Knowledge is Healing

More than 83% of the nation's employers currently use health risk assessments to make employees aware of health risks as a way to encourage more prevention. A study released in July by Forrester Research Inc. showed signs that the assessments might have an effect on patient behavior, but the study's author says there's still a way to go before they have a measurable impact on health care costs.

The study, "What Consumers Do With Health Risk Assessments," found that 17% of employees who take the HRAs usually discuss the results with a physician and that 8% enroll in some type of structured wellness program designed to address a specific risk. The survey of 5,036 commercially insured people was conducted in October 2007.

Some experts say those percentages are good, given that more than two-thirds of the population is generally healthy. But study author Elizabeth Boehm, principal analyst in the Customer Experience for Healthcare & Life Sciences division of Forrester, said it could be better because "just about everyone has some behavior they could improve."

"The biggest issue is certainly the catastrophic health care costs, especially if you are large and self-insured," Boehm said. "But [employers] are also looking at issues such as productivity and absenteeism, and those are [affected] by fairly minor healthy behaviors like getting enough sleep or eating better."

Under the agreement, Dr. McGuire will pay $30 million to United investors in a class-action lawsuit led by a California pension fund and will surrender options to purchase 3.65 million shares of stock granted between 2003 and 2005. At mid-September's stock prices, those shares would be worth about $100 million. The case had been set for trial in September.

"In effect, this was an example of runaway executive compensation," said Peter Mixon, general counsel for the California Public Employees' Retirement System (CalPERS).

The CalPERS agreement is the third settlement involving the former CEO regarding alleged improper stock option backdating.

Backdating, the practice of retroactively assigning the grant date to a day the stock was at a low value, allows for automatic profit when options are sold at a higher price. It is not illegal, but investors are supposed to be informed when a company backdates stock options.

United already had agreed to pay $895 million to the same plaintiffs and is awaiting final approval of that deal by a federal judge. Former United General Counsel David Lubben also settled, paying $500,000 to plaintiffs.

Dr. McGuire did not admit wrongdoing; nor has he done so in any previous settlement. In a December 2007 settlement with the Securities and Exchange Commission, Dr. McGuire agreed to pay the SEC a $7 million fine, return $11 million in what the SEC called "ill-gotten gains," plus $1.7 million in interest, while also returning stock options and cash to United.

A report from LECG Inc., an Emeryville, Calif.-based company that offers expert testimony and analysis, said whether state law dictates that consolidation not be approved depends on how market share is defined. Another, by New York-based international financial consulting firm The Blackstone Group, was not conclusive as to whether the deal would fail to benefit policyholders and hurt network access. Blackstone said it had found no evidence that it would but noted that further data could change that conclusion.

The reports reflect the various definitions that regulators, experts, physicians and the plans themselves have offered in debating whether a Highmark-Independence merger should be approved. The Pennsylvania Dept. of Insurance commissioned the reports, released in early September, to help determine if it should approve the deal.

"In terms of the definition of what a market share is, the answer is going to be a combination of fact and interpretation of law," said Melissa Fox, a spokeswoman for state Insurance Commissioner Joel Ario. "Everything on the table will be considered."

The LECG report said that, assuming the two compete in a statewide market and using premiums as a measure of market control, the consolidated firm would have too large a market share as defined by the state statute that applies to mergers.

The business imperative behind these advertising slogans -- in order, for Aetna, Kaiser Permanente, Humana, Cigna and UnitedHealthcare -- is increasingly tied to health plans' own ability to thrive.

Health plan executives and the people who study managed care say that with further government regulation, reform looking likely in the next few years, and the individual market for health insurance gaining importance, insurers must reposition themselves as care managers and providers of medical navigation.

If they fail, the transition to a role of trusted adviser will stall, and health plans could end up as the emperor without clothes, analysts say. Even plan executives are believing that the public and elected officials must feel health plans do something besides make money, or plans will be out of the health system reform process.

"The new way of doing things for insurers depends on engagement," said Humana spokesman Tom Noland. "A consumer will not engage with his or her health plan if he or she doesn't trust the health plan."

David Shore, PhD, associate dean at the Harvard University School of Public Health, in Boston, is founder of the Trust Initiative, which is part of the school's continuing education program. He wrote the 2005 book The Trust Prescription for Healthcare: Building your Reputation with Consumers and edited the 2006 collection of essays, The Trust Crisis in Healthcare. Shore is scheduled to speak to health plans at the annual business forum for America's Health Insurance Plans in November.

In August, Samoho Healthcare, a Mexico City-based company that runs retail clinics in a few Mexican Wal-Mart stores, opened three physician-run clinics in the Miami area. Guillermo Rochin, founder of Samoho, said the clinics were designed to serve the Hispanic population in a way that mirrors the way health care is delivered in Latin countries.

Rochin said in Latin countries where physician-written prescriptions aren't needed for medications, people generally go to the pharmacy when they have minor illnesses. They visit a doctor only if the illness continues. Because physicians are needed to write prescriptions in the U.S., "having a physician inside the pharmacy is a model that makes sense for the Latino community," he said.

The clinics, called MediGo (a twist on the Spanish word medico, which means doctor), are located inside Navarro Pharmacies, a Cuban-owned pharmacy chain popular among the Hispanic population in Miami.

Rochin said the clinics will also address other issues that have kept Hispanics from seeking medical care, including language and financial barriers.

Elena Rios, MD, MSPH, president and CEO of the National Hispanic Medical Assn., said she advocates the expansion of retail clinics, which provide an outlet for many Hispanics to get accessible, affordable care.

"The clinics will help people understand that they don't need to go to the emergency department, which is much more expensive, when they fall ill," she said.

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