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Scott Shreeve, MD

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I'm the CEO of Crossover Health, a patient-centered, membership-based medical group that is redesigning the practice, delivery, and experience of health care. We offer urgent, primary, and online care to our members who can access our technology platform, practice model, and provider network from anywhere and anytime to optimize their health. Email Me



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Cash is King: Differential Premiums as a driver of behavior change

Differential (dĭfə-rĕn‘shəl) adj.

  1. Of, relating to, or showing a difference.
  2. Constituting or making a difference; distinctive.
  3. Dependent on or making use of a specific difference or distinction.

This is the third in a four part series of interviews with the panelist of “The Business Case for Health 2.0” closing session on the opening day of the Health 2.0 Conference.  Ken Shachmut,  Senior VP Strategic Initiatives, Health Initiatives, and Health Re-engineering at Safeway, shares is thoughts on some of the highly impressive results that have been obtained by introducing market based health plans at the company.

SS: Ken, thanks for making time today. Tell me a little about your background?

KS: I have been active as an executive and management consultant for over 30 years. I graduated from Princeton in Engineering and later obtained my MBA from Stanford. In consulting, I worked first with McKinsey & Company, later at Booz Allen Hamilton, and for awhile independently.  I had done some consulting for Safeway. I later joined Safeway and have been there the last 15 years in various capacities.

Due to my consulting background and analytical focus, I am frequently asked to look at new challenges and opportunities for the organization. As health care costs continued to rise, we started looking at ways that we could engage our employees or work with the unions to control costs. The process has been highly successful, and we now have broad participation in “market-based healthcare” (MBHC) plans – starting with our non-union population and evolving into our union plans currently. In consequence, our employees are now much more actively involved in their healthcare and are making better choices that improve their health. As a result of our learning and success, we have helped to create the Coalition to Advance Health Care Reform (CAHR) which is led by our CEO Steve Burd.  CAHR now has over 60 companies as members.

SS: You have an interesting title, can you share with us some of the challenges that led to the work you are doing now?

KS: Over the first half of this decade Safeway’s healthcare expenses were rising at double-digit rates.  The situation was not sustainable, and we had to do something.  I was asked to review the situation, and develop solutions.  I formed our Health Initiatives Task Force (HITF) to undertake the work – which we accomplished in 90 days: situation to solution.

Our response was to move to MBHC healthcare.  (We didn’t feel like we could call it consumer directed, because we didn’t really see a consumer market as we would typically define it within healthcare). Our basic premise was that if people were given responsibility for their decisions, and there was transparency to the financial consequences to those decision (both good and bad, mind you!), that they would choose to maximize both their health and their financial benefit. Since we had more flexibility with our non-union employees, we introduced these ideas to the non-union population first in 2006.  We terminated many of our traditional PPO and HMO plans and replaced them with our MBHC plan. The results were nearly immediate and dramatic. We had hoped to slow cost growth, perhaps even flat-line costs for a short time.  In fact we reduced all-in per capita healthcare spending 13%.  And we shared the saving disproportionately with our employees – their expenses were cut by 25% or more.  By sharing these results with our union leaders we now offer some MBHC elements in union-bargained plans in several key geographies.  These new plans introduce mutual benefits – by controlling costs, improving outcomes, and helping to leave more money into our employees’ pockets through encouraging healthy choices.

SS: What exactly did you guys introduce? How did you measure the results?

KS: We started by encouraging everyone (employees and spouses) to take a health risk assessment (with a substantial reward) – to establish a baseline of health for the employee and his/her physician while also helping individuals realize what specific areas they could work on that would improve health status and help reduce their costs. The plan includes a Safeway-funded HRA, followed by an employee contribution, and then 80/20 cost sharing up to an out-of-pocket maximum.  We also cover the full cost of all preventive care, offer a full range of care management services, and give free access to our Fitness Center and deeply discounted gym memberships around the country.

Since introducing the plan, we have steadily improved it – adding more benefits and asking for increasing accountability and involvement to receive lowest possible premiums.  For 2009 we are introducing Healthy Measures, which looks at four key health indicators – weight, tobacco, blood pressure, and cholesterol.   On a voluntary basis we requested that our employees get tested / measured on these indicators. We then built a benefits package that had premium differentials based on your performance. People who passed the metrics get the benefit of a lower premium right away – and those who did not hit the metric the first time will have the incremental premium refunded to them if they do hit the metrics a year later. So, everyone can earn the lowest possible premiums for 2009 if they take the voluntary measurements – either right away, or within a year through a rebate of the increment.

I want to be clear – we were adamant about designing this program to cover only those things for which our employees had control and which were clearly behavioral in nature. We do not differentiate for genetics, and we did everything prospectively and transparently so that everyone had equal opportunity to improve their behaviors.  And, where there are special circumstances documented by a physician, we authorize exceptions.

We measure results in terms of program participation, by the decrease in costs and trends, and by the overall health of our employees.  76% of our eligible employees signed up for Healthy Measures.  Depending on the metric, 70-85% of those opting in passed the metric and so earned the lowest premiums for 2009.  The remaining 15-30% will earn the differential rebate a year later, if they pass the metrics during next year’s measurement cycle.  It’s all up to the individual.  When the individual modifies behavior and improves health status, then he/she wins – personally in terms of better health, and financially with a sizeable rebate.

SS: What has been the uptake to date?

KS: We have over 70% of our non-union employees (30,000) and about 30% of our Union (170,000) employees plans that include some market-based elements. We have shared our results from the beginning with our union workers by providing summary results to key leaders. The response has been very positive as they have as much a reason to ensure that their members are healthy as we do. We continue to work with our union leaders to adopt MBHC more fully and more pervasively over time.

SS: Everyone knows how hard behavior change really is – what incentives matter in promoting new and more health behaviors?

KS: While the primary objective is to improve people’s health status, we all know that just telling people to do the right thing is not effective.  After all, if “just telling” were sufficient, we would not have over 30% obesity today. We believe the best motivator is likely to be the wallet. Cash truly has been king in our program in the form of differential premiums. Our average difference under Healthy Measures is about $800 per year – for the employee and spouse, so almost $1,600 for a family. This is a meaningful amount of money.  The fact that you can earn the discount immediately when you meet the health metrics, or that you can earn the rebate with better performance next year, really levels the playing field for all.

To complement our program of incentives, we reinforce the message of good health through a holistic approach and mutually-reinforcing programs available to all employees and spouses – access to the Fitness Center, discounted gym memberships, care management programs, health and wellness programs, information seminars to employees, and other related itms..

SS: How did Safeway utilize Health 2.0 tools to accomplish these cost savings?

KS: I have got to be honest – I did not know much about Health 2.0 until recently. However, Safeway had already been using one of Health 2.0’s poster children, Destination Rx, to help us achieve some impressive savings. Most of our program has been programs, information, behavior change, and incentives. We have not really done too much with technology so far, believing real change in this space requires behavior change, and behavior change can be best encouraged with incentives. However, we have learned how technology can surface some of the motivators of behavior change, and in our case, mostly related to financial issues.

For example, since Safeway covers the full cost of preventive care, we look for ways of ensuring that the spending is prudent. We found the cost for a colonoscopy within a 30 mile radius of our headquarters building ranges from under $1,000 to almost $6,000 – without, as far as we can discern, any difference in outcomes or quality. Therefore, we have started to set our reimbursements rates at something reasonable for a colonoscopy . . . lets say $1,500 for the sake of argument today . . .  with any remainder coming from the employee.  This clearly motivates employees to do a little research on colonoscopy providers (which we make easy for the employee), since any increment over the threshold comes completely out of the employee’s pocket, and is not eligible for application against the out-of-pocket limit.  With this approach we can begin to drive people to the health care organizations who provide the best outcomes for the best price (definition of health care value). Beyond just price, we are working with CIGNA, as our admininstrator, to start to incorporate the next level of outcomes data that would help make this even more impactful.

We look forward to the day when we get to those famous four quadrant charts that help us truly answer who is a good provider (price, outcome, satisfaction, etc).  Healthcare is a complex topic and there is no one “silver bullet” – but full transparency on cost and quality comes close.  Technology tools move us towards more transparency – very important for the individual, an employer, and the nation.  And ultimately for the provider as well.

SS: Can you further describe Destination Rx’s role in some of these initiatives?

KS: Destination Rx helped Safeway to embrace and implement therapeutic equivalency to most effectively allocate our health care resources. They had developed the concept and supporting technology, which was operationalized and adopted broadly for the Medicare population through CMS.  Acknowledging DRx’s solid leadership and strong tool set, we asked them to run a full analysis on our pharmacy files. DRx helped us assess the positive financial implications for Safeway and our employees when members switch from an expensive brand drug to a much less costly, therapeutically equivalent generic.  Using DRx’s technology, we redesigned our plan to incorporate pharmacy therapeutic equivalency (RxTE) and thereby deliver superior value. We now have RxTE in place for 11 major chronic drug categories.  The results are dramatic.

Destination Rx’s ability to aggregate the body of evidence (scientific and financial), provide compelling analysis (clinical and financial), and then to provide convincing advice on the benefits enabled us to move forward. The have a host of other tools and technology that we look forward to evaluating as part of our ongoing relationship.

SS: Safeway as a large employer has clearly led out in the Health Reform area – what do you see as the big trends or your big hopes for a reformed health care future?

KS: The employer based insurance system that we have inherited is an accident of history from the WWII era. There are now strongly entrenched interests that will seek to preserve the status quo, and change will only happen with constant pressure over time (political, social, and cultural). So, we have chosen to work within the current paradigm, focusing on ways to improve the system. We have found, and would encourage other employers to consider evaluating for themselves, that we have made a dramatic impact in our company by just injecting market mechanisms into current offerings right now. There is no need to wait for government action . . . we are seeing results today.  Other than culture and / or inertia, there is no reason why all companies and organizations – union trusts, non-profits, etc. – cannot achieve similar results.

We at Safeway believe that meaningful healthcare reform should be based on five basic principles – as described by the Coalition to Advance Healthcare Reform (CAHR):

  • Market-based healthcare system – incorporating full transparency on quality and cost
  • Universal coverage with individual responsibility – every American should be in the system; there should be no “uninsured”
  • Financial assistance for the low-income – so they can afford to be in the system
  • Healthier behavior and incentives – to make the “choice to act healthy” a financially rewarding one for Americans
  • Equal tax treatment – everyone, whether employed or self-employed, should be able to pay for healthcare expenses with pre-tax dollars

We have done the math on this concept.  When the entire nation addresses healthcare in a way similar to our approach at Safeway, there will be enormous savings – in both the public and private sectors.  The potential public sector savings are large enough to fully fund the subsidy required for low-income individuals, and to bring all the 47 million currently uninsured Americans into a health insurance program.  It is one of our objectives at Safeway to help show the way.  When successful, we hope others will say, “We have learned through the Safeway experience that embracing consumerism and putting people in charge and more accountable for their health can make immediate improvements in cost and outcomes.”

SS: Wow . . . remind me to hire some engineers for my next business venture. Thanks again Ken for your time.

Next up, Vita Cassese of Pfizer.

3 comments on “Cash is King: Differential Premiums as a driver of behavior change

  1. My company has experience in the patient side with programs and technology finely tuned to this concept of measuring behaviors, educating for understanding, and measurement of actions and results. How you incent is key and can easily focus on the wrong things – as Ken points out it needs to be something the participant has control over.

    In the case of diabetes, for example, you shouldn’t incent based on outcomes like A1c results (a diagnostic test measuring average blood sugar over the previous 60 – 90 days). Rather, incent based on evidence of participation compared to goal.

    A summary of our early results with adults diagnosed with type 2 diabetes was presented at the ADA Scientific Sessions:

    Great post!

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