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Self-Service in Health Care?

by Scott MacStravic

The very idea of people serving themselves instead of relying on professionals in healthcare has been parodied in a TV commercial where a physician in a hospital is advising a patient, in his home, over the phone, to “Make an incision between the fourth and fifth abdominal muscles.”  Clearly, most sickness care requires professional training and experience, and cannot be replicated by consumers in most cases.

On the other hand, “self-care” has long been the objective of 24/7 phone advice lines, offered by insurers, to enable consumers to determine if they could take care of their own or family members’ symptoms or signs in particular cases.  Self-care medical guides have long been published to offer similar advice entirely via self-service reading thereof.  After all, when self-care is appropriate, it is the most convenient and cheapest alternative for patients, as well as saving considerable money for payors.

Self-service is a growing element of chronic disease management, where patients check their own weight, blood pressure, glucose levels, and other clinical metrics that may indicate progress in getting them under control, or a problem that a professional should handle.  Devices that measure such indicators may be directly connected to professionals for review, as well as uploaded into patients’ records or personal web pages to enable both patient and provider to track progress and evaluate treatment.

A growing number of providers are making it possible for patients to make appointments, obtain health information, arrange prescription refills, etc. online, rather than taking the time of office staff.  Enabling patients to self-serve in terms of learning about the risks and benefits of alternative treatments or medications is a way to at least reduce the time professionals might otherwise have to spend educating them, though patient self-education can also end up costing providers time in explaining why something they may ask for, due to direct to consumer advertising or online information they have obtained, is not really the best choice for them.

But the greatest potential for self-service in healthcare may be in what is truly health, rather than sickness care.  The two biggest challenges in proactive health management (PHM) — whether paid for by consumers, employers, insurers or governments – is to make participation in specific interventions and behavior/lifestyle changes required as easy and inexpensive as possible.  Unless they are easy, convenient, fit participants’ work/life patterns, etc. such interventions rarely attract and retain enough participants.  And unless they are inexpensive enough, they will be rejected by potential and current investors therein.

Self-service in PHM is easily the least expensive approach possible, in most cases.  The question is always whether self-service will be effective enough to yield optimal ROI.  Making the costs to sponsors and participants as low as possible is a great way to minimize the cost denominator in ROI ratios.  But it is by no means always the best way to obtain the greatest ROI net gains.  And unfortunately, people differ dramatically in terms of how intensive, what kind, and how expensive efforts must be to get them to make the necessary behavior changes needed for PHM success.

Involving physicians and nurses, as “promoters” of PHM participation, as coaches and motivators of behavior change, and as sources of needed prescription drug support and lab tests or diagnostic scans needed to monitor clinical measures, has proven to improve results.  But it also greatly increase PHM costs, thereby threatening both ROI ratios and amounts.  Moreover, there are many self-service approaches to PHM that cost very little to make available, accessible and acceptable to consumers, in promoting health, preventing or reducing risk behaviors and conditions, or managing chronic conditions.

For example, a recent webinar sponsored by HealthMedia, Inc. of Ann Arbor, Michigan described how automated, self-service-based PHM programs can address a wide range of individual differences, across the spectrum of behavior change motivations and barriers.  Through automated analysis of online surveys that consumers take, behavior change motivation and barriers are identified and measured, with tailored e-mail or mailed communications aimed at individualizing coaching and support, while keeping costs highly affordable.

Compared to information-only efforts, where medications adherence levels averaged 57.7% when the same information is communicated to all participants in the same PHM program.  By contrast, the customized approach has been found to achieve 75.4% adherence, a 28% higher relative level, achieved at minimal added costs.  Even more positive was the fact that high levels of adherence were reached in as little as 30 days of PHM participation, and declined only a bit after its initial success. Participants’ confidence in their medications, perceived importance of adherence, and refill-on-time behavior actually increased from the 30 to 90 to 180 days participation. [K. Wildenhaus “Improve Medication Adherence: The Missing Link to Better Outcomes” HealthMedia.com Aug 16, 2007.

The use of “custom-tailored” communications is growing among most PHM providers, as they recognize the dramatically lower cost potential in automated communications systems and the potential for self-service inputs by participants to enable these systems inexpensively.  In addition to the reduced sickness costs that are typically achieved through better adherence, participants in the program who also reported an improvement in their health because of that adherence were found to yield productivity-cost savings of $1440 on average.

In order to achieve optimal participation in PHM, and thereby optimal economic value for sponsors, participants must also feel they are gaining something worthwhile, in return for the time and effort they must put into improving their health.  In the HealthMedia adherence study, participants reported an average 27% increased confidence in their ability to control their diabetes, a 15% increase in their ability to manage the emotional issues accompanying their condition, 83% reported being better able to communicate with their provider, and almost twice as many reported a good understanding of their condition.

It is certainly unfortunate that most of the negative press that Medicare disease management demonstration projects have received, thanks to the mixed results achieved therein so far, has come from interventions that were very much on the high side in terms of expense, costing literally from ten to one hundred times as much as automated customization systems may cost.  The full potential of self-service by PHM participants, together with automated communications that can be used as often as weekly, even daily when necessary, is yet to be learned, but the signs so far seem promising to say the least.

Healthcare Providers as Health Managers: Convenience Issues

by Scott MacStravic

Traditional healthcare providers, including hospitals and physician practices have long had an “edifice complex”, expecting patients to come to them for necessary services, to rely on face visits for communications and interactions.  Even today, only a modest proportion of physicians permit online communications with their patients, for example.  Hospitals have relocated or added locations in suburbs rather than the old-fashioned “pill hill” centrality in major cities, but are still losing patients to more conveniently located ambulatory surgery centers and specialty hospitals that established convenient locations earlier.

Convenience of location, hours of availability, and communications is even more important in health management, whether aimed at providers’ own employees or the workforces of employers that are clients for revenue-generating HM programs.  The U.S. Preventive Medicine, Inc. models of “Centers for Preventive Medicine” rely on hospital locations for most of the services they offer, though participating physician “partners” increase the number of locations where patients can obtain services. (www.USPreventiveMedicine.com)

The many hospitals and a few physician practices that offer “executive health” HM programs, which are still the most common example of hospital ventures in this market, almost all offer their major program elements at their own sites, requiring a one-day or longer stay.  While this stay is usually in luxurious surroundings, with “concierge” services to help make it easier for executive and other affluent clients to wend their way through the program, it is still necessary to come to a single location in most cases.  Until recently, most clients had to manage their own lifestyle changes, perhaps with the help of their personal physician back home, though many programs now offer phone coaching follow-up between stays.

By contrast, employers that offer their own HM programs often make them available at the worksite, with a growing number of onsite health clinics that include HM along with traditional occupational health services.  Retail clinics, conveniently located in popular superstores and pharmacies, offer HM services where consumers often shop, and even enable customers to shop while waiting, until a pager notifies them that the provider is available.

HM vendors often offer convenient “kiosks”, where HM participants can have parameters such as weight, body fat and blood pressure checked, in retail stores or worksites, in order to track their progress and qualify for incentive rewards.  Virgin Life Care offers such kiosks (“HealthZone” – www.virginlifecare.com) as does IncentaHealth (www.incentahealth.com).  IncentaHealth also offers daily online coaching for weight loss and fitness improvement.

In the IncentaHealth example, its services are offered mainly through employer-sponsored programs, though it also offers consumer-paid coaching through the New West Physicians in Denver and its Physician Health Coach program.  Participants get physician health recommendations, then IncentaHealth coaching for only $20 per month while they participate.  While these programs are limited to weight management and physical activity, these represent two of the most common health challenges that consumers have.

Whether providers are sponsoring HM programs for their own employees (and dependents, perhaps), for other business clients and their employees, or both – the programs are generally free to participants.  This means that the convenience dimension, i.e. the time and effort required of participants is the major cost to them.  Making it as easy as possible for people to participate, at times and places they find most convenient to participate, with communications channels and timing that fits best into their normal routine, is often the major factor determining the extent of both their participation and success.

Traditional healthcare providers’ insistence on patients coming to their places of business, at limited days and times of access, and communications at providers’ convenience will simply not work in HM, nor can it compete with specialized HM vendors who have already recognized and responded to consumers’ expectations.  Providers wishing to engage as many employees or other consumers as possible, and to promote their continuous and enthusiastic participation, will have to adopt a host of non-traditional convenience tactics in order to compete in the HM market, or achieve optimal results with their own workforce.

As the “new consumerism” increases the power of individuals and their importance in healthcare in general, traditional healthcare providers are already recognizing and responding to increasing consumer demands for greater convenience, even in traditional sickness care.  Providers must be prepared to make even greater improvements in convenience if they hope to achieve optimal results for themselves and their clients in HM, as well.

Interview with Jim Guest, President and CEO of Consumers Union

by Hylton Jolliffe

Malorye Branca interviews Jim Guest, the president and CEO of Consumers Union. From the 4th Annual World Health Care Congress. For more coverage from the conference click here.

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Optimizing Consumer Choices in Healthcare

by Scott MacStravic

Employers are beginning to recognize the importance and value of customization with their employee health insurance plans.  To both promote employee interest in health insurance, and their choosing of employer-sponsored health insurance plans, employers are finding that different employees want different coverage.  Moreover, by offering choice, itself, employers promote happier employees and higher retention rates among them. [H. Wachdorf “Local CEOs Describe Their Fantasy Health Plan” New Mexico Business Weekly July 13, 2007 (Albuquerque.bizjournals.com)]

In such cases, “customization” is usually merely offering a set of different health plans for different demographic segments among employees.  Plans of coverage specially suited to younger singles, married couples, then parents, those with young children, and finally, empty nesters, often with more chronic conditions due to age, may be all the different plans needed to please most/all segments.  Of course, plans that cover segments differently will cost differently as well, and that is often the major reason behind segments’ having different preferences.

Customization can easily go beyond insurance plan options, however.  When it comes to sickness care, for example, providers generally empower patients and family members to play a significant role in developing the “care plan” for each patient.  Planetree hospitals, for example, champion the practice of including patients and families in creating a care plan for every patient within 24-48 hours of admission.  This tends to promote patient and family satisfaction with the inpatient experience, and participation in post-discharge care, thereby enhancing both clinical and service quality.

Customization to individuals, rather than merely segments, is also possible and practiced among at least some of the many proactive health management (PHM) providers.  Providers who employ phone coaching, for example, such as Healthways, Inc., customize their coaching sessions through the normal nurse/patient interactions of every session.  Providers who employ automated computer-generated analysis of employee and member health risk assessments, such as HealthMedia, Inc. can customize feedback and online coaching to each individual through the idiosyncratic patterns of answers to HRA questions.

But consumers are increasingly showing their desires not to merely have choices, but to participate in the design, development, and implementation of the products and services they buy.  This tendency, when coupled with the advantages that customized PHM interventions have shown with regard to impact on participation and engagement in such interventions, make customization by as well as for individuals desirable.

When customization is done through automated computer-generated analysis, the feedback and coaching communications can at least be personalized by labeling the feedback HRA report and recommendations with the name of each individual.  Online and mail communications can also be personalized with individual greetings by name, and beginning sentences with the participant’s name.  This may be accepted as total individualization by participants, even if they do not participate in the design to the full extent as Planetree patients.

But there are at least some employees (and dependents as well), who participate actively in the design and implementation of PHM interventions.  It is a cooperative participation, rather than full autonomy, however.  Participants in the Duke Prospective Health Program get advice and guidance when they select their own health goals to pursue.  And Duke University Health, itself, can choose which types and levels of intensity for the support they offer participants, based on the risk/reward potential of the health status and goals of individual participants.

It has been shown in many cases that individualized PHM interventions, including those where customization is achieved by computer analysis, delivers what appear to be the most benefits to both participants and payors.  What we need now is some research into the relative advantages and costs of empowering individuals to participate in the design and implementation of PHM interventions, themselves, as in the Duke example.

Far too many of the rigorous studies of different PHM interventions have suffered from serious limitations, by focusing on:

  •     Limited areas of PHM, primarily chronic disease management
  •     Limited participants, primarily Medicare and Medicaid participants in CMS authorized reviews
  •     Limited dimensions of success, primarily just reductions in sickness care costs compared to PHM costs added

And almost all such studies have involved PHM interventions that were designed entirely by PHM providers, with little or no involvement in participants except those who choose to enroll in what are often customized only to disease or risk condition/behavior, not to individuals.  Moreover, one of the major limitations of the studies, themselves, has been the limited proportions of people targeted for intervention that have chosen to enroll therein.

Customization has proven to be a major attraction in getting people to enroll in PHM interventions, and in keeping them participating throughout the intervention, rather than dropping out or lacking enthusiasm once enrolled.  While it may cost a bit more to customize completely for individuals, and a good deal more to customize by individuals, it should certainly be worth a comparative study of different approaches to customization to see which is most cost effective.

Disruptive Innovation in Healthcare

by Tony Chen

Since healthcare innovation has been a core topic on this blog, I encourage you to head over to the ChangeMakers website. Partnering with the Robert Wood Johnson Foundation, they are sponsoring a collaborative competition that will award the best “disruptive innovation” idea in healthcare. Here’s a list of the ideas that have been submitted so far - everything from engaging youth to exercise in new ways to the creation of a health futures market to church-based health education kiosks.

Also, check out their “Why Games Matter: A Prescription for Improving Health and Health Care” Collaborative Competition, which is “seeking diverse and creative solutions that merge two distinct but increasingly interconnected worlds?computer and video games and health and health care.” Kids already play video games that are teaching them math - maybe a new game could teach them about their health (and to go play outside instead of playing video games).

Scientific advancement

by Nick Jacobs

What is the conundrum wrapped in the enigma that is missing in American Science, and possibly all science?  The answer is very clear to me now.  It is the patients.  Except in those cases where the scientists entered the healthcare arena because of a relative who was stricken by their disease of interest, there is an abstraction of feeling embraced too many times in the profession that is enhanced by the complete objectivity already present in scientific discovery.

In the research centers, our patients come to us in the form of tissue, serum, blood, urine, and saliva. They come in aliquots, in test tubes, and on slides, and these human beings are anonymous.

What brought me to this conclusion?  As we discuss the silos of power present in research centers, it becomes clear that hospitals have similar structures or silos of power.  Certain lead physicians, strong techs or outstanding nurses create a center of gravity around which funding, support and power emanates. One of my cynical friends jokingly suggested about a very pompous physician   that “If he ever wants to commit suicide, all he has to do is jump off his ego.”

The hospital setting has as many egos as the research centers.  The unifying factor in the hospital that makes it all come together, however, is the patients and their families.

The patient hand off from the Emergency Department to the Lab to the Radiology Department to Critical Care is all made possible by the physicians and staff working closely with those patients and their loved ones.  In a collegial environment, egos, distrust, and all of the emotional luggage is immediately set aside as the patient’s life is attached to a thread of connectivity that is reinforced through unification of the effort and knowledge provided by the various professionals involved.

How different would the world of science be if, instead of slides and test tubes, the scientists were given the opportunity to look into the eyes of their patients on a daily, hourly, or minute by minute basis?  How much harder would they work, or how much more passion would be in their actions if the children of the mother dying of cancer were hanging from their lab coats begging for help?

As long as our patients are one little, abstract, anonymized piece of the puzzle in our labs, life will go on as usual. Until our researchers see and feel the pain.  Until they know the challenge first hand, and become part of the personal lives of those inflicted with suffering, we will still see plenty of scientists everywhere leaving early, taking long lunches or killing time in their cubicles.



by David Williams

A letter writer to the Boston Globe (Tired of being on a first-name basis) has the following to say:

While hospitals such as Beth Israel Deaconess Medical Center continue to investigate how their patients are being treated, I suggest they consider the appalling practice of doctors, nurses, technicians, receptionists, and virtually everyone else in the hospital calling patients by their first name. Unless the patient is a child, or the patient has asked to be called by his or her first name, this is inappropriate and patronizing. It immediately establishes a power relationship in which the patient is placed in the inferior position. What kind of conversation flows from this setup?

Most people under the age of about 50 –which includes the majority of medical and non-medical staff at hospitals– are used to calling people by their first names without asking permission. That includes bosses and co-workers. Younger people may actually feel patronized if someone calls them Mr. or Mrs. –it sounds overly formal and reminds them of being tssk tssked by their mother or first grade teacher.

Many older people –the type of people who tend to be hospital patients– feel almost the opposite, and have reactions typical of this letter writer. I remember being embarrassed for an older relative when hospital staff repeatedly called him by a shortened version of his first name that no one on the outside had ever called him in 80 years.

It shouldn’t be so hard to be sensitive enough to ask someone what they want to be called, should it?

Interview/Podcast with Mark Ganz, CEO Regence and Luis Machuca, CEO Kryptiq

by Matthew Holt
This is the transcript from the interview I did at WHCC last week with Mark Ganz, the CEO of Regence, the Oregon based Blues plan that operates in the Pacfic Northwest, and Luis Machuca, the CEO of Portland-based health IT messaging company Kryptiq. Machuca is innovative as both and employer and a technology guy, and Ganz is, shall we say, not your typical insurance company executive! This is crossposted over at The Health Care Blog

Matthew Holt: This is Matthew Holt with the World Healthcare Blog, reporting from the World Healthcare Congress, doing a podcast. It’s kind of funky back here because we are in this glass-enclosed blogger’s corner which they put together at the back of the exhibit hall, but they are still setting up the exhibit hall, so you can hear the vacuum cleaners in the background. But no matter, we are on with the first podcast of the day.

Today we have got some very interesting folks: Mark Ganz, who is the president and CEO of the Regence Group, which is the big Blue’s plan in Oregon and the Pacific Northwest; and Luis Machuca, whose name I just got wrong again. [laughs]

Luis Machuca: Machuca!

Matthew: Machuca! Sorry, my pronunciation is–they never taught you that about proper Spanish accent in the English school I went to. He is the CEO of Kryptiq, which is an IT messaging company. Well, I should let Luis tell you about that. Mark has already been on the podium twice today in two different areas; Luis has just been talking about an initiative that is being run for his employees with Regence. So let’s start there; Luis, give us the quick find out about what are you doing with your employees and how you work with Regence and what innovative things you are doing around employee healthcare at Kryptiq.

Luis: Hi Matthew. So, really what Kryptiq is all about is building tools that enable healthcare transformation. We’ve really, from day one, always felt that transformation starts from the inside out. So before we try to transform the world of healthcare outside, and build tools for them, we wanted to make sure that we were sensitized to the notion of delivering the very best possible healthcare in the most efficient of ways. So we’ve done many things along those lines, starting with reimbursing for email and patient portal enable clinics for employees.

More recently, and why Mark is here really, is to align with health plans who also embrace the notion of transformation and the notion of getting more decision in the hands of the employees, and more tools and information for employees to make the right decisions about their healthcare dollars.

Matthew: So what does that mean in real life? How have you structured your employee benefits so far, and what’s that actually mean? I’ll ask you, and then I’ll ask Mark the other side.

Luis: Yeah, in real life that means, number one, that we want to make sure that employees have easy, highly productive access to excellent healthcare, and thus the email and portal enabled reimbursement for clinics that do that; and two, a high, high component of a mix of an HSA combined with tools from our health plan that allows people to be guided about the decisions that they make, about the choices that they have, about things that are going to work for them, both in a preventive and also once they have some disease.

Matthew: So, are you funding the HSA from the company, or is that sort of more skin in the game from the employee.

Luis: We fund half of the HSA, so we fund half of their limit.

Matthew: Well, that’s pretty interesting. Now Mark, tell me a bit about how it works out from the insurer and the kind of work you are doing with them.

Mark Ganz: Well, one of our core beliefs as a company is that the fulcrum for full healthcare transformation is the individual customer, the consumer; and that if you look at, when they talk in healthcare about the misaligned incentives among the various players in healthcare, it’s because we are not aligned toward a single individual or person that we serve.

Our belief is that if we focus on the needs of the individual and engage that individual to move beyond the sort of state of entitlement that they are currently in, and create a more of a healthcare marketplace that is very responsive to consumers and in which a consumer is able to navigate and make choices, value-based choices, that that will begin the seeds of more fundamental change throughout the healthcare system.

Based on that belief, we’ve started a pilot within our own company with our own 6,000 or so employees, now we are closer to 7,000 employees, focusing on how do we engage them in their own use of healthcare benefits, in their own use of healthcare, so that they have a better understanding of the interconnection and interdependence, frankly, between and among themselves around their use of care and even their desire to remain healthy and not need the care in the first place.

Matthew: What does that mean in terms of - you showed in the last session some of the dashboards, and some of the tools and techniques. Could you go down to the details of what you’re using?

Mark: Sure. What we’ve done is focused around the key outcomes we want to achieve in terms of engagement of employees, and set up a series of programs designed to achieve those outcomes. We measure our ability based on those outcomes.

So, specifically, the first year we were into this, we designed health risk assessments that all of our employees filled out. Based on what we learned from that, from what employees told us they wanted to work on most, we then developed a series of wellness programs that were designed to address those very issues.

So we had a number of employees that smoked and wanted to quit. We engaged them in ways in which they could do this. We had a number of employees - a lot of employees - who were very overweight. In fact, I think they’d been attracted to our company because we had rich benefits and they felt they would be well cared for as employees in our company.

A lot of them were overweight, so we designed a series of financial incentives and programs that were aligned with those incentives to help people lose weight. In fact, we’ve had amazing success.

And what’s really been interesting is that once we created those programs and then helped people engage in them, what we’ve really tried to do is get employees working with each other to carry it forward. We’ve seen this amazing interplay amongst employees in terms of their desire to lose weight, to get more fit, to be more engaged in taking care of chronic diseases, that we aren’t necessarily mediating. We’ve just created the opportunity for employees to talk to one another and support one another as they try to address those issues for those own lives.

Matthew: You come here with a really crucial issue (while we’re doing this someone’s trying to break the door down), which is how do you motivate people, how do you get them to get off the dime and change behavior? And there are a couple of things going on which I think are related which were on the previous panel, with George Halvorson from Kaiser Permanente.

There’s also this move in the information therapy movement which I’m sure you guys are familiar with, talking about some of the stuff that John Wennberg just mentioned earlier about decision aids and people making the right decision about their care. In some ways, take decisions back a bit from some of the excess we’ve seen in the provider community. I don’t want to put those words in your mouth! But we are talking about how we change the behavior of individuals. Some of it’s motivated with money. Some of it’s motivated with almost a community spirit, that you were discussing.

Let’s change the focus a little bit: At the same time, some of us are saying that the move towards HSAs and individual self-directed accounts actually mitigates against that and tends to put the healthy people up against the sick people and then we have the 3% of folks who drive most of the spending as George Halvorson was mentioning, who are absolutely not so amenable that type of approach.

How do you think that this fits in to the chronic care model?

Mark: OK, a couple thoughts. First off, the healthcare system is an inefficient, opaque, paternalistic system.

Matthew: No disagreement. [laughs]

Mark: And that is true no matter whether you are suffering from chronic disease or you have a hangnail. The fact of the matter is that if we’re going to get at fundamental cultural change in the way the system functions, I believe you start with the 80% that use 20% of the care who have the ability to make choices. You can educate them about how they use healthcare and about how their decisions impact the lives of others.

And, frankly, another piece is that how their contribution to the insurance pool is actually helping others out in the community. I think they have to understand both. And it’s amazing how little we understand that in this country. We believe that somehow it’s me against the big machine when it’s time for me to use healthcare. The mindset of people is often, “How can I extract the most value out of the system?” which means “How much can I extract the most value out of the system, ” which means, “How much can I use and continue to use?” They don’t see the relationship about how, when they use care, they’re essentially taxing other people within their community for their use of care.

Trying to get at that challenge — that is one of the key challenges we face. If we are able to get the health-care system to act more efficiently when it’s dealing with 80% of the people it sees, I believe it will act more efficiently when it’s dealing with the 20% of the people it sees who use 80% of the resources. That the system will change fundamentally to become more efficient, and that maybe that 80% who are elective today might be part of that 20% five years from now.

If they change the way they view healthcare when they’re healthy, or relatively healthy, that when they do get to a certain age where chronic disease sets in, they will be more thoughtful about how they use care. So it’s a belief that you’ve got to change the fundamental economic rules of the system. I don’t believe you get there by simply focusing on changing the game for the 20% using 80% of the care. I think you have to take a broader look.

Matthew: Luis, How is that playing out with what you’ve done in your company so far? What are you seeing from your employees so far, in terms of their changing care?

Luis: I want to go back to something Mark said on his speech earlier today, when he talked about an example. He was talking about a person helping his wife go through the final stages of a cancer, and how, in summary, they were almost forced to surrender control in order to really be able to cope with the health-care system’s role or participation at those stages. What we’re trying to do, and what we are all about, is whether it’s through HSAs or some of the things that Mark talked about, that the more that the decisions become available for people to make — whether it be small decisions or big decisions — the more the dynamic will change with the providers.

What we do is we understand that most providers, it’s not that they want to retain control, and it is not that they’re cynical. It’s that, in many cases, they really are unable because they don’t have access to their own data. They don’t have access to the continuity of healthcare to be able to put data, to be able to put the full picture. So they’re only giving an opinion or a prescription based on what’s in front of them.

As a technology company, what we are trying to do is put in the connectivity tools to allow those things that are in the periphery to come in and form a better picture, so people can have more informed decisions — both as providers, so people can give a menu of choices, and then also for the patients, to be able to make better choices.

The way we see that with our employees is our employees have become very discriminating about the providers that they choose, whether it be on the chronic disease pool or not. The chronic disease employees are gravitating much faster to providers who are going to help them manage a compliant state, than who are just going to be there on an episodic basis. Too early to tell in terms of what data is out, but from a behavioral and anecdotal, observational point of view, we are right on track where we want to be.

Matthew: Yeah, and actually this leads us almost to a point which is, I know, a slightly controversial point in the Northwest around managed networks and high-performing networks. [laughs] If this was TV, you could see Mark sort of cringing there.


But it’s absolutely a key issue….

Mark: It’s a hard lesson learned.

Matthew: It’s a hard lesson learned, but it’s a lesson…. In some ways, you could argue what Luis just said was that some self-selection on the consumer side is moving towards the right thing, the right network perhaps.

Mark: I think if you actually educate…. If you provide financial incentive, however that’s structured, whether it be HSA or whether it be the employer specifically putting more money in the pocket of the employee and saying, “This is your money; go spend it wisely.” However you create that incentive, and you educate them how to be good shoppers, you create more of the marketplace economic dynamic that I think will start changing the dynamic of the supplier of healthcare, i.e., the physician, the hospital and the like.

If you look in those areas of medicine that are not subject to the third-party payment mechanism, that are subject to a marketplace dynamic where the individual is spending their own money and the health-care provider is responsive to that economic relationship, what you see over time is costs are stable, and in some cases they even drop.

Let me give you an example: Lasik eye surgery versus cataract surgery. You look at Lasik over the last several years, and you see what’s happened in Lasik. Number one, quality has gotten better. Customer satisfaction has gotten better. Outcomes are better. Prices have dropped. And there are more people available to do it, because it’s a competitive marketplace.

Cataract surgery, which is subject to the third-party payment system — there’s really not much new that’s happened in cataract surgery over the last ten years. But what’s happened there? Prices have gone steadily upward, because there is not a marketplace dynamic. It’s basically “I want cataract on demand.” Physicians, who actually are much more efficient at doing the surgeries, simply do more of them and charge more for doing it. And we, as health plans, all the while are sitting back, patting ourselves on the back, saying, “Aren’t our discounts great!” When in fact, the alpha upon which our discounts are based continually goes upward.

Now, that’s an example where I think you can look at it and say, “If you give consumers the right incentives, and you educate them how to be shoppers, they’ll figure it out.” They will make good decisions and they’ll be more satisfied with the decisions they make, because they feel like they had a sense of taking charge of their own healthcare, as opposed to being run like a rat through a maze. Which is, unfortunately, I think how healthcare works.

Matthew: Let’s just raise that, though. I’m going to try and draw two things together here. The issue of Lasik versus cataracts has come up a lot, and there’s been, as you know, studies going both sides of that equation. But it’s a very definable, neat piece that you can do. Whereas we know, when we talk about chronic care, which is where most of the money is spent, it’s less definable. Part of the problem is something that Luis brought up, which is that the average physician doesn’t have enough information about the patient, the average patient, is seeing how many number of patients?

So let me ask both of you to jump in on this. How far are we along — maybe just here in Oregon and the Pacific Northwest — how far along are we in the integration of information that makes that potential easier? Then the next question is speculate, about the end state and the way that you’re going to be paying for that expensive chronic care, because of stuff that isn’t like Lasik?

Luis: Well I want to stay to your example, because I think that it’s a good place to frame the difference of possibilities. The popular notion is that people think that we want to know who gives the greatest chronic care. “Tell me who the good doctors are versus the bad doctors.”

I think that’s really a bad question to ask, for the following reason. You’re not going to be able to drive the healthcare system with 20% of the doctors, no matter what. The premise of my point is that the data is there to make the overwhelming majority — a very large number, 80-plus, 90% of the providers — to compliance, to manage a chronic disease in a very effective way, both a cost- and outcome-effective way, if they were connected to the data.

So what I want my health plan to tell me, in terms of their network, is not “who are the good doctors and who are the bad doctors,” but steer me to the people that know how to manage to compliance — as opposed to darkness, where I don’t know the difference. I don’t need to know, tomorrow, all of the details about a particular provider versus another one. But I would like to have some qualitative information about: What kind of tools do they have? Are they committed to a compliance management system? Are they willing to take whatever those steps are?

That, to me, is an important question that can be answered by health plans and others, in terms of the managed networks and which are the better networks.

Matthew: And where would you say we are, on a one-to-ten scale? How far down the path are we to that kind of information integration between those providers, which is seriously a lot of the problem that we’re talking about?

Luis: I would say, that’s not going to give you a numerical answer, but I’ll tell you this: the toothpaste is out of the tube. We are headed in that direction; it’s going to happen, certainly within the next five years. Any attempt to suppress it or repress it will result in market uncompetitiveness and either people losing jobs or people going out of business. But I think we’re past the point of no return on that. So I am very optimistic.

Matthew: I love your optimism At Institute for the Future, I remember we always used to say that the electronic medical record, you know, it’s a technology that is five years in the future and always will be. [laughs]

Luis: A very good example, the electronic medical record, you know, 80% of physicians today do not have an electronic medical record, but 95% of that 80% can do an electronic referral or could do an email consult or could send me my lab results electronically. And those get me to my next step in the healthcare chain much better armed and much better informed.

So the electronic medical record is an example of something that I think became a big initiative without a benefit/value proposition that was to the purchaser; unlike this idea where me as an employer, you know, I want to get guidance from my health plan as to where my employee is going to get better disease management for diabetes or hypertension.

Mark: I want to come back to culture here for a minute, because I am leading the effort in Oregon to try to create an interoperable free exchange of data amongst the healthcare providers. We are starting in the greater Portland area because that is where the greatest population center is. We created a committee, a steering committee under the auspices of the broader business community, the Oregon Business Council, which I chair, and we have at the table the CEOs of the major hospitals; and they are the key to making this work.

If they don’t play, because, I think as you know, the value proposition that hospitals have used into selling the idea of EMR to their own boards has generally been that by having EMRs within their own system, that in a sense it creates a higher set of castle walls.

Matthew: Yes, sure.

Mark: They keep patients within the system, they keep doctors referring into the hospital; it’s a way to make sure that the beds stay full.

It’s been an interesting impediment to the conversation that when you realize that when you talk about democratization of that information across hospital systems, that is very threatening to an old business proposition. It was what I referred to, I was trying to refer to, in my earlier speech about how sometimes things that have gotten us here from a profitability standpoint, we have to put at risk, we have to let go of and look for other ways to provide value. And right now the challenge for hospitals is to provide a greater degree of value to the community through the more easy flow of information.

When we did the study to determine where the economic benefit was of that project, the numbers that came back were essentially, the primary economic benefit was in reduced tests, duplicate tests. Because right now, you know, I am being treated at Legacy, I go up to OHSU, OHSU gets to run all the same tests because they can’t get the information from Legacy. If they can get it, they don’t have a reason to do those tests. And that is, I mean, I understand, I have compassion for the CEOs of the hospitals saying “Wait a minute, why is this a good thing for me?”

But I’ve been very impressed with the vision of folks so far, to stay with this and believe that this is the right thing for the community as a whole. And that’s what gives me hope in believing. I’d say, you know, you asked me how far along we are, I’d say we are still, we haven’t reached that tipping point. I’d say, I agree with Luis that the toothpaste is out of the tube. That is going there, but we haven’t quite got to that place where we have everybody fully admitting or fully embracing the notion that the new world around healthcare data interchange is better than the old world of “keep the castle keep strong, build the castle walls higher.”

Matthew: Right, and the last sort of question on this concerns the “Wall Street Journal” article about Virginia Mason a couple of months back, which I’m sure you saw–Starbucks was their driving employer–and went to them saying “could we reduce tests?”. VM was having trouble getting all the health plans to actually reward them in a way that was conducive to that. What do you think? I presume you are still largely a fee-for-service based payer, as it were, what’s your likely evolution in reimbursement?

Mark: We are putting a great deal of focus–it’s one of our key initiatives right now–in fundamental reimbursement–basically, out-of-the-box thinking about how we reimburse. I am convinced that much of the brokenness of the system is a direct outcome of the way we reimburse.

And when George talked today about how fragmented the system is, how it doesn’t respond to diabetics and the like, I think we have to turn around and point the finger at ourselves and say that how we reimburse medicine creates that fragmented approach. Do you think for a minute that if a diabetic who had complete, you know, had the financial resources and that the system was completely accountable to him, do you think for a minute we would continue with this fragmented system? Diabetics, as consumers, would never allow it; and the system would respond to provide more of a holistic, comprehensive way to treat their illness.

I think that we, as health plans, have to change the way, we have to be willing to move away from the discounted, secret, negotiated rates that we have, that in a sense, I think, provide very little value in reality. I mean, is it really a benefit to consumers to have a 20% or a 25% discount off an alpha that is going up at twice inflation every year? I don’t think that we are really delivering enough value there. So we better think about a different way of reimbursing, and then use that opportunity, by the way we reimburse, to change the way that physicians practice.

So for example, if we were to pay on a regular basis for email visits, would we change the efficiency and the outcomes of people’s experience of healthcare? I think we might. On the other hand, it’s very scary to the actuaries and underwriters in our company who say, “Well, if we start paying for that, who is to say that doctors aren’t just going to start billing us crazily for email visits as well as all the other things they bill us for as an alternative too?”

So we’ve put together an interdisciplinary team of healthcare economists, informatics, actuaries, and, well I would just say, creative thinkers; to start working in an R&D kind of context, trying things, seeing if they work and looking at them in the lab, if you will, to say “Could these things work, and would they drive a different outcome? Would they increase people’s experience of healthcare and tend to lower the usage of healthcare?” And if it does, if we can accomplish those things as well as increase satisfaction through that, both of the physician as well as the consumer, I think we are on the right track, and then we can try it as a pilot, and then if it works in the pilot we can take it out broadly.

Luis: Matthew, there is a very good technology example illustration of what Mark just said. The enormity, perhaps all of the software investment that has gone into tools for health plans to date, has been in the claims. How do we pay claims efficiently? And that really gets to the point of Mark, that that happens very late in the process, really at the end of the process, and doesn’t take into account any real intelligence, any real purposefulness as to what are the behaviors that we want to incentivize.

The premise of Kryptiq’s Courier line, for example, is really to go upstream and help a health plan, from a software point of view, connect all those dots that he just went through, so that it can be purposeful and intentional about the decisions they make upstream, and then the claims payment payroll takes care of itself.

So we are seeing that shift as well, not just in the strategy piece, but also in the software investment. So the software investment is also moving upstream as well.

Mark: Yeah, and actually the primary reason that we bought that product from Kryptiq and are working together is because it starts with having a common vision. And that’s what’s made it exciting in terms of working with Kryptiq, is we sort of are coming at this issue, this broad issue, from two different angles, but there are many points where we meet; whether it’s us engaging with them around what they want to accomplish in terms of employee engagement, or they engaging with us in terms of helping us with that upstream process.

Matthew: Fantastic. So the World Healthcare Blog was started because the World Healthcare Congress was interested in looking at more innovation, and there we have a bunch of innovation! Luis, Mark, thank you very much indeed.

Luis: Thank you.

Mark: Thank you.

A conversation with Intuit’s Dan Levin

by David Williams

Had a chat this afternoon with Dan Levin, VP and General Manager of Intuit’s Quicken Health Group. Intuit may be on the cusp of doing for the health care consumer what it’s done for the financial consumer, and that would be no bad thing.

Health care is a costly, complex mess and the status quo is untenable. From Dan’s perspective, there are two things that may happen:

  1. The entire system will be revamped
  2. Consumers will take on a more active role as customers

Intuit’s betting on #2 and putting some Quicken-like tools in place to help consumers manage the financial aspects of their health care.

Dan seemed pleased that some big technology companies (think Google and Microsoft although he was too polite to mention them explicitly) are trying to disintermediate established players, especially health plans. That’s had the effect of focusing the minds of health plan executives who don’t want to see their businesses undermined; it’s opened the plans up to the virtues of working with a white knight like Intuit. The Quicken brand is a powerful one for health plans to be associated with because it connotes confidence, trustworthiness and ease –three things plans desperately want to project with consumers.

Meanwhile, Intuit has learned from its experience with its initial foray into health care, Medical Expense Manager that consumers aren’t going to key in their own information. Fortunately, health plans have a lot of the data already.

Dan was pleased to tell me that United and Cigna have recently announced plans to make Quicken Health available to their members while the technology companies’ products and services are still on the drawing boards. He’d like to see every health plan offer Quicken Health –the way Intuit has managed to sign up close to 5000 banks for data downloads into Quicken.

Intuit is big on primary research to understand consumer needs. They asked health plans what percent of their members had filed a complaint in the past year and got back estimates of around 6%. Meanwhile about half of consumers answer yes to the same question. According to Dan, “that’s the classic definition of a quality problem.” I’m guessing that’s why Medical Expense Manager placed such a heavy emphasis on tools to help patients dispute bills with their health plans.

I asked Dan whether Intuit was switching sides by selling to plans. He said no. The same sort of bill dispute tools will be available in Quicken Health but their inclusion will actually benefit the plans, Dan said. The reason: Quicken Health will help members “clearly and cogently present their argument to the health plan,” which will make dispute resolution simpler and cheaper.

So where will Intuit go from here to expand its product range? Nothing’s announced but it’s clear that Intuit has learned plenty from its other products. Over 100,000 doctors use QuickBooks today, so although Dan didn’t say so I wouldn’t be surprised to see Intuit move into the space between physicians and health plans. In the process, Intuit might find itself in the role of doing some disintermediating of its own!

Mr. Google comes to Washington

by David Williams

Google’s Adam Bosworth told the standing room crowd that came to have breakfast with him this morning that since he was in DC it was appropriate to “talk about rights,”rather than products. He enumerated a variety of rights (he also used the word “powers”) consumers should have:

  • Power to discover –from whom and where to get help
  • Power to own one’s own data — with complete control of how it is used. This he characterized as an “inalienable right”
  • The right to choice:
    • of provider
    • of insurer
    • of treatment –in partnership with physicians. If the physician sees their patient as a “partner” rather than a “puppet” it makes all the difference in the world in how the patient is treated
  • The power of privacy –meaning the consumer can decide what to disclose to whom, and whether to withhold information without having a large red X for “meds not disclosed” appear on their chart

If consumers had all these rights, they would engage in the power of action to make better choices, though Bosworth freely offered that he doesn’t have the magic bullet.

Bosworth made a couple of other interesting assertions:

  • That the technical challenges involved in getting data into consumers hands are not hard to overcome
  • That once consumers understand what’s really going on they’ll rebel against being exposed throughout their lives to the threat of bankruptcy from medical expenses and will put the burden back on the government or others

I asked Bosworth whether he felt consumers had a role in determining their diagnosis –in partnership with their physicians– as well as their treatment. His answer: “sort of.” He doesn’t want to see patients play at being doctors but he recognizes that physicians exhibit diagnosis bias and that consumers want a “breadthwise search” to see a long list of things they may or may not have so they can rule out the scary ones.

Those looking for details of the forthcoming Google Health offering were probably disappointed but not surprised that Adam didn’t reveal much. But here’s what I picked up in trying to read between the lines:

  • Google wants to include in their PHR transaction data between physicians and health plans, physicians and PBMs, labs and physicians and so on. They are not planning to rely on feeds from physician EHRs to do this –Bosworth made a point of pegging EHR adoption outside the hospital at <10% though I think he’s understating the truth– but to try to plug directly into the payment streams
  • Google is trying to lay the groundwork to have HIPAA overturned, and short of that would like to educate providers and patients about how to get at their information even within the constraints of current laws. They’d like to see consumers have the ability to review and challenge their records as is the case with credit bureau information
  • In keeping with the Google philosophy, Google Health is likely to be a “simple, sloppy solution”

And a final tip for those wanting to work with Google: he seems to like medical experts who’ve written books

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