Population Health Insider, January 2009


Workplace wellness stretches across globe

Consumer-driven plans creating cost-conscious consumers

More than one in five U.S. adults at lower activation levels

High demand, increased procedures drive compensation

DMAA’s report expands further into population health

Workplace wellness stretches across globe

Businesses devise programs for myriad reasons

Unlike U.S. companies, which implement wellness programs in hopes of lowering healthcare costs and improving employee health, foreign companies are creating workplace wellness companies as a way to stay com- petitive in the marketplace, increase productivity, and improve morale.

Wellness programs have stretched beyond the employer-based U.S. healthcare system as foreign businesses look for ways to separate themselves from competitors.

Wellness programs’ business objectives vary by loca- tion. Europeans seek better work force morale, whereas Asian and African companies seek reduced absences. (See Figure 1 on p. 4.)

A closer example is Canada, which isn’t as interested with the financial benefit of wellness. “A lot of Canadian organizations see wellness as an opportunity to demonstrate that they are an employer of choice—a good place to work,” says Barry Hall, principal at Boston-based HR and benefits consulting firm Buck Consultants, an ACS company.

Hall recently released results from an October 2008 survey of workplaces called Working Well: A Global Survey of Health Promotion and Workplace Wellness Strategies. The second annual survey analyzed responses from more than 600 organizations in 25 countries representing more than 10 million employees. Sixty percent of organizations surveyed said they have a wellness strategy, which is a jump from 49% in 2007.

Although more companies outside the United States have implemented wellness programs, North America is still home to most of them. Eighty-two percent of North American companies that responded to the survey said they have wellness programs. Hall says the U.S. employer-based insurance system means that companies see the direct bottom-line effect of wellness programs.

“I think that’s the one thing that boosted the U.S. above the rest of the world,” Hall says.

After the United States, the next highest percentages of companies with wellness programs are Africa with 45% and Europe with 44%. Hall says the vast majority of African companies that responded are based in South Africa, which has seen a boom in workplace wellness programs.

Whether programs continue to gain popularity in other countries may largely depend on the United States.

“I think if we can really demonstrate to a deeper level that the programs or certain aspects of them are effective in the U.S., that will really boost the adoption in other parts of the world,” Hall says.

The top wellness programs in Asia and Africa are biometric health screenings, which have not caught on in the United States. In Europe, employers have im-plemented gym and fitness club member discounts. (See Figure 2 on p. 5.)

The fastest-growing wellness initiatives are technology-driven tools such as Web portals, online programs, and personal health records. Other programs gaining global popularity are healthy vending machine food choices, employee health screenings, and workplace health competitions.

Workplace wellness competitions in such areas as physician activity, weight loss, and smoking cessation could grow in popularity with the emergence of TV shows such as The Biggest Loser. These programs will grow by more than 100% outside of North American during the next three years, Buck Consultants predicts.

Most don’t gauge ROI

Although U.S. companies implement wellness programs in hopes of reducing costs, Buck found only 16% of U.S. respondents claimed the programs reduced healthcare costs, with an average reduction of two to five percentage points per year. This lack of savings is largely because U.S. companies are not measuring the programs’ return on investment (ROI). For international companies, 40%–60% of organizations are not measuring the financial effect of the programs.

Buck Consultants points to a few reasons for this lack of information: Metrics to figure out productivity and healthcare costs are expensive and time-intensive, employers don’t collect data such as absentee rates that could help them calculate ROI, and businesses don’t usually gauge employee morale and satisfaction with wellness programs.

Although most companies don’t analyze workplace wellness programs’ costs and financial benefits, Hall says justifying the investment of wellness programs is at the top of the list for most companies.

“The fact that organizations continue to offer wellness programs, despite these gaps, suggests that even if program effectiveness proves difficult to quantify at this point, the intuitive value of offering these programs remains a major motivator for employers. To some extent, employers also may recognize that health and behavior changes effected by wellness programs are likely to take multiple years to fully manifest themselves as measureable savings,” Buck Consultants wrote.

“Mercer is seeing greater interest in measurement and evaluation of health management and wellness programs,” says Sander Domaszewicz, a principal at Mercer’s Newport Beach, CA, office and the consulting firm’s national health consumerism leader. “While the financial or ROI picture is a key component of program measurement, tracking other indicators like participation, satisfaction, and clinical or functional improvements can also help to show a program’s broader value.”

Incentives less popular elsewhere

Incentives for employees who participate in wellness programs have increased by 45% since Buck’s 2007 survey. This is consistent with 2007 findings showing that a large number of U.S. employers planned to implement incentives. More than two-thirds of U.S. respondents with wellness programs offer incentives, which easily outdistances other parts of the world. (See Figure 3 on p. 5.)

U.S. respondents spent an average of $145 per employee per year on wellness incentive rewards, which increased from an average of $100 in 2007. Twelve percent of U.S. respondents spent more than $500 per employee per year on incentives in 2008. (See Figure 4 on p. 5.)

The most popular activities for which employees receive incentives in the United States are health risk appraisals and workplace health challenges such as weight loss. (See Figure 5 on p. 6.) Businesses are not giving incentives for activities such as biometric health screenings, regular preventive care examinations, and adhering to disease management programs, but many said they plan to reward employees for those activities in the next three years.

One incentive that remains low on employers’ lists is rewards for employees who achieve or maintain measurable health status results. The 2008 survey found 16% of employers offer incentives for that activity, which was an increase of only one percentage point from 2007.

A major barrier for many employers is that laws such as the Americans with Disabilities Act make measuring health status indicators (e.g., body mass index and weight) a touchy—and potentially costly—topic. “This is not surprising, because this type of incentive reward introduces additional challenges, from regulatory restrictions to potential employee relations issues regarding intrusion into confidential matters involving their health,” wrote Buck Consultants.

The largest number of U.S. employers with wellness programs that responded to the survey offer gifts or merchandise, raffles or drawings, and free or low-cost preventive health services. The incentives that have seen the most growth are reducing healthcare premiums and making cash contributions to healthcare-related spending accounts, which shows a growing trend toward aligning rewards with healthcare benefits. (See Figure 6 on p. 6.)

“In this way, employers seek to emphasize a strong connection between healthy living and their ultimate objective of reducing the cost of healthcare,” wrote Buck Consultants.

Most U.S. employers believe their incentives are moderately effective, but nearly one-quarter said they were not sure of their effectiveness. (See Figure 7 on p. 7.) Buck Consultants suggests this could be because incentive systems are still new and lack defined best practices.

Incentives are not nearly as popular in other countries, but they have shown growth. Seventeen percent of respondents outside the United States say they offer at least one wellness-related reward.

Hall says other cultures find financial incentives crass. “The U.S. is just more financially focused, but I think also, from a cultural perspective, it’s more culturally acceptable and probably more common in the U.S. to motivate people with direct incentives,” he says.

Overall, 19% of respondents rated their incentive rewards as “extremely effective” or “significantly effective” at changing employee behavior, which was higher than 2007’s 16%. Buck Consultants suggests this increase shows employers believe that wellness programs can change behaviors.


Employers and their healthcare partners use a wide variety of tactics to promote wellness efforts, with Web portal or intranet presence, posters and flyers, and newsletters and articles topping the list. (See Figure 8 on p. 7.)

The largest jump in 2008 was in Web portal/intranet and workplace challenges, whereas the biggest drops were in health fairs and home mailings. Less than half of respondents said they mail wellness materials to their employees’ homes, which could be problematic if a spouse or family member is the family’s healthcare decision-maker. Without reaching out to that family member, the health information is not reaching the right person.

Buck expects employers and health plans will implement more personalized messaging. About half of those with wellness programs reported they did not have personalized messages; this shows an opportunity to move from one-size-fits-all messaging to tailored and more effective communication, wrote Buck Consultants. (See Figure 9 on p. 7.)

Different cultures

Nearly half of companies that responded to the survey employ workers in multiple countries. Given the wide variety of cultural norms in the global community, Hall says companies must understand the differences when developing wellness programs. For example, U.S. employees may respond to incentives, but employees in other countries may take offense.

Among multinational employers, one-third said they have a global wellness strategy, whereas more than half claimed they did not have global oversight for their wellness strategies. The remainder of respondents said they had no global coordination but left it to regional control.

“Given this degree of local latitude, it may be more difficult for a multinational employer to garner and/or drive consistent results,” Buck Consultants stated.

“While it’s sometimes not a small undertaking, there can be a strong value proposition for crafting global health initiatives,” Domaszewicz says. “Some key drivers that lead companies to address health globally include ‘one company’ philosophies, extending competitive advantage, accelerating work force mobility, a desire for shared best practices, and the promise of tapping into global leverage.”

Regardless of the direct reason for wellness programs, employers are viewing them as a way to show employees that they care about their health. For employers in other parts of the world, the programs are a way to make employees feel a greater connection to their employers.

“Frankly, that’s the competitive boost for any employer to have: to have a really engaged, motivated work force. If wellness is even a piece of that formula, I think a lot of employers would really like to figure out how to leverage that,” Hall says.

Employee survey

Consumer-driven plans creating cost-conscious consumers

But many CDHP members are unaware of price, quality information

Consumer-directed health plan (CDHP) enrollees are more cost-conscious, but for many it’s not their insurers or employers that are educating them about healthcare. Instead, they are finding healthcare cost and quality information on their own.

The Employee Benefit Research Institute’s (EBRI) 2008 EBRI Consumer Engagement in Health Care Survey found that CDHPs continue to grow, but the movement has been slow. An estimated 9.8 million adults, or 3% of the total number enrolled in health insurance plans, were enrolled in CDHPs in 2008, which was an increase from 2% in 2007.

Those who question CDHPs point to the relatively small percentages as proof that they’re not catching on, but Paul Fronstin, director of the EBRI health research and education program in Washington, DC, says CDHPs don’t enjoy lofty numbers simply because they have not been around that long.

Employers began offering health reimbursement accounts (HRA) in 2001 and health savings accounts (HSA) in 2005. Large employers didn’t start providing HSAs until 2006. By 2007, 7% of employers with 10–499 employees and 11% of employers with 500 or more employees offered HRA- or HSA-eligible plans, Fronstin says.

Fronstin notes that although CDHP penetration is still relatively low, HMOs also took time to gain momentum. “Going from zero to that number in such a short period of time is actually significant, and that is how markets grow over time,” he says.

The survey found that whether members understood CDHPs depended on the individual’s plan type. Fifty-nine percent of CDHP members were “extremely or very familiar” with CDHPs, compared to only 10% of high-deductible health plan (HDHP) members and 8% of traditional plans. (See Figure 10 on p. 11.)

The theory behind CDHPs is that transferring more costs to members will lead them to become better healthcare consumers and take better care of themselves. That premise appears to be well founded. Those in CDHPs and HDHPs exhibited more cost-conscious behavior in their healthcare decision-making than those in traditional health insurance plans, according to EBRI.

CDHP and traditional enrollees were more likely than HDHP enrollees to report that they had used information about quality of doctors in their healthcare decision-making, and CDHP members were more likely to find information on the cost and quality of doctors from sources other than their health plan.

Those in CDHPs and HDHPs were more likely to consider costs when making healthcare decisions, and they were also more likely to ask their doctor to recommend a less costly prescription drug. When comparing cost and quality information, respondents said they received more health quality information for their healthcare decision-making.

Although CDHP members showed more interest in obtaining information about cost and quality, EBRI reported that more respondents in traditional plans said their health insurer provided cost and quality information than those in CDHPs and HDHPs. (See Figure 11 on p. 11.)

Fronstin says those findings could be misleading. CDHP respondents were healthier, more likely to exercise, and less likely to smoke. Because CDHP members are healthier, they may not have as much experience with the healthcare system. This means CDHP members will need less information and may not even know it exists, he adds.

Another potential problem for health plans is that many CDHP members don’t realize that preventive screenings are often exempt from a deductible (the health plan picks up the full cost). The idea behind this growing trend for procedures such as mammograms and colonoscopies is that if members do not have to pay for the preventive services, they are more likely to maintain regular screenings.

However, 56% of adults in CDHPs reported that their deductible applied to all medical care. Worse, 71% of those in CDHPs with coverage through the individual market said their deductible applied to all healthcare services. (See Figure 12 on p. 11.)

Fronstin says these findings could show that people in CDHPs and HDHPs do not realize preventive services are excluded from deductibles, which is a result of health insurers and employers not providing adequate education about the plans. “[That lack of education] has some serious implications, because if they don’t know that the plan covers preventive services, they are not going to get preventive services and that defeats the purpose of providing rich preventive benefits,” he says.

Kathy Campbell, director of CDHPs at Aetna in Hartford, CT, says covering preventive care, including waiving copays for certain prescriptions, pays off in the long run.

“We cover preventive care at 100%. We strongly encourage that because that is a short-term cost that has longer-term benefit,” says Campbell.

Another concern about HDHPs and CDHPs is that members may delay care because of the added cost burden. The survey found that is not the case when comparing CDHPs with traditional insurance, “mostly because more traditional plan enrollees reported access issues due to costs.” HDHP enrollees, on the other hand, were more likely to claim they delayed or avoided healthcare services because of costs. (See Figure 13 on p. 12.)

Getting members and employees the necessary healthcare information is what employers and health plans hope to accomplish with CDHPs, but the study shows that implementation has been lacking. One company trying to change that is Compass Professional Health Services (PHS) in Dallas, whose goal is to lower employer and individual healthcare costs while improving quality.

The company does this through collecting myriad healthcare information on price and quality and provid-ing it to consumers and employers so they can make wiser healthcare decisions. That information is coupled with the company’s Health Pros, nurse case managers and experienced healthcare administrators who provide expertise and guidance for individuals to make the best healthcare decisions.

Comparable healthcare costs are not available to average consumers, and they need the help of healthcare experts, says Scott Schoenvogel, CEO of Compass PHS.

“It’s very difficult to put all this information into the hands of the healthcare consumer and then expect them to use that to lower costs in healthcare,” Schoenvogel says. “That’s where our support teams and advocates come in and do that kind of work to make those changes happen.”

HSAs and HRAs

Enrollment in HSA- and HRA-eligible plans is growing, but the market penetration is still relatively low and most people are unfamiliar with them, according to the survey.

Those who were enrolled in plans with HSAs but did not open a savings account pointed to financial difficulties and confusion as reasons why they were not interested in HSAs.

Twenty-eight percent said they did not have the money to fund the account, 22% reported the tax benefits were not attractive enough, 17% thought it was too much trouble to open and manage the account, and 10% suggested that HSAs were too complex or beyond their understanding.

Difficulties with individual market

Fronstin says most of those in HDHPs are in the individual insurance market: 24% in HDHPs, 16% in CDHPs, and 7% in traditional insurance. Having so many individual insurance members in HDHPs affects those plans.

“I think that’s going to be a constant struggle with HDHPs,” says Fronstin. “When you think about that group, they are disproportionately people in the individual market, which means they are disproportionately people who are unhealthy and paying a lot of out of pocket and probably a lot for their premiums because of their health status. It’s going to be very difficult to satisfy that group without changing the plan structure.”

Positives and negatives

A negative reported in the survey was that those in CDHPs and HDHPs were less likely than those in traditional plans to recommend their health plan to a friend or coworker and less likely to stay with their current health plan if given the opportunity to switch.

Fronstin says dissatisfaction with HDHPs and CDHPs could be because the plans are not as established as traditional plans such as PPOs and HMOs; CDHPs are so new that people might find them confusing. “Your confusion level is going to drive your satisfaction level,” he says.

On the plus side, there were nearly across-the-board increases between 2006 and 2007 in the percentage of CDHP enrollees who said:

  • Their health plan was easy to understand
  • The plan encourages healthier lifestyles
  • The plan provides information to help choose providers
  • The plan protects members against expensive illnesses

Other survey findings included that people choose their health plans for different reasons, CDHP members make more money, HDHP members are not satisfied, and respondents supported cost-sharing. These findings are detailed below:

  • CDHP and HDHP members were more apt to delay care or put off filling a prescription than those in traditional plans. (See Figure 14 on p. 12.)
  • When asked why they chose their health plan, nearly half of CDHP members pointed to lower premium costs, whereas nearly half cited cost savings and the ability to roll over HSA funds. The most popular choice for those in traditional plans and HDHPs was the physicians and hospitals in the network. (See Figure 15 on p. 13.)
  • Those in CDHPs were wealthier than those in traditional plans. Forty percent of CDHP members were in households with incomes of $100,000 or more in 2008, an increase from 22% in 2005. Only 14% of adults with CDHPs lived in households earning less than $50,000, a drop from 33% in 2005. There was little change in income distribution of adults in traditional plans from 2005. (See Figure 16 on p. 13.)
  • The survey found no difference between the level of satisfaction with quality of care when comparing CDHP enrollees with traditional insurance. However, those with HDHPs were not satisfied. (See Figure 17 on p. 14.) “Differences in out-of-pocket costs may explain a significant portion of the difference in overall satisfaction rates between traditional plans, HDHP, and CDHP enrollees,” EBRI wrote.
  • Those in CDHPs were more likely than those with traditional coverage to have a choice of health plan, which differs from 2005 and 2006, when traditional coverage members were more likely to have more choice. This is a result of more large employers entering the CDHP market and traditional plans consolidating options, says Fronstin.
  • Survey respondents across the board showed support for reduced cost-sharing programs such as health promotion programs, scientifically proven effective care, and networks of medical providers with records of high-quality care.
  • The survey also found that those with CDHPs were more likely to support lower cost sharing for active patients, members who follow treatment regimens, less invasive procedures, and high-quality doctors (See Figure 18 on p. 14.)

Regardless of whether CDHPs gain popularity and more people open HSAs, Fronstin says healthcare consumerism will survive. Greater consumerism means health insurers and employers need to educate employees about their benefits and how to reduce costs and choose the best care.

As long as healthcare costs outpace inflation, employers will look for options such as CDHPs to reduce costs, says Fronstin. “Whether HSAs continue or not, we’ll continue to see this movement toward consumer engagement,” he says.

More than one in five U.S. adults at lower activation levels

Those who are activated in their health are more apt to stay current on their medications, more engaged during medical encounters, seek out health information, and more likely to eat healthy foods, exercise, and get preventive care.

With that information as a backdrop, a recent Center for Studying Health System Change (HSC) research brief showed that fewer than half of U.S. adults are activated in their health, which can affect chronic care programs such as disease management and benefit designs such as consumer-driven healthcare.

“When you add it all up, [activation level] can have a pretty big impact,” says Judith H. Hibbard, DrPH, professor of health policy at the University of Oregon’s department of planning, public policy, and management and coauthor of the research brief How Engaged Are Consumers in Their Health and Health Care, and Why Does It Matter? with HSC senior fellow Peter J. Cunningham, PhD.

For the research brief, the authors used data from HSC’s 2007 Health Tracking Household Survey, in which 17,800 people were interviewed about their health. The survey found that slightly more than 41% of U.S. adults were at the highest level of activation (Level 4), whereas more than one out of every five was at either of the two lowest activation levels. Activation is gauged by a person’s ability and willingness to manage his or her health and healthcare. (See Figure 19 on p. 17.)

Hibbard designed the patient activation measure (PAM) to assess a person’s “knowledge, skill, and confidence in managing their health,” according to the research brief. (See “Four levels of activation” at left.)

Higher activation levels are associated with “much fewer problems with access to care, even when controlling for insurance coverage and income, which may reflect greater resourcefulness among more highly activated people in navigating the complexities of the health care system and overcoming barriers,” the authors wrote.

A person’s income or education level can play a role in activation but are not sufficient to identify a person’s activation level.

“[Socioeconomic status] certainly is related, but there are people who are quite activated who have lower income, lower education, even lower literacy skills, who are very motivated and focused on doing a good job in managing their health ... There are examples on the other end of the economic ladder where they are not focused on taking care of their health,” Hibbard says.

Those who are at the lower end of activation are discouraged, possibly because they have failed at bettering their health or don’t see a positive effect on their health, Hibbard says.

This discouragement is evident for those with chronic illnesses. Doctors often ask patients who are battling chronic disease to change their lifestyles, which is difficult and scary for many patients. “When they aren’t able to do that, they throw up their hands and do nothing and they feel discouraged,” says Hibbard.

The survey also found a connection between those more activated and those who receive greater support from their providers. Nearly 84% of respondents at Level 4 reported that a provider helped them set goals to improve their diet, compared to slightly less than half of people at Level 1. (See Figure 20 on p. 17.)

Although more than 20% of those surveyed are in the bottom two levels of activation, there is good news—an individual’s activation levels fluctuate. This means that healthcare professionals need to engage a person during those times when he or she is ready.

Physicians can stimulate patient activation

More highly activated patients have more positive and supportive healthcare experiences, the survey found. The authors added that the findings could show that support from physicians stimulates patient activation.

“If this is correct, then encouraging this type of phy-sician support may be a productive pathway for increasing activation. This may be particularly important for those at lower levels of activation, who not only engage in fewer health-promoting behaviors, but also tend to be passive with regard to their health care,” the authors wrote.

These findings show how a positive relationship between patients and their doctors creates more engaged patients and high-quality healthcare, Anne F. Weiss, MPP, senior program officer and team leader of quality/equality strategy at the Robert Wood Johnson Foundation, said in a statement.

“Doctors need to talk with their patients about setting goals for their health and how to monitor their conditions. And since we know that activated patients fare better and ultimately cost less, policymakers should consider encouraging health systems to find ways to activate their patients,” Weiss said.

CDHPs and activation

Activation level plays a role in whether patients have a regular source of care, whether there is an unmet medical need, and whether people delay care or don’t fill prescriptions, according to the survey (See Figure 21 on p. 18.)

Although the theory behind consumer-driven healthcare is that placing more financial responsibility on individuals will drive them to choose healthcare wisely and not overuse services, the researchers wrote that “cost sensitivity by itself may be a necessary but not sufficient condition for greater consumer engagement.”

Increased cost sensitivity is a manifestation of a more activated consumer who seeks information on cost and quality, but lower activation levels can create invisible barriers between the consumer and information.

With states looking at ways to cut Medicaid costs, policymakers have begun implementing consumer-driven healthcare at the Medicaid level. This could present a problem because many in Medicaid are in the lower activation levels. This means the move to consumer-driven health plans (CDHP) may not empower Medicaid beneficiaries to make better healthcare decisions and, ultimately, may not save money in the long run.

“People enrolled in Medicaid are among the least-activated patients among all insurance groups, which reflects both lower educational levels and lower socioeconomic status. The findings suggest that efforts to increase patient responsibility in the Medicaid program will only succeed if they are accompanied by vigorous efforts to educate enrollees and increase their levels of activation,” the survey authors wrote.

Chronic disease differences

Those with chronic conditions are more likely to fall in the lower levels of activation, but activation levels vary by chronic condition. (See Figure 22 on p. 18.)

For example, people with depression are least activated, but those with cancer are more engaged. Those with multiple chronic conditions who are in fair or poor health and are obese are less activated than those with a single condition or who have better health indicators.

All of this points to the need to teach these patients self-management skills to show them how to monitor their health, according to the authors.

Engaging the least activated

Inspiring those at the lower end of activation is difficult, but Hibbard says there are two ways to help those not feeling engaged:

Find out what the person wants to work on first, which will help him or her feel a degree of control.

Break down life changes into easy-to-accomplish, smaller tasks initially so the person can succeed. For example, ask a person who needs to improve his or her diet to start by eating one high-fiber, low-fat meal once per week.

Accomplishing one of those smaller tasks will spark people’s belief in themselves. “That is how a person gets a sense of confidence in experiencing some level of success,” says Hibbard.

Patient activation science

Hibbard says healthcare is still learning about patient activation science. “I think that we’re just on the edge of really learning how to use this kind of information to really tailor and personalize care in ways that we have never done before. Healthcare has been a little slow in coming to this, but I think this will open the door on this topic,” she says.

Sander Domaszewicz, principal at consulting firm Mercer in Newport Beach, CA, says these findings show there is a need for programs that help people down the activation path. Domaszewicz believes more population health companies will see the need to add services that go beyond support and information and provide teachers and trainers to help people gain a better understanding of their ability to affect their health, outcomes, and costs. These services will help people link their behavior to their health and show that improved lifestyles can affect health and spark activation, Domaszewicz says.

Four levels of activation

The patient activation measure (PAM) includes a 13-item scale that asks respondents about their beliefs, knowledge, and confidence in several health behaviors. Based on their responses, they are assigned an activation score. A person’s activation level reflects whether they obtain preventive care, maintain good diet and exercise practices, use self-management behaviors, and seek out health information, according to a research brief by the Center for Studying Health System Change.

PAM’s four activation levels are:

  • Level 1 (lowest level): People are passive and may not feel confident enough to play an active role in their health
  • Level 2: People may lack basic knowledge and confidence in their ability to manage their health
  • Level 3: People appear to take some action but may still lack confidence and skill to support necessary behaviors
  • Level 4: People support their health but may not be able to maintain support because of life stressors

High demand, increased procedures drive compensation

Overall growth remains steady, but pay for new urologists climbs dramatically

Urology remains among the most highly compen- sated specialties. In particular, pay for new urologists is growing, partially due to the overall shortage of the specialists and the increased demand for those who have been trained in the most current technology.

Overall comp trends

Urologist compensation continues to grow steadily, keeping ahead of the rate of inflation. In 2007, urologists earned a median total compensation of $388,125, a 8.53% increase from $357,605 in 2006, according to the 2008 Medical Group Management Association (MGMA) Physician Compensation and Production Survey. That’s a 12.81% jump from $344,038 in 2003. It also represents a significantly higher pay than received by those in other areas.

According to MGMA data, the 2007 median compensation for all primary care is $182,322; for all specialists, it’s $332,450.

The 2008 Hospital & Healthcare Compensation Service Physician Salary Survey Report, which measures only salary data, reported a median salary of $234,592 in 2007, compared to $208,566 in 2006. (See Figure 23 below.)

Growth drivers

The year-to-year growth in total compensation isn’t matching the double-digit increases of five or six years ago, but it’s still an upward trend, says Rick Rutherford, director of practice management at the American Urological Association (AUA).

Rutherford cites several factors driving compensation growth, including an increase in:

  • Outpatient procedures. Performing select procedures in an ambulatory or office-based surgery center improves patient turnover and productivity.
  • Ancillary outpatient services. Services such as sophisticated imaging or lab services can boost revenue.
  • Mergers. Consolidating urology practices allows urologists to take advantage of economies of scale.

In terms of overall compensation, urology was the fifth largest gainer in Dallas-based Medicus Partners’ annual compensation survey. It followed only radiology, GI, orthopedics, and ENT. “The 2008 average income for a urologist was $407,000, which represents a 2.95% increase over 2007,” says Mark Nolen, principal at Medicus Partners. “In terms of what is being offered to candidates as a salary or income guarantee, our current average is $358,125.”

Steep demand, softening supply

Not surprisingly, it’s a supply-and-demand issue. Recruiters report a strong demand for urologists: Merritt Hawkins & Associates’ 2008 Review of Physician and CRNA Recruiting Incentives reports increasing demand for certain specialists, including urologists, neurologists, psychiatrists, pulmonologists, and emergency medicine physicians; Dallas-based Delta Physician Placement’s second quarter 2008 Recruiting Standard reports a significant jump in demand from 2007.

Demand is expected to expand, largely due to an aging population with a growing need for urology services; however, the supply of trained specialists remains flat.

“As a result of the migration of urological services to outpatient facilities, even hospitals are recruiting urologists in order to stem the tide of lost procedures,” says Rutherford. The intense competition for the shrinking pool has created several casualties. In particular, small practices in rural areas often can’t compete for the available talent, he says. The aging population is creating demand and exacerbating the shortage.

Many urologists are nearing retirement and starting to cut back on their practices. Shannon Penney, director of recruiting at Delta Physician Placement, says 42% are aged 55 or older.

Big pay for new urologists

Although overall compensation growth remains steady, pay offered to new urologists is climbing dramatically, says Rutherford.

More years of experience doesn’t necessarily translate into commensurately higher pay, Nolen says. “In general, we’re seeing much less disparity between what is being offered to in-practice physicians and those coming out of training, which has been pervasive in the past,” he says. “The shortages have gotten to the point where facilities, in many situations, are comfortable paying whatever they need to pay to ensure their vacancy is filled, regardless of the experience of the candidate.” In particular, Nolen reports a higher demand for physicians with robotics expertise.

Penney says there is better compensation for uro-logists under age 47 with training in minimally invasive techniques. These techniques allow surgeries to be performed in outpatient surgery centers, resulting in greater volume and compensation.

Although experts agree, quantifying this trend has been a challenge. Rutherford notes that MGMA’s first-year compensation data aren’t necessarily limited to urologists fresh out of training. Accordingly, the AUA has launched its own first-year compensation survey of urology residents. Results should be released soon.

Strong temp market

The physician shortage has created more demand for locum tenens coverage while hospitals recruit a permanent urologist, says Mike Beckman, director of recruiting at Delta Locum Tenens in Dallas. “Locums docs have more options to choose from at this point. They know they can get higher rates, pick locations—they are driving the process instead of the recruiters,” Beckman says.

Delta reports that between 2006 and 2008, its average per diem rates for locum tenens physicians increased about $200 per eight-hour day, excluding any additional call-coverage compensation. The average billed rate for the second quarter of 2008 was $1,743 per day.

Call coverage

Not surprisingly, call coverage continues to be a hot issue. It’s compounded by the aging pool of urologists; as they approach retirement, many are dropping call coverage, says Rutherford. Some urologists have successfully negotiated with hospitals to receive compensation for call on unassigned patients in the form of a per diem or guaranteed reimbursement for services for uninsured emergency cases.

“It is not yet prevalent for urologists, but as the shortage worsens, it will continue to be an issue raised by physicians in the specialty,” Rutherford says. For now, most urologists still take call as a routine part of their hospital practice.

Nonphysician providers

The urologist shortage is driving the expanded use of nonphysician providers (NPP), Rutherford says.

In fact, many also help with on-call demands by taking first call for the physicians in small practices. It generally takes about one year for the NPP to achieve optimum efficiency in seeing urology patients. But once that happens, “they can be a valuable asset to see postoperative patients and office follow-up patients on day one,” says Rutherford.

Outcomes Guidelines

DMAA’s report expands further into population health

As population health programs grow across the industry, experts expect employers and health plans to demand analysis on costs and participation levels. In its most recent Outcomes Guidelines Report, DMAA: The Care Continuum Alliance looked to standardize methodology and measurement that will allow comparison of disease management (DM) and population health improvement programs.

Building on the previous two editions, which focused on financial goals and clinical outcome measurements, the 84-page Volume III explored the areas of small populations, medication adherence, selection criteria, and wellness evaluation methodology.

Volume III further delved into population health, which mirrors the change in DM from chronic disease to caring for patients across the care continuum, says Susan Jennings, PhD, cochair of the Outcomes Steering Committee and an independent healthcare consultant in Los Angeles. Moving from siloed DM programs to broader population health means complexities in comparing a wide variety of programs. “They are all different, so it’s got to be some kind of range of ways in which one can go about evaluating them,” says Jennings.

Seth Serxner, PhD, MPH, principal at Mercer in Los Angeles, participated in Volume III’s methodology and finance, and operational metrics workgroups. Serxner, who criticized the DMAA’s first volume because it set the bar too low, says Volume III’s recommendations showed progress, adding that although the Outcomes Guidelines Committee did not solve all issues, it did provide new approaches.

  • Serxner says Volume III’s three highlights are:
  • Moving away from pre-post analysis or at least enhancing the measurement tool
  • Presenting a participation cascade that documents the types of engagement that may influence outcomes
  • Providing measurements to gauge outcomes when compared with other programs

“I think there is a way to go here, but I think there is a tremendous acknowledgment that we need to move beyond the old pre-post aggregate population models in terms of measuring these things,” says Serxner.

DMAA president and CEO Tracey Moorhead said Volume III built on the previous editions and “honors” the “commitment to inclusiveness and transparency.”

“Reliable, validated outcomes measurement in chronic disease care shows the value of population-based interventions. Our guidelines make that possible,” Moorhead said in a prepared statement.

The Outcomes Guidelines authors noted that measurement of population health programs is an “imperfect discipline that balances suitability (rigor) and acceptability (practicality). This tension has been explicitly acknowledged from the outset of the project and is well-known to those involved in population health, but seems occasionally overlooked by those outside the industry.”

Donald Fetterolf, MD, executive vice president of health intelligence at Alere and cochair of the DMAA Outcomes Steering Committee, said that balance is an “overarching theme” in the process.

“Ultimately, your goal of improving care depends on real-world application of these guidelines,” Fetterolf said in a statement.

Pre-post debate

One area that the industry needs to move away from is the pre-post design to evaluate financial outcomes, Serxner says. Several industry experts criticize the design that measures total healthcare costs, saying the methodology benefits DM programs.

Serxner wants population health companies not to use pre-post analysis, but supporters of the idea point to the ease of pre-post compared to a randomized controlled study.

“We could theoretically design and implement every instance of a population health improvement program as a randomized controlled study, but that would be impractical and unacceptable to many who sponsor and/or deliver these programs,” the authors stated.

Realizing that some companies will still demand pre-post analysis, Serxner says Volume III provided pre-post improvements and enhancements in the areas of building baselines and dealing with outliers.

“People still use it, and if you are going to use it, there are some things that can help,” Serxner says, such as focusing on utilization rather than total healthcare costs.

Small populations

Volume III provided recommendations when dealing with small populations, which are often difficult to measure because the size can influence outcomes. DMAA noted that a small population’s high variability can result in conflicting, misleading, or inaccurate results.

To tackle those problems in gauging small populations, Volume III suggested three alternatives:

  • Blend results (using standard medical cost savings methods) for small populations with results from book of business or larger reference population.
  • Take book of business or larger reference population results and derive a factor that estimates the percentage of total medical costs saved per member receiving a significant level of support. Once that is done, use the factor to calculate savings for all members in small populations receiving that level of support.
  • Use book of business or a larger reference population’s results to build a statistical model assessing the factors that drive savings and apply the model to the smaller group’s data to calculate savings estimates.

The first option is in line with standard actuarial processes and blends customer-specific results with results from a more stable population that is comparable without specifics, such as severity, age, and sex. The second alternative enables group level of activity and possibly cost data, which can be used to derive savings, and uses a more stable population. The third option enables group-level information to be used to gauge savings, uses a more stable population, and may build upon other studies, according to the authors.

Operational measures

To figure out an individual member’s engagement level and how programs affect outcomes, a company needs to create definitions, such as what constitutes an engaged member versus an enrolled member.

DMAA put forth a presentation cascade as a way to measure engagement levels. The presentation cascade diagram moves from who is “eligible” to what constitutes “participating.” This creates a baseline for companies when determining how an individual’s engagement level affects outcomes.

Volume III also offered recommended definitions for operational stages and measures. Operational stages included identified and targeted populations, whereas operation measures focused on enrolled populations (and defined opt-in and opt-out programs), as well as the definition of engaged and participating populations.

“That model may be specific for disease management, but what we also try to advocate for is an individual-level model that documents who is participating in what program,” Serxner says.

This allows for apples-to-apples comparisons of indivi- dual and multiple programs—for example, comparing members who completed a health risk assessment (HRA) only against those who filled out an HRA and participated in a DM program.

Serxner says having the ability to separate programs allows for easier measurement of individuals and allows for companies to accurately compare program effectiveness.

“I think we need to be careful about claiming credit when maybe there’s more than one program that can accommodate some savings,” Serxner says.

Jennings says clear definitions for operational metrics, such as the definition of eligibility, are critical when comparing programs.

Medication adherence

The authors of Volume III developed a detailed specification for the medication possession ratio (MPR) as a measure of adherence.

MPR is a population-based measure, reported as a percentage, that uses administrative pharmacy claims and eligibility data within a defined 12-month period.

In its Outcomes Guidelines, DMAA suggested using MPR by condition and drug classes applicable to that condition and counting individuals with multiple conditions for all the conditions and appropriate drug classes. The measurement is intended only for oral medications (not inhalers and liquids) and for more prevalent chronic conditions such as coronary artery disease, chronic heart failure, diabetes, hypertension, and hyperlipidemia.

Jennings says oral medications were only included because a population health company can track medication usage via claims data. An item such as an inhaler, for example, is used on an emergency basis, so gauging use is not applicable, she says.


The DM industry has changed from caring for chronic illness to a wider population health model that seeks to improve health across the care continuum. With that in mind, Volume III included wellness evaluation methodology.

The methodology’s goal was to recommend evaluation strategies for wellness programs that are consistent with DM recommendations and appropriate for wellness programs. Volume III focused on comparing DM and wellness programs on key factors to find overlap.

Volume III is still a pretty early step in the process of evaluating wellness programs, says Jennings, who expects further exploration in Volume IV. “Now we are more broadly thinking about how you look at the full spectrum in an evaluation. That is challenging,” she says.

Volume IV and what’s next

DMAA has already started work on Volume IV and will publish white papers in 2009 on such topics as self-management, productivity, and behavior change.

The workgroups will consider approaches to identifying individuals with multiple conditions, as well as exclusions, including codes indicating residential treatment such as hospice and other exclusions that were noted in Volume I.

Jennings says those who read the Outcomes Guidelines should remember they are best practices and should not be used as a plug-and-play formula. It’s up to the end users to adapt the measurement approach to their specific populations and programs, she says.

DMAA is closer to providing measurement methods that allow payers to compare program results from different vendors, Jennings says, but more work is needed. “I think we’re much closer than we were [after Volume I],” she says.

Serxner says measurement tools that allow experts to compare programs have been lacking, adding that he has been disappointed that DM vendors have not published and presented findings to show methodology and outcomes. Instead, the vendors have focused on marketing, operations, and sales. This has sparked questions about the validity of DM, he says.

“I think it’s been a disservice to the industry that we haven’t done that, and in many cases, there is a tremendous skepticism out there about the marketing findings,” Serxner says. “I think we’re at a critical point now. If we don’t do it soon, we’re really going to lose credibility.”




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