Life Sciences

Medicare & Reimbursement Advisor Weekly, October 9th, 2009

Medicare & Reimbursement Advisor Weekly, October 9, 2009

Inside:

Employer medical director focuses on wellness, dollars saved, productivity

Formulary changes to consider in emerging trend



Employer medical director focuses on wellness, dollars saved, productivity

Larry Catlett, MD, who serves as medical director for Cianbro, one of the East Coast’s largest civil and heavy industrial construction companies (2,500 employees), has in recent years shifted focus to wellness initiatives by trying to convince his employer clients to pay $18 for a preventive wellness program per employee versus $1,000 in sick time. Catlett has also focused on studying the costs of unhealthy risks and pain on the job and their potential effect on employers. His company’s work is influencing other employers, and the data gained from these studies may be useful as insurers, states, and the federal government look to apply best practices to health policy. “We look at dollars saved or not spent,” Catlett says. His private company, Occupational Medical Consulting, has sent data for each Cianbro employee to the company’s insurer, CIGNA, about the cost risks of overweight, high blood pressure, depression, and stress, and how these conditions lead to unproductive work. Employees have been placed into categories; five or more risks land them in the highest cost-risk grouping. Interventions take place on-site to help employees manage or reduce risky behavior. The goal is to reduce the number of high and medium cost-risk employees and work with employees who are at risk for unnecessary overutilization of medical services, tests, and prescriptions. “I hope this program will start to give employers cost data that they can use to meet their goals.”

Educational interests

Managed markets focused on the employer segment can learn from Catlett’s focus on wellness and prevention, and on how medical directors in his position acquire knowledge for medical decisions and influence. Catlett’s preferred resources include:

  • Top resource: American College of Occupational and Environmental Medicine
  • Meetings: New England College of Occupational and Environmental Medicine annual meeting
  • Publications: Journal of Occupational and Environmental Medicine
  • Wellness resources: Major interest area/focus
  • Wellness Councils of America (welcoa.org)
  • Web: Reputable sites only (such as JNC 7 for hypertension guidelines)



Formulary changes to consider in emerging trend

In a study to be published later this year, hospitals interviewed have adjusted their formularies or discharge protocols as a result of Medicare’s readmission focus (details in Survey snapshot, left sidebar). Some of the hospitals making formulary adjustments have already moved to more open or less restrictive formularies or are considering adjustments to reduce medication changes pre-discharge for high-risk, chronically ill patients in the major categories, such as congestive heart failure and acute coronary syndrome. The emerging trend may ultimately not evolve; however, with Medicare possibly moving to a time when they don’t pay hospitals for readmissions for certain diseases (see Fig- ure 1 below of diseases most susceptible to readmission), the strategic thinking here is to make institutional changes that could reduce readmission risk. The complete findings of this study will be published later. From a managed markets perspective, think of this trend as something to follow and possibly as a benefit to typically restricted products or those that could help patients stay out of the hospital with an effective adherence program.