Ending the blame game in employee health care

Independent agency's majority-owned wellness firm helps clients curb costs

By Elisabeth Boone, CPCU

Remember that 1960s pop classic "The Name Game"?

When it comes to deciding who is responsible for the inexorably rising costs of employee health care, that song could aptly be retitled "The Blame Game."

Depending on whom you ask, skyrocketing health care costs can be blamed on hospitals, doctors, insurance companies, junk food manufacturers and the people who eat their products, and anyone in government you don't like.

Although finger pointing can provide momentary satisfaction, it doesn't last any longer than the final bite of a candy bar—and it doesn't solve the problem.

If the problem isn't health care providers, insurers, government, or bad food and the people who eat it, exactly what is the problem?

In a word, say the executives of ACAP Health Consulting, the real enemy is disease—and the way to defeat it is with a collaborative effort that involves all stakeholders: employers, employees, hospitals and doctors, and insurance carriers.

Key to ACAP Health's approach is the implementation of common-sense strategies to prevent the onset of lifestyle-related conditions like obesity, Type 2 diabetes, heart disease, and some forms of cancer. Results thus far show dramatic improvements in participating employees' health and quality of life, coupled with significant reductions in health care costs and insurance premiums.

ACAP Health's majority shareholder is Holmes Murphy & Associates, an independent insurance brokerage and risk management firm with headquarters in Des Moines, Iowa, and offices throughout the Midwest and Southwest.

"We were established in 2007 under the name Trajectory Health," says Dennis Bishop, ACAP Health's co-founder and chief executive officer, who is also president of Holmes Murphy and co-national practice leader for employee benefits. "Many of our benefits customers were looking for employee health care solutions that were achievable and measurable. When they discovered that there were no products, services, or consultants to help them meet their goals, they turned to us. We launched Trajectory Health to create and deliver solutions that could help flatten the trajectory of increasing health care costs for those employers."

Wally Gomaa is co-founder and president of ACAP Health. Other key members of the executive team are Brad Biermann, chief information officer; Charisse McCumber, chief operations officer; David Toomey, principal, and Scott Conard, M.D., chief medical officer. These individuals are seasoned professionals who have led major insurance carriers, large physician groups, HMOs, and national brokerages and consulting firms.

In 2010, Trajectory Health was rebranded as ACAP Health Consulting. "The AC stands for Accountable Care, and AP is for Accountable Patient," Bishop explains. "Our name reflects our belief that preventing disease and improving outcomes must be a collaborative effort on the part of both patients and health care providers, because neither side can do it on their own."

Rather than targeting employers based on type of industry or size of work force, ACAP Health seeks to work with employers who believe they can play an active role in improving the health of their employees.

"We've found that the key criterion is not size or industry; it's belief," Bishop says. "The employers who hire ACAP Health believe that their role in employee health care goes beyond just paying part of the premium. They believe they can be a positive change agent and take simple steps to reduce the incidence of diabetes, cancer, and heart disease among their employees. And these employers believe that they can use the platform of insurance to improve outcomes."

That said, Bishop comments, "Our clients tend to be larger employers that are self-funded, so any savings we can achieve by reducing the incidence of disease go right to the bottom line."

Defining health risk

In the early days, Bishop and Gomaa wanted to identify a consistent clinical definition that ACAP Health could use in developing employee wellness programs. "We knew that CFOs were going to say, 'I don't care how many employees participate in the program as long as they have fewer heart attacks,'" Bishop explains. "We needed a way to quantify outcomes so CFOs could see the impact of a wellness program on their bottom line.

"The concept of Metabolic Syndrome is well known in the health care community," he continues. "It's a cluster of five lab risks—blood pressure, high-density lipoprotein, fasting glucose, triglycerides, and waist measurement—and the chronic conditions they trigger in individuals whose numbers are not where they should be."

Simple, concise, and measurable, Metabolic Syndrome was an ideal clinical definition for ACAP to use. "Once we decided to use it to identify risk, we began to develop a program that could reverse Metabolic Syndrome," Bishop says.

ACAP Health's Metabolic Syndrome Reduction Program was developed by observing how people known as "True Thins" are generally able to eat what they want while maintaining a healthy weight and normal lab screenings. The program is a non-diet approach that uses behavioral changes to produce positive long-term outcomes. Presented online in a 10-week curriculum, the program provides a 100% performance guarantee based on weight loss and improvements in lab results.

Clinical Stress, ACAP Health explains, is a complex emotional and physiological reaction that produces more than 1,400 biochemical changes in the human body. These changes lead to a cognitive shutdown that results in heart rhythm changes. ACAP Health's Clinical Stress Program offers education, online support, and coaching, as well as ongoing alumni support.

The prices of many medical procedures vary greatly from one provider to the next, even if the services are performed just a few miles apart. For example, in a large metropolitan area, a CT scan can cost anywhere from $500 to $1,500—a variance of 300%. ACAP Health uses price transparency software to give patients up-to-date pricing and offers an advocacy service to help employers and employees reduce the costs of medical and prescription drug claims.

Clinical care engineering

The ACAP Health team firmly rejects the notion that employers and employees are helpless victims of a health care system over which they have no control. They embrace a can-do attitude that focuses on changing the system rather than being changed by it.

When ACAP was established almost five years ago, Gomaa says, "Our initial focus was on reducing claims by addressing the factors that give rise to lifestyle-related diseases, and thereby measurably reducing the health care costs of employers. We realized, however, that although we are able to dramatically lower the incidence of such diseases, there still will be claims. The health care marketplace is a universe of providers with significant variability in their unit costs and in the quality of care they deliver, and this directly affects the cost of a claim," Gomaa explains.

"We believe that the solution is to re-engineer the health care system so that we would not buy our care from any provider that happened to be in network, but instead we would buy it from those providers that are delivering the highest quality of care at the most affordable price," Gomaa continues. "This is called clinical care engineering, and it's designed to hold providers accountable for the quality and cost of their care, including offering some guarantees with respect to outcomes. On the other side of the equation, we need to hold employees accountable by designing benefits in a way that encourages individuals to seek their care from the high-quality providers we've identified."

Bishop credits ACAP Health principal David Toomey for introducing the concept of clinical care engineering at ACAP Health.

Prior to joining ACAP Health, Toomey was head of national accounts for a major insurance provider. He worked with a Seattle-based client whose number one health care expenditure was for back injuries and back pain. It was this relationship that led to the creation of Clinical Care Engineering.

"David and his client went to a major medical center in Seattle and defined how they wanted to receive and pay for back care services," Bishop explains. "In response, the hospital created a new model for providing back care that is based on the highly efficient production techniques used by a major auto manufacturer. David led the initiative from the insurance carrier side while his client led it from the employer side. Now, at ACAP Health, we are implementing this concept to connect the employer and the health care community so that the employer can specify the services it wants and the provider can deliver those services in an efficient, cost-effective manner," Bishop says.

Gomaa describes another case in which ACAP was able to connect an employer directly with a medical center and an insurance carrier.

"We got a call from the manager of a mid-sized city in west Texas who told us they were at the end of the line; they just couldn't shift any more of the costs of health benefits to the city employees. They hadn't given employees raises, tax revenues were down, they had to keep paying their firefighters and police, but they didn't know what to do.

"We were able to connect the city directly with one of the hospitals in its community. We brought in a new insurance carrier to administer the contract, and the new arrangement will cut the city's medical and hospital expenditures by 35% on a guaranteed basis starting on January 1 of this year," Gomaa says. "The city will save over $800,000 this year.

"This is a great example of the power of clinical care engineering as well as the benefits of communication and cooperation," Gomaa remarks. "All interests were aligned, and the results will be improved care for employees, reduced costs for the employer, and an increased flow of patients into the health care provider's system."

What's more, Bishop points out, "The insurance company wasn't the bad guy. It wasn't the insurance company telling the hospital, 'We can't pay you any more money.' We brought the insurance company in on the back end of the discussion and said, 'The city and the hospital have agreed on a plan; we would like you to wrap your services around it and become the facilitator and administrator—without being the bad guy in the middle of the contract negotiations.'

"In a sense, we act as an interpreter between the employer and the health care provider," Gomaa comments. "We find that the physician and hospital communities don't really know how to speak to the employer. The insurance carrier traditionally is the go-between, and the insurer plays a critical role. That said, we believe that the employer, who is the ultimate purchaser, and the health care provider, who is the supplier, need to understand and communicate with each other more frequently and more productively. At ACAP Health, we understand the perspectives of employers, employees, insurers, and health care professionals, so we can facilitate communication and help all the players achieve better results," Gomaa declares.

At ACAP Health Consulting, "The Blame Game" is no longer the theme song for the health care system. Everyone on the team is singing a new tune: "Let's Work Together."

For more information:

ACAP Health Consulting

Web site: www.acaphealth.com