Knowledge is Healing

The Aetna Foundation last fall gave researchers a $400,000 grant to fund a study at the University of Pennsylvania that will use prizes of $10 and $100 as rewards for taking medication as prescribed.

"If it looks like it works, we'll try to incorporate it in things we do," said Aetna Chief Medical Officer Troyen A. Brennan, MD, MPH.

Kevin G. Volpp, MD, PhD, director of the Center on Health Incentives at the Leonard Davis Institute for Health Economics at the University of Pennsylvania's Wharton School, and Stephen E. Kimmel, MD, associate professor of medicine at the University of Pennsylvania School of Medicine, have designed a two-arm randomized trial with 100 participants to test a daily lottery as incentive for taking warfarin as prescribed.

An electronic monitor will track whether all participants are taking their medicine.

The 50 people enrolled in the lottery will have a 1-in-10 chance of winning $10 every day they take their medication and a 1-in-100 chance of winning $100. Each day a text message will tell a subject whether he or she has won the lottery, or, if the dose wasn't taken, whether he or she would have won, Dr. Volpp said.

The 50 people in the control group will use the same monitor but won't be entered in the lottery.

Aetna chose to sponsor the research because adherence is key to quality of care, Dr. Brennan said. He said statistics show that a year after beginning medication, only about 50% of patients are taking their medications as directed.

Executives didn't say whether United's problems will change the way it does business with doctors. But they did say the company is looking to improve savings and boost revenues on a local level.

United issued a series of press releases on July 2, with announcements concerning profits, layoffs, reorganizations and an agreement in two federal class-action lawsuits.

ProfitsThe company's profits for 2008 will be lower than previously projected. The company revised its year-end forecast from an estimated $3.55 to $3.60 per share, projected in April, to between $2.95 and $3.05 per share, a drop of between 15% and 17%.

The company is still projecting $6.5 billion in earnings from operations, down from $8 billion in 2007. These are earnings from operations, not net earnings after such items as income taxes and depreciation -- net earnings were $4.65 billion in 2007.

United CEO Stephen Hemsley blamed enrollment drops and higher-than-expected costs, particularly in its Medicare business, for lowered expectations for the year.

LawsuitsThe company reached an agreement to settle two federal class-action lawsuits over alleged stock-option backdating.

United, and current and former executives, have faced multiple investigations and lawsuits since 2006 over allegations the company improperly backdated stock-option grants to executives. Backdating -- adjusting the option grant price to a day when the company's stock peaked -- is not illegal, but must be reported to investors.

The exodus is largely from solo or small practice to large-practice or employed situations, according to surveys such as one released late last year by the Center for Studying Health System Change. Doctors cite long hours spent pushing through towers of paperwork and working for smaller and smaller reimbursements, with less quality time left for patients and even the physicians' own families.

But it's not all one-way. Physicians tired of what they see as the politics and stifling lack of clinical freedom in a large-group or as an employee are breaking away into solo practice or a small group. They argue that the ability to set your own schedule and work under your own terms can allow for more quality time with patients -- and the physicians' own families.

Here are personal stories from two physicians who changed their practice environments.

Internist Timothy Gatewood, MD, left a small private practice in Kokomo, Ind., to become an employed physician for Howard Regional Health, the local hospital system. Robert Jones, MD, a Raleigh, N.C., orthopedist, left an employed position at a large group to open a new practice with two other partners.

Physicians who see themselves in these stories can take some instruction from these experiences, experts say. However, it is crucial for physicians to consider their own motives for changing their practice settings, whether their personality would best fit in an employed or small-practice setting, and whether they -- and their families -- are ready for what can be an arduous adjustment.

The Wisconsin health system recently offered up its CattailsMD EHR, developed in-house over more than two decades, for commercial sale. The first taker was a neighboring health system -- Ministry Health Care of Milwaukee. Ministry has hospitals and medical groups in the northern part of Wisconsin, an area also served by Marshfield.

Ministry's implementation of the system, expected to take about three years, will result in a database with more than 2.5 million patient records from both Ministry and Marshfield, the organizations said. The two health systems will be connected, creating a regional health information organization with interoperability between all of both systems' facilities. Ministry and Marshfield combined have 1,000 doctors.

Pete Sanderson, MD, director of medical informatics operations for Ministry Health Care, said part of the attractiveness of the Cattails system was the ability to share patient data with Marshfield, with whom Ministry has had a relationship for more than a century.

This year's medical spending report for the fiscal year ending June 30, 2007, was the 15th the CMA has released listing the medical-loss ratio for the health plans regulated by the Knox-Keene Act, based on data collected by the state's Dept. of Managed Health Care.

Great-West Healthcare of California had the lowest medical-loss ratio, at 69.4%. Great-West was recently bought by Cigna, which had one of the highest medical-loss ratios at 94.3%.

WellPoint-owned Blue Cross of California (now known as Anthem Blue Cross) had the second-lowest medical-loss ratio at 79%, and Blue Shield was fifth lowest, at 82.1%.

Kaiser Foundation Health Plan had a ratio of 90.6%. L.A. Care Health Plan, a public health plan with fewer than 1 million members had the highest of any plan, with 97.1% of revenue going to care.

The medical association also calculated the additional medical spending that would have been created if the plans spent 85% of their revenue on care that year: more than $1 billion, with more than $933 million of it from California's two Blues plans.

California Medical Assn. President Richard Frankenstein, MD, a pulmonologist from Garden Grove, said health plans' medical spending ratios are revealing to more than just shareholders.

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