress of racial discrimination all play powerful roles in determining health outcomes. Race-based discrimination also enters the hospital. Blacks and Latinos are twice as likely to be refused pain medication than whites for the exact same injury because black and brown patients are perceived to feel less pain or to somehow be more prone to addiction. These social and political factors, not race-based computer algorithms, must be the target of our focus as clinicians.

Figure 4. Source: Bureau of Justice Statistics.

As healthcare providers, we must focus on the much more complicated ways our country’s healthcare, education, and prison systems discriminately affect health outcomes. Thinking back to my experience with Mr. Smith, my plan should have addressed his homelessness and access to healthcare as causes for his sickness because for him, social factors, policies, and opportunities influenced his health far more than genetics. Mr. Smith’s case taught me a valuable lesson that I continue to believe today: when we see differences in health outcomes along racial lines, our focus should not be directed toward innate biological difference, but toward social inequity. The medical establishment, and we as healthcare providers, have a big role to play in changing this narrative.

Internist, Pediatrician, and Associate Professor at UCSF, Dr. Le is also the co-founder of two health equity organizations, the HEAL Initiative and Arc Health.

[1] The authors understand that the term “Hispanic” is controversial. We have decided to use this term in this instance, however, to be consistent with the categorizations used by national healthcare agencies, such as the CDC. For more discussion about on the term, see here.

from The Health Care Blog

THCB Spotlights: Matt Cox CMO of Lumeris

Today THCB is spotlighting Lumeris which creates a platform to help set-up and develop health plans and manage care delivery for patients. Working with its associated medical group Essence, Lumeris has been creating actionable steps to reduce Medical Cost Rates (MCRs) and is now taking that process to other health systems that want to set up Medicare Advantage plans. Lumeris is working with 12 health systems and is growing rapidly. Recently, Lumeris partnered with Cerner to bring their product to market.

Matthew Holt interviewed Matt Cox, Chief Marketing Officer at Lumeris to find out the details.

from The Health Care Blog

No Quick Fix for the Culture of Prescribing that Drives Medication Overload


In my mid-twenties, I was twice prescribed the common antihistamine
Benadryl for allergies. However, my body’s reaction to the drug was anything
but common. Instead of my hives fading, they erupted all over my body and my
arms filled with extra fluid until they were almost twice normal size. I subsequently
described my experience to a new allergist, who dismissed it as “coincidence.”

When I later became a nurse, I learned that seemingly “harmless” medications often cause harm, and older adults are particularly vulnerable. Every year, Americans over age 65 have preventable “adverse drug events” (ADEs) that lead to 280,000 hospital stays and nearly 5 million outpatient visits. The Lown Institute in Boston draws attention to this underrecognized problem in their recent report, Medication Overload: America’s Other Drug Problem. Policymakers, patients, and health professionals must act, because over the next decade, medication overload is predicted to cause 4.6 million hospitalizations of older Americans and 150,000 premature deaths.

Nearly half of all older adults take at least five
prescription drugs, a 300 percent increase from 25 years ago. The
more drugs we take, the likelier it is that one of them, or some combination,
will cause serious harm. When you add in non-prescription medications,
including over-the-counter drugs like ibuprofen and Tylenol, as well as
vitamins and herbal supplements, the potential for harm only goes up.

I’ve seen this in my
work. It is not unusual for elderly, very ill patients on hospice to have
prescriptions for 20 to 30 drugs. Several of their medications may treat the
same problem, amplifying any serious side effects. Blood pressure medications provide
a good example. As older patients become more debilitated, lose weight, and are
taxed by other health issues, the effect of these medications can intensify,
severely lowering blood pressure, and causing the patients to fall. Indeed, if
I am following up with a hospice patient who has fallen, the first thing I
check is their prescription medications for hypertension.

Given the prevalence of ADEs,
why are medications still prescribed so readily? We are all, patients and
prescribers, deeply embedded in a culture of prescribing, wedded to the idea
that all health problems can be solved by taking a pill, or a lot of pills. Clinicians also feel increasingly
pressured to hurry through appointments, and offering pills makes visits go
faster. For patients, receiving a prescription often gives them a sense of being
well-cared for. 

Even clinicians who try to prescribe thoughtfully may feel pressure from patients who, having been enticed by drug advertisements to “ask their doctor” about a host of different medications, view a prescription as the key to better health. Direct-to-consumer drug advertising accelerated in 1997 when requirements for listing side effects were loosened by the FDA. That increase has coincided with a rapid rise in the rate of prescription drug use—and ADEs.

Most clinicians do not know how overloaded by medications their
patients are. Patients with multiple health problems likely receive
prescriptions from multiple specialists; no one doctor, nurse practitioner, or physician’s
assistant tracks and manages every drug a patient takes. Additionally, clinicians
are reluctant to discontinue medications because they worry that stopping a
prescription will cause harm.

Finally, physicians and other prescribers receive little to
no practical training in preventing medication overload or in deprescribing.
They may have learned that taking multiple medications can be a problem,
especially for older adults, but figuring out how best to avoid that problem
for individual patients is not easy. Consider warfarin, an anticoagulant and
one of the medications that often lands patients in the emergency department.
This drug is used routinely to prevent strokes from blood clots. It also
carries a risk of spontaneous bleeding and requires careful management to be
effective without being dangerous. For some older patients, aspirin will work
as well as warfarin, and would be much safer, but for other patients, the
reverse is true.

Medication overload is a tricky, multifaceted problem
without a simple solution. Over the past six months, the Lown Institute has
brought together a group of doctors, academics, pharmacists, nurses (including
myself), and patients to discuss what can be done.

Through our discussions, it has become clear that the best
way to reduce medication overload is for patients and prescribers to work
together. Patients need to understand that every drug has side effects, and
dangerous drug-to-drug interactions are always possible. Prescribers need more training
to help them recognize medication overload, and they need to be reimbursed for
the time it takes to talk over medications with patients. Clinicians and
patients need to discuss treatment options and the potential benefits and harms
of their medications, and that can’t all be done in a 10-minute visit.

Systemic changes are also needed to prevent medication
overload. Care coordination needs to include pharmacists and nurses as active
participants in medication review and deprescribing. Older
patients need a yearly “prescription check-up” to go over all their medications, and consider lowering the doses of, or even discontinuing,
some drugs.

Stopping dangerous prescribing, or overprescribing, will not be easy. A sense of need leads patients to request medications, and good intentions, usually, cause physicians to reach for the prescription pad. But the problem must be addressed to keep our patients as safe as possible. It begins by understanding that every pill has the potential to cause harm. Then we work together—patients, clinicians, and policymakers—to kick our overprescribing habit.

Theresa Brown, RN, is a clinical nurse, author of the New York Times bestseller The Shift: One Nurse, Twelve Hours, Four Patients’ Lives and is a frequent contributor to the New York Times.

from The Health Care Blog