Health Dialog Diary

08 October 2007

Health Dialog is the national leader in collaborative Shared Decision Making^® for health plans and employers. In this process, skilled healthcare professionals use a wide range of educational tools to help patients fully understand the treatment options, risks, benefits, and possible outcomes relating to the disease with which they are afflicted. Health Dialog's program leads to more carefully focused and more appropriate care of serious medical conditions.

Product Innovations

Chronic Condition Management Program

Crossroads Patient Guide

Shared Decision-Making Coaching

Integrated Treatment Model

Average employee health benefit costs rose 6.1% in 2006 and are expected to jump another 6.1% in 2007. Health Dialog addresses both the quality and cost of healthcare.

Total health benefit cost per active employee

historical data: William M. Mercer, Inc.

*2007 projection internal estimate

Strategic Alliances

Important Links

Accenture

American Hospital Association

Healthwise

National BlueCross BlueShield Association

Health Dialog Briefs

Latest entry 122

Health Dialog home page

Foundation for Informed Medical Decision Making

The Dartmouth Atlas of Health Care

CollaborativeCare.net

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Publisher's disclosure

Offices & Coaching Centers

Boston Headquarters
Sixty State Street, Suite 1100
Boston, MA 02109
Tel: 617-406-5200 Fax: 617-406-5201
email: info@healthdialog.com

Pittsburg
Penn Center West
Penn Center Boulevard
Building 4, Suite 326
Pittsburg, PA 15276
Tel: 412-788-9025

Scottsdale
16425 North Pima Road, Suite 300
Scottsdate, AZ 85260
Tel: 480-473-5910
 

Health Dialog Briefs

In a recent Wall Street Journal Opinion piece, Bill Gates put his blueprint, and by association Microsoft’s, on how to improve our nation’s health-care system at a time when “knowledge . . . is expand(ing) at a speed that is without precedent in human history.” He notes that despite the expanding knowledge, our inability “to deliver consistent, high-quality care” has led to “billions of dollars spent each year on redundant tests and prolonged illnesses and avoidable injuries that result from medical errors.” Pointing to an Institute of Medicine study “urg(ing) swifter adoption of information technology and greater reliance on evidence-based medicine,” Mr. Gates sees an “information-dependant,” “data-rich industry” crying out for information technology solutions that would make it possible “for your doctor to assemble a complete picture of your health and make fully informed treatment decisions.”

Acknowledging that informed patients are equally important to informed doctors, Mr. Gates writes, “What we need is to place people at the very center of the health-care system and put them in control of all of their health information.” He further states, “Putting people at the center of health care means we will have the information we need to make intelligent choices that will allow us to lead healthy lives -- and to search out providers who offer care that does as much to help us stay well as it does to help us get better.”

Health Dialog is committed to improving the flow of information to patients, including via the Internet, in order to help them become better, more informed consumers of the many choices being presented by our advancing health care industry.

Health Dialog will begin providing whole-person care management services to 113,000 commercial and Medicare members and dependents covered by Capital Health Plan of Tallahassee, Florida. Services include Health Coaches, “nurses, dieticians, and respiratory therapists, who work with individuals and their family members telephonically and online to help them manage chronic conditions, significant medical decisions, and general health and wellness concerns. Using a Shared Decision-Making® approach, Health Coaches are available 24/7 to help individuals understand the total picture of their health, as well as risks, benefits, and outcomes of various treatment options, so they can gain the skills and self-reliance necessary to work more effectively with their physicians.” Members will also have “access to award-winning educational resources in

print, audio, video, and online. The Dialog CenterSM, Health Dialog’s member-facing website, provides individuals with a variety of tools, including detailed health information through the Healthwise® Knowledgebase, decision aids to support assessment of treatment options, and a suite of online health & wellness modules that address issues such as back pain, smoking cessation, nutrition improvement, weight management, fitness and exercise, and stress management.” Physicians will have access to Health Dialog’s industry-leading SMART® Registry tool. This reporting component provides primary care physicians with actionable clinical information. Reports generated for physicians through the SMART® Registry include patient reports, practice reports, and peer-comparison reports.”

Health Dialog has announced that it will be joining forces with the Rand Corporation in order to bring to market “a new provider performance measurement system that will provide best-in-class capabilities for measuring quality and efficiency in the U.S. healthcare market.” In 2003, the RAND Corporation published in the New England Journal of Medicine a landmark “study of the quality of health care provided in the United States.” Resulting QAScoresTM were derived that essentially found “that adults in the United States receive only about half of the recommended, evidence-based care for the leading causes of illness, disability, and death.” According to the agreement, Health Dialog will be

licensing the “vast repository of quality measures and the associated scoring and attribution methodologies developed by RAND.” According to George Bennett, Health Dialog Chairman and CEO, “This alliance brings together two organizations that are leading efforts to improve the quality and efficiency of healthcare in the United States and abroad. The integration of our respective knowledge, research, and experience will enhance our best-in-class healthcare-related measurement tools and further strengthen our ability to continue to bring innovative and differentiated care management products to our clients.”

Health Dialog has announced that the three founding partners of Crimson Health Solutions and the company’s intellectual property has been assimilated into Health Dialog’s health and wellness initiative, Healthy Living Solutions (HLS). HLS uses telephone, online and print resources to “support behavior change management” in order to “lower the risk of developing costly medical conditions.”

Dr. Elizabeth Barbeau, Crimson’s CEO, Gary Bennett, PhD, who served as Chief Scientific Officer, and Cathy Hartman, MS, Crimson’s Chief Operating Officer founded Crimson Health Solutions based on academic research conducted at the Harvard School of Public Health and

Dana-Farber Cancer Institute. They will “bring a wealth of knowledge in the field of wellness research and behavior change.” George Bennett, Chairman and CEO of Health Dialog, believes that Crimson's “whole person philosophy make(s) it a perfect match for Health Dialog.”

Healthy Living Solutions “follows the same basic tenets as (Health Dialog's) total care management solution - whole person, total population care management solutions built on the underlying philosophy that informed, motivated individuals who fully participate in their own health management are critical to affordable, high-quality healthcare, as well as improved health status and productivity.”

The New Mexico Public Schools Insurance Authority (NMPSIA) has decided to continue offering Health Dialog’s “whole person care management services, including Health Coaching support, to more than 60,000 employees and dependents.” Sammy Quintana, Executive Director for NMPSIA comments, “Our employees tell us they are quite pleased with their health coaching interactions, and continue to become better educated about taking a proactive role in their

healthcare. Our continued collaboration with Health Dialog supports our mission to provide quality, cost-effective benefits to our employees.” Health Coaches use Health Dialog’s Shared Decision-Making® methodology “to help individuals understand the total picture of their health, as well as risks, benefits, and outcomes of various treatment options, so they can gain the skills and self-reliance necessary to work more effectively with their physicians.”

The Boston Business Journal has named Health Dialog one of the fastest growing private companies in Massachusetts with an overall seventh place ranking among companies with more than $100 million in revenues. The award was based on Health Dialog’s 265% sales growth rate from 2003 to 2006, and it was the second year in a row Health Dialog was spotlighted. The company’s Chairman

and CEO Mr. George Bennett commented, “Our company’s success is based on the idea that when people are empowered with tools that enable them to actively participate in their healthcare, they will make educated choices that will improve their health. This honor is a testament that what we are doing is working for both our clients and their members.”

Wellness programs are offered by insurance providers as a means of encouraging healthy behavior and lifestyles. Initially, such programs were offered to smokers and others who might benefit from noticeable changes, but programs are expanding to cover those who are already living healthy lifestyles. Part of the expansion is due to the government getting involved and formulating a number of guidelines to ensure fairness and non-discrimination. But the larger driver is economics.

As M.P. McQueen reports, “More companies are adopting wellness programs as evidence mounts that the programs can help control overall health-care costs.” Dr. Brent Pawlecki of Pitney Bowes is quoted, “This is our first year of doing this. But we have been able to show that for every dollar we have spent on health-improvement programs we save $2 to $3 in health-care savings and productivity costs.”

Wall Street Transcript recently published an in depth analysis of the Health Facilities and Services industry, including the disease management sector. In a brief excerpt from the report, Brooks O’Neil of Dougherty & Company, LLC comments on the “number of new initiatives in the marketplace that we think have the potential to drive really substantial changes in the way health care is delivered in this country.” He offers the overarching perspective that there’s a general trend toward more individual responsibility indicative of a “consumer-driven system.” He sees it as a “fundamental change and it is one that will continue to ripple through the health services over the next five or 10 years.”

Another major trend is the growing acceptance that something has to be done about the fact that “a small percentage of the people drive the lion's share of cost in health care today. Specifically, the data suggests that 5% to 10% of the people account for 70% of health spending annually. So 5% of the

people account for a little over $1.4 trillion of spending each year. It is not always the same people, but the data suggests that the majority of those people are affected with chronic as opposed to acute illnesses. These are illnesses such as heart disease, diabetes, cancer and asthma - illnesses that affect individuals both today and over the rest of their lives.” He notes that a number of companies are developing new ways to support patients with chronic conditions, including greater prevention. Mr. Brooks estimates that the commercial U.S., government U.S. (Medicare/Medicaid) and international sectors represent annual markets of $8 billion, $12-$15 billion and $20 billion, respectively. He believes that “identifying the people who are the heaviest health services utilizers and working very diligently to figure out how to deliver high quality care to them more cost effectively is necessary. I absolutely believe it is an enormous market opportunity.”

Steve Lohr of The New York Times considers Microsoft’s acquisition of Medstory as but the latest evidence of companies trying to capitalize on the “rising traffic at consumer health sites on the Web.” Medstory is developing “search software that applies artificial intelligence techniques” in an effort to pull together pertinent health information. Others in the Internet healthcare space include WebMD, RevolutionHealth.com, a start up financed by Stephen Case of AOL fame, Healthline Networks, a creator of search sites for Merck, PacifiCare and others, and Google. They are all seeking to capitalize on what is referred to as

“consumer driven healthcare.” Mr. Lohr describes consumer driven healthcare as a trend, driven by “shifts in demographics, economics, technology and policy” whereby individuals will take an increasingly larger role in their healthcare decisions. “Aging baby boomers, accustomed to personal choice and to technology, tend to want a say in their treatment decisions.” The Internet, already an important resource, will play an increasingly important role in helping patients with their healthcare decisions. Health Dialog has integrated the Internet into its service offerings.

While much of the debate surrounding healthcare focuses on insurers and doctors, Laura Landro points out in a recent Wall Street Journal article that hospitals are also finding the benefits of better educated consumers. While most acknowledge that Hospitals have given lip service to consumer satisfaction surveys, only recently have hospitals begun to really implement changes focusing on consumer satisfaction. Using a “family-centered care” model, hospitals are seeking ways to better inform patients about treatments and provide follow-up contact after patients have arrived at home. This model of better informed patients and active outreach by providers appears to be gaining

momentum. Ms. Landro writes, “Increasingly, the survey findings are leading hospitals to adopt the family-centered-care approach, which advocates building strong partnerships with patients and their families to improve care.” Some of the impetus for improvement is coming from a federal government requirement that requires hospitals for the first time to participate in a patient satisfaction survey in order to receive full reimbursement from Medicare. But there is also a simple recognition that the environment is increasingly competitive and “evidence that recommendations from friends and family influence health-care choices.”

The Health Care Blog (THCB) was started in October 2003 by Matthew Holt, an experienced healthcare industry observer who’s garnered a reputation as an insightful industry researcher and forecaster. According the web site, “The Wall Street Journal calls (THCB) “among the most widely read insider publications in the field.” WebMD calls the site “a free-wheeling discussion of the latest healthcare developments.” Recent entries that have attracted attention include pieces on the Bush and California health plans. Following is an excerpt from another entry written for ABCNews titled, “Why is Fixing American Health Care so Hard?”

Reforming Care Delivery?

Meanwhile, the health care provider industry is currently awash with new ideas about improving the quality and cost-effectiveness of the care it delivers. It is well-known within academic health care

circles that somewhere between one-third and two-thirds of all care delivered is inefficient and unnecessary.

A huge body of research conducted at Dartmouth under John Wennberg shows conclusively that patients with similar conditions receive significantly different treatment depending on which area of the country they live in and which doctors they see. Even worse, it appears that the more that gets done to patients, the worse are their outcomes. But, of course, no physician or hospital believes that it is the one providing the inefficient or unnecessary care — it's those other guys who are at fault.

Meanwhile, the medical industrial complex continues to invent more and more high-tech procedures, devices and pharmaceuticals — all of which come at a higher and higher cost. And why not, as the people who write the checks keep paying.

As healthcare costs have risen to “16.5% of the nation’s economy,” employers are “urgent . . . to squeeze out the waste connected with middleman – without squeezing the valuable services they can provide.” And, indeed, they can provide valuable services, including combined purchasing power, “harvest(ing) data to uncover” valuable new procedures and a general expertise beyond employers’ capabilities. Structural issues also encourage the use of middlemen such as their use by Medicare and the healthcare industry’s fragmented nature leads to a need to deal with multiple providers. But some companies are fighting to control costs with some success.

Contracting directly with hospitals and doctors is an option for those companies who are sufficiently

concentrated in and important enough to the local community. Perdue Farms is one example; they’ve been able to corral costs by dealing direct, including the offer “to pay bills within eight days, much quicker than the 60- to 70-day norm in healthcare.” It also uses “in-house clinics” to help identify employees with chronic diseases such as Diabetes and high blood pressure. As a result, their healthcare costs are “rising more slowly than other employers and run(s) less than half of the national average.” Others are demanding greater transparency from their middleman; Caterpillar was able to reduce its spending on pharmaceuticals by over 5% by asking their pharmacy benefits manager to provide transparent drug costs.

Mercer Health & Benefits recently reported that a three-year trend that saw the growth rate in employer health care costs decline came to an end in 2006 when the “total health benefit cost rose by 6.1% … to an average of $7,523 per employee.” Employers expect health care costs to jump an additional 6.1% in 2007. The Annual Mercer survey, “With nearly 3,000 employer participants,” is the “largest and most authoritative annual survey(s) on” the cost of healthcare. Among the highlights, Mercer points out that small employers were hardest hit by a 7.0% rise, and enrollment in “consumer-directed plans triple(d).” Mercer also spotlights a trend toward “employers … breaking from traditional cost-shifting (to) focus on tactics to

improve employee health and make them better health care consumers.” In 2006, employers increasingly embraced the use of “health risk assessments, now offered by 22% of all employers and 53% of large employers.” Fully 79% of employers who’ve attempted to measure their return on investment in care management are “satisfied or very satisfied.” “Asked to rate the importance of six cost management strategies to their organization over the next five years, care management and consumerism were each rated important or very important by 43% of all employers (and about two-thirds of those with 500 or more employees).”

Health Dialog has agreed to provide care management services to Integrated Healthcare, a provider of a “fully integrated, point & click-based consumer-driven health platform for small to mid-sized companies.” Health Dialog’s Health Coaches, decision support videos, Healthwise Knowledgebase, member web site, and audio programs “will be integrated with other information tools and financial

incentives such as health savings accounts, health risk assessments, smoking cessation programs, and weight management.” Daniel Boisvert, President of Integrated Healthcare, comments that by combining his firm’s “innovative consumer-driven healthcare platform” with Health Dialog’s “state-of-the-art care management services, we’re setting the standard for produce offerings in our industry.”

November 28, 2006 release:

Blue Cross Blue Shield of Florida (BCBSF ) has expanded its affiliation with Health Dialog by agreeing to make Health Dialog’s whole person care management services available to all of its “two million commercially insured members.” The agreement will increase the number of participants by 400,000. According to Bill Kerr, MD, Vice President and Chief Medical Officer of BCBSF, the decision to renew was based on “clear” evidence that Health Dialog’s Health Coaches, steeped in the firm’s Shared Decision Making approach, are “effectively support(ing) our members” with a “multi-cultural outreach strategy (that) effectively engage(s) individuals within the context of their own culture.” George Bennett, Chairman and CEO of Health Dialog, is “excited” about building on the last four years that have seen Health Dialog and BCBSF work together to improve healthcare quality while reducing costs.

November 29, 2006 press release:

Health Dialog has expanded its role in demonstration projects sponsored by the Centers

for Medicare and Medicaid Services via its agreement to support Massachusetts General Hospital (MGH) in a project targeting high cost Medicare beneficiaries. “The three-year demonstration is intended to test the ability of direct-care provider models to coordinate care for high-cost/high-risk beneficiaries by providing them with clinical support beyond traditional resources.” In addition to training MGH’s case managers in Health Dialog’s whole person collaborative care approach, Health Dialog will also be assisting with data analysis and reporting. According to Dr. Timothy Ferris of MGH, the focus of this program is to improve the care and control the costs of addressing a broad spectrum of healthcare needs, “especially critical when dealing with Medicare beneficiaries facing multiple, complex medical issues. We hope to make great progress with these patients through regular communication with nurse case managers to ensure that their many needs are being met. The ability to collect, organize, analyze, and report the information will be essential to determine the impact of this effort.”

In a review of a “clinical study at the University of Pittsburgh School of Nursing, funded by the National Institutes of Health,” Wall Street Journal reporter Andrew Lavallee speaks to the potential advantages of better informed patients; in this case, by patients availing themselves of private message boards via the Internet to stay in touch with doctors and nurses. The study is focusing on patients with ovarian cancer due to its lower survival rate than more prevalent cancers such as breast or cervical cancer, and it has a high level of recurrence and multiple symptoms. As a result, ovarian-cancer

patients stand to benefit from having 24/7 access to qualified nurses who are ready to go beyond the “typical 15-minute clinic appointment” where doctors are more focused on the diagnosis and treatment of the actual cancer. Issues of fatigue, mouth soreness, hair loss and general issues relating to quality of life can be more fully pursued via the online communications. Heidi Donovan, an assistant professor at the school and head of the study also suggests that there might be cost savings should fewer and more productive “calls and appointments with doctors” result.

For The Wall Street Journal’s Health Journal section, Tara Parker-Pope reviews a diagnostic, healthcare web site created by the Harvard Center for Cancer Prevention; www.yourdiseaserisk.com. She writes that in addition to providing the generalized disease information of many web sites, the Harvard site, “has found a way to provide customized information to help patients better understand their personal health and risk for disease.” Furthermore, it generates “a tailored action plan on ways to lower risk for health problems.” The American Heart Association and the National Cancer Institute offer risk calculators, but they fall short of the scope of the Harvard site

that extends to “healthful behaviors like exercise, fruit and vegetable intake, and regular wine consumption.” Ms. Parker-Pope notes that, “The Harvard Web site allows users to calculate their risk for developing 12 different cancers, as well as heart disease, stroke, diabetes and osteoporosis.” She concludes with the “best thing” about the site, it provides “a customized action plan showing how you can alter your risk through lifestyle changes, such as increasing vegetable consumption, exercising more, taking calcium supplements or a multivitamin, stopping smoking or changing alcohol habits.”

Erik Eckholm writes in the New York Times on the emerging trend in hospitals toward preventive care. Hospital administrators, seeking ways to slash the costs of providing treatment to the uninsured, are beginning to embrace the quality improvement and cost savings that accompany preventive care, particularly when there is active outreach to help patients understand and implement their course of treatment. The Seton Family of Hospitals, for example, was able to reduce one patient’s medical bill by more than 45% or $86,580 over an 18-month period by providing preventive care,

including an insulin pump and “access to an endocrinologist and home counseling …” In a Seton program to “educate 631 asthma patients, (they) saved the plan $475,000 in one year.” The Denver public hospital system has found “that for every dollar they spend on prenatal care for uninsured women, they save more than $7 in newborn and child care (costs).” Health Dialog provides a wide range of tools, including experienced Health Coaches, that facilitate collaboration between patients and doctors that leads to improved outcomes and cost savings.

The New Mexico Public Schools Insurance Authority (NMPSIA) has chosen to make Health Dialog’s “whole person care management services, including Health Coaching support across a broad spectrum of healthcare needs,” available to its more than 60,000 members and dependents. According to Sammy J. Quintana, Executive Director of NMPSIA, “Health Dialog is providing us with a truly

impressive program. Employees and dependents covered by the program can benefit from a broad array of care management resources, designed to motivate and educate them to take a proactive role in their healthcare. Our collaboration with Health Dialog supports our mission to provide quality employee benefits in the most cost-effective manner.”

On August 15, Health Dialog celebrated the one-year anniversary of its participation in a Medicare pilot program being offered to more than 20,000 Medicare beneficiaries living in western Pennsylvania. According to Mark McClellan, Administrator of the Centers for Medicare and Medicaid Services, “This program is designed to help the chronically ill stay on a healthy path to managing their diseases effectively. By providing them with regular one-on-one interactions with nurses, beneficiaries can prevent many ill effects that may result from not managing their health. This, in turn, saves on healthcare costs by keeping the chronically ill healthier and out of the hospitals.” The program, expected to go for three years, is already meeting with encouraging results. According to

George Bennett, Chairman and CEO of Health Dialog, “We are more than pleased with what we have seen in the first year and are confident this trend will prove even stronger as we continue our focus of strengthening patient-physician communication and improving beneficiaries’ understanding of chronic conditions and treatment regimens.” And according to one beneficiary’s spouse, "Since the start of the program my wife's Health Coach has helped her understand and comply with her physician's plan better. Every little thing you do matters. Her Health Coach helps her know what she has to accomplish and if you have a goal to reach, you can reach it! It is excellent that Medicare offers this program."

Health Dialog will begin offering its Health Coaching and support services to nearly 500,000 members covered by the State Health Plan of North Carolina. Health Dialog’s whole-person, care-management services, according to Nancy Henley, MD, Medical Director for the State Health Plan, “gives our members the support they need to understand all of their conditions, including how they may interrelate, so that they can become more

skilled and confident in managing their healthcare.” Whole-person services include access to trained Health Coaches – nurses, dieticians, and respiratory therapists – as well as online, print, audio/video, and DVD educational resources. George Bennett, Health Dialog Chairman and CEO, observes, “With the amount of information available today about conditions and treatment options, healthcare consumers can easily become overwhelmed.”

Health Dialog has agreed to begin offering “a range of customized innovative risk-based care management products to health plans, self-insured employers, Medicare and Medicaid plans, and Section 646 plan providers” of American Re HealthCare, “a division of American Re-Insurance Company, a member of the Munich Re Group

(and) one of the world’s largest reinsurance organizations.” As part of the alliance, American Re will insure/reinsure Health Dialog’s clients that promised levels of medical cost and quality outcomes will be achieved, thus providing “additional assurance to Health Dialog’s clients that targeted performance savings will be realized.”

In a recent report on changing healthcare standards, Forrester Research has highlighted new metrics being used to evaluate patient care; particularly as relates to the evolution from Disease Management (DM) to Integrated Health Management. The report contrasts a “one-person, one-illness paradigm” of DM with a broader program that “integrate(s) data from disparate sources, coordinate(s) communications across health, wellness, and lifestyle programs, and deliver(s) interventions that address members' whole health needs.” The report highlights the contributions of Health Dialog, commenting that the company has set a “high bar … with its innovative practices.” Health Dialog’s peers have identified the company as one that is well along the “learning curve.” Specific capabilities/techniques that help Health Dialog differentiate itself include a whole-patient approach that engages patients via coaches that “deliver interventions on members’ most pressing health and lifestyle issues, regardless of what

disease bucket they fall into. Another is the ability of members to track their care treatment programs, in what Forrester refers to as “visibility,” by being able to exchange data files with plans and/or other partners and by facilitating client access via a health coach dashboard. Health Dialog plans on rolling out new visibility capabilities in the fall of 2006. Coordinating with other, third-party providers is a third area of differentiation. “Health Dialog uploads partner files directly into its system and uses this data to help determine member inclusion, exclusion, and priority outreach.” Forrester also highlights Health Dialog’s ability to use real-time data in order to improve “timeliness” and its relationship with HealthMedia to better target high- and low-risk members for better “cost effectiveness.” Generally speaking, prospective healthcare partners need to be open to sharing data and be capable of leveraging the data to better effect healthcare outcomes.

In one of several articles that BusinessWeek online recently published on the state of the nation’s healthcare system, John Carey summarizes the findings of The Dartmouth Medical School’s and Dr. Elliot S. Fisher’s research into the “paradoxical conclusion” that more medical care does not correlate with better patient outcomes. In fact, Dr. Fisher states “it looks like there is a substantially increased risk of death if cared for in high-cost systems.” According to Mr. Carey, George Bennett, CEO of Health Dialog, a company that helps individuals better understand their medical issues and become more engaged in managing their healthcare with their physicians, suggests a supply-driven problem by commenting, “A large portion of those extra costs are due just to proximity to health

care.” Dr. Jack Paradise, a professor of pediatrics and otolaryngology at the Pittsburgh School of Medicine and Children's Hospital of Pittsburgh, suggests, in addition, that one cannot rule out the inherent conflict of interest created by “enormous financial incentives to provide more and more care.”

According to Mr. Carey:

“Researchers at the Center for the Evaluative Clinical Sciences at Dartmouth Medical School have looked in detail at what happens in the last six months of life at 77 top hospitals in the U.S. The results were startling: The average number of days spent in the hospital during the last six months of life was 10.1 days at Stanford University hospital compared to 27.1 days at New York University Medical Center. The average number of doctors visits ranged from 17.6 to 76.2, with NYU at the top.”

Health Dialog’s rapid growth, sales growing 179% for the two years 2003 to 2005, placed the company 18^th on the Boston Business Journal’s annual list of the fastest-growing, private Massachusetts companies. Health Dialog’s 2005 revenue of $136 million also earned it a position on the Journal’s list of the states 100 largest private companies. “Founded in 1997, Health Dialog provides customers, such as health plans and self-

insured employers, with innovative care management solutions, including telephonic Health Coaching and population analytics. Health Dialog’s whole person services -- meaning they address the total picture of a member’s health rather than addressing one discrete issue at a time -- are designed to improve clinical outcomes, contain rising healthcare costs, and achieve high member satisfaction.”

Health Dialog will begin providing care management services, including access to its Health Coaches, to members of Fallon Community Health Plan. In addition to having telephone access to Health Dialog’s Coaches – nurses, dieticians, and respiratory therapists steeped in the firm’s Shared Decision-Making approach – Fallon members will be able to interact online through Health Dialog’s

secure website, Dialog Center. Members will also “have access to award-winning educational resources online, in print, and through audio and videotape.” All these resources are designed to encourage members to become “more engaged in their care,” resulting in “improved satisfaction, better outcomes, and cost-savings.”

According to the Centers for Medicare and Medicaid Services, “patients with five or more chronic conditions account for 23% of its beneficiaries but 68% of its spending, seeing an average of 13 different doctors and filling 50 prescriptions a year.” Ms. Laura Landro points out that the elderly are most at risk, but she also reminds us that the baby boom generation is increasingly at risk. She reports studies suggest that “by the year 2020, 25% of the American population will be living with multiple chronic conditions, and costs for managing them will reach $1.07 trillion.” The opportunity for mistakes, overlaps, and conflicting procedures and medications is substantial.

While some health plans and large employers are inducing greater doctor oversight via financial

incentives, the Centers for Medicare and Medicaid Services has a pilot program that utilizes care coordinators such as Health Dialog’s Health Coaches. Health Dialog, along with seven others, will be participating in the pilot program that will coordinate care for 100,000 beneficiaries. The programs will be targeting what Ms. Landro relates as the root of the problem, “a reimbursement system that pays doctors to treat illness and perform procedures, but provides no incentives for better preventive care or keeping patients out of the hospital.” According to Herbert Kuhn, the director of the Center for Medicare Management, the Medicare program will seek to cut costs by $30 billion by “reorient(ing) the way Medicare looks at care, and focus on prevention and the coordination of care.”

Health Dialog has expanded its coverage of Medicaid patients by contracting to provide access to the company’s Health Coaching services to Network Health’s MassHealth recipients. “Health Dialog’s whole person Health Coaching offering will inform and support Network Health members telephonically and online so they can understand and manage the total picture of their health and engage in more productive dialogs with their physicians.” Health Dialog’s Chairman and CEO George Bennett comments, “Health Dialog has served this population for some time and this new initiative with Network Health speaks to the value

we are able to deliver to this population in particular.” Health Dialog’s ability to predicatively model a patient universe in order to identify those who’ll most benefit from active outreach and guidance through the healthcare system was an important element in closing the deal. According to Pano M. Yeracaris, MD, MPH, Network Health’s Chief Medical Officer, “When Network Health members are more aware of their health care conditions, and more informed about their health care options, they are more apt to understand the issues they are dealing with and make decisions that are right for them.”

Health Dialog announced that it has partnered with HealthMedia, a developer of online services designed to help enhance the effect of counselors in managing patients’ lifestyles. Via the partnership, “Health Dialog’s whole-person care-management offering, which includes telephonic Health Coaching across the spectrum of healthcare needs, will be enhanced with HealthMedia’s online health-management modules, equipping individuals with a greater depth of information and support throughout the healthcare process.” Health Dialog’s Chairman and CEO, George Bennett, comments, “Our

whole-person, whole-family Health Coaching model of engaging, educating and motivating individuals to “get smart” about their health is complemented by HealthMedia’s behavior-focused online health management programs.” Ted Dacko, President and CEO of HealthMedia, believes that the partnership “provides an opportunity to partner our solid suite of online behavior change programs with their proven Health Coaching success. The combined result is a more seamless member experience and improved client usability.”

Health Dialog has recapitalized its financial structure with the infusion of $170 million from a number of existing investors, “including the British United Provident Association (BUPA), HarbourVest Partners, Arcadia Partners, and Spencer Trask investors,” and “funding from new investors, including venture capital firm Oak Investment Partners and American Re, a member of the MunichRe Group and one of the leading providers of reinsurance in the United States.” This new financing, allowing some early investors a return on their investment, is recognition of Health Dialog’s

rapid growth and provides the financial underpinnings for its “next phase of growth and expansion,” according to George Bennett, Health Dialog Chairman and CEO. Andrew Vallance-Owen, Group Medical Director, BUPA, remarks, “By addressing the whole person, Health Dialog is able to uncover multiple opportunities for positive impact. We fully support such a patient-centered approach and as an international healthcare organization, we envision further successes using this approach both in the U.S. and abroad.”

The National Committee for Quality Assurance (NCQA) – an independent accreditation organization that has come to be recognized as a trusted source about healthcare quality – has afforded Health Dialog with “full patient and practitioner-oriented accreditation.” “Health Dialog’s high scores in this voluntary review process have earned the company three-year, renewed accreditation of its asthma, coronary artery disease, chronic obstructive pulmonary disease, congestive heart failure, and diabetes programs, which were initially accredited by

NCQA in 2002.” “The reaccreditation requires effective performance in six major areas, including program content, patient services, practitioner services, clinical systems, measurement of quality improvement and program operations.” Health Dialog CEO George Bennett comments that the “accreditation validates our efforts to deliver industry-leading results for individuals with chronic illnesses such as asthma, diabetes and heart disease.”

Health Dialog will begin offering its Collaborative Care program to eligible participants in Health First Health Plans' Commercial, Medicare, and Self-Insured Employer populations. Collaborative Care is a whole-person, care-management program that “includes Health Coaching support for chronic conditions, significant medical decisions, and general health and wellness needs. Health Dialog Health Coaches are specially trained healthcare professionals, such as nurses and dieticians, who educate and work with individuals to help them become more active and effective participants in the management of their health.”

using a Shared Decision-Making approach. Health Dialog’s Chairman and CEO George Bennett commented, “By implementing this program, Health First Health Plans has made a commitment to helping members sift through all of the available information so they can make the healthcare decisions that are most appropriate for them.” Health First Health Plans’ Vice President and Medical Director Joseph Collins, MD, adds, “Through this offering we will be able to provide individuals with access to a service that has been shown to have a real impact on quality of care, satisfaction, and costs.”

Health Dialog announced today that it will begin delivering its Collaborative Care health services to 36,000 members of the FELRA & UFCW Health and Welfare Fund, “a multiemployer fund that provides health and welfare benefits to grocery store employees primarily in the Baltimore and Washington, DC metropolitan areas, but also in regions of Virginia, Pennsylvania, North Carolina, and West Virginia.” An integral component of Collaborative Care is the use of Health Coaches,

specially trained professionals that follow Health Dialog’s Shared Decision Making framework to “encourage individuals to learn about their conditions, consider their treatment options in the context of their values and preferences, and engage in more constructive dialogs with their physicians.” Mr. George Bennett, Health Dialog Chairman and CEO, comments, “To be selected by such a multi-employer fund demonstrates that our model can deliver value to a broad variety of organizations.”

Health Dialog has announced that it will begin providing whole-person care-management services to 212,000 members of the Capital District Physician’s Health Plan. In addition to accessing Health Dialog’s Health Coaches to support a range of chronic conditions, “including coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, and diabetes,” participants will be able to “obtain information and support across

the spectrum of healthcare needs, including support for significant medical decisions and general health and wellness concerns.” Health Dialog’s Shared Decision-Making framework of encouraging participants to become “more active and effective participants in the management of their healthcare” was “developed in collaboration with the Foundation for Informed Medical Decision-Making.”

Health Dialog announced that its 327.6% three-year growth rate of sales led to its being named to Inc. Magazines’ list of 500 fastest growing private companies for the third year in a row. Mr. George Bennett, Health Dialog Chairman and CEO, comments, “Health Dialog’s placement on the Inc. 500 for three consecutive years is largely a result of our ability to reduce healthcare costs and improve healthcare quality for health plans and self-insured employers.” The full list can be found in Inc.'s

November issue. According to the release, “This year, Inc.com is offering readers an expanded series of online features to supplement the print edition of the Inc. 500. Launching October 19, the website will feature:

• Interactive maps allowing for quick insight into regional and industry trends

• A complete, sortable list of this year’s winners

• Slide shows of Inc. 500 CEOs past and present"

Sir William Castell is President and Chief Executive Officer of GE Healthcare and Vice Chairman of the Board. According to GE, “Prior to its acquisition by GE in April 2004, Sir William was Chief Executive of Amersham plc. During his tenure with Amersham, he successfully oversaw a major expansion of the business through organic growth and acquisitions, culminating in 1997 with the mergers of Amersham International with Pharmacia Biotech and Nycomed asa. The resulting business, Amersham plc, was a world leader in in vivo medical diagnostics and life sciences research technologies.”

William Dunk Partners writes, “GE, by and large, grows its own top managers internally, and this is another departure on the part of Jeffrey Immelt, who is now chairman and who is putting heavy emphasis on innovation. … Already Castell has charged his executives to think bigger and longer, going beyond GE’s 3-to-5 year planning timeframe, and looking out 10 to 15 years. … This will amount to moving GE more fully into the biotech revolution

that is now underway.

We turn now to a July 12 Manager's Journal article in The Wall Street Journal written by Sir William Castell wherein he provides an eminently sensible recommendation on the long-term outlook for the nation’s healthcare system. There is little question that great strides have been made in pharmaceuticals, therapies, and medical devices and instrumentation that “have saved, improved and extended the lives of hundreds of millions of people.” But, "Today, our model is based on allowing ourselves, through lifestyle, environment, and latent genetic predisposition or simple ignorance, to develop serious disease.” He terms it a “Late Disease” model. To move forward in the 21st century, he postulates that “The key is to adopt a holistic view of the individual’s health and to act early, before symptomatic disease is allowed to gain the upper hand,” a process he calls “Early Health.” He argues that biology, bytes, and broadband will facilitate Early Health, a model that “may actually be less expensive.”

Though most everyone knows that healthcare costs continue to escalate, consuming ever increasing portions of our incomes, most obvious solutions seem “to involve painful tradeoffs.” But as Mr. Adler points out, that needn’t be the case. He shows that, “Increasing the efficiency of the health-care system could reduce costs while at the same time maintaining or even improving quality.” This “free lunch” is supported by data dating back to the 1970s when John Wennberg, Jonathan Skinner, Elliott Fisher and others at Dartmouth Medical School began documenting the variations in medical care in different parts of the country, even among “the best U.S. hospitals.” They also noted a huge disparity in per-capita spending. As recently as 2001, “Costs for a Medicare patient in Miami … are more than twice as high than those for a similar patient in Minneapolis.” And, most discouragingly, those in Miami suffered statistically worse outcomes. The primary cause: supply. If an area has a resource – specialists, hospital beds, etc. – they

tend to use them. Patients also suffered a lack of collaboration with doctors on procedures, such as lower back pain surgery, where it is important for patients to be involved in the decision making process.

Noting “huge impediments to change,” Mr. Adler asks, “Is it actually feasible to get rid of these inefficiencies?” Many are struggling to define quality and provide incentives, but measuring quality is quite difficult. Mark McClellan, administrator of the Centers for Medicare and Medicaid Services which controls 40% of total health-care spending in the U.S., “believes that we can identify and get rid of some of the inefficiencies in the U.S. health system.” In addition to developing evidence to support standards of care, Mr. McClellan is “giving Medicare a more preventive focus.” He’s high expectations, in part due to the belief “that 30% of Medicare spending is wasted.” But beyond saving money, it can be argued that, “We will also save lives.”

If you’ve clogged arteries, stents are called for; and if you’ve serious blockage, bypass surgery is the ticket, right? Well, according to a July 18 BusinessWeek article perhaps it may not be so. Though 400,000 bypass surgeries and some one million angioplasties are performed annually, there is actually quite a bit of disagreement among professionals as to the efficacy of invasive procedures. Experts can be found on both sides of the debate, but evidence suggests that “except in a minority of patients with sever disease, bypass operations don’t prolong life or prevent future heart attacks.”

Those questioning the usefulness of invasive procedures run up against cultural norms that suggest most any aliment should be treated aggressively; and the press, ever looking for a story, is sometimes, according to Dr. Nortin M. Hadler, professor of medicine at the University of North Carolina at Chapel Hill, “too quick to talk about the latest widget and gizmo without asking what it is and does it work.”

Dr. Elliot S. Fisher, professor of medicine at Dartmouth Medical School, has demonstrated that, by examining variations in regional expenditures on healthcare, more is not always better. Dr. Fisher concludes, “My data suggest that we are wasting 30% of healthcare spending on stuff with no benefit and perhaps causing harm.” International studies have corroborated Dr. Fisher’s findings. Those paying the nation’s healthcare bill are taking notice.

The latest debate centers around the difference between the effects of plaque accumulation on narrowing passages versus unstable plaque that breaks off and causes clots. Fundamentally, how one perceives the greatest risk can determine the course of treatment. Invasive surgeries are shown to reduce angina pain and shortness of breath, but a recent study using a control group who had a sham operation showed as much pain reduction and improved heart function as those undergoing invasive procedures. There are also questions being raised about drug-coated stents. “What worries some doctors is that people getting the new stents might have higher risk of clots.” Substantial studies are ongoing that may eventually revolve outstanding debates. But advancing technology is likely to keep the debate alive for some time to come.

BusinessWeek points out that “Some scientists argue that the rational solution is to let patients decide for themselves.” They show that “In trials where one group gets the information and the other group receives no special attention, the well-informed patients opt for more invasive, aggressive approaches 23% less often, on average, than the other group.” Dr. Hadler argues that too many jump to conclusions about the benefits of uncertain treatments. According to BusinessWeek, he “hopes that enlightening people about the limitations of medicine will help them worry less and stay well longer. It also could help cure an ailing healthcare system, making it more rational.”

While more than 600,000 Medicare beneficiaries already have access to Health Dialog’s services through commercial health plans, the company today announced that, via a three-year pilot program in western Pennsylvania, it will provide direct assistance to 20,000 Medicare fee-for-service beneficiaries in cooperation with the Centers for Medicare and Medicaid Services. It “is a watershed moment for the nation’s Medicare system,” according to George Bennett, Chairman and CEO of Health Dialog. By “collaborat(ing) with patients and their care providers to help strengthen

patient-physician communication and improve the understanding of chronic conditions and treatment regimens . . . patients become more active participants in their healthcare with their doctors, leading to improvements in overall quality, and ultimately, lower healthcare costs.” Based on the success of the program – assessed by quality and satisfaction standards as well as spending levels – the Secretary of Health and Human Services “may expand programs or program components that prove to be successful beginning two to three and a half years after the programs are implemented.”

Health Dialog announced that a proposal it jointly submitted with Kings Fund and New York University was chosen by England’s National Health Service for developing “predictive modeling algorithms that will be used to identify patients at high risk of emergency hospital admission . . . in order to ensure that case management services are targeted most effectively, and individuals receive an appropriate healthcare intervention at the right time.”

The basis of Health Dialog’s contribution to the project is “grounded in the research of Drs. John and David Wennberg” that “focuses on the overuse,

underuse, and misuse of healthcare services.” In addition to having developed “predictive modeling and provider performance measurement” capabilities, Health Dialog’s “distinctive experience working with disparate sources of data is a critical component of the UK-based initiative.” George Bennett, Health Dialog’s Chairman and CEO, comments, “Health Dialog’s entry into the UK market reflects the broad acceptance of care management as an effective strategy, and as a solution that can be applied across various healthcare systems.”

Researchers have analyzed data collected as part of a directive of the 2003 Medicare prescription drug benefit bill that reveals “significant differences in quality of care across American hospitals,” thus adding to a number of existing studies showing regional variation in healthcare quality. Harvard University’s School of Public Health analyzed how well 3,500 hospitals followed 10 treatment guidelines for heart attacks, congestive heart failure, and pneumonia. And not only were differences revealed, “the study found that compliance with the

10 quality indicators was disappointing.” Cautioning that consumers shouldn’t come to hasty conclusions about particular hospitals, summary data on individual hospitals can be found at www.hospitalcompare.hhs.gov. The Joint Commission on Accreditation of Healthcare Organizations publishes additional hospital information at http://www.qualitycheck.org. There is reason for optimism, as the Joint Commission suggests “hospitals that have been reporting data since 2002 have, on average, improved over time.”

Following the successful rollout of Health Dialog’s Health Coaching services to its Medicare and self-insured populations, Excellus BlueCross BlueShield has decided to offer Health Coaching services to its insured HMO and POS customers. The flexibility of Health Dialog’s Coaching services – specially trained professionals implementing a “Shared Decision-Making” approach to help patients more effectively engage in the healthcare process – allowed Excellus to seamlessly expand its overall

patient services. Kathleen Converse, Director of Case and Disease management at Excellus, comments, “Health Dialog’s targeted reach and engage strategy allows us to engage members at the right time with Health Coaching services that are personalized to individual needs.” George Bennett, Health Dialog Chairman and CEO, adds, “Excellus BCBS has achieved a high level of program integration that also simplifies administration for employers and enhances ease-of-use for members.”

Health Dialog has unveiled HD Connect, the firm’s latest addition to its care-management suite of products. HD Connect allows clinical staffs to obtain real-time information in a secure, web-based format “about member interactions with Health Coaches.” Health Dialog’s CEO George Bennett

 believes that HD Connect will “foster integration in the care management process” by making it easier for both clinical staffs and patients to work with Health Dialog’s Health Coaches thus providing for “a more seamless member experience and improved usability for our clients.”

Journal reporters Lueck and Dumcius report on the developing momentum behind the trend “to pay hospitals and physicians for medical services based on their performance.” On the physician front, groups of clinicians and private and public program administrators “agreed on 26 quality measures for physicians' offices that could help insurers set up performance-based payments as soon as next year.”

Providing further momentum to the pay-for-

performance trend are comments from Dr. McClellan, a Medicare administrator, who relates that the agency has seen improvements “across the board” as a result of rewarding quality improvement. He reports that gains have been made both in improving quality and reducing costs. In a Medicare experiment, “hospitals can receive bonuses in Medicare payments based on how they meet 34 national standards.”

The Dartmouth-Hitchcock Clinic will rely on Health Dialog’s care-management services as it participates in the Centers for Medicare & Medicaid Services’ first program designed to evaluate paying doctors based on performance instead of simply haven provided a service. The three-year program will reach 25,000 patients through five clinical sites. David Wennberg, Health Dialog Data Service’s President and COO, comments, “The shift from a fee-for-service system to a pay-for-performance-based system has begun.”

Health Dialog’s patient-centric or whole-person

approach to care management uses the principles of Shared Decision Making that were developed in conjunction with the Foundation for Informed Medical Decision Making. The practices call for reaching out to patients in a “proactive manner” that facilitates getting them more involved in making informed decisions about their healthcare. Evidence suggests that such proactive involvement can reduce costs as well as improve the quality of care. A whole range of healthcare issues will be addressed, “including disease management, decision-support, and general health and wellness needs.”

Commenting that Health Dialog’s “Shared Decision Making truly supports (a) member-centric approach” to delivering healthcare, Don Fischer, Chief Medical Officer at Highmark – an independent licensee of the Blue Cross and Blue Shield Association – provided the rational for Highmark’s extending its relationship with Health Dialog until 2011. He also references Health Dialog’s willingness to “customize the program to meet the specific and evolving needs of our member and employer groups.” As a result of the extension, Highmark’s more than three million members will continue to have access to Health Dialog’s Health Coaches to help them to prepare for physicians’ visits and generally help “develop treatment plans that are consistent with their values and preferences.” Specifically, “Health coaches can help an individual develop skills for managing a chronic condition such as diabetes, learn how to get objective evidence-based information on treatment

options for a condition such as prostate cancer, and learn how to get and assess information on an urgent need such as a 2:00 am fever.”

In a separate release, Health Dialog announced that its Health Coaching services will be made available to the self-ensured employer and dependents who’ve purchased the coverage through Blue Cross Blue Shield of North Dakota (BCBSND). Dr. Jon Rice, Vice President of Medical Management at BCBSND, comments that, “After an extensive evaluation process, we chose to work with Health Dialog based on the company’s unique approach to care management. The Health Dialog program addresses a broad spectrum of healthcare needs and encourages self-reliance,” thus supporting the goal of helping “individuals play a more active role in the management of their health and healthcare and to help individuals and their physicians have more effective conversations.”

Dartmouth Medical School, building on its reputation as having “pioneered the concept of ‘shared decision making’ between patients and doctors,” is taking steps to further inform patients by fully revealing how well patients fare under various medical treatments. Describing the effort as a “radical new concept,” Ms. Landro reports that “most hospitals are still loath to publicly report any statistics that might make them look bad, or increase their liability risk . . .” Nevertheless, “a small but growing number of hospitals and health- care groups” are following Dartmouth’s lead. There are barriers to overcome for many hospitals. Less than superior results and the need for allocating resources are two concerns; as is skepticism from both doctors and hospital administrators. Clearly,

publishing data that is sub par can be “daunting,” but as Dartmouth-Hitchcock Executive Vice President Paul B. Gardent points out such disclosure can provide “an additional stimulus for improving quality.” From a user’s perspective, Dartmouth-Hitchcock’s Melanie P. Mastanduno reports that research is showing the one “common theme has been trust. Just the fact that we gave all the information to the public and were not ashamed or embarrassed gave confidence.”

Ms. Landro lists the following web sites for hospital-performance data:

Dartmouth-Hitchcock Medical Center

The Cleveland Clinic

Colorado Hospital Quality

New York State Hospital Report Card

Health Dialog will begin providing Health Coaching to 1,000 of Partners HealthCare’s Medicaid and uncompensated care patients suffering from complex or chronic diseases. Dr. Timothy Ferris of Partner HealthCare has been “. . . incredibly impressed with Health Dialog’s level of innovation in creating a totally new service within their organization as well as their terrific capacity to do the challenging day-to-day work of calling our patients and coaching them in their health needs.”

Health Dialog works with the “whole person,” to better equip them to “navigate through the healthcare system.” In this 3-year pilot program, Health Dialog’s Health Coaches’ experience with the Medicaid system is clearly a plus. Coaches will be available on a 24/7 basis to meet patient needs, including, for example, preparing for doctors visits. Partners HealthCare provides healthcare services to over 100,000 patients.

In November 1995, the Ottawa Health Decision Center, part of the Ottawa Health Research Institute and affiliated with the Ottawa Hospital and The University of Ottawa, established The Patient Decision Aids program. It is a program designed “to help patients and their health practitioners make ‘tough’ healthcare decisions. ‘Tough’ healthcare decisions may have many options, uncertain outcomes or benefits and harms that people value

differently.” The Patient Decision Aids program provides a range of tools, including college credit courses at the University of Ottawa and Dartmouth College, New Hampshire. In the A to Z Global Inventory of Patient Decision Aids sections, you can search by broad topic or specific condition, ranging from Acne and ADHD (Attention Deficit Hyperactivity Disorder) to Heart Disease and Wrist/Hand Injuries & Problems.

Important links that can be found at The Patient Decision Aids program site include:

Ottawa Personal Decision Guide

An online tool for any "tough" decision.

Ottawa Decision Aids

An online tool for any "tough" decision.

A to Z Global Inventory of Patient Decision Aids

A global inventory of Available patient decision aids.

Cochrane Systematic Review

About the Cochrane Systematic Review of patient decision aids; an inventory of ALL decision aids, including those under development.

Training in Decision Support

An auto-tutorial for developing health practitioners' skills in decision support.

Evaluation Measures

Research tools for evaluating decision support including the Decisional Conflict Scale.

Resources

Frameworks, annotated bibliographies, workbooks and links.

David Wessel reports that while the insurance industry has taken steps to encourage quality-of- care metrics, the movement called P4P – pay for performance – is really getting a boost from the federal government’s involvement. After all, "About 46 cents of every dollar spent on health care in the U.S. comes from the government, the bulk of it from the Medicare and Medicaid health-insurance programs . . . the government pays nearly 60% of the hospital bills and 20% of the doctor bills."

The government’s latest program engages “10 big physician group practices that care for 200,000 Medicare beneficiaries.” Physician fee schedules will remain the same, but there will be bonus money available to those demonstrating that their costs are rising more slowly than non-participant Medicare patients. And "They get a bigger bonus if they

improve their performance in 32 quality measures, such as regular blood-testing of diabetes patients to be sure their blood sugar is under control."

Bruce Hamory, chief medical officer of Geisinger Health System, believes that the program will allow them to contact patients with severe illnesses "by mail or phone or maybe even send a visiting nurse." But as Elliott Fisher, a Dartmouth College physician, cautions, "The stuff that’s easiest to measure may not be the stuff that’s most important to the health of the population." Mr. Wessel concludes that while doctors might not like the new initiative, "tweaking the way the government and private insurers pay doctors may be the only way to avoid much more painful and disruptive approaches to restraining costs in health care."

In what is being referred to as a ‘demonstration project,’ Medicare officials have launched an experiment designed to pay physicians' bonuses if they demonstrate an ability to not only reduce costs, but, more importantly, improve the quality of patient care. The Centers for Medicare and Medicaid Services administrator, Mark McClellan, comments, “That’s the way payments ought to work – we ought to be doing more to reward good performance.” He further acknowledges that actions are “under way right now to develop quality measures in virtually all settings of care.” But the

American Medical Association (AMA) is resisting the trend toward performance-based pay. AMA secretary, John Armstrong, believes, “We think it’s too early, and that’s why these demonstration projects seem to be the right process.” The designated clinics will rely on a variety of measures, including “more actively monitoring patients with serious illnesses. For example, Dartmouth Hitchcock Clinic in Bedford, N.H., will concentrate on educating patients with diseases such as congestive heart failure and diabetes about how to manage their conditions.”

Health Dialog recently bolstered its senior management team with the addition of Craig S. Russell, “a 22-year veteran of the healthcare industry.” In his role as National Practice leader, Mr. Russell will be working “directly with benefit consultants, employers, and health plans to develop and launch new products that reflect the needs of the care management marketplace.”

Co-founder of Health Decisions International and Traveler’s Center for Corporate Health, both acquired, Mr. Russell’s most recent accomplishment was to triple membership to nine million members at CareWise prior to its being sold

to SHPS. Mr. Russell went on to “successfully (lead) the company’s healthcare strategy, and additionally managed marketing and business development.”

For his part, Russell believes, “This is an exciting time in the healthcare industry and Health Dialog is uniquely positioned to bring further innovation to this rapidly expanding market.” “Craig’s tenure in the industry and broad health management perspective are what we need to see more of in the vendor landscape," comments Sue Willette of Mercer Human Resource Consulting.

The U.S. government recently reported that while the overall growth rate of health-care spending slowed from prior years, it continued to grow more quickly than the overall economy. As a result, for the first time, health-care spending in the U.S. surpassed 15% of Gross Domestic Product, outpacing all other industrial economies. Outlays for Medicaid and Medicare continued to grow, albeit at slower rates. For example, Medicaid spending grew 7.1% versus 12.1% the prior year. Among services, prescription drug spending showed the largest decline in its growth rate.

One area that stands out in the government’s report is the private sector. Overall, the private-sector’s 8.6% increase outpaced public spending, thus reversing a decade-long trend. “Consumers dipped

into their own pockets to pay 30% of prescription drug costs.”

The only major source of spending that increased faster over the prior year was out-of-pocket payments. This trend has been fueled, in part, by employers' increasing willingness to pass cost increases on to the employee/consumer in the form of increased co-payments for physician visits and drugs and higher deductibles. Paul B. Ginsburg, the president of Center for Studying Health System Change, believes that the trends toward accelerating private sector payments and continued rising costs of overall health-care could pose long-term problems, as individuals' earnings and federal revenues are growing more slowly than their respective burden of rising health-care costs.

Health Dialog announced that Martin’s Point Health Care of Portland, Maine has decided to offer its plan members Health Dialog’s “proven disease management capabilities.” David M. Howes, M.D., President of Martin’s Point Health Care, comments that the decision to grant members access to Health Dialog’s “disease management, decision-support, and general health and wellness services” was based on Martin’s Point's desire to provide “ever increasing value” and “the best care possible.” George Bennett, Chairman and CEO of Health Dialog, believes, “The fact that Health Dialog has

been selected by a physician-led organization speaks to the clinical value of our program and its focus on supporting the relationship between physician and patient.”

Martin’s Point’s US Family Health Plan “provides healthcare services and plan administration to more than 22,000 military retirees, their dependents, and active-duty families throughout Maine and southern New Hampshire.” Over 20 percent of Plan “members live with a chronic condition that could improve with more focused care management.”

Health Dialog announced that its Health Dialog Services subsidiary has been chosen by the Department of Health and Human Services (HHS) “to conduct a three-year pilot program in Pennsylvania that will help HHS evaluate various options for providing chronic care management services to fee-for-service Medicare beneficiaries on a broad scale.” The study is part of the federal government’s effort under the Medicare Modernization Act to determine the best way to proceed in providing healthcare to patients suffering chronic conditions; in this study, 20,000 patients that have been diagnosed with congestive heart failure or complex diabetes will be evaluated over

three years.

George Bennett, Chairman and CEO of Health Dialog, is looking forward to working on the project believing, “The Voluntary Chronic Care Improvement Program will change the face of the disease management industry and, over time, could significantly influence how healthcare is practiced in the United States.”

Other three-year programs will be initiated around the country with successful programs -- based on quality, satisfaction and achieving expenditure targets -- potentially being expanded beginning two to three-and-a-half years after being implemented.

Health Dialog has launched a new service designed to assess the quality of care delivered by health care providers. The new product, Provider Measurement Service, is being launched with Blue Cross Blue Shield of Massachusetts (BCBSM). The new service’s “analytical underpinnings are built on the landmark research by Drs. John and David Wennberg on the effects of practice pattern variation across multiple healthcare delivery dimensions.” The evaluation service will be available via a new wholly owned subsidiary, Health Dialog

Data Service. The new division’s President and COO, Dr. David Wennberg, comments, “We believe our unique method of analysis is the next major opportunity for cost and quality improvement across the healthcare system.”

Dr. John Fallon of BCBSM expects, “that this approach will help to identify treatment pattern variation so that we can improve quality and efficiencies across (their) network” of provider groups by providing “more accurate and actionable metrics of healthcare services.”

Health Dialog has once again received recognition as being a rapidly growing private company by its recent inclusion on Inc. Magazine's annual Inc. 500 ranking of fastest-growing companies. John Koten, Inc.'s editor-in-chief, gives special recognition to this year's entrepreneurs by commenting that, "When people were practically giving away funding in the late 1990s, these companies didn’t overextend, and when everyone hit the panic button a few years later, they stayed calm and seized opportunity." Mr. George Bennett, Chairman and CEO of Health Dialog, goes on to say "Health Dialog's phenomenal growth is rooted in our ability to identify meaningful opportunities to reduce Unwarranted Variation in healthcare. We have a proven ability to translate these insights into cost-

effective, scalable, and replicable business practices. Health Dialog is poised for future growth as healthcare purchasers increasingly embrace our tested philosophy that cost and quality improvements can be achieved by transferring skills and knowledge to the right individuals at the right time."

To be eligible for this year's Inc. 500 , companies had to be independent and privately held through their fiscal year 2003, have had at least $200,000 in net sales in the base year of 1999 for Inc. 500 alumni and 2000 for new applicants, and $2 million in net sales for 2003. In addition, their 2003 sales had to exceed 2002 sales. Companies are ranked on averaged year-over-year sales growth. Health Dialog place 114^th on the list.

The effort by health-care providers to reach out and proactively help those afflicted by chronic disease has come to be known as disease management. It seems to make inherent sense that if chronic-disease patients who are widely recognized as accounting "for more than two-thirds of the nation's $1.6 billion medical bill" would more effectively manage their diseases, dramatic savings could be achieved at the same time as improving the quality of patients' lives. And that is the generally accepted conclusion as evidenced by, "The percentage of employer-sponsored health plans offering disease-management programs grew to 58% last year from 41% the year before, according to Mercer Human Resources Consulting." Ms. Landro writes, "Typically, chronically ill patients are monitored over the phone via nurse call centers, which work with information provided by labs, doctors and pharmacies. Disease-management programs are now expanding to include depression, cancer, kidney disease, obesity and lower-back pain."

But there are some who've raised questions about the efficacy of disease-management practices. Dr. Wagner, director of the MacColl Institute for Healthcare Innovation, particularly brings into

question those programs that "use automated response systems" over those that employ more hands-on efforts. The Congressional Budget Office has entered the fray by releasing a report that rather directly concludes that there is "insufficient evidence" of the benefits of disease-management programs. A recently launched Medicare program designed to study the issue will no doubt shed light. But even before those results are available, Christobel Selecky, president of the Disease Management Association of America, feels that the CBO report doesn't appropriately take into account more recent studies showing "clear cost benefits." And David Cutler, a professor of economics at Harvard University, also takes the CBO report to task, suggesting that it should have taken additional factors into account, including increased productivity and fewer work absences. Ms. Landro quotes Mr. Cutler, "from the societal level, comprehensive disease-management programs are clearly worth the investment," says Mr. Cutler. "What we care about is being healthy and having a higher quality of life, and if we can get there at no net long-term cost, that is undoubtedly a good thing."

The Wall Street Journal Reporter Laura Landro writes revealingly and compassionately of her ordeal with Leukemia. Cancer survivorship statistics show dramatic improvement; the five-year survival rate has improved from 50% in the mid-1970s to about two-thirds today. Nevertheless, Ms. Landro clearly considers herself fortunate to have survived. She talks about the certainty of some medications/treatments and the tenuous/experimental nature of others, at one point having to simply put her faith in her doctor's hands. She also addresses her struggles to evaluate alternate courses of action. Along the way, Ms.

Landro launched "into what would become a whole new phase of my journalism career, writing about health care and the issues consumers face in making informed decisions as patients." She writes, "Thanks to the wealth of information online, it has never been easier for cancer patients to keep abreast of new treatments and get involved in research studies . . . " The web has also "enabled cancer patients to connect with each other as never before, providing much-needed support and inside information." Other citations reflecting Ms. Landro's work toward informing patients, and doctors as well, include 52, 48, 46, 42, and 23.

In its eighth annual report on the quality of the nation's health care, the National Committee for Quality Assurance (NCQA) reported that "the quality of care delivered by the nation's managed health plans improved for a fifth straight year." The report didn't gloss over results, pointing out that "quality gaps" exist that account for as many as 79,000 preventable deaths each year and that some $1.8 billion was wasted "on missed opportunities to provide care that medical science has shown to be effective." The report concludes, however, that the

overall performance showed the best annual gain in the eight years of the study.

Harvard Pilgrim Health Care took top honors on both of the studies two top-ten lists. The New England health plan is benefiting from focusing "on prevention programs, patient outreach and physician-reminder programs." The NCQA also "applauded the plan's investment in a sophisticated information system for doctors as well as a five-year-old program that rewards physicians with pay-for-performance."

http://www.healthdialog.com/MatureMedia.pdf

Health Dialog announced that its video "Is a PSA Test Right for You?" was recently recognized for overall excellence at the 11th Annual National Mature Media Awards, a program acknowledging "the nation's best educational, marketing, and advertising materials for adults who are 50 or older." The video, an important component of Health Dialog's Shared Decision-Making program, "presents both physician and patient perspectives on the pros and cons of having a PSA blood test to screen for prostate cancer." It was developed in

conjunction with the Foundation for Informed Medical Decision Making. Bill Brennan, Senior VP of Media Production at Health Dialog, was "honored" that the company would be so recognized. He commented, "Health Dialog strives to develop informative and compassionate educational materials to help individuals better understand their treatment options and work with their physicians to make healthcare decisions that are right for them."

http://www.healthdialog.com/NHIA.pdf

Health Dialog announced that two of its videos earned awards at the 11^th Annual National Health Information Awards program, "one of the most comprehensive of its kind and recognizes the nation's best consumer health information programs." There were more than 1,100 submissions. The two videos are "Breast Reconstruction: Is it Right for You?" and "Chronic Low Back Pain: Managing Your Pain and Your Life."

Health Dialog developed the videos for use by its

Shared Decision Making program that uses highly trained Health Coaches to support "individuals to help them make more informed decisions with their physicians." The videos help people "better understand their treatment options when facing a significant medical decision." Bill Brennan, Senior Vice President of Media Production for Health Dialog, comments, "Both patients and physicians appreciate a tool that enables them to work together most effectively for the best possible outcome."

Mr. Davies reports that the key finding of a major healthcare study based on data provided by the U.S. Department of Health and Human Services is that just "15 medical conditions accounted for half of the inflation-adjusted growth of $200 billion in health spending between 1987 and 2000." The lead author of the study, Kenneth E. Thorpe of Emory University, comments, "Most of the growth in spending is among people who are very ill with chronic diseases that are expensive to treat."

Illnesses leading to the lion's share of the cost increases were heart disease/diabetes, asthma, mental disorders, cancer and hypertension. Mr. Davies concludes that the study "suggest(s) that more proactive treatment or prevention of chronic diseases could help rein in costs."

We suspect the study is based on Medicare data which has significant variance from that arising in data from commercially insured populations.

19 July 2004

http://www.healthdialog.com/HIPAA715.pdf

the 1996 federal Health Insurance Portability and Accountability Act (HIPAA). Certification "eliminates the need for due diligence around HIPAA privacy and security regulations" and "helps to facilitate easier implementation and lowers costs for covered entities and business associates." Commenting on the certification, Health Dialog CEO, George Bennett, stated, "This certification validates the stringent internal standards Health Dialog has always followed to protect members."

16 June 2004

http://www.healthdialog.com/NHEvent.pdf

states, enabling nurses licensed in New Hampshire to also practice in other participating states." Other states include Maine, Texas, North Carolina, Arkansas, and North and South Dakota.

Health Dialog, a provider of access to Health Coaching services to more than 12 million people, was a leading advocate of the bill. The signing was marked by a ceremony in the firm's Manchester offices.

24 May 2004

http://www.healthdialog.com/NEPApr.pdf

reducing costs. Health Dialog's program "teaches individuals self-reliance rather than fostering dependency on others . . . (thus allowing) members to better manage their chronic conditions and make more informed healthcare decisions."

For information on Blue Cross of Northeastern Pennsylvania, visit www.bcnepa.com

19 May 2004

Insurance expressed hope that the seminar would "stimulate discussion on reality-based health care delivery" so as to avoid creating or sustaining the type of environment that in the past led to a rash of unneeded tonsillectomies. Doctors will not lose their position as the ultimate decision maker, but Dr. Roger Allen of Minot's Trinity health center commented that doctors will need to increasingly acknowledge evidence-based, best-practice standards of treatment.

06 May 2004

medicine. So the company took a one-million-dollar-a-year gamble, the annual cost of implementing an across-the-board reduction in all asthma and diabetes co-insurance rates. The company lowered rates to 10%.

While the company noticed a shift in some cases to more expensive medications, they also noticed employees refilled their prescriptions at higher rates. Overall, employees experienced better health and the company incurred lower costs through fewer emergency room and doctor's office visits and fewer hospital admissions. The company also noticed "it was spending significantly less on rescue medications" such as might be used by one suffering a severe asthma attack. Since 2001, Pitney Bowes has seen its median medical costs for diabetic and asthmatic employees fall by 12% and 15%, respectively. The company expects "it will save at least $1 million in 2004."

06 May 2004

Health Dialog announced that its Health Coaches and analytical services will become available to 116,000 members of the National Rural Electric Cooperative Association's (NRECA) health plan. "The Health Dialog program provides both information and support to help employees be more active participants in their health care and make better medical decisions in collaboration with their doctors." Health Dialog's Collaborative Care solution, already available to 12 million people across the U.S., uses a "whole person" perspective

that includes Health Coaches that are available around the clock. The Coaches are trained in the firm's Shared Decision-Making techniques that foster greater patient self-reliance. Scott Spencer, NRECA Senior Vice President of Insurance & Financial Services, comments, "Health Dialog has developed breakthrough methodologies that can change the way patients participate in their care and interact with their physicians. Our hope is that members will benefit substantially by this approach."

6 May 2004

Health-care providers are turning to financial incentives to bring patients and doctors together with evidenced-based guidelines. Doctors can expect higher reimbursement rates, while patients will be encouraged into a 'shared decision making' role via lowered co-payments. To be sure, there are concerns, particularly from doctors about implement best-practices methodology. Even so, But BlueCross BlueShield of Tennessee plans to move forward with "a yearlong pilot program with Vanderbilt (University), stress(ing) that doctors won't be penalized for not following guidelines if it isn't the best course for a specific patient."

27 April 2004

Parents were found to reduce their use of a clinic or emergency room as a first choice response to their children's ailments from 69% to 32%. "The goal is to educate 12,000 families by the end of 2005. With each emergency-room visit costing an average $200 and clinic visits costing $30, the program could potentially save an average $198 a year per family for a total of $2.38 billion." There is an ancillary benefit of parents having to take less time off work.

March 2004

http://www.healthdialog.com/dma304.pdf

pollenization." IBC's Connections program provides physicians with feedback in the form of a Smart Registry that helps them more effectively monitor their patients.

Some early results of the Connections program "are just now being rolled out." Evaluation criteria "include clinical targets, operational performance targets, engagement rates, financial outcomes, and utilization." One clear benefit is a reduced "burden on IBC's case managers." While IBC expects an increased number of office visits as a result of the coaching, Ester Nash, IBC's senior medical director, comments, "We would rather have them in the doctor's office than in the hospital." She further states that, thus far, patient "reaction has been positive to neutral," and that "I have not heard a single complaint from a treating provider."

22 March 2004

integrated delivery systems, purchasers and others an accessible mechanism for obtaining objective, detailed information on clinical practice guidelines and to further their dissemination, implementation and use." Features include a utility program that allows users to compare differing guideline recommendations, search capabilities to quickly focus on a condition of interest, and a weekly update that includes electronic mailing (emailing) of new and updated guidelines. The site is located at www.guideline.gov.

12 February 2004

"shared decision making" between patients and doctors, particularly giving consideration to patients' goals and desires, is getting a push from an article published by researchers at Yale University in the American Journal of Medicine. Ms. Landro writes that, "The paper argues that doctors must shift their focus from treating disease alone to tailoring treatments to individual patient needs." Gathering momentum for more effective health-care regimens and results from programs such as Duke's are providing rational for health-care providers to incur the up-front costs of implementing prospective-care programs, knowing that they'll ultimately reduce costs. Evidence is mounting that there are measurable improvements in "quality-of-life issues" as well.

30 January 2004

have higher deductibles, but "money put into employee accounts can be rolled forward annually." He goes on to say, "All of the new plans provide(d) tools that let employees access health information of a sort they'd never seen before," including access to Internet-based tools and human "coaches." Coaches provide added value especially to sufferers of chronic conditions and those facing complex medical problems.

While Mr. Henninger gives recognition to reasons for pessimism, he surmises that most add "up to an excuse for doing nothing." He concludes that while nearly all interested parties recognize the advances in medical knowledge and technology over the last 25 years, "Personal autonomy, however, is a newer and ultimately more powerful force. Consumers are now at the gates of the American health-care system."

29 January 2004

the Agency for Health Care Research & Quality's www.qualitytools.ahrq.gov and the Foundation for Accountability's www.compareyourcare.org. The former is a federal agency that acts "as a clearinghouse for practical advice on evaluating care and improving quality." The latter is a non-profit organization that helps "consumers compare their own doctor's care to national benchmarks for depression, heart disease, asthma, diabetes and general heath care." Hurdles remain, but the new Medicare law and private industry initiatives along with consumers being increasingly responsible for more of their health-care expenditures should keep up the pressure for developing health-care quality standards.

27 January 2004

Health Dialog's Collaborative Care program brings together "proven medical research and industry-leading analytics" with a desire by consumers to take a more active role in making healthcare decisions to create a "whole person approach." The ability to "work effectively with their physicians" results "in far greater clinical and financial results than traditional silo programs."

4 January 2004

there's already too much. He embraces "systems-improvement" strategies that focus "on eliminating the danger, waste, confusion, and arrogance that are pulling medicine down." His vision would create a system with quick and timely access, patient control of records, noticeable customer service orientation, medication error elimination, communication and patient advocacy systems, elimination of waste, and standardized courses of medical action.

Dr. Berwick's quest appears to have taken on a new sense of urgency in 1999. That was when he acquired first-hand experience with medication errors and delays in urgently recommended care as some 100 doctors searched for the cause and cure of a mysterious loss of mobility in his wife's legs. A 1999 speech of the experience has come to be seen as a far-reaching event. "Videotaped copies have even become a standard part of some medical training programs."

Setbacks have been encountered, but there are increasing numbers of real world successes. And as Mr. Swidey reports, "The fact is, Berwick's proselytizing has produced so much more awareness about safety and quality problems in hospitals that most health-care leaders no longer argue with his diagnosis, even if many still take issue with his prescription."

22 December 2003

-- Opportunities for preventive care are frequently missed.

-- Management of chronic diseases presents unique quality challenges.

-- There is more to learn.

-- Greater improvement is possible.

National Healthcare Disparities Report:

-- Americans have experienced quality of health care; but some socioeconomic, racial, ethnic, and geographic differences exist.

-- Some "priority populations" do as well or better than the general population in some aspects of health care.

-- Opportunities to provide preventive care are frequently missed.

-- Management of chronic diseases presents unique challenges.

-- There is still a lot to learn.

-- Greater improvement is possible.

22 December 2003

director for the Centers for Medicare and Medicaid Services, observes "the best hospital in town and the worst hospital in town get paid exactly the same thing for a heart bypass or a hip replacement . . . you have zero economic penalty for being inefficient."

Disease Management . . . "Many experts agree the best opportunity to improve care and stave off costly complications is disease management -- the strategy of monitoring people with chronic conditions such as diabetes, congestive heart failure and coronary artery disease." Practitioners are demonstrating that such preventive care substantively improves outcomes while reducing costs.

Redesigning the ICU . . . By deploying a new eICU software system, Dr. Hochman of Sentara Hospitals "says two of his hospitals reduced ICU mortality rates, adjusted by the severity of patient illness, 27%, and cut hospital costs for ICU patients 25% over the last two years." He further comments that "the $2 million it spent to buy the software and get it up and running has already paid for itself with $3.5 million in saved costs and new revenue."

Getting Patients Involved . . . And lastly, Ms. Landro addresses the "final barrier;" the need to get patients to take a more proactive role in evaluating treatment alternatives, a trend being spurred by Americans being asked to shoulder more of the costs of their healthcare.

02 December 2003

more than half the time."

Primary care physicians appear simply to be "overstretched." In fact, there has been a sharp decline in the percentage of medical school graduates choosing to go into family practice due, importantly according to Dr. Jauhar, to "medical students increasingly view(ing) primary care doctors as harried and overworked."

They are looking for ways to get help, including nurse practitioners, physician assistants, e-mail communications, and group visits. But the doctor thinks "medical schools and organizations should take notice."

01 December 2003

"almost all interventions involve some risk, unnecessary tests, treatments and time in the hospital can be harmful."

Getting beyond the "deeply entrenched" belief that more care is better care will require more informed patients, including as to the incentives by which their healthcare providers are paid. The incentives themselves will have to be examined as well. Mr. Fisher observes, "If health care organizations were held accountable for improving the quality and efficiency of care, patients might believe that excellent care and lower costs are compatible." The savings -- his study showing about one third of spending goes to services that don't appear to improve health or the quality of care -- would be more than enough to provide healthcare to the nation's uninsured. He concludes, "The debate over Medicare underscores the challenge: how to pay for better care, not just more care."

20 November 2003

key role in healthcare decisions. Mr. George B. Bennett, Health Dialog Chairman and CEO, comments, "Individuals often receive care that is more influenced by geography, economics, and their physicians' training than by their own preferences and conditions." The video also won the Silver Award in the 2003 National Mature Media Awards in the Health care Video category.

05 November 2003

SMART Registry won due to its ability to meet the DMAA's award criterion, including innovation, industry impact, and measurable value. Warren Todd of the DMAA comments, "Health Dialog's ability to design and implement a successful strategy for engaging physicians and improving the quality of care for chronically ill individuals is an achievement that merits industry-wide recognition."

03 November 2003

organizations ranging from Managed Care and Preferred Provider Organizations to Disease Management companies.

Health Dialog received full Patient & Practitioner Oriented accreditation for its Diabetes, Cardiovascular Disease, and Congestive Heart Failure offerings on 10/15/2002 and for its Asthma and Chronic Obstructive Pulmonary Disease offerings on 5/6/2003.

27 October 2003

4. 80/20 is really 50/20 . . .

5. When people with diabetes are diagnosed with heart disease, they don't stop having diabetes . . .

6. You never know when a person will be ready to talk. Which is why you need to be ready to listen at all times . . .

For details, click on the What We Do link at the company's home web site and follow the pull down menu to Perspectives.

06 October 2003

analytical services. Health Coaches provide guidance to patients as they engage the health-care system. They help patients to be more informed, motivated, and prepared for productive dialog with their doctors. Available around the clock, Health Coaches are found to become "a trusted point of contact for individuals."

Mr. Bennett goes on to say, "We have developed a Health Coaching model that delivers the value of the traditional disease management programs and adds impact where they miss."

September 2003

Whatever its form, deductible, copayment, or tiered cost sharing, consumers are sharing an increasing portion of the costs of health care. But the researchers observe, "Although worker contributions and cost sharing continue to grow, the changes in 2003 were relatively modest given the continued weak job market and magnitude of premium increases."

Looking forward, the strategy most identified by employers to reduce future costs was disease management. About one quarter of employers appear to believe that disease management is "very effective in addressing cost increases." Other approaches identified include consumer-driven health plans, higher cost sharing, and tighter managed care networks. Overall, the researchers conclude that employers appear to be searching for solutions with no clear strategy dominating the landscape.

10 August 2003

that where you live plays a greater role in the course of treatment than your malady; wide disparities of treatments and costs around the country indicate that "medical practices are idiosyncratic rather than scientific." How else might one explain per-capita Medicare reimbursements of $3,074 and $9,033 in Lynchburg, Virginia, and McAllen, Texas, respectively?

Mr. Bennett comments, "The new idea is to make sure the family has access to the information that is used to make the rules." Such information will be disseminated by patients collaborating with trained nurses instead of managed-care agents of cost control." He goes further to suggest that fully informed consumers of health care would make decisions that, in the process of eliminating unwarranted regional variations, could lower Medicare expenditures by 30%. That is rather eye opening when considering the $35.5 trillion in unfunded liabilities.

21 July 2003

expectations develops that might not be warranted by the facts, and that heavy use of facilities and physicians is 'directly linked to a large supply of physicians and hospital beds.'

Physicians are driven to provide care without concern for the "public purse" and avoidance of lawsuits, while insurers are more concerned with costs. Megan Cooper of the Dartmouth Atlas of Healthcare states a different approach, commenting, "We tried to figure out how to empower patients." Mr. Dorschner reports, however, that it is difficult to get around the fear of litigation. The Dartmouth data does suggest that the $2,000 spent annually on Medicare lab tests in Miami is twice the national average and three times the level in Minneapolis.

Mr. Dorschner concludes by suggesting that patients in other areas of the country might not be to happy to learn of what amounts to a transfer of payments to those living in south Florida, especially when, as reported by the Medicare Payment Advisory Commission, 'geographical disparities didn't improve care and should perhaps be eliminated.'

07 July 2003

Decision-Making." Health Dialog's Collaborative Care Program covers both patients suffering chronic conditions and those facing critical "medical decisions related to conditions such as back pain, breast cancer, and prostate cancer." Participating plan members generally experience better doctor/patient communication and are more involved in the overall process. Health Dialog will also provided services that will help IBC 's efforts to reach out to its plan members with the greatest needs.

07 July 2003

or recommended course of action to a new doctor, and, if possible, seek an opinion from a teaching hospital. The ideal solution is to get three doctors in agreement.

As to education, make use of Internet sites such as YourSurgery.com, "which exhaustively details various procedures." And check out the Dartmouth Atlas project's Web site www.dartmouthatlas.org to see if a procedure might be overused in your area. Click on "Custom Reports" and then enter your state at "Community Profile Reports." Medical School libraries are another source of up-to-date information on procedures and outcomes.

In the final analysis, any decision to undergo surgery "should be your informed decision."

28 May 2003

members with personal health coaches." Plan members now have around-the-clock access to "licensed, health care professionals, including registered nurses, dietitians and respiratory therapists who can offer relevant on-the-spot information on health issues and help members with health-related decisions."

15 May 2003

some patients are slow to accept the pre-emptive intervention of coaches, evidence is accumulating that they are "warming up to disease management." Employers are benefiting as well as patients; Watson Wyatt estimates that employers are getting back between $1.50 and $2.00 for every dollar spent. Even so, Hewitt Associates reports that only 37 percent of employers are offering disease-management programs.

07 May 2003

and preferences into the decision-making process, and prepare to engage their doctors in a more meaningful way. Mr. George Bennett, CEO of Health Dialog, believes the Health Coaches to be "the core strength of our organization."

Health Dialog's Collaborative Care program has two elements. Chronic Condition Management covers five chronic conditions -- asthma, diabetes, congestive heart failure, chronic obstructive pulmonary disease, and coronary artery disease -- and the co-morbid conditions of renal failure, hypertension, and depression. Decision Support services range from significant medical conditions such as back pain and prostrate and breast cancer to minor events like bee stings. Patients can also pose general health questions such as screening for possible drug interactions.

28 April 2003

The Tip Sheet -- Health / by Julie Halpert

Terre Haute, Indiana.

Ms. Halpert suggests seeking information as is available from The Foundation for Informed Medical Decision Making at www.fimdm.org who partners with Health Dialog to provide "support through a team of nurses." Through www.collaborativecare.net, you can link to over 20 other resources. She also recommends the American Medical Association (www.ama-assn.org), the National Institutes of Health (www.nih.gov), the American Cancer Society (www.cancer.org), and the Centers for Disease Control (www.cdc.gov). Finally, she suggests making a list of questions to be asked, don't hesitate to get a second opinion, and even have "a trusted relative or friend" assist you, even accompanying you at your doctor's visits.

21 April 2003

BUSINESSNEWS; By Jennifer Heldt Powell

conditions. And getting into the market is a costly proposition.

Ms Powell reports that Health Dialog's revenues have jumped from $3 million in 1999 to about $50 million this year, with the prospect of reaching $100 million next year. George Bennett, Health Dialog's chief executive, highlights a study suggesting his company saves its customers $2 for every $1 they pay Health Dialog. He goes on to comment that one of Health Dialog's advantages is its ability to work on multiple conditions simultaneously.

21 April 2003

YOUR HEALTH / by Amy Dockser Marcus

10 April 2003

THE INFORMED PATIENT / By Laura Landro

for documenting appropriate preventative care. Such emphasis contrasts with the traditional health-care model whereby doctors are rewarded for the number of patients they see, not on the quality of care they administer. Patients will be called upon to take more responsibility for managing their long-term care needs. It is expected that the increased up-front costs of such a program will more than be made up in "fewer absentees and serious medical complications."

16 March 2003

Press Release / by Alwyn Cassil and Richard Sorian

It is noteworthy that half of the 78 million Americans living with chronic-care conditions, such as diabetes, heart disease, and asthma, sought out no health information. Commenting on the results, Ron Pollack, executive director of Families USA, said "most health-care consumers could benefit from information, counseling and assistance through direct person-to-person contact." And Helen Darling, president of the Washington Business Group on Health, states, "This important study raises many challenges for employers who want to support their employees, retirees and family members with information and decision-support tools."

18 February 2003

Part 1 of 2: Volume 138; number 4; pages 273 - 287 / by Elliott S. Fisher, MD, MPH; David E. Wennberg, MD, MPH, et el.

Part 2 of 2: Volume 138; number 4; pages 288 - 299 / by Elliott S. Fisher, MD, MPH; David E. Wennberg, MD, MPH, et el.

http://www.annals.org/issues/v138n4/full/200302180-00006.html

evidence that the higher spending regions provide "improved access to care, better quality care, or better health outcomes or satisfaction." As played out more in part 2, the researchers "found no evidence to suggest that the pattern of practice observed in higher-spending regions led to improved survival, slower decline in functional status, or improved satisfaction with care." The authors note, "These findings call into question the notion that additional growth in health care spending is primarily driven by advances in science and technology and that spending more will inevitably result in improved quality of care." In other words, the authors state that policy-makers' assumptions that "any constraints on growth are likely to be harmful" are brought into question. They underscore "the need to determine how to safely reduce spending levels" so as to achieve the 30% savings, thus freeing up "resources to fund important new benefits."

Requests for single reprints may be obtained by contacting Elliott S. Fisher, MD, MPH, Strasenburgh Hall, HB 7251, Dartmouth Medical School, Hanover, NH 03755 or by email at elliott.s.fisher@dartmouth.edu.

13 February 2003

when it is best to use a PSA test. For additional information on PSA testing, you might click on this related PBS NewsHour Health Unit link. Another resource available from PBS-related links is a videotape titled 'Is A PSA Test Right For You?' that is put together by The Foundation for Informed Medical Decision Making. The latest edition of the videotape can be obtained by visiting http://www.fimdm.org/psa_tape.php or http://www.collaborativecare.net.

February 2003

But how to change the system so as doctors might be willing to take more time educating and involving patients in a shared decision making environment. Dr. Wennberg's preferred solution is for buyers of health care to more carefully choose providers who embrace "proven strategies" and who are willing to submit to oversight. Buyers should, in turn, be willing to change their payment protocols so as to not punish doctors financially who would experience a drop off in procedures.

Dr. Wennberg and his colleagues at Dartmouth's Center for The Evaluative Clinical Sciences have proposed a national demonstration project for Medicare. He is also "hopeful that the recent movement among private-sector payers to make quality part of their contracting processes will grow."

February 2003

http://www.consumerreports.org/static/0302prs0.html

"encourage consumer involvement in making the decision about testing." John Wennberg, M.D., director of the Center for Evaluative Clinical Sciences at Dartmouth Medical School and cofounder of the Foundation for Informed Medical Decision Making, comments, "A patient's preferences are always important, but in equivocal or controversial circumstances they should play the pivotal role." Dr. Wennberg's Foundation has produced a 30-minute videotape available for $19.95 at www.collaborativecare.net/psadecision that will help men make the "decision about whether to undergo prostate-cancer screening."

January/February 2003

http://www.theatlantic.com/issues/2003/01/brownlee.htm

possible," it's possible to get too much, or excessive, care. Estimates by the Center suggest that upwards of 20 to 30 percent of health-care spending does "absolutely nothing" for our nation's well being. Wennberg and his researchers have shown that a major reason Miami residents pay $50,000 more than residents of Minneapolis over the balance of their lives after age 65 is a higher level of hospital resources and greater numbers of doctors.

Reducing "supply-sensitive" health care and helping doctors to deliver "evidenced-based" medicine are two broad themes Ms. Brownlee suggests will help reform American's health-care system.

11 February 2003

http://www.healthdialog.com/definity.pdf

"identify their particular concerns, values, and preferences; they educate members about their treatment alternatives, and the pros and cons of each; and they coach members on how to communicate better with their doctors." They also help transcend the geographical bias that is evidenced in health care protocols to help each patient get the standard of care most appropriate for their circumstances.

Definity and Health Dialog have also partnered in an outreach program to "proactively identify and engage members" who can be helped in a preventative manner. Through predictive modeling, claims-based detection, and the monitoring of inbound calls, the new program will seek to identify patients who might have poorly controlled chronic conditions or other significant medical conditions.

10 February 2003

http://www.healthdialog.com/lifelink.pdf

who will help patients to manage their condition "in accordance with their physician's treatment plan."

LifeLink will handle the technological and administrative aspects of providing a "steady stream of biometric and symptom data" to the Health Coaches who "will use this information to better focus the timing and content of interventions for members."

05 February 2003

http://www.globalprovince.com/letters.htm

coaching conversations is new thinking."

The concept of coaching is moving beyond the boardroom. "Nowhere is this more evident than in health coaching, which is now blossoming throughout America." Healthcare providers are employing companies to "prompt (their members) to take care of themselves in a more rational way." While some are capable of reducing health costs by 5% or 10%, Health Dialog has, through the "principles of Shared Decision Making," been able to achieve savings up to 20% while improving members' health.

03 February 2003

article available via online subscription at www.wsj.com

> Only 40% reported bonuses were based on "quality" scores; less than 25% linked "quality" with better contracts, and

> One-half incorporated none of seven different data-systems features asked about.

"Money, technology, and culture" are the culprits holding back change. But Mr. Winslow reports, "There are signs that barriers are beginning to soften." He reports that a new survey by the Center for Studying Health Systems Change (www.hschange.org) shows over half of physicians are affected by guidelines and two-thirds thought it was good for their practice and their patients.

and costs reduced "with diseases as diverse as diabetes and heart failure." In a way, "We need to help patients take far more responsibility for their own health, much like the level of responsibility we each accept for planning our retirement and managing our financial wellbeing. Additionally, we need to organize health-care providers into teams to offer patients the information they need, as well as the right treatment at the right time."

The author concludes by calling for a "coalition of providers, interested parties and payers" to come together and "develop prospective health-care models" that would outline "the best-practice care for common, chronic diseases such as diabetes and cardiovascular disease."

standard for the competition and the doctors." Dr. Carolyn Clancy, acting director of the federal Agency for Healthcare Research and Quality, adds, "The more stakeholders are engaged in evidence-based medicine, the better." Dr. Clancy went on to reveal that more than 500,000 people access the National Guidelines Clearinghouse, a web site sponsored by her agency in conjunction with the American Medical Association and the American Association of Health Plans. It can be found at http://www.guideline.gov/index.asp.

14 October 2002

http://www.businessweek.com/@@cxNnnYUQAC1BWRAA/magazine/content/02_41/b3803103.htm

free registration may be required to access this article

"approach 30% next year."

Insurers are stepping up their efforts to deliver Disease Management services. And smaller firms, such as CorSolutions Medical, "are popping up to provide the expertise and staffing required."

Providers will have to implement programs with care; doctors might be concerned about being circumvented, and patients may have privacy concerns. And though "there are no large-scale national studies "demonstrating the bottom-line benefits, General Motor's director for Health-Plan Strategy, Bruce E. Bradley, states, "We are not able to prove [that the idea saves money], but we believe it does."

07 October 2002

http://www.twincities.com/mld/twincities/living/health/5148653.htm

sites at Dartmouth College and the Mayo Clinic. As part of his work with the University of Minnesota, Mr. Schwitzer "analyzed five of the leading Web sites that offer patients multiple treatment-decision support tools."

The five sites include:

> The Mayo Clinics' new Health Decision Guides at www.mayoclinic.com

> The Database of Individual Patient Experiences at www.dipex.org

> NexCura's "treatment profilers" site at www.nexcura.com

> The Foundation for Informed Medical Decision Making and Health Dialog's decision-making tools at www.healthdialog.com, and

> University of Wisconsin-based Comprehensive Health Enhancement Support System at http://chess.chsra.wisc.edu/Chess/chessmod.htm

http://www.businessweek.com/@@rLUFroUQ*yxBWRAA/magazine/content/02_34/b3796654.htm

free registration may be required to access article

Carol Cropper chronicles in this BusinessWeek online article the evolution of events that have come together in recent years to foster an environment of closer patient-doctor interactions and better health-care outcomes.

At the same time that health-care consumers were facing a blistering array of new drugs and procedures, they've had to survive the maze of managed care. Their awareness of a need to make choices has also been raised by the efforts of drug makers to market their drugs directly to the consumer and health-care plans looking "to shift more costs to employees."

Meanwhile, expanding computer power and, particularly, the build out of the Internet has played a key role in facilitating the ability to get information to consumers.

14 May 2002

http://www.healthdialog.com/cigna.pdf

07 January 2002

www.globalprovince.com/letters2002.htm

Health Dialog, organized as an outgrowth of work done at the Dartmouth Atlas and the Foundation for Informed Decision-Making, is, "The most interesting commercial proponent of patient self-involvement today." Together, they're proponents of the belief "that informed people will pick rational treatments." In the vein of "an ounce of prevention, . . . the real place to spend big dollars is preventive medicine," particularly as it pertains to chronic care.

Businesses need to take heed. They "need to understand the true size of their health-related costs and to engage in broad health planning that deals with issues not on the agenda of the nation's healthcare providers."

02 January 2002

www.healthdialog.com/news01.htm

Health Dialog and CorSolutions announced today that, in collaboration with Highmark Blue Cross Blue Shield, they have implemented "the nation's first integrated condition management program, Blues On Call." Blues On Call "is an integrated Shared Decision Making program" covering more than 20 health conditions that will help Highmark's "members work with their physicians" to more effectively manage their health care, particularly those "who are managing multiple chronic

conditions." With this new program, Highmark has moved its 50,000 members into "one comprehensive program, thus eliminating the need to manage relationships with multiple disease management companies. The plans "patient-centered" approach reflects the move away from the healthcare industry's "unpopular traditional managed care practices," according to George Bennett, Chief Executive Officer of Health Dialog.

May 2001

www.managedcaremag.com/archives/0105/0105.accredit_dm.html

When two agencies, the National Committee for Quality Assurance and the American Accreditation HealthCare Commission, vying for a leadership role in establishing accreditation standards complete their work, "pioneers in the disease management (DM) business" may find the process of winning new contracts a bit easier. Industry insiders see standardization leading to widespread acceptance. It should also help differentiate between companies who simply seek certification in 'communications work' and those desiring 'full accreditation.' Companies will be looking to see if the evolving standards "meet or exceed their own internal inspection standards." Linda Ruhl, director of quality management of Pittsburgh-based Highmark Blue Cross Blue Shield, expects the key to the

worth of accreditation as being its ability to potentially eliminate some oversight, though the provider will "have ultimate accountability." Mr. Carroll reports that, "Like many other managed care organizations, Highmark had contracted for disease management services with a variety of DM companies, each covering a specific ailment." But Highmark has decided to roll "its alliances into one contract shared by two companies -- Health Dialog and CorSolutions." He goes on to report that Highmark sees the new relationship as a "simple way to deliver programs for patients who are likely to suffer from a variety of comorbidities -- a common complaint about the limitations of many DM programs."

Many medical decisions are rather straightforward, but, as highlighted by Christopher Snowbeck, many "involve value judgments that differ from person to person." To help patients better make these value decisions, Highmark Blue Cross Blue Shield plans to introduce a new patient-education program marketed by Health Dialog, Inc.

Mr. George Bennett, CEO of Health Dialog, comments, "What we want to do is educate people that there is variation and if patients, in active dialogue with their doctor, will understand the various risks and benefits of the options and impose their own values on the treatment, they will get health care more compatible with what they want."

The program's materials are produced by the Foundation for Informed Medical Decision Making (FIMDM), a non-profit physician group. Patients receive free video tapes and literature as well as access to "nurse coaches." While being able to make patient referrals, a point of potential contention for doctors, "nurse coaches" are primarily interested in educating patients. In particular, they are concerned with helping identify

the most critical questions for consideration. Mr. Bennett says there is evidence that time-constrained doctors come to embrace the program as it compliments their efforts to "fully present complicated issues to patients." Health care plans seem to be embracing the outreach as it boosts patient satisfaction while at the same time reducing demands on system resources.

The need for such patient interaction was identified by work done by Drs. John E. Wennberg and Albert E. Mulley, co-directors of FIMDM, that documented that the standard of care a patient might receive was, in part, dependent simply upon where a patient lived. In the early 1960s, Dr. Wennberg's work questioned why the rates of hysterectomies among women age 75 were 70% and 25% in two nearby towns. He found the difference lied in training and habits. Clearly, there was room for an educated patient, particularly at important value-oriented crossroads in the decision-making process.

Highmark is expected to roll out the new program in early 2000.

Mr. Lancaster chronicles George Bennett's journey from Boston strategist, to serial entrepreneur, to founder of Health Dialog. A desire to help patients navigate their way through the health-care system combined with a penchant for volunteer work led Mr. Bennett to form a business venture that created meaningful benefits to patients.

Mr. Bennett was no newcomer to starting one's own business. Having started his career with Boston Consulting Group, he co-founded Bain & Co. in 1976 along with some colleagues; he then started another firm that was sold to what is a now Deloitte & Touche. In 1986, he founded Symmetrix, a Boston-based management and technology consulting company. He then sold most of his Symmetrix holdings and started Fairview Medical Services. The thrust of Fairview's activities were to revolve around software that Mr. Bennett

had helped develop designed to help process paperwork through multiple departments. But his fate was turned when coming to know Dr. Albert Mulley while doing volunteer work at Trinity Church in Boston.

Dr. Mulley, a physician at Massachusetts General Hospital, had been conducting research with John Wennberg of Dartmouth through the Foundation for Informed Decision-Making. Together, they'd built "substantial evidence that there's a huge variation in how doctors interpret their science through their own values and preferences." Mr. Bennett "couldn't resist getting involved" in helping the process of enabling patients become a part of the decision-making process. As stated by Mr. Bennett, "It was one of life's strange twists, where they had something that was morally right, medically right, politically right and it saved money."

In this Wall Street Journal article, Carol Gentry weaves together the journeys of two medical groups that through fortune and opportunity came together to provide patients with a way to improve their experiences with the nation's medical system.

In the late 1960s, Dr. John E. Wennberg, a professor at Dartmouth Medical School, set out to discover what appeared to be a disparity of treatments between groups of women living just 20 miles apart. He was joined in the 1980s by Dr. Albert G. Mulley, an associate professor at Harvard Medical School and chief of general internal medicine at Massachusetts General Hospital. Together, they formed the Foundation for Informed Medical Decision-Making in 1989.

Through their work, they showed there were differences in treatments based solely on a patient's geographic location and their doctor's schooling. In a quest to provide sound information to patients in order that they might be better informed and become a more integral part of the decision-making process, Dr. Wennberg and Mulley spent $6 million and ten years developing video tapes that "provide clinically accurate but easy-to-understand medical information and testimonials from patients who have chosen different paths."

Meanwhile, Mr. George Bennett, having successfully founded several Boston-area consulting companies had founded Fairview Medical Services Corp. with $6.8 million from wealthy investors, the American Hospital Association, and the British United Provident Association. Mr. Bennett founded Fairview "to promote patient education."

The doctors had spent nine years trying to bring their product to patients with minimal success. But times were changing, and when the foundation approached Mr. Bennett, he set up Health Dialog, Inc. as a subsidiary of Fairview Medical. In May 1997, the Foundation and Fairview agreed to an arrangement providing distribution rights to a three-tier program, including a handbook, a nurse-staffed support line, and the treatment decision videos.

The benefits to patients are showing to be substantial. Patients better understand their options and are able to ask better questions. Through animation, the videos are able to go beyond what can be conveyed in a simple discussion. It has been shown that the time from diagnosis to treatment is reduced. And as Mr. Bennett comments, "it's not only the right thing to do but also a good business decision because it raises patient satisfaction and employee loyalty."

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