What Does Criticism of CVS Caremark’s New Healthcare Program Really Reveal?

CVS Caremark was in the news a couple weeks ago after they launched a new element to their health insurance program. As part of their standard coverage, all employees have been asked to take a health screening or face a $50 per month penalty through their premiums. As part of this screening, employees must disclose some sensitive information, such as weight or BMI, which would be collected and tracked by a third party.

This new policy created a firestorm.  The first objection was that it was mandatory, forcing employees to disclose information they may not be comfortable sharing.  On top of that, by including weight and BMI, some observers saw this as a first step towards a “fat tax”, where employers could raise premiums or deny coverage for poor health.

While I can't speak to how this info might be used in the future (although use of medical data by employers is illegal right now), I am bewildered by the criticism.  That criticism isn't difficult to respond to:

• Understanding your key health metrics is an important part of maintaining, and ultimately improving, your health.  Although there is little hard data around the quantified self movement, there is plenty of anecdotal evidence that having this data leads to better decisions
• Whether you interpret the $600 as a penalty or an incentive to do your health screening, employers should have some tool to encourage employees to collect this data.  Let’s be honest, most people will not do this on their own
• CVS Caremark isn't the only company doing this – according to the National Business Group on Health, 62% of large employers offered biometric screenings in 2011 and 52% of those had incentives to complete them.  And as one of the largest healthcare companies in the US, it’s important for CVS to be a leader and set the tone for other companies to follow

What I’m more fascinated by is the root causes of this fear.  Given the state of our healthcare system, you would think everyone would be open to new, innovative approaches to reducing costs.  Instead, this is a reflection of larger themes in our national dialogue:

• Backlash against any policy that is perceived to reduce individual choice, even when the decision is made with positive intent
• Mistrust of large corporations and government, with a believe they are nefarious and any data they collect will be used negatively
• A media that recognizes these fears and stirs up controversy by highlighting stories that play into them

As a country, are we so stubborn that we’re unwilling to try new approaches, even if it reduces some of our choice for our own benefit?  CVS Caremark is a Fortune 20 public company and I can guarantee if this program doesn't show results (monetarily or health-related), it will get shut down.  But that doesn’t mean we shouldn't try it, even for just one year.  I agree, there are some policies that may go too far (i.e., NYC’s soda ban – while I applaud the intent, it’s too capricious and difficult to enforce), but shutting down innovation under the pretense of individual choice sets a dangerous precedent.

On top of that, whether we want to acknowledge it or not, large corporations and government drive the economy and agenda of this nation, but also help us live better lives.  Without large business, we wouldn't have Walmart, Apple, or Google.  Without government, we wouldn't have roads, public education, or scientific advances.  And, for better or worse, in order for them to continue serving us and improving our collective lives, they need to be smart about their money, which often times means using data to make better decisions.

The controversy seems to have died down for now, but I believe this is only the start of a larger conversation about the employee-employer relationship around healthcare.

Is Taylor Swift A Bad Role Model for Healthy Attitudes?

Taylor’s at it again.  Last weekend she performed her recent breakup song “Never Ever Getting Back Together” at the Grammys and took a swipe at an ex.  This is one in a long line of send-offs inspired by the real-life heartbreak she’s become synonymous with.

Why does this happen to her so often?  I have a cynical theory - that her record label and handlers exaggerate what would typically be normal dating drama, reinforcing her image and making her songs much more personal and powerful.

But let’s say this is real and she always strikes out.  We all have friends who seem to be unlucky in love.  But how much of this is outside their control and how much is a self-fulfilling prophesy?  Taylor may be attracted to the wrong people, but if her history and music is any indication, she could be trapped in a viscous cycle, struggling to break out of it.

While this pattern sells plenty of records, there are a some issues with her message when it comes to a few widely-held health tenets:

Health Tenet #1: Importance of strong long term relationships, both romantic and non-romantic

Issue: Taylor’s music discourages or minimizes the value of these relationships and says it’s OK to be alone

Health Tenet #2: Importance of a sense of control on mental / physical health

Issue: Taylor’s songs often lay the blame of failed relationships on her partner, allowing her to play the victim and brush responsibility away from her

Health Tenet #3: Power of positive thinking and optimism

Issue: There’s an underlying pessimism in her songs and an ongoing narrative that she’ll never be able to find love or happiness

Maybe this is going too far – at the end of the day, Taylor’s just singing fluffy pop music targeted towards confused, hormonal teenagers.  But it does beg a larger question – what is the entertainment industry’s responsibility when it comes to health?  For every success story (e.g., Jennifer Hudson’s weight loss, Robert Downey Jr.’s success in rehab), we’re fed many more stories about celebrity failure and downfall.  These narratives may make us feel better about ourselves, but can reinforce negative attitudes and desensitize us to bad behavior. 

I give credit when the entertainment industry takes a more nuanced view of these issues (e.g., non-exploitive profiles on celebrity challenges and recovery), but this won’t be enough if performers like Taylor continue to be role models and send potentially harmful messages.  

What Is The Impact Of China’s Rapid Growth On Public Health?

I flew into Chicago last Thursday night and was greeted by this gorgeous sight:

It’s not the traditional skyline, but in some ways I find it even more breathtaking.  Beyond its beauty, what struck me most was the incredible planning and work that went into creating this city.  But at what price?

China is facing this exact dilemma, generating record levels of pollution that have engulfed several cities.  This issue was highlighted by several news outlets over the past few weeks, including this great photo essay.  It’s clear that China’s massive growth has had some short term consequences, including apparent environmental impacts.  But when the public is breathing in pollution 25x higher than the safe amount, what are the long term impacts to public health and the economy?

MIT released an interesting study last year examining this question.  The study first laid out common health impacts of this pollution, ranging from hospital admissions, to chronic respiratory issues, to lost productivity.  Applying various scenarios and simulations, the study estimated that China lost $112 billion due to this pollution.  While this is dwarfed by China’s $7 trillion GDP, it’s still a staggering sum that will only be exacerbated as the country continues to grow.  Given the strain the US is currently facing on its own healthcare system, it will be curious how China deals with its issues down the line.

One area it needs to tackle is the disturbing misconceptions and a lack of public information about prevention.  In the photos, you can see people wearing face masks to combat the smog.  This is also a common sight at airports, where I usually laugh because I don’t think a flimsy mask is going to prevent you from getting sick (there’s even some evidence to back me up).  Similarly, the masks in China aren’t going to prevent people from breathing in many of the smaller particulates that can be just as harmful as the ones you can see.  China’s government needs to look beyond just curbing the pollution and think about educating people on how to stay safe or risk an even larger catastrophe.

Why Does San Francisco Eat So Healthy?

I was in San Francisco this past weekend when a friend made an interesting comment.  She’s a picky eater, but throughout the weekend she found that all of her requests were honored.  After the third time she successfully got soy milk for her coffee, she commented that “it’s strange that every restaurant has soy milk.  I guess it’s because everyone eats so healthy here.”

Which begs the question – why does San Francisco eat healthier than the rest of the nation?  It’s a generalization, but this stereotype seems to hold true – there were fresh, nutritious food options everywhere.  This is pure speculation, but I have a few theories:

-          Great agricultural climate: Northern California has a mild, sunny climate that produces a vast array of fruits and vegetables.  Most of this produce comes from the Central Valley, which is one of the most productive agricultural regions in the world.  There is also an abundance of seafood, which reduces pressure to produce red meat.  This abundance of fresh, accessible produce gives locals the ability to take advantage of these healthier resources

-          Liberal culture: The west coast, and especially major cities, has traditionally been more liberal.  That liberalism may translate more into social justice and moral questions about how our food is produced and distributed.  This attitude may have led to less demand for processed, big agra food and more focus on local, sustainable products

-          Immigrant population: This is a little more theoretical, but I wonder how much the influx of Asian immigrants impacted food culture.  Traditional Chinese food (not the stuff from Panda Express) is focused around fresh vegetables, stews and steamed dishes that could take advantage of the area’s agricultural abundance

-          Higher income:  San Francisco and Marin counties have some of the highest per capita income in the US and, as research shows, higher income leads to healthier behavior

I could be completely off here, but I think many of these arguments hold some weight.  But is there a way to apply these principles to other parts of the country?

-          It would be difficult to change the nation’s agricultural landscape, but food access has improved tremendously in the past few decades.  The abundance of fresh, healthy food throughout the country and year-round has been achieved through better technology and new retailers, although with some interesting consequences

-          While the county is certainly not going to become more liberal, a greater awareness and acceptance of issues like climate change may make people question their food choices and seek out healthier, more sustainable options

-          We see ethnic foods becoming more common, which can be healthier, especially compared with meat and potatoes diets of the past

-          Increasing income is unfortunately the most difficult issue to tackle, but if we build up demand for these products using the other three factors, prices for these healthier foods may decrease and allow lower income Americans to enjoy the benefits that so many in San Francisco already do

Are You Going to Keep Your New Year’s Resolutions?

With everyone hyped up about 2013, wanted to quickly visit a study from the University of Scranton on resolutions.  Here’s some quick math and my comments:

• Percent of Americans who usually make New Year’s Resolutions: 45% (This seems pretty low – maybe the other 55% already know they’re going to fail?
• Percent of people with resolutions who maintain them after 6 months: 46% (This seems absurdly high – this means 25% of Americans are still going to the gym or saving money after 6 months?  Either people are setting really attainable goals or there’s something fishy w/ this study)
• Health-related resolutions among the top 10 most popular: 3 (Lose Weight, Staying Fit and Healthy, Quit Smoking – no real surprises here)
• Success rates of people in their twenties vs. people in their fifties: 2x more resolutions attained (Interesting statistic – does this imply people in their twenties are better suited for change, have easier-to-achieve goals, or is it the opposite for people in their fifties?  Certainly says something about which group could be a better target audience for change messaging)

Should Healthcare Run More Like Airlines?

While most people dread flying during the holidays, it’s hard to ignore how efficiently the airlines are able to move millions of people across the country.  While we tend to dramatize issues with flying, today I want to appreciate the tremendous job the industry has done to create an effective (and dare I say friendly?) member experience that healthcare could learn from.

Flight Purchasing

How The Airlines Do It: How do you like to buy plane tickets?  Some people use a travel agent, some people call the airline, others buy online (either directly from the airline or from flight comparison websites).  Airlines give customers several channels to buy tickets by creating their own infrastructure, but also opening up their data for other companies to use.  Freeing up their data also creates price transparency, leading to greater competition and lower prices.  While everybody hates the new fees airlines tack on, decoupling extras (e.g., checked luggage) can also lower costs or keep them steady since only the people who use these services are paying for them.  Finally, customers can also get lower prices through group buying, using companies like Egencia that exchange volume for price.

What Healthcare Can Learn: Right now, you have very few choices about how you can pay for healthcare – given the high cost, insurance is the only route for most people, and that’s often tied to your employer.  This may change with the individual exchanges, as employers may drop coverage and folks will get to choose which plan is best.  As a result, insurance companies will need to create more customer-friendly plans and interfaces to help customers understand their choices in a much more competitive market. 

While healthcare is mostly fee-for-service (i.e., you’re only charged for what you use), there remains a lack of price transparency – do you know how much your x-ray costs?  While new startups have emerged to address this (e.g., Change Health, Healthcare BlueBook), we need to continue to create easier tools and better incentives for people make the right treatment decisions.  Finally, group buying has existed in groups such as Pharmacy Benefit Managers, but newer incentive-based models (e.g., ACOs) have the opportunity to be scaled up.

Pre-Flight Experience

How The Airlines Do It: Airlines have embraced technology to make the pre-flight experience better.  First, airlines use code sharing agreements to fill less crowded flights on other airlines or transfer frequent flyer points across multiple carriers, completely blind to the customer.  Second, airlines have embraced newer consumer technologies – for example, United and American are two of the first businesses to work closely with Apple to integrate their apps with their mobile payment service, Passbook.  Finally, security, one of the most important parts of the operation, is handled by a centralized agency, the Transportation Security Administration, meaning airlines can focus on what they’re good at rather than the complexities of security.

What Healthcare Can Learn: The code sharing agreements are akin to hospitals and doctors seamlessly transmitting patient information across systems.  While hospital systems do this today, it needs to be more portable and touch more patients, possibly through larger alliances that cover more health systems using the same technology.  I also like how airlines are working closely with mobile companies on cutting edge consumer technology – major health systems may benefit from tighter alliances with those major tech companies.  Finally, ceding certain activities to a single group takes healthcare companies out of what their bad at (e.g., data management).  EHRs may be a good example – does it make sense for the industry to name a single standard, and then allow health systems to outsource the work to dedicated vendors?

In-Flight Experience

How The Airlines Do It: Sure, the seats are cramped and the food is mediocre (when there’s food at all), but airlines have done some things right.  First, any in-flight purchases are cash-free, limiting the payment options, but simplifying the process to make things more efficient.  Next, airlines have created partnerships with movie and television studios to present current entertainment options or started handing out tablets to personalize the experience.  Finally, frequent flyers are often rewarded in-flight through a variety of special perks (e.g., free checked bags, automatic upgrades).

What Healthcare Can Learn: Efficiencies gained through limited payment systems would be a clear benefit to healthcare (i.e., eliminating the complexities of the fragmented insurance system means less admin headaches for providers).  The entertainment partnerships are vaguely similar to ACO’s, where there’s an incentive to produce and deliver high quality products – in this case, the airline benefits from having an engaged, happy flyers, and the studios have a captive audience to pitch their best shows.  Finally, I’ve written about “frequent flyer” healthcare programs in the past – integrating something like this into a hospital system could be an effective way to gain loyalty with select consumer segments.

These are certainly pipedreams with a multitude of complexities and challenges, but after flying this past week, I’ve come to appreciate what the airlines have done in the face of tremendous challenges and I’m hopeful healthcare can do the same.

What Can Anthony Bourdain Teach Us About America’s Attitude Towards Healthcare?

If I could trade places with one person for a day, it would probably be Anthony Bourdain.  His shows allow him to travel to far flung regions and showcase culture beyond the landmarks.  Wrapped in beautiful cinematography, he often goes below the surface to uncover engaging people and stories better than any other travel show.  This past rainy weekend was the perfect opportunity to catch up on his recent trip to Paris, which showed a contrast to the US that I haven’t been able to shake.

One of the episode’s recurring themes was the newish trend of brasseries focusing on local, sustainable products, pushing aside traditional French recipes and preparations.  To accommodate this shift, many of these restaurants had prix fixe menus that changed daily, a concept Parisians were tolerant and accepting of.  This is no small task, since it requires diners to enter a restaurant blindly and trust that the chef will deliver something memorable.

A similar concept crossed my mind a few years ago when I visited Europe and was shocked to find art museums handing out iPods to visitors as audio guides.  It struck me that there was an implicit handshake between the museum and its visitors saying that the iPods would be returned unscathed, something that I couldn’t imagine seeing in the US at the time.

We may have iPods in museums now, but I believe we see less of this trust between authority and individuals in the US, substituted for rugged individualism and a need for personal control.  To illustrate using the restaurant industry, look first at the fast casual concept, which has experienced huge growth over the past few years.  Their business model (use Chipotle as an example) is that the customer can create and customize their meal however they want, no questions asked.  Many restaurants also now have open kitchens, allowing the diner to see what goes into their food preparation.  Finally, there’s been a big debate in the food community about substitutions, with many saying that chefs must accommodate a diner’s request even at the fanciest restaurants.  In all these cases, rather than trusting the chef or the kitchen, the diner has seized control back into their own hands.

While you can see this everywhere in the world, I think there’s a bit more of this in the US, the result of capitalism and our unique history of self-sufficiency.  We have been taught through history classes and the media that we need to act as an individual and control as much as possible, not letting others dictate how we should think or, in this case, eat.

I believe this ethos also extends to healthcare.  Recent areas of innovation have been focused on consumer empowerment as we plod towards exchanges and the internet becomes a bigger source of medical information.  Putting aside politics (e.g., the wisdom of the single payer system), is this a good trend?  Put another way, is our fear and mistrust of central authority, combined with the democratization of the digital age, a good thing for the US health system?

Think about the challenges a doctor faces.  After four years of med school, four years of residency, and countless more years practicing, patients now feel “empowered” to undermine, or worse ignore, a diagnosis or treatment.  At a higher level, I see this every day when our customers want us to customize our member engagement campaigns, outreaches that have been tested and tweaked to maximize their effectiveness.  Rather than trusting our approach, our country’s staunch individualism has made evidence and expertise seem like a bad thing.

Since when do we know better than experts?  In order for consumerism to be successful, I think we need to figure out how to marry up expertise and individual decision making so that we make the right decisions.  This starts with a fundamental conversation about our culture and authority – maybe in this case we need to be just a little more French.