Prescription Costs Returning to the Wild

By Clive Riddle, March 13, 2015

Numerous studies have been warning that prescription cost increases, domesticated and docile for some time now, have returned to the wild - resurging and rearing their unpleasant head.

During last fall, Evaluate published a new 18-page report , "Budget-busters: The Shift to High-Priced Innovator Drugs in the USA." that addresses the growth of high-end prescription drugs. Evaluate tells us that "the median price of the Top 100 drugs has skyrocketed from $1,260 in 2010 to $9,400 in 2014, representing a seven-fold increase," and that "the average patient population size served by a Top 100 drug in 2014 was 146,000 down from 690,000 in 2010. The number of treatments costing in excess of $100,000 per patient per year rose to seven in 2014 versus four in 2010."

When Segal released their 2015 Segal Health Plan Cost Trend Survey, they stated “Health benefit plan cost trend rates for 2015 are forecast to drop slightly for some coverage, but to increase substantially for prescription drug coverage...…The increase in the cost of prescription drug carve-out coverage for actives and retirees under age 65 is expected to jump to nearly 9 percent. Prescription drug trend for retirees age 65 and older is expected to rise to 7.5 percent, more than twice the rate of retiree medical cost trends. The projected specialty drug/biotech trend rate for 2015 is an exceptionally high 19.4 percent.”

A number of other studies cite similar concerns, and this week Express Scripts weighed in with their annual Drug Trend Report. They state “new hepatitis C therapies with high price tags and the exploitation of loopholes for compounded medications drove a 13.1 percent increase in U.S. drug spending in 2014 – a rate not seen in more than a decade.”

Here’s some key selections from Express Scripts findings:

“Hepatitis C and compounded medications are responsible for more than half of the increase in overall spending. Excluding those two therapy classes, 2014 drug trend (the year-over-year increase in per capita drug spending) was 6.4 percent.”

“Specialty medications – biologic and other high cost treatments for complex conditions, such as multiple sclerosis and cancer – accounted for more than 31 percent of total drug spending in 2014. As Express Scripts forecasted last year, specialty drug trend more than doubled in 2014, to 30.9 percent. Hepatitis C medications accounted for 45 percent of the total increase in specialty spend despite having the second lowest prescription volume among the top 10 specialty conditions. Medicare plans – required to follow Medicare Part D formulary guidelines – were the hardest hit, as their annual specialty drug spend increased 45.9 percent.”

“Spending on traditional classes of medications continues to rise as a result of compounded drugs, which emerged in the top 10 traditional therapy classes for the first time. Despite having the least number of prescriptions among the top 10 classes, compounded medications accounted for 35 percent of the increase in spending, the most of any traditional therapy class of drugs.”

“Drugmaker consolidation and drug shortages also led to increases in traditional drug trend, which rose to 6.4 percent in 2014. Diabetes remains the leading traditional therapy class for a fourth straight year based on total costs; Express Scripts expects double-digit increases in spend in this class over the next three years due to once-weekly oral and injectable drugs in the pipeline.  Cost for medications to treat pain increased 15.7 percent in 2014, due in part to new tamper-resistant formulations for opiates.”

2015 – Another Year of Uncertainty?

By Cathy Eddy, Health Plan Alliance, February 25, 2015

This year on March 23, we will mark the 5th anniversary of the passage of the Affordable Care Act. Typically, you would expect that most of the unknowns that go along with a new law would have been worked out by now. Yet as we look ahead, we have several key elements that may change. There are also other drivers that are challenging our health plans.

Here are some of the uncertainties still ahead:

• We now have a Republican Congress with the Senate flipping in the 2014 election. This will allow for legislative changes to ACA to make it to President Obama’s desk, but veto power will block most of these without some Democratic support. Some areas, such as eliminating the device tax and redefining the 30 hour “full time” work week to 40 hours, have bi-partisan support. 
• The Supreme Court has agreed to hear arguments in March about the subsidies on the public exchanges in states where the federal exchange, healthcare.gov, is in place. The wording in ACA indicates that subsidies will only be given if there is a state-run exchange and that would impact about 2/3 of the states using the federal exchange. Their decision is due by June. 
• The health plans on the public exchanges had to set rates for 2015 with little experience about those members in these programs. It will become clearer as this year progresses just what the MLR is for this line of business. By the time open enrollment starts for the public exchanges in 2016, we’ll find out if premiums go significantly higher or stay at current levels. The impact of the 3 Rs on the plans will also become clearer. Standards for being a QHP remain unclear. Introduction of compliance requirements such as consumer satisfaction measurements will be tested in 2015. Technology bugs still abound with data flowing between plans and CMS.
• Individual mandates are in place with increasing penalties for not having insurance coverage, but the implementation of the employer mandate is still uncertain. 
• A new type of insurance company – the state Co-ops – were created by ACA with federal loans. Not all states were able to offer this model. In 2015, some of the established Co-ops are expanding to new states. Others are offering coverage through off-exchange products in the commercial space. Some are struggling to maintain the necessary level of capital.  The future of the Co-op model still has a level of uncertainty. 
• Providers have been embracing the concept of “value based reimbursement,” and the movement away from fee-for-service, but the implementation of this strategy has been much slower than first expected. 
• The trend for the past couple of years has been for providers to become payers and for payers to move more into the provider space. Many members of the Health Plan Alliance have been approached to work with health systems that don’t have their own health plans. Will this trend continue or will providers find that entering the insurance space and taking on more risk is outside of their comfort zone?
• Will 2015 be the year that ICD-10 is finally implemented or will there be another delay? 
• Many states are looking at their Medicaid expenditures and trying to find ways to control increases. Some states have made major changes to their programs and are implementing the changes. Dual eligibles are being moved into managed care programs. Will more states take the federal dollars for Medicaid expansion? 
• Plans that are in the Medicare Advantage line of business continue to be challenged by risk adjustment, STAR ratings and reimbursement levels, as well as multiple audits. As plans expand these programs they continue to deal with uncertainty.

Well, at least 2015 won’t  be boring!

How the Mighty Haven't Fallen

By Kim Bellard, February 17, 2015

I recently read an article that speculated on how even the mighty Google could fade into irrelevance faster than we might think.  It made me wonder why that kind of change doesn't seem to happen in health care.

The Google article, by Farhad Manjoo in The Wall Street Journal, cited one-time technology leaders like Wang and DEC, and pointed out that other long-time powerhouses such as Hewlett Packard and even Microsoft are furiously trying to reestablish themselves after decades of (relative) decline.  

Then there's health care.

Just out of curiosity, I looked at share of spending by type of service in the National Health Expenditures, from 1960 to 2013.  Here's what I found:

For all our many clinical and technological advances, the same three health sectors that dominated health care spending in 1960 still command virtually the same shares in 2013 -- over 60% of our overall spending.  They've "lost" less than 2% of share to other types of spending during those decades.  

It hasn't all been smooth sailing, of course.  Hospital spending reached almost 40% in the early 1980s, dipped below 30% in the early 21st century, and rebounded this decade.  The physician share has been steadier -- a peak of around 22% in the early 2000's, a low of 18.3% in 1978, but mostly stayed around 20%.  Prescription drugs spending, on the other hand, got to as low as 4.5% in 1981-82, reached a peak of 10.4% in 2006, and now seems to be on a slow decline.  But, all in all, the composition of Big 3 of the medical-industrial complex remains unchanged over a very long time.

It's as if the Big 3 U.S. auto manufacturers still maintained their 1960 dominance today, or the 3 TV broadcast networks still had their pre-cable/Internet share of viewers.  Both trios still have hefty market shares, still play key roles, but are nowhere near their historical dominance. New competitors emerged to give consumers more options, and took away significant shares of those markets.  

Unlike what has happened in health care.  

Hospitals, physicians, pharmaceuticals, and the health care industry generally have certainly evolved significantly in the past 50+ years, but it is more incremental evolution than the kind of "punctured equilibrium" Steve Jay Gould and others posit that result in rapid changes that overthrow species.  

I don't have anything against hospitals, doctors, or prescription drugs, at least not in principle.  It just doesn't feel like progress that we're not coming up with radically new care and delivery options that don't rely on them.  

Unlike most markets, health care isn't really driven by consumer demand.  A couple years ago, JAMA published a survey of physicians, in which  they blamed rising costs on pretty much everyone else but themselves, more than half even blaming patients.  A new study has cast doubt on the view that patient demand is driving unnecessary spending.   The saddest thing for me from the study was that only 8.7% of patient encounters included a patient demand.  We're a long, long way from informed patients taking responsibility for their own care, or their own health.

Having control over what constitutes the "practice of medicine" is certainly an effective way of forestalling new kinds of competitors.  That control has been placed in the hands of the providers practicing care, ostensibly to safeguard patients' interests,. but it's getting harder and harder to believe those interests are primary.  It seems more like protecting turf.  

A couple months ago I wrote a post that raised the question of whether, in a world where microbiome treatments, gene therapy, even nanobots may emerge as prevailing types of treatment, we'll even need physicians, at least in the same way we do now.  I received a number of comments that were aghast at the notion that we might not always need physicians to deliver our care.  I believe it is this kind of thinking that has allowed the Big 3 of health care to retain their dominance.  

If we can't even imagine a health care system that doesn't solely rely on the traditional sources of care, we'll certainly never achieve one.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Making the Old New Again

By Kim Bellard, January 22, 2015

I always love it when someone looks at something familiar in a completely new way.  I only wish health care had more examples of that.

The example of this kind of totally fresh thinking that caught my eye concerns traffic lights.  If researchers from Carnegie Mellon University, led by Professor Ozan Tonguz, have their way, those familiar yellow boxes with the lights could become unnecessary.

The CMU researchers have developed "virtual traffic lights" (not to be confused with the separate CMU "smart traffic signals" project).  Instead of using physical traffic lights, lights would show up on the driver's dashboard as needed.  As Professor Tonguz told CNN: "With this technology, traffic lights will be created on demand when [two cars] are trying to cross this intersection, and they will be turned down as soon as we don't need it,"

The researchers claim the virtual, on-demand signal could reduce commuting times by 40%, as well as reduce carbon emissions and accidents.  And, of course, we wouldn't need all those physical lights; think of the savings on new lights, poles, and wires, plus on ongoing maintenance.

All that would be required is that every car -- and that means, every car -- is equipped with the required vehicle-to-vehicle communications technology.  No small task!  Some think this could happen in a year or two, others a decade or two.  Either way, it's mind-blowing to think that such a familiar part of our driving experience could be so utterly transformed by what seems, in retrospect, such an obvious solution.

Let's contrast this kind of thinking with health care.  Yes, I know -- health care has plenty of new technology and many kinds of improved treatments, but I'm not sure we're getting a lot of reinventing.  Where are our virtual traffic lights?

One small -- well, maybe not so small at that -- health care example is a new patient tracking system called PatientStormTracker, developed by Lyntek Medical.  As the name suggests, PatientStormTracker borrows from weather tracking to present patient monitoring data as systemic color monitoring.  Instead of trying to follow the usual rows and rows of data, clinicians can actually see a patient's status -- color-coded -- and watch it progress in real time, including which body systems are currently being impacted and how much.  

Lyntek's founder and CEO, Dr. Laurence Lynn, told The Columbus Dispatch that traditional patient monitoring is like a fire alarm -- either on or off.  As he said: "We have this simple fire alarm idea that existed from the 1980s, and it didn’t evolve, it didn’t improve."  Dr. Lynn wants to monitor patterns and detect trends earlier, when interventions are more likely to be effective.  PatientStormTracker is in clinical trials.  

One proponent of radical changes in health care has long been Dr. Eric Topol, who happens to have a new book out (The Patient Will See You Now: The Future of Medicine Is In Your Hands).  I have not yet read his book, but I did read his related op-ed in The Wall Street Journal.  His version of virtual traffic lights, if you will, is the smartphone.

Dr. Topol outlines not just increasingly common functions like virtual visits or monitoring using a smartphone, but also apps that assist with testing and even diagnosis.  I especially like his prediction that wearable sensors will make it possible that "...except for ICUs, operating rooms and emergency rooms, hospitals of the future are likely to be roomless data surveillance centers for remote patient monitoring."  That would certainly upend how we view hospitals...finally.

Perhaps those remote patient monitors will use something like PatientStormTracker.

The smartphone technology options are cool, but what Dr. Topol sees as an even more important trend in putting all the newly-captured data in the cloud, mining it, and using it to target interventions.

Changes are going to come at us from seemingly left field.  We can never be quite sure where they will lead. It just takes some innovator to see the familiar in a different way -- and then manage to convince us, and the medical-industrial complex, to change.  

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

What exactly is Qliance?

By Clive Riddle, January 16, 2015

Qliance, recently discussed in Time Magazine as they are quick to tell you, just issued a news release  that their New Primary Care Model Delivers 20 Percent Lower Overall Healthcare Costs, Increases Patient Satisfaction and Delivers Better Care.

Qliance conducted a study "of insurance claims data from 2013 and 2014 for approximately 4,000 Qliance patients covered by employer benefit plans, and compared the cost of their care to that of non-Qliance patients who worked for the same employers. The results revealed a savings of $679,000 per 1,000 Qliance patients on total claims –19.6 percent less than the total claims for non-Qliance patients during the same period."

Here’s data from a table they provided:

	Incidents Per 1,000 Qliance patients	Incidents Per 1,000 Non-Qliance patients
ER Visits	81	94
Inpatient (days)	100	250
Specialist Visits	7,497	8,674
Advanced Radiology	310	434
Primary Care Visits	3,109	1,965

Impressive enough data, albeit its hard to know how much is apples to apples in the comparison. But the bigger question from examining this, is what is Qliance, what the heck is a Direct Primary Care model, and how is it different from other, more familiar models?

The first question is how exactly does one pronounce Qliance? The website FAQs didn’t have an answer for that question – like “clients” one would assume.

The next question would be, is Qliance a form of health coverage? The answer would be yes and no. Yes – you can contract to receive their medical services for a fee, but no – they are not an insurance plan.  One might think so when first arriving at their website – the navigation menu  refers to Members, Clients, Locations, etc, so one might assume Qliance is an integrated health plan.

But it is not.  As their FAQs will inform you, they are NOT insurance.  Instead they charge a monthly fee to provide primary care, with no fee for service charges.  Here’s what they say:  “We work directly for our patients to provide direct primary care. Your monthly care fee pays for our primary and preventive care services. Qliance does not bill any insurance carrier for our services, and Qliance monthly care fees are not reimbursable by any health insurance company, and may not be applied to any insurance plan deductible. Your insurance plan may be billed by others for services such as emergency, hospital, specialty care, laboratory tests, diagnostic imaging, prescription drugs or other goods and services that are ordered by your Qliance health care provider but are not performed or provided in our offices.”

So with or without health insurance, you can pay Qliance a monthly fee, and receive all the coordinated direct primary care services you want. But you or your health insurance, and not Qliance, will pay for any healthcare services Qliance does not provide. And depending on the type of managed care plan you have. your health insurance won’t pay for outside services ordered or prescribed by your Qliance doctor.

Sounds like a major stumbling block. Except that Qliance also works with self-insured employers to integrate with their health benefits.  Again, quoting from Qliance FAQs:  “We can work with any type of insurance plan. Most employers that incorporate Qliance into their benefits plans save 10% or more, with some employers saving over 40%”

Reading up on all the bells and whistles of Qliance – they seem to be a hybrid of a patient-centered medical home, concierge care, retail/urgent care clinic, with some purchaser-like capabilities. So the question is, in an age where integrated care holds much potential promise – why not keep moving bit by bit down the spectrum towards the purchaser end of the bar?

Perhaps first Qliance will just need to keep moving – to some additional locations. Right now you’ll just find them in the Seattle – Tacoma metro area of Washington.

Your Healthcare Lexicon for 2015 from A to Z

by Clive Riddle, January 9, 2015

Accountable Care Arrangements in Medicare, Commercial and Medicaid flavors

Big Data in healthcare parsed with Analytics

Collaboration between providers and purchasers

Deductibles loom large with continually increased consumer cost sharing

Engagement by purchasers with consumers and with providers

Federally Facilitated Marketplaces may or may not be able to provide future subsidies (see “K” & “S”)

Generic Drug prices are on the rise

Health Insurance Exchanges (Marketplaces) both public and private

Innovation Officers abound in health systems trying to transform how they do business

June is when we should find out what SCOTUS has to say about the next item (see “K”)

King vs. Burwell looms large on the Supreme Court docket

Long Term Care continues to be largely ignored while boomers age away

mHealth technology advances on all fronts

Narrow Networks are being deployed in Exchanges and elsewhere

Obamacare somehow remains the politically charged umbrella term for all things Affordable Care Act

Population Health Management has been embraced in the mainstream of plans and health systems

Quality Measures are being transformed with advances in analytics and reporting capabilities

Republican control of Congress ensures continued chipping away at the Affordable Care Act

Subsidies for public exchange enrollment are threatened (see “F”, “K” and “R”)

Tax Filings now require healthcare coverage information,

Uninsured are the topic of conversations of health plan marketing departments and political pundits

Value Based Purchasing is being sought by almost every purchaser

Wellness Programs for employers are being significantly scrutinized for effectiveness

X-Prizes in healthcare are on the rise with Innovation initiatives (see “I”)

Young Invincibles reluctant to signup for healthcare coverage (see “U”)

Zebras – may be easier to find in healthcare with advances in Big Data and analytics (see “B”)

The Convenience Truth

By Kim Bellard, December 17, 2014

The U.S. Mint reports that it now costs 1.7 cents to make a penny; nickels are slightly better, costing "only" 8 cents to make the 5 cent coin.  This is economics the way health care practices it.

According to Christopher Ingraham of the Washington Post, we could save $100 million annually by eliminating both coins.  Or we could change the metal composition to make them cheaper, but that would create havoc with vending machines.  So we just blithely chug along, mostly because we've always had them and the businesses that revolve around them don't want to change.

See how this is like health care?

What made me think about this was a recommendation from Britain's National Institute of Health and Care Excellence (NICE).   They now say that midwife-led birthing units are safest, and advised more women to consider them for low risk pregnancies.  They believe this could account for as many as 45% of live births.  Moreover, they think home births are just as safe as births in a hospital.  The Netherlands is considered the leader in home births, at a little under 25%.  The U.S. has 1.36% home births.

The literature -- often drawn on Netherland's data -- generally supports the NICE recommendation, but not everyone is convinced. It would be very easy to weigh all the factors, and conclude that even a relatively small increase in risk is not something you'd want to take for your own baby, and opt for the "traditional" OB/hospital delivery.

This is where the penny analogy starts to really apply.  These decisions on risk reduction are not without financial consequence.  A vaginal delivery with no complications averages about $10,000, whereas a birthing center costs under $2,500, according to Childbirth Connection.  I assume home delivery is less expensive.

In a piece for The New York Times, professor/physician Aaron Carroll notes that the ACA-created Patient Centered Outcomes Research Center is explicitly prohibited from considering cost effectiveness.  Its website says: "We don’t consider cost effectiveness to be an outcome of direct importance to patients."

Huh?

In theory, value-based purchasing will help us address these decisions.  In practice, though, most of the value-based purchasing arrangements I am aware of -- and that certainly is not an exhaustive list -- reward providers whose outcomes are simply what we'd hope for, may penalize them slightly for disappointing results, and are indifferent about if the care could have safely been done elsewhere for less.

I'm beginning to think that trying to reshape our health care system through value-based purchasing, cost-effectiveness, or even greater transparency may not work.  The "killer app" may not prove to be any of those high-minded strategies but rather a much more basic one: convenience.

Indeed, one of the earliest urgent care chains attributes its inspiration to the example of McDonald's.  We are, after all, the nation that invented fast-food, decided even that wasn't fast enough and so invented drive-throughs, which we use for over half of our fast food.  We liked the convenience of them so much that we've extended the approach to banks, car washes, pharmacies, even weddings and  funeral homes.  The concept of drive-throughs itself is rapidly being supplemented and even superseded by mobile apps, allowing consumers not to even have to get in their car.

Health care cannot ignore these consumer demands for more convenience.

Walgreens' chief medical officer recently noted that: "The idea of convenience ... is really becoming a dominant theme in health care."  It's no coincidence that Walgreens has been investing in in-store clinics, has a 24/7 Pharmacy Chat option, and just rolled out a direct-to-consumer physician virtual visit app, similar to American Well's Amwell service.  Not to be topped, Kaiser is now offering EMT home visits, in addition to its array of in-office and virtual visit options.

Our traditional approaches to care delivery have revolved around convenience for the providers, not the consumers.  Many consumers, especially younger ones, find ridiculous the notion that they have to call for an appointment that may end up weeks away, go to an office or facility that may not be close, only to wait there with sick people, and perhaps be sent to some other office or facility for more services.  They'd rather get their care via their mobile devices and/or in their home, and the technology is increasingly allowing that for many health concerns.  

We've come to recognize that health care is one of the few industries where technology typically not only doesn't lower costs but usually adds to them.  Maybe, though, expecting providers whose revenue is at stake to focus on cost-effectiveness is asking too much of them.  Focusing on convenience shouldn't be.

Focusing on convenience is simply a way to make sure we're focusing on the consumer (AKA "patient").  Isn't that supposed to be the point?

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

The Age of Discontinuity

By Cathy Eddy, Health Plan Alliance, December 8, 2014

Newt Gingrich and David Nash

On December 2, I was invited to be on a panel at a Health Care Executive Forum in Washington DC that was sponsored by the Academy of Managed Care Pharmacy. David Nash, MD, MBA, dean of the Jefferson School of Population Health facilitated discussions about:

• Population Health and the Insurance Marketplace (my panel) 
• Narrow Network vs Value Network: Where’s the Greater Value? 
• Specialty Pharmacy & Biosimilars: Improving Population Health?  

One of the most interesting aspects of the day-long discussion was the morning keynote by the Honorable Newt Gingrich, the author of the Contract for America and Speaker of the House when the Republicans took both the House and the Senate in 1994 – a political point in time that parallels the recent 2014 election.

He referred to one of his mentors Peter Drucker and a book he wrote in 1968 called “The Age of Discontinuity.”  I’ve read some of Drucker’s work and always found it to be very insightful, but I hadn’t heard about this book, so I looked it up and found this summary:

Drucker begins by examining four major areas of obvious discontinuity:

1. The explosion of new technology and its resultant new technology 
2. The development of knowledge as a result of mass education and its impact on work, life, leisure and leadership
3. The social and political realities of the new industries
4. The change from an inter-nation economy to a world economy. 

He was writing this in a time before cable TV, the internet, cell phones or the fall of the Berlin Wall. But I do remember 1968 as a year of political unrest in this country.

However, Drucker's framework for discontinuity is very relevant today and especially to the challenges that are facing the health care industry. Here are some of my take-away perspectives from the discussion we had in DC:

• We are trying to leverage and integrate multiple forms of technology as part of our approach to care. The smart phone, which is with people now 24/7, will become the monitoring and informational tool of choice in the future.
• As healthcare pushes the “consumer” to become more self-governing, the value of information as a driver of behavior continues to grow, while at the same time the expectation is for more services, but at a lessor cost.
• ACA – what happens next? The direction and degree to which the new Congress can change the current health care law is uncertain. The impact of a Supreme Court decision on subsidies can impact millions on the exchanges run by healthcare.gov. 
• How will the instability of the rest of the world impact the US economy and spending demands, while an increasingly large portion of the federal budget is going toward healthcare expenditures?

Although it is clear that healthcare has the attention of leaders in business, state government, Congress and the Supreme Court, it is as yet unclear how that attention will change our industry in the future.

The health insurance industry by definition manages risk, but in this “Age of Discontinuity,” it is hard to plan for some of the risks that are coming our way. Hold on - 2015 looks to be an interesting year.

What’s In a Name?

By Clive Riddle, December 3, 2014

Wellpoint is now Anthem. The re-titling of the national health benefits company was publicly announced months ago, the new corporate website has been designated as www.antheminc.com, and the change from the New York Stock Exchange ticker from WLP to ANTM became effective today.  

WellPoint Health Networks and Anthem merged in 2004, with WellPoint assuming the corporate name of the merged company. Why the name change back to Anthem ten years later? It’s mostly about branding. Joseph Swedish, Anthem’s President and CEO tells us “the change to Anthem will help us better communicate our values and simplify the way we connect with our associates, consumers, investors, and the communities we call home.” Simply put, the company has lots of products around the nation branded as Anthem. They have none branded as WellPoint.

So why did they take the WellPoint name in the first place? Branding may have been less the issue at the time than negotiations between two large BBCBS for-profit corporations. The corporate headquarters went to Anthem’s Indianapolis, but with the WellPoint name. WellPoint’s Leonard Schaeffer got the title Chairman of the Board; Anthem’s Larry Glasscock took the title President and CEO. A telling sign of the shifts in competing corporate cultures and recognition of the branding issue would have been in 2009 when the flagship from the WellPoint camp, Blue Cross of California, assumed the trade name Anthem Blue Cross.

The era of corporate names that are independent of the subsidiary divisions and products seems to have faded as branding is deemed more essential.

As we dig around through the graveyard of bygone healthcare names, the branding issue is forever complicated by mergers, acquisitions, spinoffs and scandals. 

Humana once was a hospital company that developed a health plan division, back when corporate integration of healthcare was in vogue in the 1980’s, before falling out of favor in the 1990’s and re-discovered this decade. Humana’s hospital division was spun off as Galen Healthcare, which was acquired by Columbia, which merged with HCA to become Columbia/HCA, and finally just HCA (Hospital Corporation of America), partially to simplify branding, and perhaps more to re-brand away from the Columbia identity after a Medicare fraud scandal in 1997.

Tenet was once National Medical Enterprises, becoming Tenet in 1995 partly to re-brand after large acquisitions, but motivated to distance from the NME name after scandals with NME’s Psychiatric hospitals division.

In New York, Group Health Inc. and Health Insurance Plan of New York merged in 2006, under the corporate name EmblemHealth. Eventually, the corporate name became branded as a product name. Such strategies - to deploy the corporate name in branding - have become much more prevalent during this decade.

But then there is Regence, the Pacific Northwest BCBS company who in 2011 announced their new corporate name would be Cambia Health Solutions, while the health plan products are still branded Regence.  So what’s in a name – and in 2024 will Cambia pull a WellPoint and re-title themselves as Regence?

The Future Is Still Not Here

By Kim Bellard, November 13, 2014

US News & World Report had some fun looking back at what experts in 2004 predicted for health care in 2014.  Not surprisingly, they found that we're not quite there yet, but might be by 2025.  The future, it would appear, is always ten years away. 

Those 2004 pundits expected that health care would be one of the industries most impacted in these past ten years; specifically:

2004 prediction: In 10 years, the increasing use of online medical resources will yield substantial improvement in many of the pervasive problems now facing healthcare—including rising healthcare costs, poor customer service, the high prevalence of medical mistakes, malpractice concerns, and lack of access to medical care for many Americans.

Whoops.

To be sure, there have been several important changes in our health care system over the past ten years.  Some of the more important ones would have to include:

• PPACA has assisted several million more people to obtain coverage.
• HITECH has spurred EHR adoption.
• Share of coverage through employers has dropped significantly.
• Provider consolidation continues relentlessly.  

In terms of realizing those predictions about controlling costs, improving customer service, reducing medical mistakes, or addressing malpractice concerns: well, not so much.

The absolute number of the uninsured has only dropped from 42.0 million in 2004 to 40.7 in 1Q 2014.  Increases in spending have moderated, thank goodness, but most experts attribute this to the recent economic downturn rather than to any structural changes.  Half of Americans now have a chronic disease, and our life expectancy rates still lag most other developed nations -- and may be declining.

If this is progress, I'm not sure we can take much more of it.

By way of contrast, think about the technology world in 2004:

• Apple was selling the heck out of iPods, with the iTunes Music only a year old.  The iPhone, iPad, and App Store were only gleams in Steve Job's mind.
• Google had just gone public.  Google Maps had yet to debut (2005) and its Android mobile platform was years away (2007).  
• Most mobile phones did not have cameras, the Motorola RAZR was the cool phone, and the Blackberry still set the standard for what passed as smartphone, with the Palm Treo giving it a run for its money.
• Facebook was still limited to university users, and Twitter was two years away from its first tweet.   
• YouTube did not exist (2005), and Netflix hadn't started streaming (2007).

Why isn't health care seeing those kinds of radical changes in the landscape? 

Certainly there have been plenty of important clinical innovations in the last ten years.  Still, I'm hard pressed to think of changes that have become part of people's everyday lives the way that the above tech changes have, 

Critics might claim that smartphones, social media and video streaming don't improve the quality of life, but just dare to try to take them away from people.  By contrast, if you offered to swap health insurance plans from 2004 with today's, I bet most people would jump at the chance, since they cost about 40% less and typically had much lower cost sharing requirements (Kaiser Family Foundation).

I'm also waiting for reports of either physicians or patients being delighted by all those EHRs.

The U.S. News & World Report article mentioned telemedicine as an example that many (still) predict as a key part of the future.  Honestly, if a big breakthrough for 2024 is wider use of telemedicine, I'll be disappointed. 

Don't get me wrong: I'm a big proponent of telemedicine, but in ten years shouldn't we be hoping for something more radical -- like, say, holographic or virtual reality visits?

Or maybe the future is wearables, as everyone is trying to get in on the expected gold rush.  I suspect that wearables in 2024 will bear as much resemblance to today's as our mobile phones do to 2004's, but the real problem won't be the technology as how we'll use all that data.  By 2024 we should be using real-time data to prevent hospitalizations and other acute episodes, but who will pay for, and act on, the monitoring and interventions?

Some people might argue that other ACA initiatives, like ACOs or value-based purchasing, simply haven't had enough time to prove their worth.  That may be valid, but I'm still not seeing the where-did-that-come-from aspects of either.

If in ten years we're all getting care through integrated delivery systems like Kaiser, that might be better for us, but it wouldn't be a breakthrough.

As I wrote in Getting Our Piece of the Pie, I want to see health care's versions of Napster: innovations that are willing to wreck the system in order to reshape it.  I want to see something that connects us to our health in the way that Facebook has connected us with our social circle, that democratizes health information and even treatments like Wikipedia has done for reference, or that untethers us in the way smartphones and YouTube have.&

Let's not wait ten years.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Healthcare Innovation Models and Accelerators

By Clive Riddle, November 7, 2014

Intermountain Healthcare and Healthbox just announced an interesting healthcare innovation collaboration, with their Innovation at Intermountain Healthcare Initiative. Intermountain is the Utah-based health system non-profit juggernaut with 22 hospitals, 185 clinics, 1,100 employed physicians, and the SelectHealth health plan.

A physical structure in Salt Lake City is being constructed next to Intermountain’s flagship medical center to house the initiative, which includes three components:

1. The Intermountain Foundry which they state “provides a structured framework for help high-potential employee ideas and near-market concepts become commercial businesses.”
2. Strategic Investments that “will source companies from the broader healthcare ecosystem and develop partnerships that include investment and potential customer relationships.”
3. The Healthbox Salt Lake City Accelerator, which launched in September in partnership with Health Equity, Zion’s Bank and BD.

Healthbox sees themselves as a “preeminent source of healthcare innovation and drives actionable collaboration between inventors, entrepreneurs and the healthcare industry.” They have operations in five key markets across the U.S., in addition to London and Tel Aviv, and a portfolio of more than 80 active companies and strategic partnerships with more than 30 healthcare organizations.

Speaking of Accelerators, the just released November issue of Healthcare Innovation News addresses the question “how can healthcare accelerators ensure success in their quest to nurture entrepreneurs and support their startup ventures?” in their Thought Leaders’ Corner. Below are three selected responses to this question from their Thought Leader panel.

Tom Olenzak, Director, Innovation at Independence Blue Cross in Philadelphia says “we believe that the key issue facing healthcare innovators is access to customers. The investment of time, expertise and resources by potential customers is critical to help startups turn their innovative ideas into sustainable businesses and products. That’s why we participate in healthcare accelerator programs, such as DreamIt Health Philadelphia. DreamIt Health puts a focus not only on providing funding, but also on the mentorship and access needed to nurture the startups.  I’ve seen firsthand how access to a customer’s point of view, along with business knowledge and data, can have a direct impact on the success of startups. Last year we provided anonymous claims data to the startup Grand Round Table and these data helped the company to solidify its value proposition, helping doctors find appropriate diagnoses faster and reducing the number of unnecessary tests and treatments. The healthcare industry, as we know it, is experiencing dramatic change, and the future of the industry relies on innovative thinking to overcome our biggest challenges. Healthcare accelerators that establish the perfect blend of entrepreneurial coaching and corporate support are the ones that will be successful in developing ventures that push the envelope, and deliver solutions that provide high-quality, affordable care that patients deserve. The future of our industry depends upon innovation, but the opportunities are endless when you embrace partnership and have the right mix of bright minds. Most accelerators help companies grow, but those that provide access to customers and other decision makers breed startups that develop sustainable and scalable solutions to the most pressing challenges.”

Scott Shreeve, CEO at Crossover Health in California says he believes “the challenge for health accelerators is to nurture disruptive ideas and companies yet remain connected to the needs of healthcare providers and payers. Accelerators are good at incubating consumer-focused, digital health innovations. Exciting for sure, but we don’t always see how these isolated innovations bridge the ongoing divide between consumers and providers, and the realities of our current third-party payer system. This is critical in our view because transforming the costs and quality of care won’t be consumer, provider or payer led, but a powerful mix of all three. Crossover Health works with leading employers to deliver primary care services directly to employees via worksite, near-site and virtual care models. We focus on delivering an exceptional patient experience, which not only develops deep patient/provider relationships but also inspires people to take ownership of their health. Innovative provider-led, care delivery and new direct payment models support our experience-centered approach. And, critical to its success are our discovery and adoption of digital health technologies that create new channels of communication, enable population health analytics and facilitate chronic health management in new and different ways. Accelerators can help ensure the success of their startups by making a strong effort to collaborate with equally disruptive providers, who are working with payers that are willing to think differently about health. It’s the responsibility of the accelerator to match different key players together to yield the greatest opportunities and results. By creating a mutual selection process, accelerators can show the power and values of true technology and market disruption.”    

Jason Wainstein, Principal at Deloitte Consulting in Philadelphia shares that “ensuring success is a lofty quest given the nature of accelerators. Not all ideas will pan out. So it’s not about batting 1000; its about providing the best environment to foster the maturation of concept into a viable business. Four dimensions that are critical for accelerator success are: Maintain the right temperature. Many start-ups are focused on building their product/service offering and can benefit from enhanced structure and commercialization cadence, as well as lessons learned from prior startups. Providing a playbook allows the thought leaders to stay focused on building the business. Perfect the role of super connector. One of the greatest values of an accelerator is connecting startups with industry leaders, potential investors and target distribution channels. The top accelerators work relentlessly at building their networks and actively connecting their portfolio companies to these relationships. Be a talent agent. With top talent in high demand, having a network of highly skilled resources that can be brought to bear on short notice can make the difference between success and failure given how aggressively startups must move. Know the white space. There is no shortage of ventures that pop up to capitalize on the hype of the moment, for example, analytics, patient engagement, chronic disease and remote monitoring—like moths to a light. Knowing the white space within these areas and guiding startups to differentiated positions are critical. Otherwise, young companies risk becoming noise in an overcrowded system. Accelerators must treat each startup as a customer, focus on the four dimensions above and be selective in which ideas are brought into the fold based on cultural and content fit.”

Derek Newell, CEO of Jiff in Palo Alto says that “accelerators, by definition, exist to help develop very early stage companies. At this stage, entrepreneurs must transition their companies from a concept phase to a delivery phase. In order to do this effectively, they need to clearly define their value proposition, product and business model. There are two key ways accelerators can support entrepreneurs in facilitating this process.

First, accelerators should connect entrepreneurs to potential customers. Customers validate the product and let companies know they have a commercially viable concept. Talking to customers is the most important thing a startup can do to refine its value proposition. In addition, customers provide critical feedback on product. For the first time, the venture will understand the problem and their target customer’s’ needs at the level of detail necessary to create a meaningful solution for it. Finally, accelerators can help startups figure out their business models early. Many entrepreneurs coming into the healthcare space lack a deep understanding of the complexities and nuances of the industry. Unless the venture is developing a new technology, there is probably a good reason that the solution doesn’t already exist. Within an accelerator, industry experts can help the entrepreneur identify and understand the stakeholders, existing systems and barriers to entry. The forces inhibiting the adoption of the company’s solution could include technology, regulation, operations and/or sunk costs, just to name a few.

By introducing entrepreneurs to potential customers and helping them better understand the healthcare industry, accelerators can help startups navigate this space and support them as they refine their value proposition, business model and product.”

Top Ten Medical Innovations for 2015

By Clive Riddle, October 31st, 2014

The Cleveland Clinic annually announces their take on the Top Ten Medical Innovations that are likely to have major impact on improving patient care in the coming year. They have just released their ninth annual version of this list, selected by a panel of 110 Cleveland Clinic physicians and scientists. With no further adieu, here – verbatim – is their narrative on their compilation of the Top 10 Medical Innovations for 2015:

1. Mobile Stroke Unit
   Time lost is brain lost. High-tech ambulances bring the emergency department straight to the patient with stroke symptoms. Using telemedicine, in-hospital stroke neurologists interpret symptoms via broadband video link, while an onboard paramedic, critical care nurse and CT technologist perform neurological evaluation and administer t-PA after stroke detection, providing faster, effective treatment for the affected patient.
2. Dengue Fever Vaccine
   One mosquito bite is all it takes. More than 50 to 100 million people in more than 100 countries contract the dengue virus each year. The world's first vaccine has been developed and tested, and is expected to be submitted to regulatory groups in 2015, with commercialization expected later that year.
3. Cost-effective, Fast, Painless Blood-Testing
   Have the days of needles and vials come to an end? The new art of blood collection uses a drop of blood drawn from the fingertip in a virtually painless procedure. Test results are available within hours of the original draw and are estimated to cost as little as 10% of the traditional Medicare reimbursement.
4. PCSK9 Inhibitors for Cholesterol Reduction
   Effective statin medications have been used to reduce cholesterol in heart disease patients for over two decades, but some people are intolerant and cannot benefit from them. Several PCSK9 inhibitors, or injectable cholesterol lowering drugs, are in development for those who don't benefit from statins. The FDA is expected to approve the first PCSK9 in 2015 for its ability to significantly lower LDL cholesterol to levels never seen before.
5. Antibody-Drug Conjugates
   Chemotherapy, the only form of treatment available for treating some cancers, destroys cancer cells and harms healthy cells at the same time. A promising new approach for advanced cancer selectively delivers cytotoxic agents to tumor cells while avoiding normal, healthy tissue.
6. Checkpoint Inhibitors
   Cancer kills approximately 8 million people annually and is difficult to treat, let alone cure. Immune checkpoint inhibitors have allowed physicians to make significantly more progress against advanced cancer than they've achieved in decades. Combined with traditional chemotherapy and radiation treatment, the novel drugs boost the immune system and offer significant, long-term cancer remissions for patients with metastatic melanoma, and there is increasing evidence that they can work on other types of malignancies.
7. Leadless Cardiac Pacemaker
   Since 1958, the technology involved in cardiac pacemakers hasn't changed much. A silver-dollar-sized pulse generator and a thin wire, or lead, inserted through the vein kept the heart beating at a steady pace. Leads, though, can break and crack, and become infection sites in 2 percent of cases. Vitamin-sized wireless cardiac pacemakers can be implanted directly in the heart without surgery and eliminate malfunction complications and restriction on daily physical activities.
8. New Drugs for Idiopathic Pulmonary Fibrosis
   Nearly 80,000 American adults with idiopathic pulmonary fibrosis may breathe easier in 2015 with the recent FDA-approval of two new experimental drugs. Pirfenidone and nintedanib slow the disease progress of the lethal lung disease, which causes scarring of the air sacs. Prior to these developments, there was no known treatment for IPF, in which life expectancy after diagnosis is just three to five years.
9. Single-Dose Intra-Operative Radiation Therapy for Breast Cancer
   Finding and treating breast cancer in its earliest stages can oftentimes lead to a cure. For most women with early-stage breast cancer, a lumpectomy is performed, followed by weeks of radiation therapy to reduce the likelihood of recurrence. Intra-operative radiation therapy, or IORT, focuses the radiation on the tumor during surgery as a single-dose, and has proven effective as whole breast radiation.
10. New Drug for Heart Failure
    Angiotensin-receptor neprilysin inhibitor, or ARNI, has been granted "fast-track status" by the FDA because of its impressive survival advantage over the ACE inhibitor enalapril, the current "gold standard" for treating patients with heart failure. The unique drug compound represents a paradigm shift in heart failure therapy.

Wondering what Cleveland Clinic proclaimed a year ago would be the top innovations for this year? Here was their top ten list from last year:

1. Retinal Prosthesis System – Early Stage Bionic Eye
2. Genome-Guided Solid Tumor Diagnostics
3. Responsive Neurostimulator For Intractable Epilepsy
4. Direct-Acting Antiviral Oral Hepatitis C Drugs
5. Perioperative Decision Support System
6. Fecal Microbiota Transplantation
7. Relaxin For Acute Heart Failure
8. Computer-Assisted Personalized Sedation System
9. TMAO: A Novel Biomarker For Heart Attack, Stroke Risk
10. B-Cell Receptor Pathway To Treat Blood Cancers

Healthcare (Health Care) in a word (or two)

By Clive Riddle, September 5, 2014

MCOL has launched a survey, albeit a little tongue-in-cheek, on solving a great question for the ages:  do we spell it healthcare (one word) or health care (two words)? You can click here to take the survey, and see real-time results, or click here to check out a one-minute video on the topic.

Early results from the survey to-date indicate a slight preference for one word: 44.7% have said one word; 31.6% have said two words; 13.2% have responded that it depends on the context; and 10.5% have answered that either is fine. Remember though, respondents work within this industry (more on that to follow.)

How have others weighed-in on this conundrum?  Major news organization, medical journals and the AP consistently use “health care” in two words.  Many major blogs have taken the same position, such as The Incidental Economist (Feb 2013) and Archelle On Health (May 2011).

But many  either take the position of one word, while lamenting the times they are a-changing, or they argue the both uses are acceptable, depending upon the context.

One of the most quoted blogs regarding this topic comes from Michael Millenson’s The Doctor Weighs In, in his August 2010 post - “Healthcare” vs. “Health Care”: The Definitive Word(s) .  Millenson makes the case that learned authorities use two words, but goes on to say: “So why isn’t that the end of the issue? Because conventions are not set in concrete. For example, at the time the Internet first became popular, the AP preferred the term “Web site” over “website” because the World Wide Web is a proper name. “ and acknowledges one word use is on the way up: “However, I think a tipping point for fusing “health” and “care” was reached with the federal legislation setting up the Agency for Healthcare Research and Quality at the end of 1999.”

Are the times a-changing? Certainly a review of Google search results placing both terms within quotations, indicates two words is the clear winner:  109 million results versus 47.8 million – a ratio of 2.28 to one.  When the results are filtered to only display content created in the past twelve months, two words still easily wins: 15 million results versus 9.4 million, but the ratio reduces to 1.6 to one.  The times it would seem are changing – but not at the rate of Bob Dylan record sales in Greenwich Village in 1961.

But what about context?

While many make the case that usage is driven by context, there isn’t agreement about what that context is.  Some say one word is used by those in the business when communicating to each other, and two words is for use with the general public. The Metropolitan Philadelphia Chapter of HFMA concluded in The Great Debate of Our Industry: Healthcare vs. Health care “so there still is no final answer here. Both health care and healthcare remain acceptable term.”  The author seems to go for the context route, stating” the single word healthcare may show you are an industry insider, and I save the term health care for those who write about our industry from the outside.”

In the March 2008 Medical Malprocess Blog post Health Care or Healthcare?, an often mentioned approach regarding context -  in which two words refers what a patient receives, and one word refers to a system:  “Health care as two words refers to what happens to a patient. …Healthcare as one word refers to a system or systems to offer, provide, and deliver health care (two words).”

Grammarist.com, in Healthcare vs. health care tells us the times are a-changing but context depends upon international use: “Healthcare is on its way to becoming a one-word noun throughout the English-speaking world. The change is well underway in British publications, where healthcare already appears about three times as often as health care and is used as both a noun and an adjective. Many American and Canadian publications resist the change, meanwhile, and health care remains the more common form in North American newswriting, as well as in government and scholarly texts. In many cases—such as on health-related U.S. government websites—health care is the noun (e.g., “your health care is important”) and healthcare is the adjective (e.g., “find a healthcare professional”), but this is not consistently borne out, and both forms are widely used both ways. Many publications and websites seem to have no policy on this at all. Short answer: Outside North America (Australia goes along with the U.K. on this one), use healthcare. In the U.S. and Canada, make it two words (unless you want to help speed the compounding process).”

What to make of all of this? Google search results, and purists would agree that two words is still king – for the general public, but eventually it would seem one word will take hold – although perhaps not as rapidly as some might think. During this transition – context will drive usage, and those in the business of healthcare might be more comfortable with one word with conversing with each other.

What Is Amazon Up To?

By Kim Bellard, August 27, 2014

Back in April, PwC and HRI issued a report that asked what new entrants might be healthcare's Amazon.com.  Now it appears that it might just be Amazon itself.

What we "know" is that unnamed "Amazon leadership" met in late July with Howard Sklamberg, FDA's deputy chief for global regulatory operations and policy, and other unnamed "various FDA leadership."

That's it; everything else is speculation.  Not much of a story perhaps, but, hey, without speculation there would be no point of blogs, and then I'd have to spend my time doing something else.

Still, the speculation is interesting, especially with a company like Amazon that has repeatedly demonstrated its ability to disrupt markets.

They already outsource their cloud services (Amazon Web Services, or AWS), their distribution capabilities, and their payment systems, the latter now being expanded to in-store payments, going up against the likes of Visa and Mastercard.  In a smartphone world dominated by Apple, Samsung and other established manufacturers, they fearlessly have introduced their own version, the Fire.  I could go on in various other spheres, but the point is clear -- they're not afraid of anyone.

So now health care?

Here are three ways that I would love to see if Amazon could add value to health care:

Reviews: OK, all you Amazon shoppers -- and there are a lot of us -- how many of you buy a product (even if not on Amazon) without first checking out the Amazon reviews?

Their reviews already cover various medical supplies/devices sold on Amazon, but wouldn't you love it if those reviews applied to, say, physicians or hospitals?

Recommendations: Amazon is noted for their personalized shopping recommendations, based on user's shopping and purchase history on the site and a lot of Big Data collaborative filtering.  Whether it is a recommended item, the "also viewed" products, or the "frequently bought together" combo suggestions, the recommendations are pretty effective in helping boost Amazon's sales.

Imagine if Amazon applied this to health care products, services, and even providers, recommending ones that they believe might best fit you, and possibly helping map out the various steps of a treatment plan (as they are "frequently bought together").

Medical tourism:  No, I don't mean the out-of-country packages of lower-cost health care services often thought of as medical tourism (although I'm not excluding them).  I mean more broadly making services or packages of something that consumers actively shop for, and breaking the traditional pick-the-closest doctor/hospital mindset that most consumers have gotten used to.

It's fun to speculate what Amazon might do, but the real benefit of them coming into health care in a bigger way would be that they might do something truly unexpected and unique, without health care industry blinders limiting their creativity.

They haven't asked for my advice -- and please feel free to get word to them that they should -- but what I'd urge Amazon

• Keep it retail: Amazon made its reputation as a retail company, and yet health care has stubbornly resisted being truly retail -- Remember your roots!

• Make people mad: I hope the AMA, AHA, and the state medical boards are furious, that individual health systems and health care professionals are scared to death, and there generally is a lot of arm-waving and teeth gnashing.

If everyone is applauding, Amazon didn't go far enough.

If all Amazon wants to do in health care is to make it easier for us to buy even more of the things we already buy too much of, and pay too much for, I wouldn't be surprised, but I will be disappointed.  We have plenty of companies who can help us tinker around the edges of the status quo, but all too few companies

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Goldman Exec: Economy is Growing, but…

By Cyndy Nayer, CEO, Center of Health Engagement, June 18, 2014

Goldman's top economist, Jan Hatzius, believes that the US economy is now growing at an above-trend pace. This is great news regarding economics and income security. For most.

But Hatzius calls out the high student debt and overall slow pace of job creation as a hindrance to the recovery and expansion of the marketplace.  

And there is still the issue of those without health care coverage or those with income insecurity--making less than the cost of living, managing multiple jobs, or at risk of losing their pensions.  

A video was recently published on the relationship of poverty to readmissions, featuring the Detroit Henry Ford health system. When there is low income, lack of access to pharmacies and healthy food, and poor public transportation, patients discharged from hospitals are often readmitted due to poor compliance in follow-up recommendations. They skip drugs, they eat poorly and they miss regularly scheduled physician checkups. Many are readmitted to emergency rooms and inpatient stays.

This, then, becomes not only a patient risk (for both increased costs and poorer outcomes) but also a health system risk (since CMS is penalizing health systems for avoidable readmissions). Costs go up for the patient (copays, deductibles, new prescriptions, more outpatient visits). Costs go up for payers (avoidable medical and drug costs, among others; absence management if the payer is the self-insured employer). Costs go up for the community (unreimbursed medical costs go up, tax dollars are used for some of these and needed infrastructure, education, and job creation are left behind).

A new study from Mannatt and Commonwealth Fund clearly lays out the advantages of clinicians helping patients to get the community services needed to overcome these inequities.

"Before physicians can substantially cut costs and improve outcomes, they must first address patients' social needs, including whether a patient has a home or heat or access to healthy food, according to findings from a new report," says the report.

This is another opportunity for value-based reimbursements to those entities that can coordinate care beyond clinical intervention. The study calls for patient-centered medical homes (PCMH) to onboard these tasks.  

But ACOs, public health and even business entities can become allies in this effort to identify resources to improve access to healthy food, needed pharmaceuticals, expanded consumer debt counseling and educational resources.

Using value-based reimbursement strategies, payers, health systems and public entities could benefit by providing clear increases to those clinical practices that use care coordination and document better health and health cost outcomes.

Sometimes, health is achieved through non-clinical, social determinants (influences) that are improved by using the trusted resources in a patient's life. The physician, nurse, and pharmacist are 3 of the most influential.

Hacking a Better Health System

By Kim Bellard, April 9, 2014

Who knew hacking might help us reinvent our health care system?

I must be old-fashioned, or at least not a true techie, because I still thought of hacking as a bad thing.I was thus surprised to read in The Wall Street Journal that “hackathons” are a trend for the good in health care. 

For others who are also behind this particular curve, hackathons are intense, all-night (or more) sessions when a small groups of programmers band together to attack tough specific problems with concentrated coding efforts.

The Journal article highlighted MIT’s Hacking Medicine’s Grand Hackfest, which is part of MIT’s Hacking Medicine initiative.  MIT has been at this since 2011, seeking synergies between MIT’s technical expertise and the vaunted Boston-area medical community.  They believe hackers can help health care with: Scaling Medicine, Accelerating Data, Identifying and Tackling Big Opportunities, Hacking Ethos for Lean Medical Innovation, and Infecting Non-Life-Scientists with the Mission. 

Pretty lofty list of goals.

Health 2.0 has their own version, which they call Code-a-thons.  They offer some $6.5m in prizes in their developer challenge, and have several events and challenges scheduled in the next few months.

Goodness knows that health IT has never been known for being either nimble or on the cutting edge, so some fresh blood with new perspectives certainly seems like a good idea, right?  As one clinician whose mobile app benefited from solutions suggested at the MIT hackathon said, "Sometimes when you are too close to something, you stop seeing solutions, you only see problems.  I needed to step outside my own silo.''

Not to be outdone by Boston, New York-Presbyterian Hospital recently held what they claim was the first Hackathon for New York Hospitals, which the specific aim of helping them improve myNYP, their patient portal. Out on the other coast, UCLA-Berkeley has had three iterations of their own version, Hacking Health. 

Just to rub us oldsters’ noses in it, there’s an organization called YTH (youth + tech + health) that believes the “#selfie generation” can do better. They just hosted their own Health Hackathon in conjunction with their YTH Live 2014 conference.     

The trend is not limited to the United States.  The British National Health Service has NHS Hack Days, in Canada there is Hacking Health, and in Europe there’s CPH Health Connect HackDay in Copenhagen and Hacking Health Stockholm.

Looking back at last fall’s healthcare.gov debacle, or more recent reports of similar issues with various state exchanges, one has to wonder if they just should have held a hackathon.

PwC’s 6^th Annual Digital IQ Survey found that healthcare CEOs were far ahead of other industries in championing information technology as an integral part of their strategy.  I rather doubt that many health systems or payors are using hackathons for their big mainframe-based systems – like eligibility, billing, claims payment, or (most) EHRs – but mobile efforts are natural targets for this kind of approach. 

There’s no shortage of targets.  Payors are finding ways to use mobile technology to cut administrative costs, engage members, and manage patients’ care. Still, in a recent Robert Half Technology survey of CIOs, health care led the pack in lacking a mobile strategy.

No wonder they might be looking for hackers.  

It’s great to bring in new ways of attacking the many problems of health care, but I do worry what happens when they hit the may brick walls health care has.  I’ve been seen several instances where non-health care companies – especially financial services firms -- dipped in to health care, thinking they could bring their expertise to bear, only to be shocked at how messy much of the data is. 

What I like best about the hacking in health movement is twofold – bringing in new kinds of expertise and an attitude that problems can be solved.  Those have been sorely missing in health care.  Or, as Mark Twain once put it, “all you need in this life is ignorance and confidence, then success is sure.” 

Hack away!

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

I'll Take My Care To Go

By Kim Bellard, February 17, 2014

I have to admit that when fast food restaurants first got into drive-throughs, I didn’t really see the point.  Well, I missed that one: they now do 60-70% of their business via the drive-through, changing the architecture, menu, and consumer expectations of the fast food industry along the way.  Aside from pharmacies, I haven’t seen drive-throughs impact health care yet, but one doesn’t have to be much of a seer to recognize that that the need to actually visit providers’ offices for health care is quickly being whittled away.

Let’s start with kiosks, which are increasingly providing quick alternatives for some services that used to require consumers to visit their doctor.  For example, in the news recently was a deal higi did with Rite Aid, which will put higi’s kiosks in some 4,000 Rite-Aid stores.  higi already has kiosks in Publix and Whole Foods.  Their approach features kiosks that allow consumers to measure and track their vitals, while gamifying that mundane process.  They combine all the measures into a single “higiscore” that consumers can easily track, and also offer some community features.

higi is not alone in the kiosk business.  There’s SoloHealth, which claims 40m annual user engagements, driven in large part due to its deals with Walmart/Sam’s Club and Safeway, as well as some deals with health insurers, such as Wellpoint and HCSC.        

Not unlike higi, SoloHealth offers quick self-service screening options, but the deals with insurers have them offering information on health plan options as well, a move that is not without critics due to the perceived privacy concerns. 

HealthSpot goes the other screening kiosks one better by also offering video visits with board-certified physicians.  They’ve been doing deals with provider organizations.  HealthSpot also recently teamed up with telepharmacy – there’s another wrinkle! – vendor MedAvail Technologies to create an all-in-one Redbox-type system. 

Of course, non-office visit alternatives are broader than kiosks, especially “virtual visits” offered via phone or computer.  Parks Associates recently found over 25% of American households have used some kind of virtual care, and predict that will grow to 65% by 2018. 

Examples of virtual visit vendors include TeleDoc, American Well, and MDLive.  TeleDoc has been offering a telephone-based physician consult service for years, and now also offers a video consult service. 

American Well started with email physician consults, added video consults, and recently went beyond its traditional payor partners to offer a direct-to-consumer option at $49/visit.  American Well notes that its services are available via web, kiosk, and mobile – and, in fact, says that 60% of its video visits are from mobile devices.  MDLive is the most recent newcomer of the bunch, but has a wide range of tele-services and some serious backers, including Sutter Health and John Sculley.  

Kiosks themselves may end up being a niche offering along the continuum of points-of-care, as the video consults are already available on computers and mobile devices and as more and more biometric measures can be done via remote monitoring and apps – why drive to a kiosk when you get do the same things at home or on your phone?  After all, health related apps are booming, and include screening and diagnostic tools.  The stethoscope app, for example, has been around for several years and has proved popular with both consumers and – surprisingly -- physicians. 

So we’ve got sophisticated bio-metric screenings at your convenience in a wide number of retail settings and, increasingly, via mobile devices, plus we’ve got physicians available literally in the palm of your hand.  That’s not all.  IBM’s Watson is teaming up with “social health management” vendor Welltok to help answer consumers’ health and wellness questions without the assistance of a physician – or any live person. 

All these new options for receiving care and medical advice remind me again about how much behind the curve traditional health insurance and health providers are. 

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Stakeholder Views on Trends, Winners and Losers for 2014

By Clive Riddle, February, 14, 2014

MCOL recently conducted its annual Future Care e-Poll, asking stakeholders their perspective of trends, winners and losers for the coming year and beyond. Here’s a sneak peek at some of the results from the soon to be released report on this year’s findings. The full report still being compiled addresses additional e-poll questions, breaks down responses by stakeholder category and compares results to previous years.

Here’s a table of how respondents view the business trend that will have the greatest overall impact in 2014. The Affordable Care Act of course dominates all other issues, and even more so than last year, when exactly half of respondents list it as the trend with the greatest impact.

Affordable Care Act Implementation	61.1%
Government Spending Cuts	9.7%
Consumerism Initiatives	6.9%
Effects of the Economy	6.9%
Increased Consumer Cost Sharing	5.6%
Compliance Issues	4.2%
Other	2.8%
Advances in Health Care Technology	1.4%
Population Health and Wellness Initiatives	1.4%

Below is an infoGraphoid MCOL published earlier this week illustrating the e-poll results on this question. The designer of this graph informed me it looked like a green Pac-Man (the ACA respondents) vomiting a rainbow (of all the other respondents.)

Regarding winners and losers, here’s what stakeholders thought 2014’s fortunes would bring to other stakeholders:

Losers:

Hospitals – 56% say Hospitals are the big losers (only 18% said better off; 26% the same)

Physicians – 53% view Physicians as worse off (only 8% said better off; 38% the same)

Employers  - 52% think Employers are worse off (only 15% said better off; 33% the same)

Consumers  - 51% placed them in the losers column (34% said better off; 15% the same)

Status Quo:

Pharmaceutical – 60% see Pharmaceutical organizations as staying the same (29% said better off; only 11% said worse off)

Winners:

Health Plans – 47% say Health Plans as the big winners (29% said they will stay the same; 24% said they will be worse off)

It’s interesting that the stakeholder that the ACA was designed to benefit – the Consumer – is not viewed by stakeholders as the biggest beneficiary. It’s also interesting that last year respondents didn’t view health plans fortunes near as positive – at the start of 2013, 27% replied health plans would be better off;  34% said the same; and 39% said worse off.

2014 TOP 10 Watchlist

By Lindsay Resnick, January 21, 2014

Here's what's on this year’s radar screen for leading healthcare companies.

1. Obamacare 2.0 Robust post-enrollment learning agenda to understand which customers came into the market, who stayed out, how they shopped, what’s their mix of risk, and new competitors to look out for.
2. Risk Management Millions of underserved, high-risk health care consumers with unmanaged illness entering the insurance and medical delivery systems shiny new health insurance ID cards and pent-up demand for care.
3. Quality Outcomes Providers of healthcare putting skin in the game with pay-for-performance risk sharing schemes moving healthcare toward outcomes-based financing system based on quality and clinical results.
4. Chronic Care Next generation care management to deal with chronic medical conditions accounting for $3 out of every $4 of the country’s $2.8 trillion health care bill and 17 million boomers turning 65 over next 5-years.
5. Personal Wellness  Consumers changing health attitudes and behavior to improve quality of life and find ways to reduce personal health expenditures as they are forced to take more individual healthcare responsibility.
6. Connected Data Gathering, analyzing and interpreting consumer data to understand variations among market segments to develop a complete snapshot or “360° view” of customers to achieve true member engagement.
7. Retail Healthcare Benefit standardization, regulatory constraints and price transparency commoditizing markets and neutralizing brands means new approaches to awareness, acquisition, activation, retention and loyalty.
8. Mobile Health Always-on consumers expect any desired information or service is available on any device at a person’s moment of need; a mobile lifestyle now defines a customer’s way of connecting and interacting.
9. Socialnomics Social media driven consumer communities for collaboration and communication that cut across every market segment and every aspect of the customer relationship, from sales to product to service.
10. Customer Centricity It’s the new selling: engaging health insurance consumers with a superior, loyalty-based user experience; it’s guided by customer insights, cross-functional metrics, and championed by the C-Suite.

Keep a close watch on these impact trends to proactively managing change and stay ahead of your competitors.

Can the Consumer Choose Wisely in 2014?

By Clive Riddle, January 3, 2014

The just released January 2014 issue of Medical Home News includes a profile of Paul Keckley, PhD, in which he is asked this question: “Looking back on your years as a health care analyst, what has been this country’s major achievement and what has been its greatest disappointment in terms of health care delivery?” His answer: “Greatest disappointment: the consumer is ignorant about the health system, even after all the fuss for and against health reform. Greatest positive: data-driven healthcare!!”

In August 2013, Kaiser Family Foundation released new survey results that the Wall Street Journal summarized as:  Consumers Remain Baffled By Health Law, Poll Shows. At the end of the year, things got no better. Consider findings from a December 2013 Consumer Reports survey of consumers regarding the Affordable Care Act which found:

• 38% of respondents indicated they felt LESS informed over the course of the past month.
• 48% thought the ACA established a government-run health plan
• 36% thought the new law allowed the government to control their selection of doctors
• 30% believed the law set up government panels that would dictate decisions about end-of-life care
• One-quarter or less of respondents correctly identified the above as false statements.

But Paul Keckley’s point wasn’t just that consumers are confused about reform – rather that they are confused about the entire system, in spite of reform. And there a plethora of survey results previously cited in mcolblog postings to back that up.

George Van Antwerp, in blogging his 2014 healthcare predictions, posts that “consumer engagement in healthcare will continue to be the elusive Holy Grail.”

It is difficult to engage someone who is confused, and ignorant about the system. The consumer might feel as if they are in the scene at the end of Indiana Jones and the Last Crusade, confronted with a hundred different goblets, with only one being the true Holy Grail, as they try to navigate their health choices, and fear that the Guardian of the Holy Grail won’t be telling them that they “have chosen wisely.”