In October 2009, dozens of encoded hard drives with stored audio and video recordings of customer service calls were stolen from a network data closet at a facility leased by Blue Cross Blue Shield of Tennessee (BCBST).  The closet had been secured by biometric and keycard scan security with a magnetic lock and an additional door with a keyed lock.  The landlord also provided security services for the building.  The health plan’s internal investigation confirmed that the protected health information (PHI) of 1,023,209 individuals was stored on the stolen drives. BCBST sent the required breach notification letters and provided timely notice to HHS.

BCBST now has agreed to pay $1.5 million to resolve consumer complaints filed with the HHS Office of Civil Rights (OCR).  The company also agreed to a 450-day corrective action plan requiring revision of its privacy and security policies and procedures and distribution of those documents to all employees with access to ePHI.  Specifically, the revised policies must address performance of a comprehensive risk assessment; development and implementation of a risk management plan; deployment of facility access controls and a facility security plan to limit access to electronic information systems and facilities where they are housed and to safeguard equipment containing ePHI from unauthorized physical access, tampering, and/or theft; and use of physical safeguards governing the storage of electronic storage media containing ePHI.  The resolution agreement and corrective action plan are available here. 

While it would seem BCBST had appropriate security measures in place to protect the network data closet, apparently OCR criticized the health plan for not having updated its formal security plan in light of operational changes.  Here’s another reminder that the risk assessment and risk management plan required under the HIPAA Security Rule are not one-time exercises.  Instead, a covered entity must regularly revisit and update its assessment and plan to address technological changes, relocations, new facilities, and expanded operations.  It’s not enough to do the hard work of implementing and maintaining appropriate security measures (walk the walk); a covered entity also must reduce to writing the threats it has identified and the measures taken to minimize them (talk the talk).

On March 2, 2012, CMS published revisions to the Interpretive Guidelines for hospitals addressing hospital patient privacy and medical record confidentiality.  The Interpretive Guidelines are directions to state surveyors who perform hospital surveys on behalf of CMS to determine compliance with the Medicare Conditions of Participation.  A hospital that fails to satisfy each of the standards set forth in the Interpretive Guidelines runs the risk of being cited for a deficiency. 

The new patient privacy guidelines will look familiar.   For the most part, they are consistent with the requirements of the HIPAA Privacy Rule.  The guidelines address the need to employ safeguards to minimize incidental disclosures of protected health information, the development of role-based access rules, and restrictions on disclosures through facility directories.

The guidelines, however, go into greater detail on certain topics.  For example, on the subject of patient monitoring, the guidelines state audio or video patient monitoring is permitted only if the patient or his/her representative is aware of the monitoring.  Video recording during treatment is permitted only with prior consent.  

Although not addressed specifically, it is apparent CMS expects hospitals to regularly train employees regarding privacy policies.  The guidelines direct state surveyors to quiz employees regarding those policies and their application in real-life situations.

The guidelines also address disclosure of information from patients’ medical records.  Particularly troubling is the following statement:  “A hospital  must obtain the patient’s or the patient’s representative’s written authorization for any disclosure of information in the medical record when the disclosure is not for treatment, payment or health care operations” (emphasis added).  As we well know, the HIPAA Privacy Rule contains 20 or so more exceptions to the written authorization requirement, including disclosures required by law, disclosures for law enforcement purposes, and disclosures to persons involved in the patient’s care or payment for care – just to name a few.  Hopefully, CMS is not attempting to rewrite the HIPAA Privacy Rule through these new guidelines; this statement will be clarified in the near future.

Content aside, the real reason to pay attention to these new guidelines is that they evidence a new HIPAA enforcement strategy.   Until now, the HHS Office of Civil Rights has been charged with enforcing the HIPAA Privacy and Security Rules.  That agency has the authority to pursue civil money penalties against covered entities that violate these regulations.  Now, CMS is getting into the game, apparently willing to pursue corrective action against a Medicare provider that does not adequately protect patient privacy as defined by HIPAA Privacy Rule standards.  Now routine surveys and complaint investigations may include mini-HIPAA audits.

Now is the time, therefore, to dust off your HIPAA policies and procedures and compare them against the new guidelines, making changes as necessary.  And it’s certainly time to reinforce those rules with your workforce through training and appropriate disciplinary action when violations are detected.

It’s always something, isn’t it?

On Friday, February 10, CMS released a proposed rule requiring Medicare providers to return any and all overpayments within 60 days of identification.   

Here are the relevant portions of new 42 CFR §401.305, Requirements for Reporting and Returning of Overpayments, as proposed:

(a)    General

1. If a person has identified that it has received an overpayment the person must report and return the overpayment in the form and manner set forth in this section.
2. A person has identified an overpayment if the person has actual knowledge of the existence of the overpayment or acts in reckless disregard or deliberate ignorance of the existence of the overpayment.

(b)   Deadline for reporting and returning overpayments.

1. A person with an identified overpayment must report and return the overpayment by the later of either of the following:   
   (i) The date which is 60 days after the date on which the overpayment was identified.
   (ii) The date any corresponding cost report is due, if applicable.

….

(d)   Contents of report.

An overpayment required to be reported under this section to a Medicare contractor must be made in writing and must contain all of the following:

1. Person’s name.
2. Person’s tax identification number.
3. How the error was discovered.
4. The reason for the overpayment.
5. The health insurance claim number, as appropriate.
6. Date of service.
7. Medicare claim control number, as appropriate.
8. Medicare National Provider Identification (NPI) number.
9. Description of the corrective action plan to ensure the error does not occur again.
10. Whether the person has a corporate integrity agreement with the OIG or is under the OIG Self-Disclosure Protocol.
11. The timeframe and the total amount of refund for the period during which the problem existed that caused the refund.
12. If a statistical sample was used to determine the overpayment amount, a description of the statistically valid methodology used to determine the overpayment.
13. A refund in the amount of the overpayment. A person may request an extended repayment schedule as that term is defined in § 401.603.

….

(g) Lookback period.

An overpayment must be reported and returned in accordance with § 401.305 only if a person identifies the overpayment within 10 years of the date the overpayment was received.

In the preamble to the proposed regulation, CMS offers the following examples of when an overpayment has been “identified,” thus starting the 60-day clock ticking:

• A provider of services or supplier reviews billing or payment records and learns that it incorrectly coded certain services, resulting in increased reimbursement.
• A provider of services or supplier learns that a patient death occurred prior to the service date on a claim that has been submitted for payment.
• A provider of services or supplier learns that services were provided by an unlicensed or excluded individual on its behalf.
• A provider of services or supplier performs an internal audit and discovers that overpayments exist.
• A provider of services or supplier is informed by a government agency of an audit that discovered a potential overpayment, and the provider or supplier fails to make a reasonable inquiry.…
• A provider of services or supplier experiences a significant increase in Medicare revenue and there is no apparent reason – such as a new partner added to a group practice or a new focus on a particular area of medicine – for the increase.

Under the proposed rule, it does not matter whether the provider was completely innocent in receiving the overpayment; even if the overpayment was CMS’ fault, the provider will be liable if it maintains the overpayment once identified.  Retention of the overpayment would expose a provider to liability under the False Claims Act (i.e., three times the amount of the overpayment, plus a mandatory penalty of $5500 to $11,000 per claim).  Additionally, CMS advises that “[p]roviders and suppliers should be aware that the contractors will scrutinize overpayments received through this process and may make referrals to OIG whenever the contractors believe circumstances warrant such a referral.”

On February 14, U.S. Attorney General Eric Holder and HHS Secretary Kathleen Sebelius announced $4.1 billion in health care fraud recoveries during 2011, a new record.  Assuming this proposed repayment rule is finalized, you ain’t seen nothin’ yet.

On February 7, the House Ways and Means Health Subcommittee held a hearing focusing on innovative quality and efficiency recognition and reward programs developed by physicians and private payers.  Chairman Wally Herger (R-CA) scheduled the hearing as part of the Subcommittee’s continuing investigation of potential ways to reform Medicare’s physician payment system. 

The subcommittee heard testimony from five individuals on their respective organization’s strategies.  We found particularly interesting the payment models discussed by Lewis G. Sandy M.D., Senior VP of Clinical Advancement at UnitedHealth Group, and David Share M.D., VP of Value Partnerships for Blue Cross Blue Shield of Michigan.

Dr. Sandy discussed the UnitedHealth Premium Designation Program, which analyzes physician performance against national benchmarks for 300 quality and 230 efficiency measures.  A physician’s quality score is measured initially, and only those who meet a pre-determined quality score can be evaluated for cost-efficiency.  All physicians are evaluated relative to their peers’ performance.

The Premium Designation Program shows impressive results.  According to Dr. Sandy’s testimony:

• Cardiologists who earn a quality designation have 55% fewer redo procedures and 55% lower complication rates for stent placement procedures than cardiologists who did not receive the quality designation.
• Orthopedic surgeons who earn a quality designation have 46% fewer redo procedures and a 62% lower complication rate for knee arthroscopy surgeries than other orthopedic surgeons who did not receive the quality designation.
• For all 21 physician specialties that are evaluated using these benchmarks in the program, the incremental savings between a physician who meets quality and efficiency standards and one who does not is 14 percent.

Dr. Sandy also testified concerning lessons learned from medical home projects in 13 states.  Specifically, he opined that any value-driven financial incentives must come from the savings achieved in the ongoing initiatives and must not increase overall costs of care.  Dr. Sandy also offered that one way to spur the development and sustainability for those new risk-bearing delivery models (e.g. medical homes and ACOs) is to create patient demand by developing value-based benefit designs, consumer navigation, and information resources that encourage people to become more active and involved in their own care.

Following Dr. Sandy’s testimony, Dr. Share discussed the Blue Cross Blue Shield of Michigan (BCBSM) Physician Group Incentive Program.  Under this model,  BCBSM pays self-created Physician Organizations a financial incentive based upon claims data.  Initially, BCBSM provides the aggregate, population-level quality and efficiency outcomes data to the Physician Organizations, who are held solely responsible for the net result on cost and quality for that specific population-level.

Each year, BCBSM pays out incentive payments based on absolute performance and rate of improvement.  BCBSM’s incentive pool, which is currently at $110 million per year, is funded through a percentage of all professional payments, and is paid out completely every year.

The program has grown over its seven-year history from ten Physician Organizations representing approximately 3,000 physicians to its current forty Physician Organizations with 15,000 physicians. While the program initially targeted physicians who treated chronic conditions, care transitions, and high cost diseases, it is now open to all specialists.  According to Dr. Share,  the program impacts more than two million BCBSM members and approximately five million Michigan residents.

Originally, BCBSM measured performance based upon efficient use of health care resources and chronic disease case management.  As the program has grown, BCBSM has identified thirty outcomes-based goals founded on quality measures that track the Physician Organizations’ performance.

Dr. Share reported the Physician Group Incentive Program shows significant potential to curb long-term cost growth.  In 2011, BCBSM’s the overall cost growth was 2.1 percent lower than other Blue Plans nationally. 

Both Dr. Sandy and Dr. Share’s testimonies present significant opportunities to utilize delivery system innovations as ways to improve quality, lower costs, and curb the growth of medical expenditures.  While the House Ways and Means Health Subcommittee will surely take note of such programs, providers elsewhere can also look to these initiatives as potential for adding value to their payment models.

On February 6, Jeff Ellis and Martie Ross presented “From Competition to Collaboration:  A New Vision for Rural Health Networks” at the 25^th Annual Rural Health Care Leadership Conference in Phoenix, Arizona.  Jeff and Martie addressed the economic imperative for collaboration among rural providers in the transition from volume-based to value-based reimbursement.  After briefly discussing obstacles to collaboration among rural providers, they analyzed five models for Collaborative Care Organizations (CCOs).  CCOs are a rural alternatives to urban strategies such as consolidation and accountable care organizations.  Jeff and Martie presented real-world examples of CCOs, all of which are transportable to other rural communities.    

To see slides from their presentation, click here.

Historically, policy makers have addressed rural challenges by creating new programs to sustain patient access (e.g., rural health clinics, critical access hospitals, sole community hospitals, rural referral centers), each with its own set of regulations mandating service requirements and rigid frameworks of care. 

As a result, delivery systems have developed to match these regulatory imperatives rather than addressing community need, underscoring the mantra:  form follows finance.  Rural providers have been fragmented and forced into economic and practice silos by the very programs designed to sustain patient access.

Form should follow function.  Rural communities need a delivery model that (1) provides primary care services for all their residents including the uninsured and underinsured in a cost-effective manner, and (2) promotes accountable care among the community’s providers.

Of existing models, the federally qualified health center (FQHC) holds the greatest promise.  It is well established that populations served by FQHCs enjoy better health outcomes because they provide demonstrably improved access to primary care services.  Research demonstrates the cost per-beneficiary per-year for an FQHC patient is significantly less than the cost for a patient seen elsewhere.  More specifically, rural communities served by FQHCs recognize significant health care cost savings. 

However, the establishment of a traditional FQHC is not practical for many rural communities due to strong resistance usually encountered from local physicians.  Competitive tension and distrust between community health centers and local physician practices are well documented.  Adding yet another bricks-and-mortar clinic in a rural community creates costly duplication and disruptive competition in areas already struggling with the economic pressure of low volumes. And as a result, the traditional FQHC model is, for the most part, an unsatisfactory solution to the challenge of securing the rural safety net. 

On the table now is an entirely new model for safety net providers in rural areas:  the virtual community health clinic.  The vCHC would contract with local physicians to care for vCHC patients in their offices.  Contracting physicians would agree to adhere to evidence-based clinical protocols and to report certain quality data, similar to physicians participating in accountable care organizations.  These physicians would be linked to the vCHC through electronic health information exchange. 

The vCHC would set a target payment rate for services furnished to vCHC patients.  For services provided to Medicare and Medicaid beneficiaries, the vCHC would pay the physician the difference between the target payment rate and payment received from the federal program (and any applicable co-payment).  For services provided to uninsured patients who meet certain income standards, the vCHC would pay the physician the full target payment rate (less any sliding scale co-payment).   

vCHC staff would provide care coordination and other support services to vCHC patients in collaboration with contracting physicians.  The vCHC’s care coordinators would employ innovative strategies to improve patient outcomes and reduce costs.

Unlike an FQHC that must invest federal funds in bricks and mortar, the vCHC would use those dollars for direct patient care and technology supports.  It would foster collaboration among the community’s providers rather than introducing another competitor. 

The vCHC model creatively fills a critical void in CMS’ reform strategy:  it is a reliable vehicle to achieve accountable care in rural communities.  By providing physicians a financial incentive to care for the underserved and tying those payments to specific performance standards, the model achieves ends similar to the Medicare Shared Savings Program, but with the crucial added benefit of ensuring full community access to care. 

The vCHC would be funded in the same manner as an FQHC (i.e., grants and cost-based reimbursement).  It would deliver the same level of service to the target population as would an FQHC, but with three distinct advantages: 

1. the vCHC would have lower overhead costs;
2. the vCHC would aggressively employ effective care management with supportive technology; and 
3. the vCHC would lead rural providers willingly down the path to accountable care.

     Lower Overhead Costs

An FQHC involves the same overhead expenses as a physician clinic:  office space, utilities, medical equipment, electronic health records, nursing and administrative staff, and supplies.  By leveraging existing infrastructure, the vCHC model would eliminate duplicative overhead and strengthen the financial viability of local providers by spreading their fixed costs over higher volumes of Medicaid and uninsured patients.

The vCHC would identify and appropriately assign patients to contracted providers who would provide medically necessary primary care services and would be economically incentivized to manage patient care to achieve improved patient and population health.  The provider would submit a claim to the vCHC and be reimbursed for the difference between the target payment rate (e.g., the freestanding rural health clinic payment rate) and the provider’s payment from other sources (i.e., Medicare, Medicaid, and/or the patient). 

In exchange for these “add-on” payments, contracting providers will agree to share patient-level data via connection to an electronic health information exchange for purposes of care coordination and quality monitoring.  Also, these providers would actively participate in evidence-based care pathways and other key components of the patient-centered medical home model, working collaboratively with the vCHC’s chief medical officer to refine and adopt standardized protocols and communication tools.

     Care Coordination and Supportive Technology

Because it has significantly lower overhead costs as compared to a traditional FQHC, the vCHC would divert capital from clinic facilities, equipment, and staffing to a more meaningful investment in patient outcomes through care coordination and supportive technology.  These investments would include a strategically placed care coordination staff and supportive technology linking this staff to providers and patients.

This team of trained coordinators, located throughout the vCHC’s service area, would provide boots-on-the-ground for in-home patient assessment and mental health screening.  Focusing upon a wider range of environmental and patient-specific needs than possible through traditional social screening tools, the frequency and method of one-on-one encounters would remain flexible based upon the identified risk factors of each vCHC patient.  

            Path to Accountable Care for Rural Providers 

The current payment and delivery system and the existing rural practice environment discourage collaboration among rural providers and accountability for their care decisions to the disadvantage of the population served.  The vCHC model, which has evolved from discussions among those frustrated rural providers, would encourage collaboration and provide both economic and professional incentives for them to coordinate care, reduce inefficiencies, and otherwise be accountable for the care rendered. 

The payment and care delivery models now heralded by policy makers as effective vehicles for achieving Triple Aim do not have practical application in the rural setting:

Much of medical management maturation has taken place in urban integrated delivery systems….  Consequently, the ACO concept is based primarily on an urban experience.  An urban model may not be as feasible with multiple independent ambulatory practices…and several smaller hospitals.  Further, a unified mission and consistent approach to health care delivery is common in well-established integrated delivery systems, but not among unaligned rural providers.  Many integrated delivery systems took decades to develop cost-control systems and a unified clinical care culture.  The cultural authority to consistently manage organizational and provider behavior is a strong strategic asset to an integrated delivery system and is often underdeveloped or absent in autonomous and isolated rural practice situations.  Rural provider practices, already frequently smaller than urban practices due to lower population density and greater geographic separation, are likely to be particularly disadvantaged in a system that requires practice redesign, care coordination, and provider collaboration.

A. MacKinney, K. Mueller, T. McBride, The March to Accountable Care Organizations – How Will Rural Fare? The Journal of Rural Health 27 (2011) 131-137

By contrast, the vCHC would create a common care model through which independent rural physicians may practice.  It would provide them with technical and professional assistance to coordinate and monitor care.  The vCHC would allow providers to maintain their prized independence while fairly sharing the load for caring for the under- and uninsured residents of their communities – an ethical and moral commitment they want to fulfill. 

The virtual configuration of the clinic would eliminate the unnecessary expense of bricks and mortar.  Those savings would be reapplied to engage shared care coordinators to facilitate more intimate and effective patient contact and follow-up.  Those savings would be used to enhance technology for better communication among providers and to monitor the health status of patients served.  Those savings would be used to enhance the reimbursement to providers, enabling them to fulfill their commitment to the under- and uninsured.

In addition, the virtual model would enable providers to see patients in their existing offices, which would generally be closer and more accessible to patients than a central bricks-and-mortar facility. 

The result is more personal care; better coordinated care; better technical and professional ability to monitor care; better ability to follow-up with patients; and better capability to demonstrate improved personal health outcomes, community health status, and efficiency.  All of this would be accomplished within the existing rural health culture which values autonomy but which perhaps envies urban medical cultural advantages, such as better reimbursement and professional connections.  The vCHC would hold its contracted providers to the same performance measures imbedded in the Medicare Shared Savings Program.

The vCHC model would effectively create a bridge across what Dr. Atul Gawande has identified as the “cowboy to pit crew” chasm.  Independent rural providers would have the means to work together to the great benefit of the patients they serve without losing their independence, feeling compromised by the collaboration, or feeling overwhelmed by the obligation to serve the under- and uninsured.  The benefits that would be achieved through the vCHC model are real, demonstrable, and replicable across the country.

Additionally, the collaborative has defined very specific measures by which the CDCC Project’s performance will be evaluated, with a focus on improved health outcomes for the target population. Grant monies will support a robust evaluation process, ensuring continuous refinement for maximum benefit.  These evaluative activities also will support models for replicating the strategy in other communities.

Under today’s volume-based reimbursement, there is no incentive for providers to engage in care coordination, and thus there is no skilled workforce to provide these services.  However, new value-based reimbursement models necessitate effective care coordination.  The CDCC Project bridges the gap:  critical investments in workforce development and deployment will ensure care coordinators are integrated into the health care delivery system just in time to meet the demand created under new payment models. 

By building statewide care coordination capacity, the CDCC Project will deliver on the State’s projected eight to ten percent increase in savings on the Medicaid program.  Similar savings are expected for the entire target population. Over the three‐year grant period, the collaborative projects improved scores on identified quality measures reflecting enhanced health status, along with a conservative estimate of 5 percent increase in savings on health care costs for the target population.

The collaborative will lead development of three business models to achieve a sustainable care coordination workforce throughout the state:  (1) work with payers (including state Medicaid MCOs) to establish reliable reimbursement for care coordination services; (2) promote the use of care coordinators to employers or groups of employers to better manage employee health; (3) incorporate care coordination workforce into providers  assuming risk under new payment models (e.g., bundled payments, ACOs)

The collaborative fully appreciates grant funding is seed money only, and that achieving sustainability is as mission critical as achieving improved outcomes and cost savings.  The breadth and depth of stakeholder involvement in the CDCC Project reflects an industry-wide commitment to developing an economic model to sustain this fundamental care transformation.

For a print out of this white paper, click here.

Happy Chinese New Year!!! 

This is the Year of the Dragon.  According to chinesezodiac.com, “dragons symbolize such character traits as dominance and ambition.  They’re driven, unafraid of challenges, and willing to take risks.  They’re passionate in all they do and they do things in grand fashion.”

It seems, therefore, that 2012 is the perfect year to launch our newest product, strategic grant advisory services!  We assist communities and organizations identify grant opportunities, engage in strategic visioning to develop proposals, and oversee the drafting and submission process.  Over the last several weeks, we have been burning up the keyboards filing multiple proposals for the Centers of Medicare and Medicaid Innovation’s Health Care Innovation Challenge Grant Program, the Robert Wood Johnson Foundation’s Payment Reform Strategies for High Value Care, and HRSA’s Rural Health Care Services Outreach Grant Program.  After catching our breath (and turning our Twitter account back on), we will bring you up to date on some of the innovative concepts we have helped develop over the past few weeks. 

In the meantime, here are slides from some recent presentations. On January 18, Martie Ross presented on how payment reform will impact private physician practices.  The presentation to the Greater Kansas City Medical Managers Association examined the economic and political market forces that spurred some of the key transitions the market is undergoing today.  Martie also discussed the on-going issues providers will deal with in the future, including value-based purchasing and physician quality incentives.  Here is a copy of the GKCMMA Presentation.

Two days later, Martie presented to the Kansas Association of Local Health Departments on the KanCare program – the Kansas Medicaid reform effort.  After describing an overview of the new Kansas Medicaid managed care program, Martie laid out strategies to overcome antitrust barriers and achieve new efficiencies through clinical and financial integration, multi-provider networks, and various collaborations.  Here is a copy of the KALHD Presentation.

If you build it, they will come. 
     Field of Dreams (1989)

But what if they don’t?

As we look to “bet the farm” on health insurance reform and the transformation of our payment and delivery system, we must increasingly consider the role of the consumer.  If patients do not follow doctors’ orders and do not make healthy choices, supply side efforts by providers and payers will have little impact in the end.

This was one of the major take-aways from last week’s Care Innovation Summit in Washington D.C.  Jointly hosted by the CMS Center for Innovation, the West Wireless Health Institute, and Health Affairs, the one-day conference drew over 1,200 attendees to explore dozens of promising health care innovations.  Those attendees were challenged to move patient behavior changes to the center of the strategic efforts. 

With new value-based purchasing models (e.g., ACOs, bundled payments), providers will assume risk for patient outcomes, and therefore will have a financial stake in reducing patients’ risky behaviors.  Each patient who fails to take prescribed medications, smokes tobacco, or has a poor diet will take money directly out of providers’ pockets.  There is now a financial imperative to identify and implement effective prevention tools.0

The traditional community-based prevention programs, however, show disappointing results.  Anti-smoking and other substance abuse campaigns all too often have the opposite impact, actually increasing risk behaviors in the target populations.  The effectiveness of these programs tends to collapse under the program’s weight:  overly-complex curriculum, costly and time-consuming training, delayed outcomes reporting.  Simply put, bigger is not better.

By contrast, simple “behavioral vaccines “ show positive results.  Dennis Embry with the Paxis Institute, and a recognized expert on these strategies, defines behavioral vaccines as follows:

1. Any intervention that inoculates recipients against morbidity or mortality - in this case, problematic, aggressive, or potentially dangerous or lethal behavior, hospitalization, incarceration, suicide, or murder;
2. Low cost - exemplified by hand washing to prevent infections, diet and exercise to prevent high blood pressure and diabetes;
3. Ease of administration – would ensure minimum costs and maximum benefits with daily routines, assuring every-day practice with a minimum of training; and
4. Mass administration.     

These vaccines can be “administered” quickly and easily across whole communities using social marketing principles, with stunning results in a relatively short period of  time.

Mr. Embry cites the example of Project Freedom, a community effort to reduce drug and alcohol use in Wichita, KS.  The project was built on a “reward and reminder” platform:  participants issued citations to store clerks who were willing to sell alcohol or tobacco to under-age individuals and commendations to those who refused to do so.  Those stores in the program showed a decrease from 83 percent selling to minors to 33 percent.  The program has been replicated in several other communities with similar – and lasting – results. 

Behavioral vaccines are built on “evidence-based kernels,” i.e., “a behavior-influence procedure shown through experimental analysis to affect a specific behavior and that is indivisible in the sense that removing any of its components would render it inert.”  In Project Freedom, the “kernel” was the proven impact of immediate reward and reminder strategies.  Neither the reward nor the reminder need be significant; instead, the key is immediacy and causal relationship.  For example, promising an at-risk pregnant woman the chance to win a $10 gift card from Wal-Mart if her drug test is clean results in a significant reduction in substance abuse in that population. 

Behavioral vaccines are simple, inexpensive, and effective:  almost too good to be true.  But given the high cost of risky behavior soon to be borne by providers and the promising results, they are a strategy to be incorporated into patient-centered care.