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Former United Healthcare Leader Stephen Bolles on the "Inexorable Retailizing" of Health Care PDF Print E-mail
Written by John Weeks   

Former United Healthcare Consumerism Leader Stephen Bolles on the "Inexorable Retailizing" of Health Care

Summary:  When this interview with Stephen Bolles, DC, was first published in the Integrator two years ago, United Healthcare asked that it be pulled. The issue was not with facts. United was officially upset that Bolles hadn't gone through channels to get the information approved - which approval would not have come, as he later learned. Bolles, a longtime colleague who was then a senior director for consumer health initiatives with United, told me after the interview was first published that United was applying extreme pressure and that he felt his job was at stake. I clicked the article off. Bolles and United have since parted and the information in the interview remains useful although United has gone in some different directions since our interview. I spoke with Bolles recently when he wrote his excellent response to the recent "cultural authority" piece. He cleared me to "republish" it. Enjoy this look at something that stirred up United's executives enough to threaten an employee.
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for inclusion in a future Your Comments Forum.

The moment in time of the most significant exploration of complementary and alternative medicine (CAM) coverage by employers and insurers coincided with the weirdest economic boom in modern history: the high-tech and dotcom explosion of the late 1990s.

Stephen Bolles, DC, former consumer health leader with United
The story-behind-the-story had two themes. One was that such "integration" was typically in non-covered, discounted services. The second was that where CAM services were covered by an employer, the reasons for inclusion frequently had little to do with perceived clinical or cost-saving value. In most cases, the coverage was state-mandated. Where CAM was a pro-active addition, the employer typically dropped CAM into their benefits packages to lure and hold employees in an intensely competitive market for high-tech talent. It wasn't about good health care, or cost-effectives care, per se.

Today, as healthcare costs continue to climb, with employers balking at coverage of any kind, those who are in the business of selling CAM services are in a whole new world. Stephen Bolles, DC, is [former] senior director for consumer health initiatives at the CAM-oriented ACN Group. ACN is among the leading CAM specialty companies, and is presently a component of healthcare giant United Health Group. Bolles was a vice president at Northwestern Health Sciences University before moving into the private sector. Some of you will know him from his insightful columns in the 2002-2004 CHRF News Files. Bolles and I talked electronically. Bolles currently works as a consultant and adviser on education , consumer health and integrative clinic projects.

If any of you have comments or questions, I will make sure that Bolles will also have a chance to respond.

Interview with Former United Healthcare Leader Stephen Bolles, DC

Originally Published April 25, 2006, when Bolles
was Senior Director for Consumer Health Initiatives with United

Integrator: So what's new with ACN and United relative to CAM and IM?

Bolles: We have some interesting programs in development which should be very influential in terms of integrative health care, especially as health care becomes more and more "retailized," which is clearly the inexorable direction of the marketplace.

Integrator: Okay, we'll learn about the programs as they roll out. Say more about this direction you envision for healthcare.

Bolles:  What I personally believe is absolutely going to happen is that, for the health plan member, the actual delivery of care will become more personalized, more "modularized," more individually priced than has been true to date.
Healthcare business processes - what currently passes for health plan "care management" - will become more and more visible as, basically, financial transaction management processes.

Integrator: So then we will be in an era of actual "managed cost" rather than "managed care"

"Health plan 'care management'
  will become
more and more visible 
as, basically, a financial

management process."


which detractors already call "managed cost." Chalk one up for transparency. How will this change things for the practitioner?

Bolles: Healthcare providers are going to have to learn how to be retailers. They will have to learn to speak in new ways and communicate new value propositions to consumers. These consumers will essentially have discretionary income to use on service purchases - whether it's out of pocket, or with a Medical Savings Account, or Health Savings Account, to back them up. As consumers become more educated and influential, efforts at managing costs at the provider level are probably going to be more subject to competitive marketplace forces at managing costs at the provider level are probably going to be more subject to competitive marketplace forces than a "top-down" imposition of fee schedules.

Integrator: But what's the change here for the CAM world? Most of these distinctly-licensed  CAM providers have been in a retail, fee-paid-for-service environment all of their working lives.

Bolles:  For those who are not involved in third-party payment yet, yes. But the chatter I hear from the professional ranks is still too closely based on the assumption that the system will, in some form or fashion, come to their rescue. Frankly, it ain't gonna happen. I fear for our brothers and sisters in CAM and integrative care. Unfortunately, no one's going to ride to the rescue. Now at the same time, as data get evaluated, one of the wonderful truths that is

     "I fear for our brothers   
and sisters in CAM
and integrative care ...
    The chatter I still hear is that   
the system will, in some
form or fashion, come
to their rescue. Frankly,
it ain't gonna happen."

likely to emerge is that CAM providers can justifiably be understood to deliver cost-effective care. So, in a sense I think we're going to find out we've won the war, but the world will have changed so much that what we think winning means is quite different than what it's actually going to mean.

Integrator:  There are a lot of yet unpaid student loans among chiros, NDs and AOM professionals -- not to mention IM docs -- that certainly would be easier to pay off with expanded coverage of their services. But what do you mean by the system "not coming to the rescue"?

Bolles: The brave new world is this. We now know a great deal about the clinical outcomes of an approach to care that is framed more in terms of quantity of care. This model encourages a perspective of "minimalism" more than "effective-ism" - to coin a word. Because of costs, efforts on behalf of health plans will be to focus on provider clinical decision-making processes. These will push care closer to a mean in terms of numbers of services and numbers of visits. These will be weighted against approximate clinical outcome expectations.

Integrator:  But what is new here? Isn't this Managed Care 101?

Bolles:  In my opinion, one difference is that plans will have to begin communicating more clearly and honestly about what's covered. Instead of saying, for instance, that they have an "open-ended" chiropractic benefit that starts with a certain number of visits and can be adjusted upward, depending, the plan will say: "If it's acute chiropractic condition, you get 6 visits." Period. The plan will not get involved in the documentation tug-of-war with the provider to increase the number of covered visits. For providers and patients/consumers, this

"The plan will not get involved
in the documentation tug-of-war  
with the provider to increase
the number of covered visits."

transparency will facilitate a transition to more retail, self-pay, cash-based purchasing decisions.

Integrator: So this is the sort of "modular" unit you are talking about. And the ending of the documentation tug-of-war is the plan's stepping away from care management.  

Bolles: Yes, and it also seems likely that the value of the CAM network business or CAM carve-out business as a cost or risk-management structure is going to diminish. This is where the "retailization" come in. The opportunity for the providers who realize these changes is that they can shift more appropriately to a retail relationship with consumers.

Integrator:  So any additional care for the condition would be only through a cash transaction between the provider and the customer?

Bolles:  The locus of control of the transaction between consumer and provider in care management decisions will only continue to shift toward the consumer/patient and away from the plan and the provider. This disruption of the old social contract is irreversible. The paternalistic relationship is unrecoverable. This is a good thing, in many respects.

Integrator: Yes, good, and I suspect many patients or consumers - not to mention providers -- will not immediately take to the newfound, and not paid for, freedom from paternalism.

Bolles:  We're working on providing some tools. I'm working internally to take what we know about provider decision making on clinical issues and figure out how to "port" that information to consumers as actionable information to inform good decisions. We're looking

"The new currency is information.
This information may end up influencing  
the stabilization of health care costs
more than any other efforts."

at what tighter clustering means in terms of predicting outcomes. We're trying to figure out how to make this information relevant and understandable - and essentially framed in retail terms. I see that there will eventually be a host of decision-making tools and aids that are going to spring up. This information may end up influencing the stabilization of health care costs more than any other efforts. The new currency is information. Those who figure out how to get consumers what they want in ways they want it, and in the way they'll use it -- these will be the business survivors. Those who do not will perish, in my view.

Integrator:  You are sounding prophetic. It is an interesting coincidence, isn't it, that the dialogue about "integrating" CAM with a larger system has arrived at the moment of the system's significant reconfiguration, if not dismantling.

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