Mock Surgery day

The 19^TH Annual Mock Surgery day at Brackenridge Hospital was a huge success. Approximately 1500 people attended the event. A wide variety of groups and organizations were represented as they shared information on various topics pertaining to good health and general safety. Those who attended learned about subjects like; kidney disease, diabetes, cancer, fire safety and more. The hospital also had staff on hand to show people how to bandage wounds and even the trauma department was represented.

Vantage Outsourcing was invited to participate in the event and for the first time ever cataracts were covered. Information was shared, which answered a variety of questions, such as:

• What is a cataract?
• How does it form?
• Who can get cataracts?
• How long does the procedure take?

Along with this information, the cataract surgery was described, the surgical instruments were on hand for viewing and some of the different types of lens implants were discussed. Overall, a lot of information was provided.

Vantage Outsourcing had a great time at this public event and is looking forward to further the publics knowledge when it comes to Cataract Procedures.

Making Infection Control Central to an ASC’s Operations

In my parallel life, I also edit one of our company’s sister publications, Infection Control Today (ICT) magazine, so as you can imagine, infection prevention in all healthcare environments is dear to my heart. I have been following closely the new conditions for coverage (CfCs) issued last year by the Centers for Medicare and Medicaid Services (CMS) addressing infection control in ambulatory surgery centers (ASCs), and the sense of panic that these CfCs have triggered. ASCs have traditionally enjoyed a very low infection rate, but some rather high-profile infectious outbreaks at outpatient facilities prompted a greater investigation by the government into the state of infection control at surgery centers and a few bad apples have forced a new regime. But perhaps that’s a very good thing in disguise. It’s true that human nature being what it is, people don’t always do what they are supposed to do, and so rules are made to enforce mandatory compliance. It’s always a shame when doing the right thing must be legislated instead of met voluntarily, but the bright spot in the new CfCs relating to infection control is the hope for even better patient outcomes — a distinct hallmark of the ASC industry in the first place.

In this issue you’ll meet Bruce Wallace and Anthony Pings, two people who have made infection control the focus of every decision they have made in the design and development of Renaissance Surgical Arts at Newport Harbor, LLC, a brand new multi-specialty ASC that will surely be a destination for healthcare in the Orange County, California region. Central to the center’s long list of innovations is the numerous concessions made to making infection control an imperative, from the multi-chamber sterile and substerile areas in between the operating rooms, to the extensively automated surgical device and instrument sterilization systems, to the use of touchless scrub sinks and surfaces impervious to bacteria.

OR Technology: A Glimpse Into The Future

As we move into 2010, a new wave of technology awaits us. Highly-developed health information technology (HIT)-driven systems and equipment are becoming the standard in many operating rooms (ORs), whether they are in a single-specialty ambulatory surgery centers (ASCs) or advanced surgical hospitals. It is important to stay up-to-date on these new technologies which not only reduce medical errors, but improve patient comfort and post discharge follow-up. The following case studies highlight this trend.

Enhancing Communication, Collaboration and Education: An Olympus Case Study

Three years after adopting integrated ENDOALPHA ORs, Penn State Hershey Medical Center is ready for more. As the only teaching hospital in central Pennsylvania, Penn State Milton S. Hershey Medical Center is one of the area’s largest healthcare providers. The hospital is equipped with 23 surgical suites and its department of surgery performs more than 19,000 procedures annually.

Staying Ahead of the Technology Curve

As industry trends move toward minimally invasive techniques, the hospital was quick to understand the benefits of integrated surgical suites as a way to stay competitive with the specialized technology demands of increasingly sophisticated procedures. “Several years ago, we realized we had a need for advanced, integrated technologies in our OR as we anticipated the convergence of laparoscopic and flexible endoscopic instrumentation,” says Randy Haluck, MD, professor of surgery and division chief for minimally invasive surgery and bariatrics. “We also recognized the need for a sophisticated system relative to data acquisition, storage, and transfer.”

Penn State Hershey began the process of integration in 2005, building three new Olympus ENDOALPHA surgical suites in 2006 and then converting two existing ORs to ENDOALPHAs the following year. The hospital anticipates completion of four more integrated ORs, for a total of 27 surgical rooms with one-third of them set up as state-of-the-art ENDOALPHAs this year.

Taking a Comprehensive Approach

True systems integration goes beyond the equipment and operating platform. It also takes into account the ergonomic design, workflow and technology optimization of each surgical suite. This means designing rooms with ceiling-mounted booms for holding imaging equipment and monitors off the floor, allowing for more efficient post-procedure clean-up and ergonomic positioning of monitors during the procedure. It means integrated equipment (scopes, imaging platforms, monitors, video and accessories) that work together and can be easily interchanged during a procedure. And it means a cohesive information management system for patient and procedural data, images, and audio that can be captured, stored, and retrieved from both inside and outside the sterile field. “We needed to have multiple surgical services using the same operating room, between general surgery, urology and minimally invasive GYN surgery,” says Gerald Harkins, MD, medical director for minimally invasive GYN surgery. “We’re all able to function in the ENDOALPHA laparoscopic suites, and it’s been a fantastic platform for that utilization.”

Experiencing the Installation Process

Olympus offers turnkey solutions, working with customers from start to finish on the design, construction and set-up of integrated operating and intervention rooms. “The flexibility of Olympus’ ENDOALPHA system means it can be easily customized to create a right-sized solution unique to each facility,” says David Alexander, Penn State Hershey’s Olympus integration consultant. “We were able to incorporate their legacy equipment along with their pre-existing video-conferencing system and streaming video package into their ENDOALPHA ORs to create one seamless solution. Hershey proved to be very knowledgeable, so it was a highly collaborative effort.”

Taking Centralized Control

The nerve center for each ENDOALPHA OR is a centralized control panel. With audio, video, data and images all controlled via a single touch screen, clinicians have the power to connect, communicate and collaborate with others outside the procedure room. Clinicians can also control surgical and room lighting, in-room observation cameras and all information and imaging systems without ever leaving the sterile field. To further enhance efficiency, the ENDOALPHA system provides preset capabilities so that monitors, lighting and all equipment can be custom-tailored to surgeon preferences and made available at the press of a button.

Communication, Collaboration, and Education

Penn State Hershey Medical Center’s custom-placed displays ensure all team members have the perfect view of live images. They regularly create video networks for sharing, collaboration and education from within and outside the hospital. “There’s no question that the Olympus system has dramatically changed how we teach in the OR,” says Peter Dillon, MD, chairman of Penn State Hershey’s surgery department and surgical director of perioperative services. “We’re now able to broadcast these procedures to first- and second-year medical students, exciting them about the wonders of surgery at a much earlier stage in their training. So it really has changed dramatically and in a very exciting fashion how we teach.” Haluck adds that it also gives the Penn State Hershey team a better way to collaborate with other physicians and share information with patients. “We can educate other physicians and record images for colleagues or bring them in when needed to confer and/or assist on a procedure. We are also able to show patients what their surgery was about and why they were having problems. That’s a great benefit to us, and certainly patients appreciate it as well.”

Interventional Radiology Breaks New Ground: A Skytron Case Study

Philips and Skytron have teamed up to help fully realize the promise of a hybrid angiography suite by implementing new cardiovascular solutions with the latest Allura Xper FD technology from Philips and state-of-the-art surgical lighting and boom technology from Skytron.

For more than a decade, Barry T. Katzen, MD, medical director of Baptist Cardiac and Vascular Institute (BCVI) in Miami, has pioneered the integration of surgical and interventional procedures. Katzen and his team continue to show that surgical procedures in an angiographic environment can be accomplished with the same degree of efficiency as in an OR.

“The specialties of interventional radiology and vascular surgery bring more to each other when we work together,” Katzen says. “Procedures that help drive this relationship include aneurysms of the thoracic aorta and abdominal aorta. Having an environment where we can use a surgical option allows us to think out of the box for individualized patient solutions.”

In 2008, Philips Healthcare and Skytron entered into a collaborative agreement to provide comprehensive, integrated solutions for the cardiovascular environment. Katzen seized the opportunity to refine the surroundings. Based on a well-coordinated plan from Philips and Skytron, a room at BCVI underwent a significant upgrade to enhance hybrid functionality.

“One of the great advantages of the new room design is it’s so spacious that we can all function effectively without being in each other’s way. Information can be transferred to the head of the bed — to the anesthesiologist — down to where we’re working very easily,” says James F. Benenati, MD, medical director of the peripheral vascular laboratory.

A Room That Works

BCVI’s surgical team appreciates the changes made. Katzen believes the upgrade has created a better environment for all involved. A recent experience demonstrated how the teams successfully combined surgical access with an interventional solution. A patient presented with critical narrowing of an artery to the brain and chest, and a narrowing of that same artery in the neck. “It was a very complex situation,” recalls Katzen, “but we combined our skills. The surgeons removed the plaque in the neck with an endarterectomy and we used that same access to go down and stent the chest.”

Installation With Minimal Impact

“We’re a busy lab and taking a room down for a period of time is always an inconvenience,” says Katzen. “The one thing everybody remarked upon was how fast this upgrade was accomplished.” In two and a half weeks, Philips and Skytron, working closely with the implementation team at BCVI, completed the staging and upgrade. The new room reflected the input of interventional radiologists, surgeons and anesthesiologists, with each group helping to define the clinical specifications to make it a multi-disciplinary environment.

OR Technology Update: A Steris Case Study

The epitome of surgical technology today is one OR in which surgeons can perform image-guided, catheter-based interventional procedures; minimally invasive endoscopic procedures; extremely precise robotic surgery; or full open surgery, depending on the case load or discoveries made in surgery. In this type of hybrid OR, integrated imaging, computerized patient information and live video routing technologies instantly display test results and critical real-time information on high-definition monitors in the sterile field. This allows surgeons and staff to ascertain the most timely and accurate diagnosis and treatment for the patient. It also helps them achieve the most flexible and effective uses of the room and optimize scheduling and utilization.

These are also the types of rooms in which medical leaders and pioneers train residents and other clinicians, develop new minimally invasive procedures, such as natural orifice trans-luminal endoscopic surgery (NOTES) and trans-catheter heart valve replacement and master new surgical devices.

These highly advanced rooms can incorporate advanced communications, connectivity, LED surgical lighting and high-definition visualization such as intra-operative fluoroscopy, intra-operative computerized tomography, magnetic resonance imaging, image-guided navigation, 3D software extrapolations of the imaging, robotics and many other technologies. Each of these tools are important in today’s hybrid OR, but when integrated correctly they form a seamless whole that is greater than the sum of its parts.

To accomplish this synergy, STERIS collaborates with leading manufacturers to design and install customized, integrated HD360°™ Hybrid ORs for healthcare facilities. STERIS project design managers configure STERIS’s open infrastructure Harmony® Lighting and Visualization systems, equipment management systems and advanced integration technologies with interoperative imaging, robotics, endoscopic and video technologies and more. The result is a suite that enables fully informed staff, highly efficient procedures, extremely flexible room use, successful surgeon recruitment, medical education, ongoing surgical innovation, leading edge robotic surgery, telemedicine, and new possibilities yet to be imagined.

OR Technology Update: A Berchtold Case Study

Problem

Before hybrid ORs existed, imaging and communications capabilities were not an option during cardiovascular and neurosurgery operations, resulting in patients getting diagnosed and treated in two different visits. Separate procedures and imaging consultation can be costlier for patients and surgeons, can result in additional stress, more down time and longer hospital stays for the patient, and are not conducive to emergencies that sometimes arise during surgery.

Solution

Combine minimally invasive and interventional surgical technologies with medical imaging and communications equipment in one operating room: the hybrid OR.

A growing trend involving endovascular procedures during cardiovascular and neurological surgeries requires equipment to accommodate open and closed procedures in the same room, even at the same time, although this is not necessarily planned from the start. The new hybrid OR model provides the surgeon flexibility in performing a variety of interventional, imaging and surgical services in one setting, eliminating the need to transfer the patient.

For example, two of the most popular hybrid ORs are for cardiovascular and neurosurgical procedures:

» Neurosurgical hybrid ORs can include magnetic resonance imaging (MRI); computed tomography (CT) and angiography equipment within a neurosurgical operating room.

»Cardiovascular hybrid ORs often features: Fixed ceiling- or floor-mounted C-arms, ultrasound and endoscopy equipment, coupled with cardiac catheter laboratories.

Because a hybrid OR is specifically designed for endovascular procedures, careful planning from the beginning can help to ensure all rooms are equipped with necessary tools. Some tips to consider while creating a specially designed hybrid OR include:

»Identify factors that are important to the hospital team, such as, should all equipment hanging from the ceiling (surgical arms, flat panel arms, etc.) be able to cover the whole patient in all orientations?

»Think as far ahead as you possibly can to “future proof” the room, reducing the need to renovate the OR moving forward. For example, what is the most extreme type of procedure the team might do in the OR? Then outfit the room in preparation for the procedure.

»Involve the end user at the very start of the project to give a real world perspective for offering scenarios, as well as discussing needs and concerns. This can include nurses, surgical technicians and staff, as well as anesthesiologists.

»Consult with the vendor providing lights, booms and imaging equipment to accommodate all of their needs. For example, many imaging companies have different requirements for ceiling heights.

Hybrid therapies enable hospitals and clinicians to provide less invasive care that is safe and cost-effective for the patient. Careful planning can lead to an effective hybrid operating room design that offers the following benefits:

» Cost-effective operations for patients and surgeons, with better outcomes.

» Reduced stress, faster recovery and reduced hospital stays for the patient.

»Safer procedures, especially in the case of an emergency.

New Bair Paws® Gown Brings “Flex Appeal” to Patient Warming: An Arizant Case Study

The recent Centers for Medicare and Medicaid Services (CMS) adoption of the SCIP-Infection-10 normothermia quality measure has made it more important than ever to simplify the process of warming every surgical patient. Arizant Healthcare’s latest innovation in forced-air warming, the Bair Paws Flex gown, does just that by incorporating a surgical warming product — Bair Hugger blankets — into a comfortable patient gown that warms before, during and after surgery.

While clinical versatility is a key benefit of the Bair Paws Flex gown, so is the practical economic approach of standardizing multiple warming capabilities into one gown that can accommodate most perioperative warming needs. While helping to improve outcomes and boosting patient satisfaction, the Bair Paws Flex gown may save facilities money by supplanting multiple OR warming blankets and the warmed cotton blankets and gowns often used to comfort patients.

Just One Gown Warms From Start to Finish

Before surgery, patients appreciate the Flex gown for its controllable warmth; they can simply dial the temperature of the air flowing through the gown to a level that’s comfortable. The surgical warming products built into the gown are unknown to the patient because they are deployed only by surgical staff.

In the operating room, the same Bair Paws Flex gown offers clinicians the ease and convenience of having multiple patient warming options available during surgery. Seamlessly integrated into the gown are: a head drape, adhesive tape to isolate the surgical field, and deployable arm extensions to transition into a Bair Hugger upper body blanket with tie strips. A second insert in the lower portion of the gown may be used to prewarm before surgery and then warm again as a lower body blanket once in the OR. The gown’s design allows upper or lower body warming for any surgical positioning — supine, prone or lateral.

After the procedure is over, the upper body blanket arm extensions, head drape and surgical tape strip perforate off, returning the garment to a standard warming gown for post-operative use through the lower warming blanket insert.

The Bair Paws Flex gown is comfortable for patients, convenient for clinicians and warms from pre-op to the OR to PACU. Best of all, it’s also economical. One gown handles almost all your warming needs, including contributing to quality goals like SCIP-10 and improved patient satisfaction. It incorporates a highly effective surgical warming device directly into a soft, comfortable hospital gown that does something positive for patients and hospital staff. It’s not just a gown. The Bair Paws Flex gown is a patient warming and patient satisfaction tool. It’s the future of patient warming, and it’s available today.

Practicing Arthroscopic Surgery on Computers, Not People: A Toltech/Sensable Case Study

Learning diagnostic knee arthroscopy is not unlike learning to play the violin — both art forms require a mixture of cognitive and proprioceptive skills that can only be developed through rigorous practice. And while both require intensive mentoring, surgical apprenticeship is unique in its resulting increase in operating room time and potentially patient risk. Just as with a violin that makes no sound, little can be learned from surrogate surgical environments having no objective feedback, including costly and labor-intensive cadaver training. And little transference of either skill can be expected from computer based training lacking the feel of the instrument(s).

In late 2009 the University of Michigan Medical Center’s Orthopaedic Surgery department, led by James Carpenter, MD, became an early adopter of the Knee Arthroscopy Surgery Trainer (KAST) from Touch of Life Technologies (ToLTech). This simulator was co-developed with the American Academy of Orthopaedic Surgeons (AAOS), Arthroscopy Association of North America (AANA), and the American Board of Orthopaedic Surgery (ABOS). It provides both cognitive and haptically-enabled skills training for the proper and efficient techniques required for diagnostic arthroscopy of the knee as done on an outpatient basis — including training to competency, and a modality for complete evaluation of residents’ skills.

In the KAST simulator, trainees hold a customized stylus in each hand — emulating the probe and camera used in actual surgery — that are attached to PHANTOM® force-feedback haptic devices, made by SensAble Technologies. The haptic devices allow trainees to navigate in true 3D space while interacting with high-resolution models that are viewed on-screen, as if through an actual arthroscope. The force feedback devices are programmed to push back on the user’s hand to deliver the “feeling” of the soft tissue, cartilage, and ligaments involved in knee arthroscopy.

The “Virtual Mentor” in KAST guides, critiques, and scores the resident on each part of the procedure. In one module, trainees must perform three steps for examining the medial meniscus with a probe. The Mentor requires the trainee to score 100 percent on each step before attempting subsequent tasks, and finally a time-trial. A special “cheater view,” only available at the novice level, shows the outside image of the knee (seen in the right hand portion of the Mentor screen), to help residents understand where the tools they are using are located with respect to the anatomy. KAST switches seamlessly between a right and a left knee, forcing the trainee to be ambidextrous with respect to the camera and probe.

Haptically-enabled surgical simulation provides cognitive and skills-based training — freeing up the outpatient facility’s attending physicians to teach higher-level skills, and giving residents unlimited autonomous practice opportunities. It allows residents’ skills to be objectively measured and validated before they undertake procedures on patients. The University of Michigan Health System’s Orthopaedic Surgery department plans trials comparing beginning residents who have trained on KAST, against a control group. Separate validation studies led by the AAOS using KAST are underway nationwide during 2010.

Bausch + Lomb Releases Single-Use Silicone I/A Handpieces

Bausch + Lomb announces the U.S. release of two new additions to the Storz® Ophthalmic line of single-use instrumentation.

Optical technique can identify early diagnosis

An early diagnosis of common ocular diseases can be determined via an optical technique that had never before been used for this purpose, researchers from the University of Granada said. The researchers studied the image quality in subjects affected by one of two pathologies, finding a greater amount of ocular aberrations and a higher level of scattering (term associated with the dispersion that light suffers when passing through the various ocular media) in affected eyes compared with results in healthy eyes.

Age-related macular degeneration (AMD) is the leading cause of central vision loss in developed countries, and mainly affects people over 50 years of age. As far as keratitis is concerned, this condition causes inflammation of the cornea and can cause blindness, due to the severe alterations that the corneal surface may suffer.

Carolina Herrera Ortiz and colleagues measured the image quality with two optical instruments and used a psychophysical test for assessing visual performance. Results from patients with AMD were compared with those obtained from a control group of similar age without any ocular pathology. Thus, the researchers could verify that for individuals affected by this condition there is an increased level of ocular scattering that could be mainly due to the disruption suffered by the light reflected in the damaged retina of the AMD eyes, because a priori optics are not expected to be altered, since it is a retinal pathology. The studies will be published in Cornea and Journal of Modern Optics.

Teamwork with pride

The OR can be “brought to life” by all of the people that spend their daily work hours involved with it.  The attitude of the OR “life” is made by each person that comes in contact with the room.  This can make it a beast or a gentle giant.

The best practices for running an OR start with teamwork and pride.  Each person involved should be able to work with the others in the room and know the daily routine. Each person has to take pride in the work that they do.  The circulator must be ready to be in charge and know where all items are.  The room has to be kept stocked – this keeps the running and the down time to a minimum.  The scrub tech must know what the physician needs and anticipate this at all times.  All of the instruments must be processed and available as needed.  The CRNA must be able to keep the patient at ease and comfortable during the procedure.

When all of the members of the team work together it shows in other ways also.  Our number one reason for being in the healthcare field – the patient – is pleased and less stressed to be in an unfamiliar environment.  The patient that sees the staff getting along and working together will be able to feel more at ease.

Room turnover time is minimized by each person doing their share in a timely manner.   This can only be accomplished when each staff member takes pride in the job that they do and knows that each duty is an important one.

When all of these people are able to work together to keep the OR organized and running smoothly the physician seems to keep a positive outlook.  This positive outlook can make the whole process a “gentle giant”.

The minds of members

Just when MCOs think they’ve got value-based insurance design (VBID) wrapped up in a neat little package, the underlying force of behavioral economics begins driving the actions of the beneficiaries. In simple terms, behavioral economics is the effect the actual decision-making process has on the decisions that members reach.

While behavioral economics might be new to healthcare, it is not a new concept. Economists and psychologists have been studying it since the 1950s. Josh Klapow, clinical psychologist at the University of Alabama at Birmingham, says it is basic “operant conditioning,” which says changes in behavior are the result of an individual’s response to stimuli that occur in the environment.

“In short, we are studying how we engage populations in changing behavior, and modifying the environment is the most powerful way to influence behavior,” he says.

While this effect can cause unintended results for VBID initiatives, it can also be leveraged to the health plan’s advantage.

“Applied behavioral economics can help optimize value-based benefit designs,” says Emma Hoo, director, Pacific Business Group on Health. “Healthcare decisions can be as much emotionally driven as fact-driven. Financial incentives can help direct individuals to high-quality, cost-effective services such as preventive diagnostic services or treatment-option decision support, but copayments and coinsurance by themselves are relatively blunt instruments. Equally important are how we structure and communicate evidence-based healthcare choices to help people get the right care at the right time.”

Cyndy Nayer, founder and president/CEO of the St. Louis-based Center for Health Value Innovation (CHVI), which serves as a collaborative hub for value-based design, acknowledges that VBID ties in with the emerging study of behavioral economics.

“To reduce avoidable waste and future risk and to drive individual competency in managing personal health, we use levers—mechanisms for promoting desired behaviors to optimize performance. These are fundamental components of the behavioral economics scenario.”

Nayer describes three important elements of behavioral economics:

• The ability to overcome resistance to change by presenting a vision of potential benefits that will not cause member disruption;
• Making information relevant by showcasing success in similar populations—identifying with peers who have succeeded; and
• Promoting urgency so that the change happens in a short period of time and individuals are rewarded quickly for it.

Alan Garber, MD, professor of medicine at Stanford University and of economics at the Stanford University Graduate School of Business, believes that social norms are a strong factor in influencing decisions. He also cites the importance of regret and the opt-out choice.

“Social norms are what are expected of us, although they may earn praise or criticism,” he says.

Although Dr. Garber says that VBID and behavioral economics intersect—they both take human behavior and benefit design into account in trying to improve health—he believes that VBID relies on incentives while behavioral economics finds other ways to influence decisions, especially by recognizing what motivates a person, which is often, but not always financial gain.

Although looking at it from a psychological point of view, Klapow agrees that assumptions about motivating incentives are not always right.

“Incentives are rarely delivered in a manner that is consistent with behavioral modification,” he says. “The challenge is to be able to create an incentive structure in which individuals have the opportunity to choose their own reinforcers, which most employers don’t enable. That will increase the power of the system. I’m seeing good intentions with no science to back them up.”

While the psychological innerworkings of member behavior are worth exploring, the more practical task is applying behavioral economics to plan design to gain the intended results for plan sponsors and members.

CHOOSE YOUR DEDUCTIBLE

Lowe’s Companies, a large home improvement retailer based in Mooresville, N.C., designed a benefit structure that applies behavioral economics principles to health risk assessments (HRAs). Lowe’s offers its 225,000 employees the choice between a $500- or $750-deductible benefit plan.

For 2010, if employees wanted to opt for the lower deductible plan, they had to complete a health risk assessment during 2009, according to Bob Ihrie, senior vice president, employee rewards and services at Lowe’s.

“It didn’t take much convincing,” Ihrie says. “Employees wanted the best plan possible.”

He says that Lowe’s had been trying to encourage HRA completion for years by using an incentive, but only 15% of employees took advantage of the offer. Its new approach using the lower deductible has garnered 82% participation in the HRA.

“There is more aversion to risk than attraction to gain in the decision. Employees don’t want to lose the best coverage, so they choose to participate,” he adds. “Previously, they earned an incentive, but apparently it was not enough to urge them to take the HRA. However, with the penalty of a higher deductible, they see it as losing money.”

Pharmacy benefit programs are also fitting opportunities to apply behavioral economics.

Express Scripts’ chief scientist Bob Nease finds that the use of loss aversion is effective, with fear of loss outweighing need for gain. Knowing the enrollees’ sensitivity to loss can help shape strategies to influence behavior, such as encouraging the use of mail service for ongoing drug therapy.

The PBM has been targeting members with low medication adherence through different communication vehicles and found that a letter signed by the chief medical officer was effective when it emphasized the downside of not using home delivery. A message stressing that members would lose money if they didn’t use mail service elicited an 84% response—a percentage that reflects the relative increase in click-through rates—while an approach emphasizing time and money savings only received an 18% response in click-through rate increases.

“We are not wired to be rational,” Nease says. “The underpinnings of our behaviors are carved into our brains.”

To reduce costs, Lowe’s explored ways to urge employees to use mail delivery for their maintenance medications. Partnering with Express Scripts, Lowe’s “nudged” employees to voluntarily select mail service by emphasizing that the switch was not mandatory, did not require any changes in plan design and offered many benefits, including lower copays.

If employees did not want to use mail service, they would have to opt out.

“We used social norms—the idea that ‘everyone else is doing it’—to frame the right message and choice architecture, which are the conditions under which decisions are made, to overcome procrastination, while also making it easy to switch to home delivery by offering employees assistance,” Ihrie says.

For example, Lowe’s put a message on its Web site, inviting employees to sign up for home delivery by noting combined savings for the plan and employees of $5 million. The communication also told employees that they could fill their first and second supply of maintenance drugs at any network pharmacy, but would have to pay full price for the third fill at retail. A personalized letter to employees also reinforced using mail service.

Prior to the program, only 15% of employees used home delivery, increasing to 39.5% with the new approach. Ihrie says that all new employees or current employees who get a new maintenance prescription in 2010 will have to use home delivery. Those who opted out of home delivery in 2009 are permitted to continue filling their prescriptions at retail, but they will pay double the copayment starting next year.

According to Ihrie:

• Know your culture and employees’ tolerance for change;
• Target those most in need;
• Make communication a priority;
• Increase the intensity of communication as the time of decision nears; and
• Promote shared responsibility.

Behavioral economics has tremendous potential to get people to do what’s right without imposing a mandate, he says.

Getting members’ attention can also drive higher participation.

“An incentive might drive employees to choose home delivery, but it would just get lost in the tsunami of more important things. Instead, you have to add a ‘nudge,’ such as a reminder at the point-of-service about the ease of refills through mail service,” says David Laibson, professor of economics at Harvard University who teaches behavioral economics. “It makes you stop and think about the activity. Although incentives can work, you need a default selection process with an easy opt-out, deadlines and social pressure.”

Laibson uses enrollment in a 401(k) retirement plan as an example of the power of the opt-out alternative. He cites that only half of U.S. employees save enough for retirement, partially because they procrastinate on starting an account. When using an opt-out approach enrollment for new hires can jump to 85%.

“People already know what they should do and want to change their behavior, but they don’t want to follow through,” he says. “Delayed gratification doesn’t work. It’s hard to sacrifice today for tomorrow so you need an intervention that will facilitate behavior change—not dictate it—and make the change easy to execute,” he says.

The behavioral economic force in delayed gratification is that costs come early and benefits arrive late.

“Employees have a hard time aligning their good intentions and their actions,” Laibson says. “When costs precede benefits, decision makers fail.”

Laibson recommends interventions that make good behavior easy or bad behavior hard. While he believes that incentives alone will not do the job, he still sees a complementary relationship between behavioral economics and value-based design.

“Value-based benefits improve the tool box by offering other nudges to do the right thing,” he says, “but you need to leverage the psychology of problems to steer people in the right direction.”

Laibson cautions against interventions that are not cost-effective and don’t deliver the biggest bang for the buck, such as offering incentives to those who would demonstrate good behavior even without a reward.

HEALTHCARE’S ECONOMICS

There is widespread acceptance that incentives for patients and clinicians are not aligned. Patients regularly confront financial barriers while clinicians are paid for the quantity of services they provide, regardless of the results.

“As we consider healthcare system transformation, behavioral economics principles, which include social and emotional factors in consumer decision making, should play a substantial role,” says A. Mark Fendrick, MD, professor, Department of Internal Medicine and the Department of Health Management and Policy at the University of Michigan at Ann Arbor. He says he can see the common thread of loss aversion running through value-based benefits and behavioral economics

“Empirical evidence suggests that the clinical and financial effects of adding a healthcare benefit for those who don’t have it will not have the same, but rather, the opposite effect if that exact same benefit was taken away from those who already have it,” he adds.

Dr, Fendrick says that loss aversion is taken into direct consideration in evaluating the impact of VBID programs, which explicitly attempt to align incentives by lowering patients cost share and increasing clinician payment for high-value medical services.

“The expected differential effects of an equal incentive—the carrot—and disincentive—the stick—which diverges from classical economic decision-making can be explained by behavioral economics,” he says.

Jeff Munn, principal, health Management Consulting Practice for Hewitt Associates, says behavioral economics offers real-world insight into people’s day-to-day behavior and what guides decision making.

“Since behavioral economics looks at how real people take action and make decisions, it enables us to predict when poor decisions will be made,” Munn says. “If we apply this insight, we can take measures to counteract these decisions.”

Deeper data points revealed in health risk assessments

The employee health risk assessment (HRA) remains a powerful tool for employers, but uncertainty over incentive guidelines and frustration over participation rates can stall even the most innovative programs. The goal of an HRA is two-fold.

HRAs provide employees with measures of their current health status and future health risks as well as actions they can take immediately to improve health. Additionally, employers can use the HRA information—aggregated and de-identified—to develop a wellness strategy.

“Most employers recognize that you can’t manage what you do not measure,” says Michael Taitel, vice president, Alere Center for Health Intelligence. “If you are trying to manage the health of your population, you can’t achieve that goal unless you have the data that shows the prevalence of health risks, chronic conditions, and absenteeism and presenteeism rates in your population.”

More data can be better when it comes to health measurement. Alere offers a Health and Productivity Assessment (HPA), which analyzes the effects of specific health problems on work performance and absence.

“For example, we ask them to indicate if they are missing work because of a health condition,” Taitel says. “In another series of questions, we ask them to rate and compare their performance to other employees. So simply looking at risks alone only gives part of the picture.”

For example, many HRAs assess the presence of depression.

“We understand that depression plays a key role in an employer’s productivity losses, as well as overall benefit costs, so we believe it is an important component to study,” Taitel says.

Another feature of an effective HRA includes a link into personal health support interventions so that employees may be steered into programs that can provide assistance. Employees who require assistance may also be identified for contact by a health coach or for participation in special wellness or prevention programs.

DRIVING PARTICIPATION IN HRAS

According to “Wellness Programs, Survey & Sample Series,” published in February 2009 by Brookfield, Wisc.-based International Foundation of Employee Benefit Plans, only about 14% of employers have indicated participation rates in HRAs above 75%, while 18% of employers indicated participation rates of 51% to 75%.

Bryce Williams, director of prevention and wellness at Blue Cross Blue Shield of Massachusetts (BCBSMA), believes that best-in-class participation begins at 80%.

“When [80%] of a population completes an HRA, the data becomes more meaningful and informative to future program strategy,” Williams says.

LURING EMPLOYEES WITH CASH

Incentives are the most popular tool to encourage participation, and there are a number of carrot-and-stick approaches, according to Carl R. Mowery, managing director of SMART Business Advisory and Consulting LLC, a business advisory services firm based in Devon, Pa.

“Some employers have even required employees, as a condition of participation in the healthcare program, to complete an annual health assessment,” Mowery says. “Others will give discounts on premiums for those who complete a health assessment, and others will provide cash or gift certificates to the employees.”

The Equal Employment Opportunity Commission (EEOC) issued an informal opinion letter stating that requiring employees to participate in an HRA may violate provisions of the Americans with Disabilities Act (ADA). However, HIPAA had earlier outlined a recommendation that noted the incentive can’t be greater than 20% of the cost of the health plan. Most employers are currently following the HIPAA guidelines.

Much discussion has taken place on how to apply incentives for completing HRAs. The company can opt to pay cash or the incentive may be tied to reduced health insurance premiums.

“The important thing to keep in mind is that incentives do not have to be costly,” says Taitel.

In CIGNA’s experience, its clients with the best overall HRA completion rates have offered a reduced premium or cash payment.

“Incentives play an instrumental role as a mechanism to engage individuals to participate in HRAs and in other programs designed to improve lifestyle behaviors,” says Emelia DeMusis, CIGNA product manager. “Levels of participation in HRAs have been found to vary significantly depending on the type of incentive that is used to motivate participation.”

While DeMusis says that optimal participation rate is obviously 100%, she believes that “even at levels below 100%, such as 20% to 40%, there can be medical savings.”

WALKING THE TALK

Participation is greater when it is supported by management and when it is linked to a more comprehensive intervention, specifically when it becomes an instrument used to help shape the corporate culture.

Incentives are a useful tool, but the best thing employers can do to encourage participation is ensure there is organizational commitment to the process, Alere’s Taitel says.

“Top leaders must become wellness champions,” he says.

In fact, in a peer-reviewed study Taitel led last year, researchers found that the strongest predictors of HRA completion are the monetary value of incentives and the employer’s level of communication and organizational commitment.

In the study, organizational commitment was a metric that included communications, the level of employee involvement through committees and internal champions, and visible executive management leadership support through advocacy, program participation and allocation of resources.

“Perhaps the most important finding was that the higher the organizational commitment, the lower the incentive cost needed to be,” Taitel says.

BSBSMA’s Williams agrees. Communicating with employees in advance of an HRA launch can ensure employees have a clear understanding of what data from their HRA will be shared with their health plan and their employer, he says.

CASE IN POINT

Visible senior management support, an engaging wellness platform and meaningful data have been demonstrated at SPS New England (SPS), a Salisbury, Mass.-based construction services company with 211 subscribers.

Under SPS’s wellness program, which is offered through BCBSMA, employees who elect to participate receive a higher contribution (up to 20%) from the company on their health insurance premiums depending on several wellness factors. SPS’s goal is 100% participation, says the company’s CEO and chairman, Wayne Capolupo.

Participation includes completing the BCBSMA online HRA, as well as being individually screened for tobacco use and three health metrics (BMI, blood pressure and cholesterol) and setting goals to maintain or improve those metrics over the coming year. BCBSMA wellness consultants work with SPS to run analytics on the HRA data and identify population health risks, which inform future interventions.

“SPS’s company contributions to health insurance premiums are based not only on employee participation but also on whether employees meet the health goals they set for themselves,” Capolupo says. “In the long run, it is our hope that by focusing employees on their own health issues and high-risk behaviors, and providing services to attenuate those risks, that employee wellness will improve and lost time and claims will be reduced. As a result, SPS’s health insurance premium will be reduced.”

DIG DEEPER

Historically, HRAs were mortality based and data didn’t go far. Today, data analytics get more mileage out of HRAs.

“Analysis of HRA data at the population level is used to support client decision making by analyzing how current health risks impact future health status, costs, productivity and disability, by identifying the most appropriate health strategies to support a population and by monitoring health status and health changes over time.” CIGNA’s DeMusis says.

By employing the University of Michigan HRA and Trend Management System, CIGNA is able to forecast costs and health status, use targeted improvement strategies and recommend the optimal outreach method to engage individuals, according to DeMusis.

But, in today’s economy, can employers afford to implement full-scale HRAs? Overwhelmingly, experts believe employers can’t afford not to implement an HRA as part of an overall wellness program.

“These programs can help employers reduce turnover, increase productivity, improve employee health and help potentially high-risk individuals from becoming future high-cost claimants,” says SMART Consulting’s Mowery.

HRAs typically cost just pennies per member per month. It’s a small investment with high potential for return.

However, there’s no real ROI for an HRA alone, according to Taitel, who asserts that the value of an HRA comes in measuring the changes in health risks over time. Large employers can link HRAs to claims data to see actual changes in costs.

However, the real key is link HRAs back to meaningful interventions. To secure true value, employers must take the information and use it to build tailored and useful health and wellness programs.

Tracey Walker is a senior editor with Advanstar Communications.

Kipp Fesenmaier Joins Vantage Outsourcing

Kipp Fesenmaier, who was instrumental in the growth of Sightpath Medical (formerly Midwest Surgical Services) into the largest cataract outsourcing business in the United States, has joined the team at Sightpath’s primary competitor, Vantage Outsourcing.

Fesenmaier assumed the position of Vice President of Business Development at Vantage, which is headquartered in Effingham, IL. He will work out of Minneapolis, MN, where he has many established relationships with physicians and facilities. During his 15-year tenure at Sightpath, Fesenmaier was successively employed as technician, Mobile Operations Manager, National Accounts Manager, Vice President of Operations and Vice President/General Manager of Diagnostic Services.

Fesenmaier’s responsibilities with Vantage will include sales for Vantage’s Northern Plains territory, national sales management, vendor relations and strategic alignment of the company for continued growth. “With Kipp’s history of leadership and relationship-based business management, we have added one of our industry’s top professionals,” said Vantage founder and CEO Ann Deters. “We are confident he will help us tremendously in our goal to be the industry leader.”

Fesenmaier lives in Albertville, MN, with his wife Amy, daughters Paige and Libby, and son Reed.

Bausch & Lomb Releases E2407 Raviv Capsulorhexis Caliper

Bausch & Lomb Storz® Ophthalmic Instruments announced the release of the E2407 Raviv Capsulorhexis Caliper.

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