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Choosing the Best Specialist Using Data
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Choosing the Best Specialist Using Data

SentryHealth Senior Vice President Ed Dillabough and Al Lewis, CEO of Quizzify, got together recently for a webinar to discuss how benefits advisors and employers can help employees find the best specialists using comprehensive data and clinical expertise. They discussed:

  • Why quality of care is valuable when choosing the best specialist
  • What kind of data is important to evaluate
  • The ways cost and quality are and aren’t related
  • How to engage employees to choose a specialist wisely
  • How to make the most of a specialist visit
  • Real-life examples of why it’s important to choose a specialist based on data and not opinion

Choosing the best specialist is an important decision and should not solely be based on referrals from friends or the internet. As an advisor or employer, you’ll want to offer benefits that help employees get the right care for the right price.

Having a medical advocate program can help employees and their family make more informed decision that will save the employers money.

Check out our recent blog, ‘What is Care Navigation and What are Its Benefits?‘ to find out more about how employees can get the help they need in finding physicians and facilities with the best outcomes and more.

In This Podcast

Ed Dillabough, Senior Vice President at SentryHealth

Ed brings more than 30 years of executive management experience in health insurance companies, claims, and managed care organizations. Prior to joining SentryHealth, Ed co-founded and served as the President of MAP Health. He works firsthand with employers, advisors, and third-party administrators to implement strategic initiatives focused on improving quality and making health care more affordable for both employers and their employees.

Meghan Henry:
Hi, everyone, and welcome to For Your Benefits, the podcast where we discuss hot topics in the world of employee health and well-being. I’m Meghan Henry, Director of Marketing at SentryHealth, sponsors of For Your Benefits.

Recently, SentryHealth Vice President Ed Dillabough joined Quizzify for a webinar to discuss how benefits advisors and employers can help employees find the best specialists, using comprehensive data and clinical expertise. They discussed how to identify the right specialist, as well as the importance of having good information for better decision making. So we thought we’d share this with you. Enjoy.

Introductions

Mark Dellecave:
I’m going to start by making some introductions to get us going here. I’ll introduce myself first. This is Mark Dellecave, I’ve been with Quizzify for about five years. Prior to that, I’d worked in the brokerage industry, with Willis and USI, and Al and I have been doing these presentations with complementary vendors. In many ways, it’s health literacy for the broker, and for the benefit manager’s side of the business, versus our core business, which is health literacy for employees.

Al Lewis is on the call with us today, and most of you know Al. Al is recognized as one of the foremost authorities on wellness and population health. He’s authored a book about that. He wrote another book that was about cracking health costs, with Tom Emerick. Tom managed benefits at Walmart for more than a decade. Back in 2013, they were talking about better pharmacy benefit management, better medical management centers of excellence. Many of these strategies are now going mainstream in next generation benefits plans. Al is also a Harvard trained lawyer, and that spills into our ER Prevent Consent, which has been working to save a lot of people money from surprise bills in the ER.

Now, we’re going to be talking about data today, and we have some expert panelists with us. Ed Dillabough is president and co-founder of MAP Health, which is now owned by SentryHealth. And Ed built a business that essentially mines this data, that helps people to make better decisions when choosing a specialist.

Ed is joined today by his colleague, Colleen Hekkanen, who manages a group there. She’s their chief clinical services officer. This is a team of people that interacts directly with the employees and employer group to help them understand why they might want to use a certain specialist that comes up in data, and guide them to their best possible health.

Agenda

Mark Dellecave:
So engaging employees to use this data is also an important part of this process. And Colleen will be talking about that, as we get into our conversation. But let’s talk about our agenda.

We’re going to talk about some polling questions, to start us off. Where does this data come from? The components of specialist quality and cost decisions when choosing a specialist, engaging employees to use this data. Once you’ve found a specialist, what do you do? Can you get prepared for that doctor visit, with the right questions to ask? And Quizzify2Go can do that.

Al’s going to talk about that, and we’re going to also have a Quizzify challenge to wrap, after that. Let’s start with some polling questions.

Polling Questions

Mark Dellecave:
I’m going to put up two questions on my screen here, and we’re going to have you take a look, and answer these questions, in terms of how you pick a specialist right now, and another question about diagnosis. In the meantime, Al Lewis is going to share a story about his efforts to pick a specialist.

Choosing the Best Specialist

Al Lewis:
Yes, I am here to learn as much as anybody is, because, while Quizzify claims world class leading expertise in, as Mark said, what questions to ask when you get to the specialist, health literacy, and certainly, ER, I don’t know the first thing about picking a specialist. That’s why we have these folks on, and I’ve picked some of the worst specialists in the history of specialists. To give you one example, this is just one, and hopefully, I have time for all of them.

I had back pain. Now Quizzify teaches, quite correctly, that while 80% of back pain goes away on its own eventually, but 80% of us are convinced, at some point, that we are in that other 20%, and we go seek medical care. That’s exactly what I did. So I go to my PCP. She refers me from my back pain to an orthopedist, who pokes me a little bit, and then announces I have piriformis syndrome. That was the disease du jour back then. I say, “What’s piriformis syndrome?” He says, “Look it up in any sports medicine encyclopedia.”

Okay, that’s not even the punch line. The punch line is, I go to look it up, and it turns out, I can’t find it. I’m looking P-E-R, P-I-R, never occurred to me that this was P-Y-R, pyriformis syndrome. So I got nothing out that visit whatsoever. It took for, I was billed at a Level Four, so I’ll just stop there, because I can keep going, and how do things wrong, all day? Let’s see what the answers came in as. Mark?

Discussing the Polling Questions

Mark Dellecave:
Now, for the question, “How do you choose a specialist now?” It’s, 51% said, “PCP referral,” 16%, “I ask a friend,” 24%, “I search on my health insurance network,” and 9% said, “A friend recommends one.”

In terms of, “What percent of patients visiting at the Mayo Clinic for a second opinion, learned that the initial diagnosis was truly accurate,” that 49% said 50%, 27% said 70, and 11% said 80. The actual correct answer there, unfortunately, is 12%. That’s a bit of a shocking study that was by the Mayo Clinic. But the reality is that misdiagnosis is a little bit more prevalent than people realize, and that makes choosing a specialist, a quality specialist, more important than ever. This now spills us into, actually, so where does this data come from? Colleen, I’ll ask you to talk to us about that.

Choosing a Specialist Using Data

Coleen Hekkanen:
All right, sure. I’d love to kick us off. We saw that 51% rely on their primary care physician, to direct them to a specialist. I think this is the perfect analogy. When you’re thinking about just navigating the healthcare system, you are in treacherous waters, right? And when you think of the Titanic and what brought the Titanic down, it was the iceberg. It was what they could not see under the surface of the water.

A lot of our patients, when they’re looking for identifying a quality provider, they rely on people like their primary care doctor to steer them, or they’re looking for referrals from friends and family. And I think they’re really focused on what they know above the surface of the water. They’re looking at some convenience factors. How close is that doctor to them? What are some appointment availabilities? If they were given a specific name, usually they’ll go, and the first thing they do is, they go on Google, right? They’re looking maybe at, what’s the doctor’s background or educational history? They may even look at some Google reviews. That can be a little bit more dangerous than helpful, but it’s really underneath the surface of the water. That is how they should be determining what’s the best doctor for them.

Sometimes, it’s just not having the knowledge that that information is out there. Sometimes, it’s just not having access to that information. You want to be able to, when you’re identifying a quality provider, look at some different data sources. And you never want to rely on just one data source, right? You want to get a really good mixture. You want to get information from CMS, but you also want to make sure you’re getting to that commercial payer information, as well. From there, that data should really help in steering and navigating you to the best quality provider. Let’s look at what some of those data points would be that you’re looking at.

All right, so when I started the discussion, I talked about, what are some things that patients will typically look at, before they make a selection? Educational background is one of the things that they look at, they’re not looking at the right thing.

Lots of times, I’ll hear, “My doctor graduated from Harvard Medical School,” or a very prestigious medical school, which is wonderful, but they’re not looking at things like, is that doctor board certified? Is that doctor fellowship trained? What was the time of their graduation? You definitely want to consider those types of things when you’re searching for a quality provider. You don’t want someone right out of medical school doing a surgery or procedure on you. At the same time, you don’t want someone that is nearing their retirement age, right? So you need to consider those types of things. Then you really want to down into, “Okay, if I’m having a surgery or procedure, what are the number of cases my doctor has performed?” You want a doctor that has very good volume.

We see this so much with orthopedic cases all the time, where you have a doctor, a specialist that really specializes in a certain area of the body. But then, every now and then, they will perform surgery on another part of the body. Just because they do it every now and then isn’t the doctor that you want to go to. You want to go to the specialist that’s doing that regularly, that is their primary focus of surgery. You want to go to a specialist that has really good quality outcomes.

What are the Quality Outcomes to Look At?

Colleen Hekkanen:
So what are some quality outcomes we’re looking at? Unfortunately, we are looking at mortality rates. You don’t want to go to a doctor who has a mortality rate that’s high. We’re looking at surgical complications. Does this doctor require really long lengths of stay after they’ve performed a surgery? Are there any outlier cases out there? Are there really high cost procedures? That’s usually a red flag for something.

We look at disciplinary actions and malpractice issues. You don’t want to be going to a specialist that has those on their records. And then, network participation, that’s really important. I think patients are a little bit more savvy nowadays of being mindful that they’re going to a doctor that’s in-network. Unfortunately, a lot of times, they’re not getting the accurate information. They’re calling a provider’s office. They get the front office staff, they’ll ask, “Do you accept my insurance?” “Do you accept my insurance?” is very different than network participation. So you want to make sure that you’re steering patients, not only to a quality provider, but one that’s also cost effective for them, so that they can have a really good health outcome.

Al Lewis:
Colleen, while you’re on the subject of disciplinary and malpractice issues, should those folks even be in the network? I mean, aren’t networks supposed to be getting rid of those folks in the first place?

Coleen Hekkanen:
It’s so funny that you should ask that. Not only do we get that question about, what are your credentialing procedures, when you’re actually bringing in a provider into your network? Most of the time, it’s just that that doctor is going to accept the reimbursement rate of that plan. They’re not looking at any of that background information. That’s probably if we were to do a myth page, that would be a really good myth that these networks are checking to see if there’s any malpractice or disciplinary actions before they bring the provider into the network.

Another question I get asked is, “What about these big healthcare systems? Aren’t they checking those, as well?” No, they are not. So it’s really on the patient to make sure that they’re identifying a quality provider, and by accessing an advocacy program like ours, to help them make sure that they have all of that information when they’re making that decision.

The Components of Specialist Quality: Identifying Quality Providers

Mark Dellecave:
Great. Well, thank you. Okay. The next part of this is, once you have the data, and you’ve pulled the data that you want, it’s funneling that data down to the actual doctor’s decision. Ed, would you like to elaborate on this?

Ed Dillabough:
Sure. When you’re looking for a preferred provider, what we’re looking at here is some market area. This is an area in Pinellas County, Florida, where we look at how many physicians are performing a certain procedure. In this case, we’re looking at a total knee replacement. So there are 60 doctors, orthopedic doctors in the marketplace, that meet the participants’ criteria for distance and travel. Then you determine, the first step is, of the 60 positions, how many of them perform the procedure, at least 50 or more a year? Now that’s our criteria for total knee replacements, 50 procedures. To be proficient in that procedure, we feel like that’s a good number that’s been verified by different institutions, that’s at 50. So now we’re down to 14. Of the 14, how many of them are quality physicians? And quality, we mean, are they credentialed? Are they board certified? Do they have any disciplines?

Do they have good outcomes, in the sense that their mortality rates are acceptable? Their complication rates, the number of outlier cases they have, how do they all fit in together? Now you’re down to eight physicians. You started with 60, and now you’re down to eight. Of those eight physicians, how many of those doctors are cost effective? You look at the cost of the charges, You look at the cost of the implants, because implants are a pass through item, usually.

That’s the biggest variable that causes us not to select a physician, because they’re using prosthesis, or a prosthetic device that’s very expensive. Once you turn your defamation of cost, then you define those, and come down to six positions. Say, of those six, how many of them are participating in a network? Now, again, we’re looking at the network of a PPO plan here, so that if four of those 60 are cost effective, have good quality, adequate volume, and are in your network, we would provide those names to the participant for a total knee replacement.

We’ve also verified the participation in the network, and we’ve also verified appointment availability. Those criteria are taken into consideration within a network so that we usually give two or three of those four positions to the names of the participants.

Al Lewis:
This data all comes out of two databases, right?

Ed Dillabough:
Yeah, this is a commercial and Medicare database. So it’s not just looking at only Medicare, it’s looking at probably 95% of the cases of the particular doctors in a general area. So we look at nationally, commercial, and Medicare. We may not look too much at Medicaid. That’s mostly the children, but again, for adults, and the commercial population and Medicare contributes most through the hospital admissions.

Again, we’re looking at an inpatient setting here. Some of these procedures can be done outpatient, and we do take that consideration, too. Now, in total need, some are done on an outpatient basis. Most of them still are done on the inpatient setting.

Al Lewis:
Assuming that perhaps, shockingly, somebody might not want to use Sentry, they can access this data on their own. From what specific database are they getting it?

Ed Dillabough:
Well, it’s not so much having the database. It’s also having software that runs its information, to determine these particular numbers. You can buy data, but the question is, you have to have a software package to be able to take this data and make sense out of it. Yes, you can buy information from the states. You can buy from MEDPAR, you can buy it from clearinghouses, a lot of places you can buy data, but the problem is, you’re not adjusting the data, so you’re being able to benchmark it, compare one doctor to another doctor, in a geographic area.

That’s what we provide. It’s the analysis of that, and determination of who is the best doctor for your specific need in a general area. And do you need a second opinion, which we’ll get into in a second?

Specific Example: Choosing a Heart Surgeon

Mark Dellecave:
Okay, thank you. Our next slide here is about a specific example, at about choosing a heart surgeon. Would you like to elaborate on this one?

Ed Dillabough:
Yeah. This is a bubble chart that we’ve used over the years, and this is actual data, looking at a general area. In this case, we’re looking at nine bubbles, or nine positions, that meet the criteria of at least 75 open heart procedures per year. Again, when I’m saying 75, I’m referring to not just Medicare, but commercial and Medicare population, how many of those procedures are performed? So, of the 75 or more, and again, the smaller bubbles are 75, and the bigger bubbles are up to 250.

What we do is we index in this example here, looking, giving you a little bit more information about quality, quality we view as either complications or mortality. There are also outliers. But again, looking at those two factors that we can get on an exhibit is important for us. Because in complications, the question is how many complications did the physician have, and benchmarking that against the other physicians? An example, maybe, of mortality would be, the doctor had seven deaths, and the population, we expected 10. So seven divided by 10 is 0.7.

That would be to the left of the one, in other words, that would be better. If it was higher, obviously, we had 10 deaths, and there only should have been five. It would be overall on the right hand side, and it would be worse. Again, we look at the actual results of a physician by the procedure. Not all of their procedures, just the procedures associated with what we’re looking at, in this case, open heart. Now, obviously, these physicians are qualified all of them are qualified to do it. But we picked A, B, and C, because we felt like, if you have a lower complication rate, and a lower mortality rate, with high volume, those are the doctors that I would use for my own family, or myself. With the data, it’s quite easy for us to determine who those physicians are within a general area.

Al Lewis:
Okay, so we have a few questions that have come in. One is that we’ll send everybody the different ways, If you want to get the raw data, we’ll send you how to get the raw data. That’s question one. Question two is, “You said a minimum of 50 total knees. I had assumed that was because there are many markets in the country where the highest volume orthopedists wouldn’t be doing more than 50. It’s been pointed out that in major metro markets, you should be able to find people who are doing 200 or more, and they should have a higher quality. How would you feel about that?”

Ed Dillabough:
Well, I mean, we have a physician in Florida, who does about 800, and we don’t use him, not because he doesn’t have high volume. His outcomes are very good, but he has a habit of doing surgery on everybody. Just because they have high volume, doesn’t mean that’s the right doctor for us to select. You want to select a doctor that has good volume, not necessarily the highest volume, but very, very good volume in taking care of the patients. We don’t want the physician to have a different standard of care than the community. Again, we do want to use high quality, high volume physicians, not necessarily the one that has the highest volume, because again, the standard of care is what we’re measuring.

Al Lewis:
Yeah, we have that in Quizzify, as well. That it’s a bit of a red flag, if somebody does a ton of stents, a ton of joint replacements, a ton of back surgeries. So I’m glad you have the same … Mark, did you want to add anything?

Cost vs Quality

Mark Dellecave:
No, we’re going to move to our next section here, which will bring out the cost versus quality. We’ve got two more polling questions here that I’ll put up on the screen, and give everybody a chance to think about what we’re going to be talking about in our next section here.

We’ve got an example of an actual, comparative hospital and physicians, but there are a couple of questions. One is, “The relationship between cost and quality in the medical marketplace, what is it?” And the second question is about the cost of providers. It’s an interesting question, in the sense that it’s, at one hospital in Florida, what’s the disparity in pricing for a total knee replacement between different physicians? And there are numbers that you can take a look at.

Once we finish these polling questions, we’re going to actually go into some data. Does anyone have a comment in our panel, while we’re waiting for these answers?

Al Lewis:
Yeah, actually, I have more stories. Once again, what I’ve done, the mistake I make is, just take my PCP’s word for these things. So I used to host a radio showdown on the NPR affiliate in Washington, DC. Don’t ask why, it’s a long story.

But after my first episode, the producer said, “Okay, for your first time, that was pretty good. You’ll sound better when you get over your cold.” Because this is the way I normally sound, and apparently, it was going to cost me this gig. I called back to my PCP, and said, “Can you get me to see an ENT?” Because years ago, someone had told me that I had a deviated septum or something.

You get graded on satisfaction. One of the things, the ways you satisfy your members is getting them all the medical care they ask for. So she gets me in to see an ENT. Well, the ENT puts a scope up my nose, and says, “Well, a deviated septum’s the least of your problems. You have polyps.” I think, “Oh my God, polyps, I’m going to die.” I didn’t know what they were. So she says, “Well, there’s four things we can do about them.” She says, “We can take them out, they could grow back. We could treat you with a three-week course of antibiotics and Flonase. We could do Flonase alone.” And she says, “Those are the three. And oh, and we’re going to want a CAT scan of your sinuses.” So the first thing I said was, “Well, shouldn’t we do the most conservative therapy first?” She said, direct quote, with the exact intonation, “Well, you could,” meaning, only an idiot would, but you could, right?
And then, the other thing, and mind you, this was somebody who was salaried. So it wasn’t like she was trying to pitch me on a surgery. This is just what she does. She does surgeries. The other question I asked was, “Well, I don’t think this is bacterial. Why would we do three weeks,” which is a huge length of time for an antibiotic? I didn’t say that. “Why do we need an antibiotic for three …” She says, “Well, my patients get good results with the antibiotic.”

I’m thinking, “I got to get out of here,” think I got to get out of here, because first of all, that’s not a reason to do anything. And second, you don’t give people an antibiotic, if they don’t have a bacterial problem. That’s a big Quizzify thing. I’m not going to get the CAT scan, I’m going to get out of there. So I got to make a deal here, to get out. I said, “Why don’t we just do the Flonase?” She says, “Fine. It says on the bottle once a day, you can take it twice a day.” So I say, “Fine.”

Two next things happen. One is, I go home, they’ve already tried to schedule this CAT scan for me. Someone has already called, and I’m thinking, “I’m just going to ignore this. I don’t want somebody pointing radiation at my head.” So I just ignored it. They called back, and they called back a third time. I’m thinking, “If I don’t call these people, they’re going to charge me.” So I called to cancel the CAT scan that I never wanted. I’m just doing the Flonase, for my hoarseness, and then, at one point, I actually stopped to read the label on the Flonase. It says, “Side effects can include hoarseness.” Okay? So I’m going to say, I stopped taking it right away.

That’s not even the end of the story. The end of the story is, I get, number one, I told the producer that this just wasn’t working out, da, da, da. She said, “Oh, don’t worry about it. We’ll just give you some tea with some honey, and just sip it, between comments.” And in fact, the show did off the air, but whenever the complaints came in, nobody said, “This guy sounds like he has polyps.” So that part really worked out.

Number two is, I got a nasty note from the PBM, saying, “You haven’t filled your Flonase renewal.” Number three, and this is actually the only … Well, there are actually two pieces of good news is, one is this story, which was in the book, it’s in Cracking Health Costs, got back to the CEO of the … It’s a $2 billion medical organization, actually. He looked at it and said, “We need to have this guy on our board, so he can help us, prevent us from doing those things in the future.” And I did, and I have been. We’ve just sold to Optum, bur I was on the board for several years.

And the fourth thing is, this is why I started Quizzify. Because I’m thinking, “If this kind of medical care, completely unnecessary, and possibly harmful medical care can be thrown at people, it’s not just me, it’s everybody.”

That’s how I got to Quizzify. So that’s the story. Let’s go to the poll.

Polling Question Results

Mark Dellecave:
Okay, we can share the results here. And for the first question, we have a pretty sharp group here. The answer, “High quality healthcare is often the lowest cost,” which is a true thing, and very interesting component of the medical marketplace in the United States.
The second question is an interesting one, and that actually goes into our next slide here. “At the same hospital in Florida, what’s the difference in cost for a knee replacement for different specialists?” And the most commonly chosen answer, 43% picked 25,000, 33% picked 75,000, 18% picked 100,000, and 6% picked 10,000. The correct answer is 100,00, and that leads to our next slide here. That we’re going to talk about here. And Ed, would you like to elaborate on this?

Knee Replacement Example: How Cost & Quality Are & Aren’t Related

Ed Dillabough:
Yes. In this example, we’re looking at a lot of numbers. I apologize, but we’ll try to focus on some of the numbers. There are 30 hospitals we’ve looked at, and within the hospital, we showed a range of the Chargemasters, and also, some factors that contributed to that, such as length of stay.

But an example of Morton Plant Hospital, based in Clearwater, we looked at physicians on the very first line. It says 254 cases. If you look at, his length of stay is quite good, 1.38 days, and you look at his statistics, his Chargemaster charges that are associated with that physician at that hospital.

In other words, the next hospital-physician down shows the high quality doctor does 86 at St. Anthony’s. And the next hospital down below, is Mease Countryside, where positions performed 200. Again, what we do is we kind of benchmark each of those doctors against each other, within a general area. But within these hospitals, that specific hospital using a chain, Chargemaster, you can get a doctor, both performing at least 50 total knee replacements a year. The one doctor that performs 100 has a length of stay of 1.34 days, The one who performed 53 had a length of stay of three days. Same hospital, just, again, the physicians controlling the length of stay.

But if you go into the red, you look at the Chargemaster, one doctor that performed 100, his average bill charge is $51,210 per case. The other doctor at the same hospital, 53 cases, three-day length of stay, used a different type of implant, had a longer OR time, and could generate a charge of 153,000. Again, what’s important about these bill charges are, is what you pay off these charges. Even Medicare pays more, but again, commercial pays more, but we used this data to be able to determine payment, and also determine, in the reference-based pricing, the amount of balance billing, or exposure.
So if you use the doctor who has a hundred procedures, you’d expect a balance bill of about $34,000. Whereas if you used the doctor with 53, that physician’s balance bill will be 123,000, almost a $90,000 difference. Again, when you’re selecting a physician, we’re looking for outcomes, we’re looking at cost. This is just an example of some statistical cost information we consider when we’re picking that physician.

Identifying Cost-Effective Providers

Mark Dellecave:
Great. Thank you. Okay. After looking at this data, we’ve determined, the high quality physicians, on an outright basis. And then, we can adjust that for the, to put cost into the equation, as well.
So that when an employer is looking for physicians that are high quality, and also reasonable cost, this data can also be very relevant. And I think that spills into the next slide. Ed, would you like to elaborate on this?

Ed Dillabough:
Sure. This is an example of, this is MEDPAR data nationally, and looking at just only Medicare recipients. And you say, “Who are the top four markets for a total knee replacement?” An NYC facility is Specialty Hospital of New York.

Again, what we all tend to look at are the averages. In this case, it’s $71,000. But what you really need to understand is the breakdown of the hospitals, each hospital. So the range of the bill charges for a specific procedure, arrangement, in this case, 45,000, up to $84,000.

It’s all over the board, and again, the driving force behind the variations are the physicians. Again, they control length of stay, they control the OR time, and they control which implants they purchase through a hospital system. If you compare every hospital, you’ll notice the range is quite significant. Some Chargemasters, like in Delaware, and is significantly less in New York Specialty Hospital, where the average is only 30,000, but the range is from 27 to $49,000.

Again, in Duluth, Minnesota, it’s 21 to 62, and then, in Portland, Maine, it’s 30,000 to 125,000. Again, the doctors, based on outcomes, based on quality indicators, and now looking at, also, the cost factors, the green bubbles are the doctors that we would a patient to see. When we give the names out, we also look for appointment availability, we provide then a list of questions. Again, a list of questions is important. We’ll get into it in a second, because it’s, how do you talk to a doctor, and how do you educate the consumer, about talking to a physician about a specific procedure, and what’s really important to understand, and walk away. With the understanding from the next steps?

Again, what this data really represents is a range within each hospital. I know there’s a difference between each hospital, but within the hospital, there’s more variation, than comparing the doc facilities to the other facilities in the same geographic area.

Al Lewis:
Well, so are you saying, let’s take the New York hospital for special surgery. Are you saying that if I am, say, Aetna, and I have a particular procedure code for a total hip replacement, and it’s just that there’s certain procedure codes where there’s more complexity, for a given procedure, you’re saying, that they get different bills from New York Hospital for special surgery, based on who the doctor was, that they didn’t negotiate a price for a total joint replacement, total hip replacement?

Ed Dillabough:
Yeah. Every procedure, by hospital … If you had 10 different patients were of that, the amount of those bills would be like this. It could be 45, 50,000, or it could be $80,000.

Now, again, it is not necessarily the patient that’s that much different. It’s the physician that’s different. Physicians will use a certain implant. It takes a physician longer to perform a surgery.

The doctor takes longer to perform a surgery, what does that mean? It means your anesthesia bill will be higher, as well. So there’s lots of variables that doctors control, and it’s not necessarily always the length of stay, in this case, commercial, compared to commercial, to Medicare, [inaudible 00:37:43], it really is, the physician that’s the biggest variable. But there are always going to be differences.

It doesn’t make any difference what procedure is, the bills are all based on a la carte master charges, and based on how they’re coding. So the bills will all be different.

In this example, every one of these hospitals, for the exact same procedure, this is not a revision of an existing … This is a total knee replacement. Some have complications, and some don’t. Very few, not too many have complications. So the biggest variable here is, we use this example in total needs, because it shows a variation of what a doctor controls within a certain hospital system.

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Engaging Employees to use Specialist Data

Mark Dellecave:
The next part is about, actually, once you’ve found the right specialist, who is in a reasonable cost range, then you need to engage your employees. So Colleen, would you like to talk about this?

First: Education

Coleen Hekkanen:
Sure. I think the first thing we really need to focus on is education. Education is key here. The who, what’s, when, where, why is what needs to be focused on. Hopefully, we’ve got the why down. Why is it important to use data when making a decision, in choosing a specialist? I’m going to assume that most of the people today on the webinar are really smart and intelligent.
It’s being able to take that information back to the employees and help them understand that they shouldn’t be to taking these decisions into their own hands, that they should be using some experts, to help guide them through making that decision. Again, it’s that idea of the iceberg, of not just focusing what they can see, but it’s everything underneath that they need to be able to consider when making that decision.

I think, also, it’s the timing of the education that’s really, really important. You really want to get your employees engaged sooner rather than later. What I mean by that is, it’s much easier to steer a patient to a quality provider, when they first start having signs and symptoms of an issue, than trying to come and how have them change their surgery date, because they’re linked with a provider that has poor quality outcomes. You really want to focus on education, on the timing of having patients engaged earlier, rather than later, in order to get them some really good quality outcomes.

Let’s talk a little bit about the who and how. So, how do you get that message out? I think one of the things is, you really need to use your contacts within the groups as allies. HR is usually a really big ally, to make sure that they’re getting the message out there. They’re also usually the boots on the ground, where they will hear things, or they’ll hear about patients or employees having issues. And they can remind that there’s a service out there that can help patients make really good decisions.

Open enrollment is a great time to educate your employees, but you have to remember, open enrollment is also time where they’re getting overloaded with information. You want to make sure that you’re spreading that message all throughout the year, whether that’s e-blasts, or reminders or postcards, you don’t want to just focus on that one and done.

Second: Proving Guidance to the Employee with a Navigator, Nurse or Concierge

I think, in terms of navigating, it’s really important to consider who’s providing the guidance to the employees. I think having a nurse, a clinical person is really key. And why is that?

I mean, I’ll tell you, from my perspective, from an operations perspective, it is not cost effective to have clinicians’ nurses guiding our patients. However, I think it’s such a critical, important part of that. A nurse is going to be able to pick up on things that a layperson isn’t necessarily going to be able to pick up on. They’re able to redirect the patient to go and get the right care. I can’t tell you how many times we’ll get calls for a patient who has back pain, who wants to see an orthopedic spine doctor. And really, it’s more of an issue with, let’s say, their kidneys.
A clinical person is going to be able to get the patient to the right specialist, and that’s really important. Maybe the patient, without a nurse, would have gone to orthopedic, and the orthopedic would’ve been able to re-steer. But then think about that employee. Who’s now gone down the wrong path. They start to get discouraged, they start to get frustrated, now they’ve taken time off of work.

Third: Plan Design and Incentives

So all of those types of things come at a cost. I think the nice thing that we have here is, we have an opportunity to be really creative in our plan design, and really offer incentives for employees to engage, and follow through with the recommendations.

With the self-funded plans, you get to make the rules, and you get to have a little bit of fun here. So you can really encourage patients to utilize the services, to engage with the program, by offering incentives. And it doesn’t have to be anything complicated. In fact, I recommend that, the simpler the better. But I’ve seen incentives, such as specialists’ co-pay waivers, or deductible waivers, or even HRA contributions. That really gets employees excited and engaged, and in the program. So consider that, when you’re coming up with a plan design that maybe would use some type of navigation program. And I’ll turn it over to Ed, to talk a little bit about the implementation of that.

Brokers Role in Designing the Incentives

Ed Dillabough:
Yeah. I tell you, the broker’s role on designing the incentives is imperative. And I think that the cost analysis part, tying in with the advocacy services to the paid claims, is critical.

In other words, we spoke to 50 patients who were having surgery. How many of those 50 actually used those doctors, and followed through, with the facilities that we suggested they go to? So, looking at your analysis of paid claims to the advocacy services, it’s critical to determine the effectiveness of an advocacy service.

We’re doing that at SentryHealth, where we’re tying in the payments with the advocacy, with the complete steerage of the population. Also, doing predictive modeling, I think, is important too, is analyzing the data with the specialists, making sure that we stay ahead of the game, and being proactive in dealing with that population.

Why it’s Key to Have a Clinical Person on Staff

Al Lewis:
Now, can I just ask a question? Because you talked about specialists’ waivers for the specialist fees and stuff, and trying to get people early, to get referred to specialists.

Ed Dillabough:
Sure.

Al Lewis:
I think there are a lot of folks on this call who might say the opposite, that if you have a good advanced primary care model, you try to get as few specialist referrals as possible. And the last thing you would want to do is waive a co-pay for a specialist. So how do you reconcile?

Coleen Hekkanen:
Yes, and that is why it’s so key to have a nurse running the program, right? So they’re really able to screen when it’s an appropriate time, to engage with their primary care doctor, versus when it’s time to link with a specialist. We’re constantly a redirecting patients back to their primary care when it’s appropriate.

Actually, I have a really good example of that. We had a patient who called us, and they wanted a neurosurgeon for headaches, a neurosurgeon, not a neurologist. So we were already off on the wrong foot. But with some assessment, the nurse was a able to determine it was likely a high blood pressure issue that was causing the headaches, and was able to get them redirected. Their primary care issue was resolved, didn’t need a referral to a specialist.

Again, I think that’s why it’s so important, where you have a clinical person really helping make an assessment. I know we live in a day and age where we’re so used to having data at our fingertips, and I can see some of the stuff coming in, while we’re doing this webinar, and people want the data, they want the data.

The problem with just having the data is if you don’t have a person who’s really understanding what that information means, and set a scene for whether it’s appropriate for the patient to engage with a certain specialist, you can have a really poor outcome. So, having accesses to the data is just one piece of the puzzle, and making sure that you’re getting a patient engaged with the right specialist at the right time.

Mark Dellecave:
Well, thank you, Colleen.

Quizzify2Go: Making the Most of Your Visit, Asking the Right Questions

Mark Dellecave:
Okay, and that leads us to our, our next section here. I’m going to put up our last polling question here, and I’m going to ask Al Lewis to take us through this here.

Al Lewis:
All right, I got to just close this out. So now that you’ve had a found a good specialist, what questions do you ask, okay? So we’d like you to fill this out, but this is actually what Quizzify2Go is I all about. It’s lists of questions by topic, 110 different topics. And Mark, after we put this up, and we’ll go to Quizzify2Go, I did have, actually, I got a bunch more stories.

Well, one more story worth telling is that my daughter, who was a dancer, was an aspiring dancer back then, and she had a hairline back fracture. And we referred to an orthopedist. Now, the orthopedist wanted to do a CAT scan. Knowing what I know about Quizzify now, I would have said two things. I would have said, “What are we going to learn from that CAT scan, that’s going to change the course of treatment?” Because the fact is, if you have a hairline back fracture, there’s nothing you can do about it, anyway, you just have to rest. I did not know to ask that question.

The other question I did not know to ask is, should we really be doing CAT scans on the abdominal region of a teenage girl? And the answer, of course, is no. That’s what you would have learned from Quizzify, and that’s what I didn’t know. So we got the CAT scan. Of course, nothing happened, as a result, and my daughter is still upset with me for letting her get that scan, even though I said there was no Quizzify back then, I did not know to ask how much radiation was in that scan. So what do we have here, Mark?

Mark Dellecave:
Ah, okay, this is good.

Poll Question Discussion

Al Lewis:
I said Quizzify2Go, to prompt me. And I swear I did not, none of us actually participated in this poll.

So the correct answer is, in fact, the last answer, which is to be prompted with the right questions on the day of your visit. Okay.

So here is a classic Quizzify question, specifically to gently people from exactly what Ed and Colleen are talking about, which is getting unnecessary surgery. We don’t say, “Don’t get unnecessary surgery,” because we found early in Quizzify2Go, that if you tried too hard to convince people not to do something, the backlash from the employees is, “You’re just doing this to save money.” Now, we’re much more subtle about it, and making sure that the employees can come to their own conclusion.

So this question, note the Harvard Medical School seal, which is on all of our clinical material, “What is the number one diagnosis leading to a spinal fusion?” And the answer is a failed spinal fusion. This turns out to be about, somebody referred to it once, as “our generation’s lobotomies.” That years from now, where they’re going to look back and say, “Why are they doing that?” Now, the fact is that they are doing more than ever, because they’re shifting to outpatient, and it’s much easier for a patient to agree if it sounds like a minor procedure, not realizing that the issues are going to take place down the road. Mark, I think you’re still, you’re still, the screenshot over there?

Mark Dellecave:
Yes, there we go.

Al Lewis:
Okay. Now, one of the questions that we used to get in Quizzify is, “Well, that’s great. You’re teaching folks all this stuff, but what if they forget? What if they take a question on say, back pain in February, but they don’t start experiencing back pain until June?”
Well, the answer is, that’s Quizzify2Go. And Quizzify2Go, for more than a hundred different topics, lists the questions that you should ask your doctor. Always starts out with a paragraph, and I had mentioned before, that the classic thing about back pain is that 80% of it goes away on its own.
But we, at some point, virtually everybody with back pain for more than a week is convinced they’re in the other 20%. That’s the first thing you should know. Then you have all the questions here to ask.

You can click on Playing a Quizzify quiz on back pain. You can actually e-mail this to other relatives of yours, or friends, and you can actually calendar it.

The Quizzify Challenge

Al Lewis:
But now, we’re going to see how incredibly convenient unit is. We’re going to do what we call the Quizzify challenge. The Quizzify challenge is, we have here a, this is Quizzify2Go. As mentioned, it has more than a hundred different topics that are going to expand, and all you need to do is enter a keyword. So I’m going to challenge you to enter a keyword, just any old keyword, just put it in the chat box. And we’re going to see if that, if just… Let’s say you need it to go, I mean, this is an easy one.

If you’re pregnant, you had your pregnancy, and you’re going to get three or four different topics, depending on where you are in your pregnancy. So what do we have coming in here on the chat? Okay, Diabetes.

Mark Dellecave:
What do we have? Both.

Diabetes

Al Lewis:
Well, okay. Actually, we have a bunch coming in. We just did, pregnant diabetes is a good one. So let’s see what happens, if you get diabetes. For diabetes, you get, there’s …

Mark Dellecave:
You have four categories there.

Al Lewis:
Actually, looks like there’s there’s eight categories.

Mark Dellecave:
Yeah.

Al Lewis:
Oh, well, there’s eight different things that you could ask. Let’s click on diabetes and see what pops up.

Yeah, so then, these are the questions that you ask, on the initial diagnoses. The other thing about diabetes is that there are a ton of a ton of ways to actually be increasing your sugar, that your dietary sugar, that you don’t know about. And it’s important to learn about those, not just from your doctor, but also from Quizzify.

So it turns out that I’ve been getting this green juice, or one time, got this naked green juice from Whole Foods, that looked very healthy, but it had more sugar in it, that even, it says No Added Sugar, but it had more sugar in it than it can of Coke. You might say, how can they do that, and say, No Added Sugar? That’s a Quizzify thing. The answer is that if you’re a juice, and your added sugars are concentrated fruit juices, that doesn’t count as added sugar. And I don’t make the rules. So we have a whole bunch coming in here, joint pain, you can just put in … I mean, as you can see.

Joint Pain

Mark Dellecave:
Yeah. I see joint pain shows up different ways, low back. Joint pain can be caused by tick bites, So you want to make sure you cover that.

Endometriosis

Al Lewis:
Now somebody put in endometriosis. I don’t believe we have that, because you typically wouldn’t go to the doctor and say, “Doc, I have endometriosis.” You would go to the doc with a symptom. So we’ve got plenty of symptoms in here. We’ve got plenty of symptoms, and reasons to go to the doctor, but not necessarily specific clinical diagnoses.

Having said that, I see, it is a common diagnosis. And one of the things about the Quizzify2Go challenge is, occasionally we flunk. When we do that, we take the word, which is “endometriosis,” and along with our friends at Harvard Medical School, we research, and we’ll come up with a number of very good questions to ask for that topic. So we’ll be filling that topic in.

Ask the Questions

Al Lewis:
And one of the things that we get all the time is, “Well, this is great that you have this list of questions, but what if, number one, we forget to bring our phone?” Well, who forgets to bring their phone?

But number two, more importantly, a lot of patients are reluctant to ask these questions, right? We have that handled in the PS. We just say, “Look, this is just something I have to ask, if I’m going to get reimbursed. I got to ask these questions, I’m sorry.” So if you’re a little bit shy, we’re happy to take the blame.

Q & A

Mark Dellecave:
Now there’s a question here is, “How is this different from free info on the Internet, such as the Mayo Clinic, WebMD, et cetera?”

Al Lewis:
Well, have you ever seen anything like this on the Internet, where you just put something in, and you get a list? And it falls out into the specific questions, and you can put them in your calendar, and you can e-mail them to friends, and you can take quizzes on them.

Now, the fact is, we do actually get some of this information that we don’t get from Harvard. We get it from Mayo Clinic. We even get it from WebMD, which is actually a shockingly good source of information, I have to say, even though it’s commercial, for profit.

The value add for Quizzify2Go is to put it all into one, convenient, calendar-able place, with quizzes, laid out with links, so that you can see it at a moment’s notice. You don’t have to be searching all over the Internet.

Mark Dellecave:
Okay, I’m just going to go to one of the questions here. This came up in a couple different places. Again, we’re going to answer the questions we didn’t get to independently here, but the question is about bundled payments. And we know that that’s a strategy, with next generation strategies.

Ed, can you comment on how your service may work with a bundled payment plan, or how it’s different, so that that becomes clear to our audience?

Ed Dillabough:
Yes. Well, it’s interesting. We were evaluated by the Validation Institute, and we were evaluated for looking at how we select physicians, reference based pricing, and bundled pricing.

Actually, two years ago, we won, for bundled pricing, the Validation Institute award for those services. So we can coordinate within our own services, and we can coordinate with other companies on bundled pricing. So we’ve bundled price with ambulatory surgery centers, with hospitals, on just about any procedure there is, looking at the specialists, looking at the anesthesia, and looking at the facility. So we performed that service internally, within the SentryHealth wheel of services.

Mark Dellecave:
So, one other question here, specifically about the knee implant is, “If one of the factors in a knee implant is the cost of the implant, couldn’t a more expensive knee implant be potentially a better fit for a specific patient?”

Ed Dillabough:
Well, this is it. In my opinion, the implants, some are a lot more expensive than others, but statistically, they’re not any better. Basically, we see our patients to those particular physicians that have cost effective implants, not necessarily the ones that are much more expensive.

I can’t think of a situation where, again, in a need, it’s more important to, I think, use physicians that use computer generated alignment systems, to make sure that the implant is put in correctly, than using a more extensive implant themselves. So the process and procedures, I think, are more important than the, actually, implants themselves, as far as we can tell.

Al Lewis:
And I will just wrap up with one thing to that point, which is that because of the FDA has a huge loophole, in how you get new implants approved, that does not require them to be tested. And it’s led to disasters, like the cobalt hip for J&J.

That, Mark, on its own, is enough for me to go with a standard implant that’s been around for five or 10 years, rather than a new high tech one that looks like it’s been tested but hasn’t. And on that note, I think we’re out of time.

Mark Dellecave:
We are? Yeah.

Al Lewis:
Mark? Yeah, isn’t it Mark?

Mark Dellecave:
We are.

Mark Dellecave:
Yeah, thanks, everyone. Everyone’s going to get a copy of the slides, as well as a recording of the webinar. We’re going to answer all these questions that you had sent into the question box. And thank you, everyone, for attending. Thank you.

Al Lewis:
Bye, everybody.

Meghan Henry:
Well, that wraps up this episode of For Your Benefits. Thanks to all of you for joining. If you like what you heard today, don’t forget to subscribe to our podcast. And if you want to learn more about SentryHealth, visit our website, at sentryhealth.com.

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