Managed Care

Docs Rate Plans

The AMA recently issued its first health insurance report card grading how quickly and accurately doctors get paid. Docs hope the report card will reduce the cost of claims processing and help in contract negotiations with the health plans. 

According to the AMA, the report card compares Medicare and seven national commercial health insurers on the timeliness and accuracy of claims processing. UnitedHealthcare had the lowest rate  – only 62 percent of medical services billed were paid by them at the agreed rate. Aetna came in higher at 71 percent, and the Medicare at an impressive 98 percent.

What you can do:  If you are a healthcare IT physician practice management or EMR vendor who facilitates electronic coding and billing, use the AMA report to highlight how you can improve payment rates for you customers.  It's likely your solution improves reimbursement rates and speed, translating into a more efficient and profitable practice. 

Posted by Shawn Whalen on September 30, 2008 at 2:15 PM
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Costs and Opportunities

Health care costs are expected to rise more than 10 percent into next year, says an Aon Consulting survey of 70 national health insurers. This is actually good, considering it’s the smallest increase Aon has seen in six years.

Employers take measures to combat such increases through new designs, adoption of CDHP and HSA plans. Costs are still rising to keep up with growing patient demand for services, the needs of an aging population and prescription drug and technology costs, according to Aon.

What you can do: If you are a healthcare technology vendor whose solutions help lower costs for employers, leverage surveys such as this to highlight the savings you can provide customers. Highlight employer group success stories in the HR and benefits trades. Consider a round table of customers and experts to put your solution in a trend story context.

Posted by Shawn Whalen on September 28, 2008 at 7:11 PM
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PHR Thoughts

While it may take a decade for widespread adoption of PHRs, it will definitely happen. It is another medium for communicating your medical condition to a doctor, which today is done verbally. Data supplied into the PHR by health plans, or the doctors via EMR interchange, will be more accurate as patients memory – selective or otherwise – isn’t often reliable.

What will help doctors is a high degree of interoperability between the PHR and the EMR, otherwise it’s still easier to take down a patient’s information verbally. When the Certification Commission for Healthcare Information Technology (CCHIT) starts certifying PHRs this will hopefully be addressed.

Other obstacles that will be overcome with time is general technology acceptance by doctors. The old guard's resistence will be replaced by younger doctors who are more comfortable and trusting of technology. Ubiquity of PHRs via Microsoft, Google, health plans and hospitals will move PHRs from “nice to have” to “must have."

This presents PHR vendor PR folks with opportunities to highlight how their solutions are making adoption easier, helping facilitate the vision of universal PHRs.

Posted by Shawn Whalen on September 16, 2008 at 11:03 AM
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PHR Factoids

A recent Markle Foundation survey found that regardless of their interest in using an online PHR service, 79 percent or more of the public believe using an online PHR would provide benefits to individuals in managing their health. Fifty six percent cited worries about privacy and confidentiality as a reason for their reluctance.

Only 2.7 percent of adults have an electronic PHR today (representing about 6.1 million persons). Most (57.3 percent) do not keep any form of personal health records, and 40 percent keep some paper health records.

What you can do: If you're a PHR vendor PR person, utilize the survey findings to support your solution. Use the statistics in press releases or collateral to help make your case. Highlight the privacy and security safeguards that your product takes, given that privacy is a major obstacle to PHR acceptance.

Posted by Shawn Whalen on September 2, 2008 at 6:39 PM
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Doctor.com

The latest twist on telemedicine came last week from yet another online care virtual consultation launch, this time TalktoaDoc.  Much like American Well’s launch a few week’s ago, TalktoaDoc combines VoiP-based video, voice and text to enable patients to consult real-time with docs.  Variations on this theme include MDwebLive, ConsultaDoctor, Teledoc, OrganizedWisdom Health and others.

Fees vary to the services. TalktoaDoc charges $2.98 per minute after the first minute.  Physicians receive 55 percent of the fees charged to the patient. American Well works through the health plan (at this point, Hawaii’s Blue Cross Blue Shield.)

It will take six to eight years for such services to reach any critical mass, based on how much money health plans think they can make. Payors, as they are doing with PHRs, will power adoption slowly but surely.  RelayHealth for example is working with heavy weight Aetna for e-mail consultation systems and reimbursements. These early tests and ROI analysis will fuel future growth in the more sophisticated online systems.

Posted by Shawn Whalen on July 11, 2008 at 11:12 AM
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Blue PHRs

Locally here in Massachusetts Blue Cross Blue Shield of Massachusetts partnered with Google Health to enable members to import their claims data into their Google Health profile.  BCBSMA says that members with Google Health PHRs will be able to share data with healthcare providers who currently don't have access to their data.  Also, they can download medical records and prescription history from other connected providers.

This move echoes my past sentiment that it will be the health plans who make PHR adoption a reality.  Prepopulation of data is key. Witness the success of ActivePHR. Otherwise PHRs will go nowhere except for those individuals highly motivated via medical condition.

Continue reading "Blue PHRs" »

Posted by Shawn Whalen on July 7, 2008 at 4:52 PM
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AHIP Pix

And speaking of payor technology vendors, last week’s AHIP conference was considerably smaller than 2007.  Our intrepid Account Executive Melissa Bruno provided a pictorial report:

Getting priorities straight - the busiest booth of the conference.
 

The second busiest booth of the conference.
 

Make sure your health plan covers Wii wrist sprains before visiting Portico’s booth.
 

This boat manufacturer was selling new technology paradigms. Fish love them.

Posted by Shawn Whalen on June 26, 2008 at 12:54 PM
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Your Premiums at Work

It seems that health plans have a little money left after paying all those healthcare costs. The trend of health plans acquiring technology vendors continues.  Care management vendor MEDecision is to be acquired by Health Care Service Corporation (HCSC), which operates Blue Cross and Blue Shield plans in Illinois, New Mexico, Oklahoma and Texas.  HCSC paid $121 million and will keep MEDecision independent.

BlueCross BlueShield of Tennessee and The Regence Group Blue are taking a minority ownership in TriZetto Group, which will be going private.  Others include UnitedHealth’s Ingenix , Aetna’s ActiveHealth Management, and Independence Blue Cross’ AllOne Health Management Solutions.

As I’ve written before, payors will be the major players in pushing technology adoption in healthcare, be it provider side with EHRs or consumer side with PHRs.

Posted by Shawn Whalen on June 23, 2008 at 8:47 AM
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Rated PG: Physician Good

CIGNA announced a national website ranking doctors and hospitals by cost and quality measures. As I’ve written before on doctor ratings, this movement is inevitable despite all the my-patients-are-sicker claims by doctors, or the efforts of various Attorney Generals.  Such watchdogs efforts are important though to see that health plans don’t skew the data for their own financial goals.

Cigna’s site names hospitals in specific regions with the lowest death and complication rates. It also offers lists of questions patients can ask their doctor about specific conditions and tools to help patients locate pharmacies with the lowest prices.

In New York, Cigna was one of many plans who pledged in writing to detail its ranking criteria. They’ve also tapped the National Committee for Quality Assurance to guide their ranking program.

Meanwhile in Massachusetts the MA Medical Society is up in arms about the state’s doc rankings. They sued the Group Insurance Commission to stop the rankings, claiming low-ranking doctors will be defamed and those patients who have to pay higher copayments based on their doctor’s ranking have been defrauded.

And last but not least, though most confusing to Joe Smith consumer, will be Consumer Reports new hospital rating service for 3,000 organizations. Their “intensity of care” index of 1 to 100 will rate how intensely a hospital treats patients, based on time spent in the hospital and number of doctor visits for nine serious conditions. This strikes me as a controversial and incomplete criteria compared to other methods.

Posted by Shawn Whalen on June 6, 2008 at 10:51 AM
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Don't Believe the Hype?

But Don’t Let That Stop You Promoting It ;)

A sobering case study for CDHP/HSAs. Financial services company T. Rowe Price adopted its consumer-driven health plan in 2004. You’d think they’d succeed, given the 5,000 financially savvy U.S. employees and a sophisticated benefits program already in place.  Enrollment in the plan hit 8 percent the first year, not bad.

Enrollment remained flat for three years, then rose in ’08 to 9 percent - too low to produce substantial savings. What could (maybe) make a difference? More incentives and tools for consumerism. A majority of consumer-driven plans today are stagnating like T. Rowe Prices. The most common plan designs don’t contain the seeds for their success.

It’s telling that when Towers Perrin wanted to quantify cost savings from CDHPs in a recent study, it found the CDHP landscape too small to do a credible survey.  PR folks at vendors or companies succeeding in CDHP’s may have a media story in that success, going against the grain of poor performance through the solutions or approach that you offer.

Posted by Shawn Whalen on May 30, 2008 at 11:12 AM
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CEOs Support Wired for Health Care Act

Today brings a guest column on healthcare quality and technology by Maria Ghazal, director of public policy with the Business Roundtable, an association of CEOs of leading U.S. companies with $4.5 trillion in annual revenues and more than 10 million employees.

Health IT Will Save Lives and Money - First We Need Policymakers to Wire Us for Health Care Quality

Imagine if every few days a passenger plane crashed while travelling across America. There would be a massive outcry over safety standards and America would want answers…the airline industry would be investigated, held accountable and would make the necessary changes to ensure air travel is as safe as possible. Shockingly, the equivalent is happening in the healthcare space and no one seems to notice. Every year as many as 98,000 people die due to preventable medical errors, the equivalent of a 747 crashing every two or three days, and yet there is no public outcry, no call for reform and no alteration to our current health care system.

This must change. I work for the Business Roundtable – an association of CEOs of leading U.S. companies such as Verizon, Aetna and General Motors – who are pushing Congress to recognize that the cost we currently pay for our outdated system, in both human lives and dollars, is unacceptable. Based on both their business experience and their insights from insuring more than 35 million Americans, Business Roundtable CEOs believe that utilizing health information technology, more commonly known as health IT, will provide better quality of care while saving money and ensuring the security of private medical information.

 

Continue reading "CEOs Support Wired for Health Care Act" »

Posted by Shawn Whalen on May 19, 2008 at 1:46 PM
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Support Your Local HCIT Events

Here in Massachusetts, the Massachusetts Technology Leadership Council’s  Healthcare/IT Summit is being held Thursday, June 5, 2008, at the Hyatt Regency in Cambridge.

Is the Consumer the next big HealthCare IT Buyer?
Opportunities & Obstacles

Thursday, June 5, 2008
8:00-11:00am Program
7:30am Registration

Register here.

According to MTLC, during the past 18 months, we've seen significant investment in patient-centric healthcare technology solutions from major IT vendors such as Microsoft (HealthVault), Google (Google Health), IBM (Center for HealthCare Management), Intel (Digital Health Group), and Apple (iPhone as healthcare platform -- Kleiner Perkins is investing $100M into companies developing new applications for the iPhone).

MTLC has convened a panel of thought leaders from the IT community to brief us on their investments and their vision for the healthcare IT market. They've also assembled a panel of healthcare CIOs and IT buyers to give their perspectives on these investments.

Participants:
- Michael Barrett, President, Critical Mass (moderator)
- Patrick Boyle, Vice President, America's Healthcare & Life Sciences, IBM
- John Halamka, CIO, Care Group/Beth Israel Deaconess Medical Center
- Paul Mattes, Managing Director, US Health & Life Sciences, Microsoft
- Dan Nigrin, CIO, Children's Hospital
- Gary Sevounts, Senior Director, Global Healthcare Solutions, Symantec
 

Posted by Shawn Whalen on May 16, 2008 at 1:19 PM
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Care Management Thoughts

At the recent World Healthcare Congress there was much talk about health plans and care management. In the increasingly competitive payor market differentiation is important, so some insurers are looking to move beyond disease management to “care management.”  This focus on member care comes with longer term cost savings that go beyond comparatively simple utilization management.

Executing this care management beyond marketing pabulum requires a combination of new technologies, particularly in the data analytics and evidence based medicine realm, as well as more aggressive communication with members via HRAs, PHRs, clinical content and more health/wellness programs.

Some health plans are doing better than others in particular slices of the care management spectrum, but few have brought it all together in an integrated fashion. While outsourcing certain simple functions such as transaction processing remains an answer for many, the wisdom from WHCC attendees favored a holistic in-house effort to achieve care management.

The risk and reward of care management resides with both insurer and provider, as the specialized networks can gain from pay-for-performance initiatives aligned with different populations.

For the healthcare marketers, consider that the care management topic will be growing in popularity in the media. As more plans and vendors discuss care management, media will seek examples of approaches, tools and end users. This could mean a PR opportunity for you.

Posted by Shawn Whalen on May 12, 2008 at 2:55 PM
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Frankenstein vs. BC CA

E-newsletter FierceHealthcare reported on Blue Cross of CA's attempt to enlist doctors to help expose patient’s healthcare discrepancies in order to cancel policies (read below). This is of course troubling, though not surprising (do health plans have ulterior motives like this in pushing PHRs?) 

Even more troubling is the existence of Dr. Frankenstein, who is head of the California Medical Association. This Dr. Richard Frankenstein was “outraged” by Blue Cross’ action.  I would be careful Blue Cross. Dr. Frankenstein doubtless has powerful progeny who you do not want to meet on a dark and stormy night, unless you have a lot of torches.

“Blue Cross of California has raised eyebrows around the state, and sparked protests from some physician groups, by sending medical groups applications filled out by beneficiaries and asking the doctors, in effect, if the patients lied about their health. With the applications, which went out to large medical groups who have capitation contracts with the health plan, Blue Cross advised doctors to narc on patients who had any conditions not listed on the applications. This is just the latest in the plan's attempts to aggressively weed out sick patients. Blue Cross has already faced the ire of regulators for issuing policies then canceling them when the patients incur big medical bills.

The Good Doctor, Before His Outrage

The letter and accompanying application "outraged" the California Medical Association, according to president Dr. Richard Frankenstein. He argues that with doctors in the role of police, patients may be afraid to share their whole medical history with doctors, putting their health at risk. The association has sent a letter to state regulators asking them to order Blue Cross to stop asking doctors for patient information. A spokesperson for the state insurance commissioner said that while their office hadn't gotten any complaints about the letter, they consider it "extremely troubling," in that it effectively places doctors in the role of underwriters.”

The Villain of our Tale

Post Script.  A few weeks later, BlueCross of California relented before the outrage of Dr. Frankenstein and his physician minions. Policy changed. Happy ending.

Posted by Shawn Whalen on April 1, 2008 at 6:06 AM
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PHR Privacy?

As summer rolls around so will the general availability of Google Health and Microsoft HealthVualt’s Personal Heath Records (PHR). These major players, plus the offerings from WebMD, Revolution Health, ActiveHealth Management and a dozen other PHR players raises the question of privacy and HIPAA.

These third-party PHR technology vendors are not covered healthcare entities according to HIPAA. Hospital and managed care associated PHRs do fall under the HIPAA privacy and security mandates.

As most readers of this blog know, HIPAA provides strict standards that classify medical information as a privileged communication between a doctor and patient. If the medical records aren't protected by HIPAA, the information could be used for marketing purposes.

In most cases, each health profile, including medical history, prescriptions and allergies, will be password protected. Vendors will likely have their own privacy policies which could match HIPAA laws, however they are just policies and not laws. 

Smart PHR vendors will go the extra mile to assure customers that their data is private and secure. This issue should be proactively addressed by PHR vendor PR people.
 

Posted by Shawn Whalen on March 26, 2008 at 11:44 AM
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A European Perspective

Research and consulting firm Health Industry Insights (HII) released its 2008 Western European Top 10 Predictions. According to HII analysts Jan Duffy and Silvia Piai, European healthcare providers are facing an "inconvenient truth": the traditional healthcare service delivery model — based on big box hospitals set up to deal with acute episodes, doctors as the only owners of clinical information, and little attention dedicated to wellness and prevention — is no longer sustainable. New patterns of demand, resource constraints, and glitches in the quality of service have brought this model to the point of no return. Health Industry Insights foresees common patterns of transformation of both the service delivery model and information technology modernization in Western Europe.

For their predictions for 10 key changes taking place in 2008, please click the "Continue Reading" link.

Continue reading "A European Perspective" »

Posted by Shawn Whalen on March 18, 2008 at 9:05 AM
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EMR Blues

I thought it progressive of Blue Cross Blue Shield of Massachusetts to give out $50 million in grants a few years ago to medical practices to adopt EMRs. So it was interesting to see BCBSMA suggest that the financial ROI wasn’t worth the cost to doctors in medical practices.

Citing studies including an AMA report saying docs get only 11 cents of every dollar saved through the use of an EMR, BCBSMA decided not to require physicians to install an EMR to participate in its bonus program. They still however offer financial incentives to medical groups to adopt EMRs.

BCBSMA’s own cost-benefit analysis showed that CPOE made financial sense in the hospital setting. So they will require health systems to install CPOE by 2012 to participate in the bonus program.

The BCBSMA news came after a local study by the New England Healthcare Institute. It found that that CPOEs could help prevent 55,000 medication errors in MA and provide an annual cost savings of $170 million, or $2.7 million per hospital.  No surprise there, given medication errors are one of the more easily addressed problems with IT.

BCBSMA estimates it would take five to six years for an EMR to recoup its cost in an office-based practice. AMA policy supports EMRs but does not support requiring physicians to purchase them.

While I think the financial ROI aspect of EMRs is important, especially if you’re the doc paying for the system, there are other quality, safety and pay-for-performance benefits that should be considered. Understandably however, the small and medium sized medical practice has a tough time swallowing the cost of the typical EMR.

Industry is responding with cheaper, simpler, hosted solutions. Insurers continue to support and provide financial assistance.  Changes in the Stark Law are allowing hospitals to provide free or discounted systems to their network practices. And perhaps government will start providing tax incentives.

Massachusetts may pass legislation that would provide $175 million in grants to physicians to adopt EMRs.  This may change MA insurers perspective on EMRs and bonuses.

Posted by Shawn Whalen on March 10, 2008 at 10:17 AM
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Transparent Motives

Payers and Healthcare Transparency

In a survey of U.S. payer organizations, research firm Health Industry Insights found that more than half of respondents plan to make significant investments in transparency initiatives in 2008. According to Health Industry Insights, key payor initiatives include investments in creating electronic access to information; improving data and information processes; consolidating duplicative, redundant, or disconnected data sets to produce accurate, reliable data sources; adopting standards; and moving toward common formats.

For key survey findings on online claim payment and adjudication, cost and quality information and payor investment trends in 2008, please click on the "Continue Reading" link below.
 

Continue reading "Transparent Motives" »

Posted by Shawn Whalen on March 3, 2008 at 12:16 PM
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Report from HIMSS

Another year, another HIMSS.  Florida was a nice break from the cold of Massachusetts. We had about 10 clients at the show, fielding a combined 100 media interviews.  Plenty of others whose job it is to analyze have covered the show, such as Healthcare IT News.  So I’ll just share some photos.
 

Sniffing out prospects. Attendance seemed lighter than last year, though HIMSS claims otherwise.
 

Klaatu barada nikto. The aliens have landed, and they come bearing interoperability.
 

This doc looks smart enough to buy an EMR.
 

Hyland not only had the most popular booth - a sports pub serving beer - but also a novel marketing idea using baseball cards.
 

Vroom, vroom. Driver decision support and PHR come standard.
 

The GE Kingdom. Will they follow Cerner and not return next year?
 

These sleek filing cabinets hold up to 200 patient records per drawer ;)
 

Organic, green, enviro-styling booth, though I can’t recall what they do.
 

R2-D2-EMR. Good for carting around rebel IT secret plans.
 

The wheeling and dealing home base.

Posted by Shawn Whalen on February 27, 2008 at 3:15 PM
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2008 Trends to Watch

Industry analyst firm Health Industry Insights released their 2008 healthcare IT predictions. Business intelligence tops the list.  Their announcement discusses how data integration and interoperability will continue to drive major shifts in IT spending. These initiatives will be sharpened by an industry focus on cost containment, process improvements, and improved patient outcomes. Listed below are key highlights from their provider and payer top ten trends.

U.S. Provider 2008 Top 10 Predictions identifies major trends that will impact the provider IT landscape in 2008. The industry is approaching a critical turning point whereby delivery models and applications are increasingly accessible and easier to use providing much needed data exchange and interoperability. Providers need to examine opportunities to expand EMR investments as this is becoming a key requirement in the inpatient and ambulatory care setting. Health Industry Insights also predicts that providers should keep an eye on Health 2.0 as it is changing the way consumers interact with healthcare information.

U.S. Payer 2008 Top 10 Predictions reflect a volatile and changing business and technology environment, with investment planned in multiple traditional areas and new initiatives, rather than the more single-themed focus of some previous years (e.g., HIPAA, consumerism, the collaborative business model). Business intelligence, prioritized investment on consumer information management and transaction tools, as well as "extra-enterprise" technology investment emerge as overarching themes and areas of the greatest investment in the next 12-18 months. Fragmentation and high technology costs will continue as the U.S. healthcare payer market technology investment encompasses over 50% of the total worldwide healthcare payer IT spend.

Health Industry Insights’ Top 10 predictions across the industry sectors include:

- Business intelligence and related information management are leading categories of technology spending increases in 2008 across all segments
- Outsourcing seen as instrumental as the focus on cost reduction continues to increase
- Drug safety will remain front and center as a primary concern in 2008
- SaaS (software as a service) will spur adoption of EMR's for small providers
- Healthcare/financial services interface and competition will heat up in 2008 as healthcare payers shift costs and payment responsibilities to consumers
- "Extra-enterprise" investments become mainstream as over 40% of healthcare payers report technology investments for use by consumers and providers
- Retail clinics and their technology will proliferate, increasingly disrupting healthcare delivery

"We predict there will be accelerated investment in 2008 in the Business Intelligence segment with spending growing more than 13% over the next 12-18 months," said Scott Lundstrom, vice president of Research, Health Industry Insights. "In addition, the healthcare industry should anticipate more innovative use of Web 2.0 technologies in healthcare by mainstream technology vendors and niche companies over the next 12-24 months."

Posted by Shawn Whalen on January 14, 2008 at 10:32 AM
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Health 2.0 - The Next Big Hype

Health 2.0, likes its older cousin Web 2.0 and uncle Web 3.0, is getting more and more attention. My colleague Bonnie Andersen pointed out the December 11 Modern Healthcare article, in which the magazine describes the three most important principles of what a Health 2.0 company or application is. 
 
The first principle is the software of a Web 2.0 company has to be  Web-based, has to provide a service and that service has to be structured  so that the more people use it, the better it becomes. An example is eBay;  as more and more buyers and sellers participate, the broader the eBay  market becomes, which creates more value to the customer. 
 
The second key principle is "harnessing collective intelligence," which  also is referred to by others as "the wisdom of crowds." To avail  themselves of this wisdom, Web 2.0 developers must create applications that  are dynamic, with user participation designed into the systems, so that  participation itself becomes an integral part of making the underlying  database more valuable. 
 
The third principle, "Data is the next 'Intel inside,'  notes that  specialized data, enhanced through analysis performed by the service  provider as well as by the contributions of service users, becomes the core  asset of a Web 2.0 company. Amazon wish lists, for example, are aggregated  by Amazon and used as buyer's guides.
 
Matthew Holt of the Healthcare Blog and co-founder of the Health 2.0 conference is looser in his definition, placing the qualifying emphasis on whether the service or application promotes the healthcare experience as an "ongoing process" rather than a "series of episodic events.

Another view expressed is that Health 2.0 is centrally concerned with improved outcomes and, in the spirit of consumer-driven care, giving doctors and patients the tools they need to better achieve them.

Whatever the definition, if there is money to be made I'm sure more companies will be making a land grab in the Health 2.0 landscape.  There is still a much hype on the topic. As usual the payors and employer groups will be the driving force. Much of what's bandied about around Health 2.0 is being done by larger players already.

Posted by Shawn Whalen on December 19, 2007 at 4:44 PM
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Paranoia Andy Grove Would Be Proud Of

I was reading about progressive wellness programs last week, and yesterday watching Moore's Sicko again. A thought occurred to me. Personal health coaching as part of wellness programs is in vogue right now. Are health plans tracking compliance to such programs, for the purpose of later denying associated condition claims on the basis that the individual's noncompliance contributed to a pre-existing condition?  I wouldn't put it past them. What do you think?

Posted by Shawn Whalen on November 23, 2007 at 6:06 AM
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A Joking Matter

A few have said my last several posts are getting to be too cynical. How could I ever be that ;) To lighten the mood, perhaps I should offer a monthly doctor joke?

Three Doctors in Heaven

Three doctors are waiting in line to get into the pearly gates.

St. Peter walks out and asks the first one, "What have you done to enter Heaven?"

"I am a pediatrician and have brought thousands of the Lord's babies into the world."

"Good enough to enter the gates," replied St. Peter and in he goes. The same question is asked of the second doctor.

"I am a general practitioner and go to Third World countries three times a year to cure the poor." St. Peter is impressed and allows him through the gates.

The third doctor steps up in line and knowing the question, blurts out, "I am a director of a HMO."

St. Peter meditates on this for a while and then says, "Fine, you can enter Heaven... but only for 2 days."

Okay, nevermind the monthly jokes ;)

Posted by Shawn Whalen on November 5, 2007 at 1:29 PM
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A Joking Matter

A few have said my last several posts are getting to be too cynical. How could I ever be that ;) To lighten the mood, perhaps I should offer a monthly doctor joke?

Three Doctors in Heaven

Three doctors are waiting in line to get into the pearly gates.

St. Peter walks out and asks the first one, "What have you done to enter Heaven?"

"I am a pediatrician and have brought thousands of the Lord's babies into the world."

"Good enough to enter the gates," replied St. Peter and in he goes. The same question is asked of the second doctor.

"I am a general practitioner and go to Third World countries three times a year to cure the poor." St. Peter is impressed and allows him through the gates.

The third doctor steps up in line and knowing the question, blurts out, "I am a director of a HMO."

St. Peter meditates on this for a while and then says, "Fine, you can enter Heaven... but only for 2 days."

Okay, nevermind the monthly jokes ;)

Posted by Shawn Whalen on at 1:29 PM
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Rank Profits?

From PRing doctor-ranking companies Subimo, Best Doctors and HealthShare Technology, I figured it was only a matter of time before MCOs would use transparency altruism to mask ulterior profit motives.  NY Attorney General Andrew Cuomo seems to think so, calling last week on NY health plans to halt doctor ranking programs. He also directed Empire BBCBS to disclose their criteria in doctor rankings.

Information from the press release: In an expanding industry-wide investigation, New York Attorney General Andrew M. Cuomo today issued letters to Empire Blue Cross Blue Shield, Preferred Care, and HIP Health Plan of New York/GHI requesting information on the insurers' doctor ranking programs. The Attorney General also alerted New Yorkers about potentially deceptive programs driven by financial motives and not consumers' best interests.

"Consumers need to be aware that doctor ranking programs as currently designed may steer patients to the cheapest, but not necessarily the best doctors, letting profits trump quality," said Attorney General Andrew Cuomo. "Transparency and accurate information are critical when making health care decisions and should not be clouded by conflicts of interest."

To read on, hit the "Continue Reading" link... In the three separate letters sent today, Attorney General Cuomo said:

Continue reading "Rank Profits?" »

Posted by Shawn Whalen on October 26, 2007 at 4:29 PM
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Outsourcing - What's the Big Deal?

Today's New York Times article on outsourcing by the State Department should be no surprise. Outsourcing, business process outsourcing, smart sourcing - whatever you want to call it, contracting out services is a business mainstay and fundamental. 

Healthcare is no different, though of course few people like to talk about. Privacy concerns abound. The reality is there's not much privacy to begin with and outsourcing will continue to grow.

In healthcare, offshore outsourcing is commonly used for claims processing, customer service, medical transcription and billing services. However, as certain clinical areas experience talent shortages amidst rising demand, healthcare providers are looking for more outsourcing solutions.

According to research firm IDC, nearly $322 million was spent on offshore healthcare services in 2005. They project a 79% increase to $575 million in 2008.

According to public data, among those managed care organizations that do offshore outsourcing are Aetna, BCBS Michigan, BC of N. PA, Cigna, Coventry, Horizon BCBS, Humana, Kaiser Permanente, Regence Group, United Health, WellCare, Wellpoint/Anthem and others.

According to U.S. Government Accountability Office (GAO) reports, 19 percent of Medicare Advantage contractors do offshore data transfers as part of outsourcing. Four percent of Medicare FFS contractors do so, and 2 percent of state Medicaid agency contractor vendors do so.

Posted by Shawn Whalen on October 24, 2007 at 12:01 PM
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Outsourcing - What's the Big Deal?

Today's New York Times article on outsourcing by the State Department should be no surprise. Outsourcing, business process outsourcing, smart sourcing - whatever you want to call it, contracting out services is a business mainstay and fundamental. 

Healthcare is no different, though of course few people like to talk about. Privacy concerns abound. The reality is there's not much privacy to begin with and outsourcing will continue to grow.

In healthcare, offshore outsourcing is commonly used for claims processing, customer service, medical transcription and billing services. However, as certain clinical areas experience talent shortages amidst rising demand, healthcare providers are looking for more outsourcing solutions.

According to research firm IDC, nearly $322 million was spent on offshore healthcare services in 2005. They project a 79% increase to $575 million in 2008.

According to public data, among those managed care organizations that do offshore outsourcing are Aetna, BCBS Michigan, BC of N. PA, Cigna, Coventry, Horizon BCBS, Humana, Kaiser Permanente, Regence Group, United Health, WellCare, Wellpoint/Anthem and others.

According to U.S. Government Accountability Office (GAO) reports, 19 percent of Medicare Advantage contractors do offshore data transfers as part of outsourcing. Four percent of Medicare FFS contractors do so, and 2 percent of state Medicaid agency contractor vendors do so.

Posted by Shawn Whalen on at 12:01 PM
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Newt on Hilary

Speaking of politicians, Newt Gingrich has been making some noise again. I thought his David Merritt-ghosted Oct. 15 National Review Online article (link) on Hilary Clinton healthcare proposals somewhat interesting. The disgraced former Speaker for the House, the only Speaker to ever be fined for ethical misconduct, runs the for-profit pseudo-think tank Center for Health Transformation. I'm not going to rehash the many criticisms media such as the Associated Press and blogs have heaped on his corporate sponsor pay-for-play issue support scheme.

Posted by Shawn Whalen on October 21, 2007 at 10:52 AM
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Newt on Hilary

Speaking of politicians, Newt Gingrich has been making some noise again. I thought his David Merritt-ghosted Oct. 15 National Review Online article (link) on Hilary Clinton healthcare proposals somewhat interesting. The disgraced former Speaker for the House, the only Speaker to ever be fined for ethical misconduct, runs the for-profit pseudo-think tank Center for Health Transformation. I'm not going to rehash the many criticisms media such as the Associated Press and blogs have heaped on his corporate sponsor pay-for-play issue support scheme.

Posted by Shawn Whalen on at 10:52 AM
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A Smart PHR Vision

Continuing the discussion of PHRs started on Aug. 28, this week brings a guest blog post from Dr. Lonny Reisman, CEO of client ActiveHealth Management. Dr. Reisman explores what to look for in a PHR solution.

Fulfilling the PHR Vision: Analytical Interactivity Empowering the Consumer

In today's fragmented healthcare system, patient data is scattered among physicians, hospitals, lab companies and pharmacies. This can lead to medical errors, adverse patient outcomes, costly hospitalizations and disabilities. Efforts are now underway by leading health plans and employers to aggregate patient information into personal health records (PHRs). This aggregation of data into a patient-centered and patient-controlled record can empower consumers of healthcare and enhance care optimization among physicians, other caregivers and patients.

PHRs can help enable the consumer-driven health movement, and support President Bush's federal priority to provide Americans with electronic health records by 2014. They are a centerpiece for public and private sector initiatives for healthcare IT connectivity to improve care, reduce medical errors and lower costs. PHRs also offer an opportunity to tailor information to the unique needs of the individual and support patients as they play an increasing role in managing their health.

The Model for an Ideal PHR: Analytical Interactivity is the Key

Continue reading "A Smart PHR Vision" »

Posted by Shawn Whalen on September 17, 2007 at 10:27 AM
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UnitedHealth Settles - The .005% Fine

UnitedHealth Group, the company doctors love to hate, rolled over in the lawsuit brought by 36 states for the insurer's claims processing practices, or lack thereof.

In the settlement, UnitedHealth will be pay $20 million to the 36 states. They will also start a three-year "process improvement" plan of quarterly reports and annual benchmarks to cut down on claims-payment errors, help speed payments and better field complaints. If the process improvement plan requirements aren't met, the managed care giant could pay up to $20 million more in fines.

In 2006, UnitedHealth made $4 billion in profit. I'm sure they'll feel the pain of that $20 million.

Continue reading "UnitedHealth Settles - The .005% Fine" »

Posted by Shawn Whalen on September 10, 2007 at 12:55 PM
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R U PHRed?

Magazines are spilling much ink over Personal Health Records (PHRs), the latest piece of IT that will fix healthcare. I asked my small-practice doctor a few weeks ago what he would do if a patient presented him with a PHR.  Not much, he answered (first I had to explain what it is.)  No insurer would pay him to populate the data and it isn't integrated with his (limited) PPM system.  The patient would be welcome to a copy of his medical records (for an exorbitant "handling & copying" fee) to populate the PHR himself, but good luck making out the doctors handwriting, medical abbreviations and terminology. If one had seen specialists, those seperate records would need to be secured and entered as well.

The PHR hype is in full swing, and it will likely take a decade minimum for a majority of patients to have PHRs.  I doubt most people will even look at their PHR even if they have one, but that's besides the point.  Progressive insurers like Aetna offer members a pre-populated PHR based on claims data.  In the long term, this will help Aetna improve care, reduce errors and lower costs. Follow the money and one will see the adoption path PHRs follow.

As with all technologies, the question of standards is arising with PHRs. AHIP has taken a good first step in creating a standard that is expected to be ready by December of '08. The standard includes data set and portability requirements to take into consideration a person's change in employers and health plans.

Some payors like Medical Mutual of Ohio and  Anthem BCBS have PHRs that align with the AHIP standard. Time will tell how PHRs are accepted by consumers, but for now it's a great story angle for healthcare PR pitching.

Posted by Shawn Whalen on August 28, 2007 at 2:20 PM
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Pay Cuts in Never Never Land

In corporate America, when people make mistakes they or their company pay for it. In the world of healthcare, doctors get paid for their mistakes. Thankfully some of that will be ending, as the Bush Administration is stopping Medicare compensation to hospitals for "reasonably preventable" and "never events."

The former includes patient falls, pressure ulcers, UTIs, catheter infections and other conditions. The latter, or "never events," are for objects left in the body during surgery, blood incompatibility, air embolisms and other believe-or-not medical stupidities.  Score one for pay-for-performance.

Posted by Shawn Whalen on August 24, 2007 at 1:26 PM
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A Tip for HCIT Marketers

Part 11 in a Continuing Series on PR Strategy and Tactics

Forrester Research is offering a free trial membership on their Web site (http://web2.forrester.com/forr/reg/loginreg.jsp ).  The service offers access to free research alerts and other valuable nuggets that can help in marketing and PR campaigns.  Analyst Liz Boehm writes in a "First Look Alert" about healthcare consumerism, to see hit the "Continue Reading" link...

Continue reading "A Tip for HCIT Marketers" »

Posted by Shawn Whalen on August 10, 2007 at 12:08 PM
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Too Little Too Late?

A Commonwealth Fund report says that congressional proposals to boost health information technology do not go far enough to make appreciable difference in American health care. The proposals in question include those that died last year as well as the upcoming Wired for Health Care Quality Act of 2007.

The report says none of the health IT bills "would commit the funds and central leadership required to realize the potential benefits of a health information system."  The solution, says the Commonwealth Fund, is more funding that is in line with the country's $3 trillion spend on healthcare.

Posted by Shawn Whalen on July 30, 2007 at 2:01 PM
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Aspiring PR

Decision support vendor Asparity made a smart PR move last month in issuing a survey and reporting the findings that employees who used decision support during the 2007 enrollment season made different -- and more cost-effective -- health care choices that better met their needs than employees who did not use decision support. While there is a certain amount of obvious "duh" factor in this, the breakdown of findings is nonetheless interesting:

Continue reading "Aspiring PR" »

Posted by Shawn Whalen on June 26, 2007 at 11:00 AM
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Where Quality is Nice, But Profit a Must

"It's a healthcare company with car issues," proclaimed TIME Magazine last month in a story about Chrysler. It's no secret that among the top factors hurting the Big Three automakers (and many of the Fortune 1000) is healthcare costs. Its crippling effect has contributed to foreign leadership in many sectors of U.S. commerce. It has also led to many corporate initiatives such as the Leapfrog Group to address the issue.

Healthcare quality and cost concerns are the hot button issues for consumers, business and politicos.  But it's the cost issue that clearly is the problem and motivation.  If we're lucky, better quality will be byproduct of cost savings.

The successful healthcare IT vendors make sure their provider and payor prospects understand how their solutions reduce costs. Sure the press release headlines are about quality - who doesn't want to make patients healthier?

But in the sales environment it's all about cost reduction. Hospitals get systems to increase efficiency and revenue. Medical groups to reduce the number of FTEs and the DAR with payors. The health plans want claims systems to keep as much reimbursement from docs as possible. Companies want employees paying more premium and getting well quickly to reduce absenteeism (read costs).

Is CDH an answer? The consumer directed healthcare panacea shifts risk, responsibility and costs onto consumers who may or may not come out ahead (or healthier, for that matter.)  It is simply too soon to see categorical results on the CDH experiment; some surveys look gloomy (see my previous post on the Towers Perrin survey.)  Tools to educate consumers are few but are increasing. Hospitals and doctors need a sea-change in their perspective on revealing costs. Anemic HSA adoption will grow slowly over the decade. 

But more than any of this in making CDH work is consumers caring enough to begin with. They won't until forced to pay a larger portion of their medical and drug bills.

I certainly don't have the answers, but it seems that unfortunately government will have to step in and run a variation on national healthcare.  Sure, the doubters' lobbyists are legion. They cite pure cost as an excuse - if the issue is important enough to the right people, it can be paid for (like Iraq.)  If skeptics claim such a program can't be logistically run, look at other huge programs such as social security. My uncle gets his social security check like clockwork every month.

Posted by Shawn Whalen on June 19, 2007 at 2:59 PM
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CDHP Self Sabotage?

Like other past experiments in the world of managed care, the much-hyped consumer directed health plan (CDHP) and it many flavors could very well flame out due to lack of interest.  So says Towers Perrin in a recent survey.
 
Not surprisingly, the survey found that employees' views of CDHPs reflect how well their employers explain the plans, rather than the plans' specific features. In 2007, about 25 percent to 30 percent of companies offered employees a CDHP option; 2008 will see half of them offer a CDHP option.

Only 50 percent of those in CDHPs were satisfied with their coverage against the risk of major healthcare costs, versus 65 percent of those in traditional plans. Forty-four percent of those in CDHPs were satisfied that they had access to affordable healthcare, versus 63 percent in traditional plans. Forty-four percent of those in CDHPs felt they could find quality doctors and hospitals, versus 63 percent in traditional health plans.

How should you as a healthcare IT marketer respond?  I would highlight the benefits of your technology to enabling effective and intelligent use of CDHP. Play off the findings, illustrate how you address the perceived weaknesses of CDH. For example, if you are a decision support vendor, can you help educate consumers to the best choice of doctor, hospital or drug?  It will be a team effort on the part of payors, employers, providers and patients to truly make CDH a mainstream reality.

Posted by Shawn Whalen on June 12, 2007 at 11:34 AM
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Our Hidden Health Crisis: Misdiagnosis

Jerome Groopman's widely reviewed book "How Doctors Think" highlights the problem of misdiagnosis in America's healthcare system. Misdiagnosis and incorrect treatment are critical to quality healthcare but are often overlooked, despite misdiagnoses happening almost 20 percent of the time and wrong treatment plans 60 percent.

Is the current emphasis on EMR, transparency, health plan and cost efficiencies to improve quality misplaced? No, but to think these are the big answers to achieving quality misses the point. Healthcare is the right diagnosis, the correct treatment, a condition/illness healed the first time. Consumers want healthcare delivered correctly the first time, not having the system experiment on them.

Quality improvement impacts not just consumers, but also employer group and health plans costs. Three to five percent of cases represent 30-50 percent of healthcare premium costs and increases. Focusing on this critical segment of the medical population can improve healthcare quality while lowering costs for employers and health plans.

Companies like Best Doctors, Isabel Healthcare, ParadigmHealth, Health Dialog, ActiveHealth Management and Quantum Healthcare are addressing the problem from different angles.  Isabel Healthcare offers a diagnosis reminder system for hospitals. In the employer and payor world, Best Doctors' medical intervention service brings medical expertise to bear on individual complex cases. ActiveHealth's automated, evidence-based Care Considerations alert patients and their doctors about medical issues and treatments.

More attention should be put on the issue of misdiagnosis, which is far and away a problem whose solution impacts quality and cost more than any health IT issue.

Posted by Shawn Whalen on May 1, 2007 at 4:24 PM
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One in Three

Administration associated with health care claims and billing accounts for nearly one out of every three dollars that patients spend on health care, according to a PNC Financial Services Group survey of executives from hospitals and insurance companies.

According to their press release, more than three-quarters (76 percent) of the U.S. consumers surveyed said they think that health care administration should account for just 10 percent or less of total health care costs, with a large majority indicating they would be "highly upset" if those administrative costs were as high as 30 percent.

Additional survey results include:

- Hospital executives reported that one in five claims submitted, on average, is delayed or denied and 96 percent of all claims must be submitted more than once.
- Hospitals that do not use electronic billing or claims submission processes reported, on average, resubmitting a claim 11 times or more, or nearly four times more than those hospitals using electronic processes.
- Insurance executives surveyed said they go back to hospitals two times, on average, to get all the information needed to pay a claim.
-  Nearly a quarter of consumers reported having had a legitimate claim denied by their health plan; one in five ultimately paid the claim out of their own pocket.
- When asked how much could be saved annually if they had a more efficient claims, billing and payment process, one-third of hospital and health plan executives both said their organizations could save at least $1 million a year.
- The benefit of automated processes most often cited by insurance executives was that claims processing time significantly reduced, and 63 percent said that customer satisfaction had improved.
- When asked where the cost savings would be applied, the area most often cited by hospital executives was "reinvested in improving patient care."

Posted by Shawn Whalen on March 26, 2007 at 3:39 PM
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EMR Grumbles

I heard some interesting grumbles at HIMSS from doctors about the evolving pressures of EMR adoption. Acute care vendors see small medical group practices as a major market opportunity. Spurred on by Stark law reform, the vendor big boys are forcing acute care systems onto small practices. They are tapping their hospital CIOs to distribute their EMR solutions to the associated medical practices. Docs often have to choose to adopt hospital-recommended systems or deploy and pay more for their own. If they go with the hospital choice, their data may be owned or co-opted by hospital.

Some docs feel their EMR choices are being narrowed by third parties, be they payors, RHIOs, CCHIT or hospitals each of whom have their own preferences. Certain states are funding initiatives to deploy EMRs to small practices, using a self selected list tied to CCHITT. All these pressures and continued market consolidation may put the more economic or specialty EMR developers out of business.  Then again, new services like the free Google EMR and V.A.'s Vista will continue to make the EMR market interesting to watch.

Posted by Shawn Whalen on March 19, 2007 at 2:58 PM
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Follow the Money

Managed care and big business continue to step up to the plate in driving IT adoption to improve healthcare quality and lower costs.   This is natural since doctors certainly can't be relied upon to do, and payors and employers feel the economic pinch most.  Payors are granting technology to providers to improve revenue management. Pay-for-performance will force adoption by doctors interested in avoiding salary cuts. 

Examples: Aetna is making PHRs powered by ActiveHealth Management available to their 15 million members (Dr. Mike Magee writes on the benefits and risk of this in his Health Politics blog.)  Locally here in Massachusetts, the Blue Cross Blue Shield Foundation awarded $50 million to almost 100 small and medium sized medical practices for EMRs. Stark Law reform will help accelerate these efforts.

Business interests continue to come together to encourage reform. This month two more coalitions have formed.  The Business Roundtable has joined the AARP and the Service Employees International Union to campaign Congress for better legislation for healthcare and retirement issues.  A second expansive group unites the U.S. Chamber of Commerce, insurance companies, and advocacy groups including Families USA.

High on the agenda is healthcare for the uninsured. One in six Americans doesn't have health insurance.  Not all of these are poor - according to the Census Bureau, 70% live in a family with one worker, and a fifth are in families with household incomes above $40,000. The problem is many small and medium sized employers are doing away with healthcare benefits due to cost, or passing along the prohibitive cost to employees.

States have lost patience with Federal inaction and Massachusetts, Vermont, Maine, California and most recently Pennsylvania have moved forward with their own universal healthcare plans.  Most big insurers, facing dwindling medical plan enrollment, favor such state plans.

It will be interesting to see if more coalitions have deeper impact. Leapfrog Group has had limited success. A more receptive Democrat Congress will likely help.

Posted by Shawn Whalen on January 21, 2007 at 4:40 PM
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Lies, Damned Lies, and Statistics

Though Twain had his doubts, marketers love statistics. So to help out healthcare IT marketers here are some stats from the Census Bureau, CMS and analysts.

The U.S. spent $2 trillion on healthcare, or $6,697 a person, in 2005.

Healthcare costs account for one-sixth of the economy, compared with one-tenth in the early 1980s.

In 2006, 61% of businesses offered health benefits to at least some employees, down from 69% in 2000.

Young adults are the most likely to be uninsured. Those between the ages of 18 and 34 account for 25% of the population, but 41% of those without insurance. Texas has the largest percentage of uninsured citizens (24.6%), followed by New Mexico and Florida. Can you say que?

According to Forrester Research, CDH enrollment will reach 12 million, or seven percent of the commercially insured market, in 2007.

Up to 98,000 Americans die each year from preventable medical mistakes they experience during hospitalization, according to the Institute of Medicine.                                                                          

Mistakes in healthcare are costly.  A wound infection costs $21,000 on average. A post-operative infection costs more than $25,000 and re-opening a surgical site will cost more than $36,000.  The Juran Institute and Midwest Business Group recently quantified the direct costs of health benefits for poor-quality care over $1,300 per employee per year with indirect costs of lost productivity from poor care at another $500 per employee per year. 

Posted by Shawn Whalen on January 12, 2007 at 5:39 PM
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Crystal Ball

Analyst firm Health Industry Insights/IDC is holding its "Top Ten Predictions for the Health Industry in 2007"  Webinar on January 10, 2007, 12:00-1:00 pm EST. Here is the link to register:

http://www.idc.com/getdoc.jsp?containerId=IDC_P14515

Posted by Shawn Whalen on January 4, 2007 at 2:58 PM
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2007 Healthcare Predictions

It's the time of year when consultants and industry analysts make their 2007 predictions on healthcare.

PricewaterhouseCoopers releases their own, calling 2007 a watershed for the health industries as health savings accounts reach a tipping point, states act where the federal government hasn't and pressure on pricing amid demand for transparency forces pharmaceutical companies, hospitals and health plans to rethink their strategies.

PricewaterhouseCoopers' top seven trends:

1. States Take the Initiative:  In the presence of federal gridlock, states are taking the lead on divisive issues such as stem cell research, health insurance coverage for the uninsured and oversight of advertising and promotion by pharmaceutical companies.  Responding to local social and fiscal concerns, states are developing innovative insurance programs, forming public-private partnerships to spur innovation and passing legislation to drive greater accountability and transparency from hospitals, physicians and pharmaceutical manufacturers.  According to PwC, such state-led initiatives will likely expand in 2007, but the risk is a patchwork quilt of local programs and regulations.

2. Transparency Could be Revealing:   The demand for transparency around pricing, quality measures, safety standards and community benefit is being driven by and is supportive of consumer-directed healthcare and pay-for-performance.  In 2007, the health industries will focus on becoming more transparent, but government, insurers and employers need to educate consumers about the availability and use of such information.  Providers will need to dedicate more resources to reporting, a strategic issue that can no longer be delegated down in the organization.

For the other five predictions follow the link...

Continue reading "2007 Healthcare Predictions" »

Posted by Shawn Whalen on November 30, 2006 at 5:34 PM
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PHR Event

In December a panel of local experts will discuss personal health records at an event held by the Massachusetts Technology Leadership Council. More information and a registration link follows.

Friday, December 15, 2006
7:30 am registration; 8:00 am panel; 10:00 am networking
UK Trade & Investment, One Memorial Drive, Cambridge, MA
The Personal Health Record (PHR) is central to consumer centric healthcare. The promise that PHRs offer is to provide the information patients need to understand their health history and clinicians need to make effective treatment recommendations while fostering informed conversations between patients and clinicians. The opportunity is so compelling that we are seeing an explosion of PHRs becoming available to health consumers, whether they are from health content providers like webMD, PHR providers like ActiveHealth Management, providers or payors such as Aetna. The reality is that since health information comes from all of these sources including patients, their providers, and payers, the development of effective PHRs will require close collaboration between health content, technology and health care delivery professionals.

A panel of experts will look at how PHRs can enable a user-friendly experience in healthcare. Also they will explore the technology and infrastructure needed to capture accurate information, integrate it with medical records, and/or claims data, and make it easy to access and use. Join us as we explore issues that arise regarding how the data sources can be integrated (potentially through Regional Health Information Organizations - RHIOs), who controls the information in the PHR and how it all will be secured.

Featuring:

• Dr. Jeremy Nobel, MD, Harvard School of Public Health,
• Stanley Chin, Director, Practice Development, Altarum Institute,
• Dr. David Cochran, MD, Senior VP of Strategic Development at Harvard Pilgrim Health Care,
• Rose Higgins, President, iMetrikus, Inc.,
• Delia Vetter, Director of Benefits, EMC Corporation,
• Dr. Jon Wald, MD, Corporate Manager, Partners

Register Now:
http://function.masstlc.org/programs_new/event_single.cfm?eventid=744

Posted by Shawn Whalen on November 12, 2006 at 3:06 PM
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Pop Goes the IPO

Gone are the days of IPO mania and stock run ups. I had the pleasure to be part of several client IPOs in the Bubble hey days.  So a 78% rise in the opening day of eHealth’s IPO was nice to see.  The stock was priced at $14, above its pricing range of $10-$12, and opened at $25 (up 78%) and closed at $22.90 (up 64%). eHealth provides a portal to compare and sell health insurance. At a projected $65 million in revenue for ’06, valuation is 68 times earnings. Pretty expensive premium.  We’ll check in again in six months.  From my perspective working with emerging growth tech and healthcare companies, I hear many hopeful plans for ’07 IPOs so look for more such action next year.

Posted by Shawn Whalen on October 13, 2006 at 4:25 PM
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Profitceuticals

While public and private interest groups wring their hands about the ever-increasing cost of drugs, one drug list publisher quietly wields monumental impact on pricing.  First DataBank, a unit of Hearst Corp., publishes a benchmark list of pharmaceutical prices that health plans and state Medicaid programs use as a guide.

As reported in the Wall Street Journal on Oct. 6, First DataBank reached a legal settlement in a case of price gouging. Implicated was McKesson, who is the only company that First DataBank "surveys" to arrive at price averages. As a result of the settlement, prices on many of the most common drugs will be lowered.

This is an egregious example of unmonitored pricing, one which when addressed does more to help alleviate pricing than all the excuses of pharma executives.

Posted by Shawn Whalen on October 8, 2006 at 4:34 PM
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Bridging CDH Islands

This week I wanted to share an interesting column on consumer directed healthcare. Benefitfocus CEO Shawn Jenkins wrote in Health-IT World an insightful piece on overcoming the data challenges to make CDH a reality.

Integration: The Key to Bridging CDH Islands
By Shawn Jenkins

Consumerism is the biggest trend in healthcare in 30 years, as the combined forces of federal and state government, the private sector, and consumer advocacy groups call for greater healthcare transparency and cost control. CDH [spell out – does it stand for consumer-directed health?] plans offer patients more flexibility in selecting doctors; large networks; and financial control over their healthcare. For employers, CDH plans reduce premium rates and annual cost increases but are complex to design and administer.

But what will it take to make CDH a reality?

Consider this vision of an integrated CDH portal: An expectant mother, uncertain and nervous of her many health options, uses a CDH portal to obtain the best information to make choices. An integrated portal should show which insurance plan is best for her family's care, the best local labor and delivery hospitals, compare nearby pediatricians, and offer immediate advice on financial planning and spending. Her employer, health plan, and doctor communicate electronically, thereby improving care while reducing costs.

Continue reading "Bridging CDH Islands" »

Posted by Shawn Whalen on October 5, 2006 at 2:53 PM
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Aisle Nine: Cheap Healthcare?

Wal-Mart is an American business trend setter, so news about their new low premium, high deductible healthcare plan has been making waves. As reported in the Wall Street Journal today, the Value Plan has a monthly premium as low as $11, a high deductible of $1,000, and three doctor visits and generic drug prescriptions a year. Critics contend the plan cuts corporate costs for healthcare benefits and discourages unhealthy employee prospects.

CDH and HSA plans are still in the infancy of adoption; time will tell how popular they will become.  There is no doubt employers will offer such plans to stem the tide of rising premiums. Young and healthy consumers will clearly benefit; the rest are likely to be ill-served by high deductible plans.  This creates a built-in limit to the viability of such offerings. But whatever the case, options that lower costs should be embraced.

Posted by Shawn Whalen on September 28, 2006 at 12:39 PM
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An Unsustainable Path

While Senate Finance Committee testimony usually isn't the most riveting reading, Dr. John C. Goodman's warnings about heatlhcare spending, health savings accounts (HSAs) and consumer directed healthcare (CDH) were interesting.

Testimony before the Senate Finance Committee; Subcommittee on Health Care

Dr. John C. Goodman, president of the National Center for Policy Analysis 

September 26, 2006  

An Unsustainable Path

Government at all levels in the United States currently spends about 7.2 percent of gross domestic product (GDP) on health care, mainly on Medicare and Medicaid.  Yet Christian Hagist and Laurence J. Kotlikoff have shown that if benefits expand at the rate of the past 30 years and if the population ages the way demographers predict, government health care spending will equal one-third of national income by mid-century, when today's college students reach the retirement age.[1]  If that is not immediately alarming, note that one-third of GDP is about equal to all government spending for all purposes today.  If private spending on health care keeps up with public spending, the nation will devote about two-thirds of national income to health care by mid-century - an amount roughly equal to the total consumption of all goods and services today. 

So in the public sphere, health care is on a course to crowd out every other government program - from education and roads and bridges to Social Security and national defense.  And for the economy as a whole, health care is on a course to crowd out every other form of consumption, including food, clothing, housing, etc. 

Clearly we are on an impossible path.  And the longer we stay on it, the more painful it will be to get off of it.  Yet it is impossible to get off of it unless someone is forced to choose between health care and other uses of money.  The question is:  who will that someone be? 

Continue reading "An Unsustainable Path" »

Posted by Shawn Whalen on September 26, 2006 at 5:37 PM
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Doctor, Doctor Give Me Some News

VHA’s Dr. Robert Kolodner, developer of the VA’s EMR system, has been tapped to replace Dr. David Brailer to head the Office of the National Coordinator for Health IT (ONCHIT).  Brailer resigned in April. Kolodner will likely last through the change in Presidential administration. 

Kolodner brings considerable healthcare IT experience to the post given his role in developing the VA’s Decentralized Hospital Computer Program, which preceded the EMR system which is technically the nation’s largest integrated health system (though many EMR vendors call it antiquated at this point.)

Said Health and Human Services Secretary Mike Leavitt in  statement: ““Kolodner joins us at a time when we are making steady progress in advancing the president’s health IT initiative, and his experience in patient care, health IT, and government will be invaluable to those efforts.”

I think it’s about time a replacement was found for Brailer, even if “interim” (technically Kolodner is on loan from the VA).  It shouldn’t be too surprising though, given the position has been one of big hat, no cattle since Bush’s paltry funding of the office. Perhaps the new administration will bolster the priority in ‘08, but likely not. The private sector will continue to inch along in the various RHIO experiments and eventually form an NHIN, but I think it will be a decade past Bush’s desired date.

For Dr. Kolodner’s full bio, follow the link.

Continue reading "Doctor, Doctor Give Me Some News" »

Posted by Shawn Whalen on September 21, 2006 at 8:00 AM
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Executive Order Up

Healthcare IT vendors should be aware of a President Bush executive order on healthcare IT. It presents media possibilities for comment. On August 22, 2006, President Bush signed an executive order that requires the Department of Health & Human Services (HHS), the Department of Defense, the Department of Veterans Affairs and the Office of Personnel Management to collect more information about the quality and cost of healthcare they provide and share that data with each other and with beneficiaries.

The order directs the agencies to work with the private sector and other government agencies to develop and enact programs to measure quality of care. The agencies would also work to identify practices that promote high-quality care. The information will enable consumers to make informed choices among doctors and hospitals, and it will help support doctors and hospitals in their efforts to improve care and lower its costs.

The order also calls for the agencies to use interoperable electronic health records “where available,” and requires the agencies to compile information on the prices they pay for common services available to their members. Agencies must have the new programs in operation by January 1, 2007.

The President said he hopes the Federal action will be followed by similar commitments in the private sector, and in the state and local government. The U.S. House of Representatives also recently passed a measure (HR 4157 “The Health IT Promotion Act of 2006”) that serves to remove legal barriers to the provision of IT technology to physician.

Posted by Shawn Whalen on August 22, 2006 at 4:39 PM
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Lunch and Learn

Support your local healthcare IT events:

Sponsor: Mass Technology Leadership Council
Event Title: Healthcare IT Lunch & Learn with Health Industry Insights
Date/Time: Friday, Sept. 8, 12:00 pm
Location: BlueCross BlueShield of Massachusetts, Landmark Ctr., 401 Park Dr., Boston
Registration is required, contact me via Comment to this blog post

Event Details: The Mass Technology Leadership Council presents an executive Lunch & Learn with Health Industry Insights Vice President Scott Lundstrom. Lundstrom will explore the latest trends in healthcare IT adoption, providing insightful market data, research highlights, success stories and actionable analysis. As public and private sectors move the healthcare industry toward wide-spread IT adoption, both providers and payers are improving not only quality of care but also their bottom line. Data mining, integration and evidence-based medicine are driving personalized care management, pay-for-performance and healthcare transparency. Join us for this executive briefing 'Lunch and Learn' session.

Posted by Shawn Whalen on August 17, 2006 at 1:21 PM
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P4P MD

Here in Massachusetts, Blue Cross Blue Shield of Massachusetts continues its progressive stance on healthcare with new pay-for-performance (P4P) incentives. This comes not long after its $50 million technology grant for small practices to adopt EMRs (see my April 25 post, "The Wal-Mart of EMR.")

BCBSMA is spending $189 million on performance incentives this year. Though controversial and disliked by many doctors, pay-for-performance is gaining national traction. The long standard automatic payment to doctors for care is being shifted to a portion of payment contingent on quality, in the belief that it will make healthcare more cost effective. Premiums have been rising in double digits this decade.

In P4P, health insurers grade doctors and give bonuses on factors such as the number of patients who receive cholesterol testing, regular pap smears and mammograms, etc. About 13 percent of BCBSMA payments to primary-care doctors will be incentives, about $10,000 per doctor, up three percent from 2005.

In critiquing P4P, doctors frequently complain about having sicker patients or dispute third party standards. Often
doctors will boost their business volume to raise income to offset potential incentive hits. I wonder if increasing the number of patients lessens their individual time and overall care quality?

Another wrinkle: Data amassed and crunched by IT systems runs most P4P analysis. While large hospitals have IT systems with more comprehensive data, a majority of care is delivered by small and medium sized practices who lack such IT. In their case, BCBSMA uses billing data which many in the industry say lacks the necessary detail. And this may be simplistic, but if doctors get stiffed because a patient's health doesn't improve, will they start rejecting chronically ill patients?

Payors are certainly aware of these issues and are slowly working out the wrinkles. As a business practice, P4P is putting capitalist pressure on a bloated system to bring to bear quality and cost improvements, which I think is a good thing.

Posted by Shawn Whalen on July 19, 2006 at 1:31 PM
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Goosing EMRs, and Can 700,000 Doctors Be Wrong?

Recently retired national healthcare IT coordinator Dr. David Brailer once called himself the lead goose guiding the flock in healthcare IT. Leavitt of HHS seems in no rush to replace him, though Brailer's office did get an '06 budget increase to $125 million. If one finds a quarter on the ground, that will count as much toward your retirement fund as Brailer's budget does to national IT adoption.

While a voluntary approach to EMR adoption is preferred, Dr. Brailer's inferences at HIMSS and in other speeches about a possible national sponsored healthcare system (and corresponding EMR - the antique Vista EMR used by the VA system) is unlikely under President Bush. That would also kill the EMR market of the big vendors, all of whom support HIMSS' EHR Vendor Consortium.

The political, consumer and technological heat will put doctors who don't adopt EMR out of business by 2015. Small doc practices who've had legitimate price complaints against adoption have increasingly cheap options from small vendors like NextGen and eMDs. Even the large vendors like Cerner are eyeing the small doc group market.

In the payor world, UnitedHealth scored a legal victory when a Federal judge dismissed the class-action suit against it from the 700,000 doctors who claimed the insurer unfairly cut their reimbursements. The country's largest managed care company held out for seven years for their victory, while peers Aetna, Cigna and Wellpoint settled for many millions.

Robert Seligson, president of the North Carolina Medical Society who participated in the law suit, was cited in my May 16 post, "United We Stand, Together We Fall," about UnitedHealth's allegedly abusive reimbursement practices. UnitedHealth's legal victory comes at a time when the SEC is looking into the stock option timing of CEO Dr. William McGuire.

While the judge liked what UnitedHealth had to say, Wall Street hasn't: The stock is down over 25 percent this year due to the stock timing scandal.

Posted by Shawn Whalen on June 29, 2006 at 4:52 PM
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A Penny for Your Health?

As we celebrate National Health IT Week this week it's interesting to put the United States healthcare IT consumption into a global perspective. As reported in AISHealth.com, the May/June issue of Health Affairs states that U.S. government is spending just a few cents on the dollar on healthcare IT when compared with other industrialized nations. America is about a dozen years behind most other industrialized nations in healthcare IT adoption. Citing a lack of studies that prove a correlation between cost reduction and HIT adoption, the study points out that simply because the U.S. trails in HIT spending, one can't conclude there is a direct relationship between its relative performance and its spending on care. Congress authorized $125 million for fiscal 2006 and $155 million for fiscal 2007 for healthcare IT. A RAND study puts the amount at $156 billion over a five-year period.

Posted by Shawn Whalen on June 5, 2006 at 2:50 PM
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United We Stand, Together We Fall

After the oil companies, guess what is one of the most profitable companies in America? The answer is UnitedHealth, the biggest HMO in the country. The Wall Street Journal profiled UnitedHealth CEO Dr. William McGuire last month. It chronicled his talented management skills guiding the company to record performance.

The article also raised quite a stir over Dr. McGuire's uncannily timed stock option awards granted while the stock was down. Some may call this insider trading, some may call it just being lucky. After all, many people win the lottery multiple times.

As the country's largest HMO, UnitedHealth does throw its weight around. Many doctors complain about United's denied treatments, unpaid claims, unfair pay-for-performance practices and hardball contract negotiations. Ask Robert Seligson, president of the North Carolina Medical Society, who mildly characterized UnitedHealth's behaviour as "demonstrating the unrestrained greed and arrogance of an organization that has systematically undermined the very health-care system that provides the basis for its wealth." Seligson's state has joined 17 others in a class action lawsuit against UnitedHealth.

On the other hand, many claim the efforts of UnitedHealth and their ilk have helped rein in rising healthcare costs. This is likely so, but at what cost?

In purely economic terms, Dr. McGuire's track record and company performance justify his compensation by the standards of Wall Street. The standards of Wall Street are often whacked to begin with, which is why this justification holds so little water to non-millionaires. It's too bad such overwhelming profits can't be made without angering the medical establishment.

Healthcare is a much more complicated issue than oil. It engenders high emotions from many stakeholders, most of whom probably don't own UnitedHealth stock. Media love to attack the exceptions -- rarely do the everyday stories of care delivered by in-network docs paid for by health plans make the headlines.

Until someone implements a better healthcare system, managed care organizations are a necessary evil (or good). Regardless of how the healthcare system evolves, the HMOs of the future will profit and take arrows for it.

Posted by Shawn Whalen on May 16, 2006 at 11:20 AM
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Support Your Local HCIT Events

A quick plug for the Massachusetts Technology Leadership Council's Healthcare IT Program. This group brings together local HCIT end users, vendors, thought leaders and interested parties to discuss important issues. The next event, open to the public, is Wednesday, May 17, 7:30am-12:30, at Sun Micro Systems in Burlington, on healthcare technology and robotics. Panelists include executives from Harvard Pilgrim, Boston's Children Hospital, Sun, CIMIT, Foley Hoag and Benemax. Register here.

Posted by Shawn Whalen on May 8, 2006 at 4:04 PM
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Windows Open; Brailer Exits; A Stark Reality

The company everyone loves to hate announced its panacea for the managed care industry. Microsoft unveiled it's Knowledge Driven Health Plans at the recent World Health Congress. The solution set, usually customized for managed care via partners, is comprised of the .NET framework, BizTalk Server, Windows Servers and Communications, SQL Server and of course MS Office.

Scuttlebutt among the cynical at the conference was that Microsoft was following its usual strategy of setting forth a borrowed vision, solution set, partner list and demonstration of momentum that makes its "leadership" position only natural. This is news to the payor IT leaders who own the market -- Amisys Synertech, EDS, DST Health, Perot Systems and TriZetto Group -- none of whom appeared in Microsoft's partnership press release.

But you can't argue with success, and no one has been more successful in technology than Microsoft. Their formal entry into the managed care market comes as Federal healthcare IT czar Dr. David Brailer resigns. Microsoft will help bring further attention and technology to help connect islands of information in healthcare. This is one of Brailer's chief concerns in his resignation speech, as reported in eWeek.

"Everybody's connected but nobody is sharing," says Brailer. "That's the natural consequence without federal intervention." Brailer's other big worry: Smaller healthcare providers will be left behind (see my Plight of the Small Doc post).

Those worries aside, Microsoft, other vendors and hospitals are still wondering about the Stark and anti-kickback legislation that has hindered health IT adoption. These laws prevent hospitals and vendors from donating technology or services to doctors. Congress proposed some exceptions, but the issue remains. Time will tell if Brailer's replacement has the cure.

Posted by Shawn Whalen on May 1, 2006 at 1:00 PM
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The Wal-Mart of EMR

Recently the Massachusetts eHealth Collaborative announced the winners of a $50 million EMR pilot funded by the Blue Cross Blue Shield of Massachusetts Foundation. Among the EMR vendors in the bake-off for the 180 medical group practice contracts: GE Healthcare, NextGen, Allscripts, eClinicalWorks. eClinicalWorks roasted the competition, garnering 170 of the 180 practices.

eHealth Collaborative chief Micky Tripathi says "that was somewhat unexpected" to the Boston Globe. But to those who follow the EMR market, it shouldn't be that surprising. eClinicalWorks beat out a host of larger EMR players. Why? I've heard competitors refer to eClinicalWorks as "the Wal-Mart of EMRs." This is a compliment, given the company's success in the small and medium practice group market. A regular Best in KLAS favorite, eClinicalWorks is cheap, easy to use, built natively on the Web, and strong on functionality without laboring under lots of bells and whistles. "Value," as Wal-Mart shoppers would say. And eClinicalWorks' independent customer Web site keeps the company honest and listening to their customers.

Do the EMR big boys have such responsiveness? Obviously those Massachusetts doctors didn't think so. These practices are for the most part small medical groups, who tend to follow each other like a herd and seek inexpensive, simple technology. Money wasn't an issue in this case, as BCBSMA financed the IT purchase. This make eClinicalWorks' victory all the more telling about its technology.

Sure, the contract value for eClinicalWorks' customers is much smaller than the Cerners and GEs of the world. The big dollars are still at the high end with hospitals (until, or if, Uncle Sam ramps up grants or tax breaks - see "Plight of the Small Doc" post), where the eClinicalWorks of the world rarely qualify. Nonetheless, the EMR vendor big boys should take heed of the lesson of Massachusetts.

Posted by Shawn Whalen on April 25, 2006 at 11:00 AM
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The Race for Better Healthcare

Massachusetts' recent legislation requiring every citizen to purchase healthcare insurance was widely reported in the media. The state's 500,000 uninsured, mostly of lower income, will be offered new, affordable plans and subsidies. People and businesses who refuse may face tax penalties. The interesting and still-to-be-developed aspect of this plan is the pay-for-performance requirement. All that additional Medicaid money (hundreds of millions) going to docs will be contingent on meeting quality standards. Said standards to be developed by 2007. The Boston Globe reports that Governor Romney has a web site comparing hospitals and doctors on quality and costs, using billing data to analyze individual hospital mortality rates and other measures. Hospitals are arguing for measures from clinical data or patient's medical records.

Massachusetts adds a dollop of liberalism in also insisting that doctors show they are reducing racial and ethnic disparities in healthcare outcomes. Surprise surprise, politicos and media have been silent on just how this will be done. Any ideas?

Posted by Shawn Whalen on April 21, 2006 at 4:00 PM
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Managed Care: Changing the Anti-CDH

Many years ago when I was in college, Harvard Community Health Plan was my HMO. I have only one memory of them. I didn't need much healthcare then and I don't recall why I was there (probably a general check up). What I do recall is sitting in the waiting room for almost 40 minutes, complaining, and being shown to the examination room. Then waiting another half hour. Being an impatient youth, I hopped off the table and walked down the hall to the offices. I found my doctor in his office, on the phone on a social call. I knew that because I stood in his doorway for a good minute before he noticed me and asked if he could help me. I told him he should have been helping me an hour ago and stalked off out of the building never to return. No surprise, Harvard Community Health Plan went bankrupt and had to be bailed out by the fine commonwealth of Massachusetts (who says socialist medicine doesn't exist in this country?) Today Harvard Pilgrim is a highly rated managed care plan, though I can't personally vouch for it.

Even if the doctor was to blame in my example, I like so many consumers was left with a bad taste for the HMO itself. How health plans treat their members is often the antithesis of the spirit of consumer directed healthcare (CDH). Health plan members often first hear from their health plan for a denied claim or payment request. No wonder they don't have a good reputation.

As media have widely reported, the Federal government kick-started CDH with proposals for HSAs, calls for more technology adoption and launching Medicare Part D. Pundits point out that consumers are gaining risk and increased responsibility, often without the tools and knowledge to make them informed decision makers. An often overlooked part of the solution is health plans, who have a stake with all parties and are a center point of communications.

Many health plans are not up to the task. MCOs have been marketing to employer groups and providers for so long that member/consumer communications have suffered. Take for example Medicare Part D. The often-reported difficulties of Part D are a microcosm of the broader challenges facing healthcare. The ill-prepared senior population had to grapple with a complex issue. Government and managed care's education efforts were weak, and the result was mass confusion and low enrollment.

What are the smart health plans doing to counter this? My uncle recently told me about his conversation with his health plan. They had called to remind him of drug and medical issues around his chronic condition and to check on open reimbursement issues. I was surprised - was he sure it wasn't his doctor or a nurse? No, it was indeed his health plan and the call had been automated, using the voice of a nice older woman. Apparently his MCO, one of the top three in the country, uses automated voice services. My uncle doesn't use the Web, and probably ignores letters as junk mail, so in his case the good old fashion telephone was the delivery mechanism for value-added, interactive information that improved his health while likely helping the MCO's bottom line.

This anecdote is echoed in the sophisticated member communication being done by such payors as Aetna, Unicare, Oxford Health Plans/United and others. An article in Healthcare Informatics explores how these vendors are closing the "information gaps" with their members. It's as much a trust gap as information gap. Aetna's MedQuery program sends e-mails and phone calls to members who have not complied with doctor recommendations. Unicare in Massachusetts followed up with members with chronic conditions, resulting in a much higher rate of best practice guideline adoption. These are smart moves by insurers that can ultimately improve outcomes while at the same time lower costs.

Managed care is due for an overhaul of their member communications. As my client Silverlink's CEO Stan Nowak says, the best plans of the future will be healthcare guides for their members, assisting them through the whole healthcare life cycle. Communications should be proactive and coordinated among the many departments of the MCO. The proper dose of value added data should be delivered at the right moment, instead of a deluge of information that goes unheeded. As so many other industries have proven, technology solutions exist to make this happen. Efficiency in operations can result in better healthcare.

Posted by Shawn Whalen on April 10, 2006 at 4:14 PM
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