Friday, November 4, 2016

Health Wonk Review is up at Wright on Health

Can’t stomach any further discussion of the election? Then unless you’re a Chicago Cubs fan you should probably steer clear of the Health Wonk Review: Game 7 of Politics Edition, hosted by Wright on Health. But if you’re up for it, there’s a good rundown of presidential related posts plus a few, like mine, that have (almost) nothing to do with the campaign.

 

 



from Health Business Blog https://healthbusinessblog.com/2016/11/04/health-wonk-review-is-up-at-wright-on-health-13/
via A Health Business Blog

Thursday, November 3, 2016

TytoCare: Comprehensive telehealth exam platform

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TytoCare hopes to take telehealth to the next level by providing a solution that allows clinicians to conduct remote examinations. Patients (or caregivers) will use a TytoCare device to conduct an exam that can be interpreted by a physician over a cloud-based platform with video conferencing.

The company took a step forward recently by obtaining FDA clearance for its digital stethoscope. The approach looks pretty cool, but clearly it will be a challenge to get the devices out to patients ahead of need and to do so cost effectively.

CEO & Co-Founder Dedi Gilad answered my questions via email:

1. What was the inspiration for Tyto?

I founded TytoCare along with Ofer Tzadik, another lifelong leader in Healthcare IT, in 2012. The story is similar to that experienced by most families when at a young age, my daughter suffered from a series of earaches requiring constant medical treatment. With two working parents, it became increasingly difficult to travel in and out of the local physician’s office on a regular basis. The experience was not easy for my daughter either, waiting for hours in the crowded doctor’s office in considerable pain and discomfort. 

After consulting with my pediatrician, I recognized the strong need for change in the way primary care is delivered today. I collaborated with Ofer Tzadik to design a new medical experience, one that would not only mutually benefit both the doctor and the patient, but also serve to strengthen this vital relationship. The result of this endeavor is TytoCare, a company prepared to lower the load and cost of U.S. healthcare services, improve accessibility to healthcare services even from the comfort of home, and reshape day-to-day healthcare as we know it.

2.      Why a dedicated device instead of using a tool everyone already has, i.e., a smartphone?

 TytoCare’s examination tools and complete telehealth platform work with a smartphone or tablet and include a stethoscope, otoscope, tongue depressor, camera, and thermometer. While a smartphone can only offer video and audio technology, Tyto enables the patient to conduct actual exams of the heart, lungs, heart rate, temperature, throat, skin and ears. This cannot be done with video alone and more importantly, it requires an interface and technological infrastructure that simply wouldn’t be cost effective in a smartphone.

 3.    How will distribution to end users work? It seems like logistics will be difficult. For example, do you expect everyone to have a device in place before they need it?

 To begin, distribution will start with health institutions though a full consumer product is coming in 2017. We expect that consumers will see the value in being able to perform live, remote medical examinations at home, in place of rushing back and forth to the doctor’s office. 

 4.  What is the cost of the home and pro solutions?

 TytoPro will cost $999.00 plus a monthly fee based on usage, and TytoHome will cost $299.00.

5.  More broadly, what are the overall economics of the solution? Is there a financial return on investment? How do you think about calculating that? Is it more appropriate for certain segments of patients or providers?

Certainly, and our work with leading financial institutions has reinforced the financial ROI.

 The incredible benefit of the product is that its applications are endless because it simultaneously empowers doctors and clinicians while unlocking the full benefits of telehealth for patients. TytoHome can be beneficial in many different scenarios – for geographically isolated patients and those who lack easy access to medical facilities; those who are turning to urgent care because they cannot get an appointment in time at their regular establishment; patients with chronic illnesses or other conditions that require monitoring and frequent, tiresome trips to the doctor or hospital; school or traveling nurses; and of course, parents at home with kids.

 6. What is the lifecycle for this solution? Do you expect to upgrade the devices over time? Can that be done through software or will it require hardware to be replaced?

We will likely add additional examination capabilities over time, but the majority of upgrades can be made through software updates.

 7. What else should readers know?

TytoCare is a complete end-to-end telehealth platform that provides a telehealth experience comparable to in-person visits. It truly fills the missing link in telehealth between the in-office professional and the at-home patient by delivering comprehensive exam results – of the ear, nose, throat, heart, lung, stomach, skin – as part of a complete telehealth visit. The exam data can be delivered to a clinician via “live telehealth exams” or through the “exam and forward” function – sending the exam results on to be examined by the clinician later.

 TytoCare can be used anytime, anywhere and by anyone. Patented guidance technology directs and enables anyone to collect the right data so a clinician can make the proper diagnosis. The advanced digital exam tools use clinic-grade technology to capture high resolution images and sounds, allowing for more kinds of remote diagnoses and increased accuracy.

The secure cloud-based platform enables integration with existing HER systems and provides analytics for decision support with health alerts. TytoCare offers HIPAA compliance, and the modular product design also supports open APIs so other examination devices can be integrated within TytoCare.

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By healthcare business consultant David E. Williams, president of Health Business Group.



from Health Business Blog https://healthbusinessblog.com/2016/11/03/tytocare-comprehensive-telehealth-exam-platform/
via A Health Business Blog

Tuesday, November 1, 2016

PCSK9 experience shows drug market isn’t completely broken

 

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Why isn’t this thing growing?

Everyone knows that the market mechanisms that make most of the US economy efficient are lacking in healthcare. That’s especially true for pharmaceuticals, where drug companies can raise prices at will, and only the government can step in with price controls to put things right. At least that’s what we’ve been hearing in the press and on the campaign trail for the last year or more.

So I read with interest a recent STAT article These pricey cholesterol drugs aren’t selling. And that has the biotech industry sweating, about how the market is blocking high-priced drugs –and preventing pharma companies from doing all the things we’ve been told they can do at will.

No one disputes that the new drugs, Repatha and Praluent, are excellent at lowering bad cholesterol, or LDL. They often succeed where the traditional treatment — an inexpensive class of drugs called statins — fails. The problem boils down to doctors who are reluctant to write prescriptions, insurers who are unwilling to pay for them, and drug companies that have failed to understand a fast-changing marketplace.

The failures could send a chill through the still-booming biotech business, which relies on the idea that the risky, expensive process of developing new drugs can one day pay off big.

Contrary to the views expressed in the STAT article, I think the market is actually doing an ok job here. There are two main reasons why the drugs haven’t sold well:

  • First and foremost, while they are proven to lower cholesterol they are not proven to reduce heart attacks or strokes or to lower death rates
  • Second, most patients do just fine with generic statins, which are inexpensive and have a long track record, compared with the new drugs that have list prices of about $14,000 per year

The result is that doctors who want to prescribe the drugs have to jump through a lot of hoops to get insurance company approval. That’s a hassle and it’s expensive and time consuming, so I sympathize. But by the way, before we get mad at the PBMs and insurers, consider that the experience for prescribers might not be that different under a fully capitated payment model since health system administrators would still be worried about their budgets.

The companies that make these drugs are conducting studies of the impact on outcomes that people really care about: heart attack, stroke, death. If they demonstrate that the drugs are effective on these measures, they will have no problem generating prescriptions or charging premium prices –at least in the United States.

Image courtesy of iosphere at FreeDigitalPhotos.net

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By healthcare business consultant David E. Williams, president of Health Business Group.

 

 

 



from Health Business Blog https://healthbusinessblog.com/2016/11/01/psck9-experience-shows-drug-market-isnt-completely-broken/
via A Health Business Blog

Monday, October 24, 2016

Why I’m voting against marijuana legalization in Massachusetts

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I’m not dead set against the eventual legalization of marijuana for recreational use. Still, I’m strongly opposed to Massachusetts ballot question 4: Legalization,  regulation and taxation of marijuana, and will be voting No.

Why? Because the arguments in favor of approval are not strong enough to make Massachusetts one of the first states to legalize. And some of the arguments against the ballot measure raise serious concerns. Instead I’d like to take five years or so to observe  how things go in early-legalization states like Colorado and Oregon and apply the lessons in Massachusetts.

I thought Massachusetts did the right thing by de-criminalizing marijuana. That kept police and the courts from wasting resources on possession of small amounts of marijuana and stopped lives from being ruined through unfair imprisonment and the stigma of  a criminal record.

Voters then went further and approved medical marijuana, which as I expected, became a precursor to the push for full legalization just a couple years later.

The innovative Citizens’ Initiative Review Project summarized the pros and cons of Question 4. The strongest pros were as follows (quoted verbatim):

  • Legalized and regulated marijuana is safer than black market marijuana because the legalized product will be tested and clearly labeled according to state regulations.

  • Question 4 will create a large number of regulatory, law enforcement, legal, and licensure jobs that are supported by taxes on the sale of marijuana.

  • Question 4 would give patients and health providers ready access to marijuana without committing a crime. Legalization could help people avoid opiates, addiction and worse problems. 

The first point is accurate, however there is an implicit assumption that legalization will eliminate the black market. Colorado’s experience indicates that the black market may continue to thrive alongside the regulated, legal market, and that the official market is the province of middle and upper class white people, while the poor and minorities are priced out. So that’s not such a strong argument.

On the second point, it’s weird that one of the strongest arguments for a libertarian-oriented law would be to create large numbers of government jobs. That’s a terrible rationale as far as I’m concerned.

On the third point, there is already ready access to medical marijuana for patients and health care providers, thanks to the legalization of medical marijuana. There are some hints that people may be substituting marijuana for opiates. That’s probably a good thing and we should follow it closely.

The strongest “con” arguments from the Review Project include the views I expressed above about the black market and large number of new government jobs. The cons include two additional, compelling points:

  • Although in development, at this time there is no definitive method of testing for impaired drivers.

  • There is conflicting evidence of an increase in teen use or motor vehicle accidents in states that have legalized recreational use.

Beyond the Review Project’s findings, there are other good arguments against legalization. Marijuana is addictive for some people, it affects the developing brain in negative ways, and “edibles” are too easy for kids to get ahold of and to consume before or during school.

Please join me in rejecting Question 4 in Massachusetts in this election. If you do, I promise to be open minded about reviewing my stance in a few years, once evidence is in from other states.

Image courtesy of Paul at FreeDigitalPhotos.net

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By healthcare business consultant David E. Williams, president of Health Business Group.

 



from Health Business Blog https://healthbusinessblog.com/2016/10/24/why-im-voting-against-marijuana-legalization-in-massachusetts/
via A Health Business Blog

Friday, October 21, 2016

Health Wonk Review is up at Health System Ed

Health System Ed hosts the election edition of the Health Wonk Review, where healthcare bloggers do their very best to keep democracy alive. This edition leads off with a set of opportunities for bi-partisan cooperation in healthcare. Amen to that!



from Health Business Blog https://healthbusinessblog.com/2016/10/21/health-wonk-review-is-up-at-health-system-ed-5/
via A Health Business Blog

Thursday, October 20, 2016

The case for healthcare cooperation with Cuba

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I learned quite a bit from a brief Perspective in the New England Journal of Medicine (The United States and Cuba –Turning Enemies into Partners for Health).

A June Memorandum of Understanding (MoU) between the US Department of Health and Human Services and the Cuban Ministry of Public Health lays out a wide variety of areas for cooperation, including infection diseases like Zika, plus cancer and chronic conditions.

Thanks to the embargo, products developed in Cuba aren’t available in the US because they are not allowed into the FDA approval process. As a result, certain drugs like Heberprot-P, to reduce amputation risk for diabetic foot ulcers, aren’t available in the US even though they are on the market in many other countries.

We don’t need to copy the Cuban health system, but there are some lessons to be learned from Cuba’s experience with population health, community-based programs, disease control, and chronic care management.

It isn’t possible to fully implement the MoU now, because the embargo remains in place and only Congress can lift it. If Democrats take control of Congress, that could happen soon. If not, the author argues that the President has the authority to allow Cuban products into the US regulatory process just like products from any other country. He’d also like to see the President allow US students to attend medical school in Cuba, where some have been offered scholarships.

These all sound like good ideas to me and I hope they are implemented.

Image courtesy of taesmileland at FreeDigitalPhotos.net

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By healthcare business consultant David E. Williams, president of Health Business Group.



from Health Business Blog https://healthbusinessblog.com/2016/10/20/the-case-for-healthcare-cooperation-with-cuba/
via A Health Business Blog

Tuesday, October 11, 2016

Mass Health Quality Partners: 21 years young

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Barbra Rabson, MHQP President and CEO

Health Business Group is a sponsor of the upcoming anniversary party for Massachusetts Health Quality Partners (MHQP). I asked MHQP’s President, Barbra Rabson to reflect on the first couple decades.

MHQP is about to celebrate its 21st anniversary. What are you celebrating?

We are celebrating the courage and vision it took 21 years ago to found MHQP, and the amazing two decades of progress we’ve made since our inception. Our 21st anniversary is symbolic of our coming of age and reaching a level of maturity. MHQP has become an important part of the Massachusetts healthcare landscape over the decades thanks to the commitment and hard work of our diverse stakeholders – including patients, physicians, hospitals and payers.  More than 40 sponsors and over 300 people are gathering on November 2 to celebrate MHQP’s unwavering commitment to reliable healthcare measurement and transparency and our pioneering work in the Commonwealth and the nation to systematically capture the patient voice and integrate it into care improvements.

At our anniversary celebration we will be honoring the vision of MHQP’s Founding Circle –Blue Cross Blue Shield of MA, Fallon Health Plan, MA Business Roundtable, MA Hospital Association (MHA), MA Medical Society (MMS), Harvard Pilgrim Health Care (HPHC), Tufts Health Plan and the State (Governor Charlie Baker was a founding member of MHQP when he was Secretary of Administration and Finance).

We will also be awarding MHQP’s first award in honor of the late Richard Nesson, MD, a founding visionary of MHQP when he was the Chair of the MHA Board in 1995 when MHQP was established.  We are delighted that Susan Edgman-Levitan, the executive director of the John D. Stoeckle Center for Primary Care Innovation at Massachusetts General Hospital and the founding president of the Picker Institute will be the first recipient of MHQP’s H. Richard Nesson Award.

How has the environment changed in MA over the past 21 years? What role has MHQP played in that?

The healthcare environment is drastically different than it was when MHQP was founded in 1995.  When MHQP first started collecting and reporting comparative statewide performance information, we were the only game in town.  For example, MHQP’s first in the nation statewide patient experience survey of acute care hospitals and public release came a full decade before CMS developed the hospital H-CAHPs survey! Likewise, when MHQP began collecting and reporting statewide clinical and patient experiences measures for ambulatory care, MHQP’s data was the only reliable source for quality benchmarks for our provider organizations.  Before MHQP’s comparative quality reports, Massachusetts provider organizations only knew their own performance scores, they had no comparative benchmarks or best practices to drive performance improvements.  Physician leaders  (Barbara Spivak, Tom Lee and others) have told us MHQP’s performance reports were invaluable to them because our reports became the writing on the wall that they needed to make significant investments in their organization in the form of electronic health records and quality improvement infrastructure to advance their performance to the level they aspired to.

Another big change is that our reimbursement systems now provide millions of dollars of incentives for provider organizations to improve performance.  When MHQP first started the term ‘pay-for-performance’ had not yet been coined.  MHQP has always [encouraged] improvements through public reporting of reliable and trusted comparative performance information – relying on physicians’ intrinsic motivation to perform as well as they can. Now that provider compensation depends heavily on measurement we need to work harder to make sure we have accurate and fair measurements of quality care.

Finally, back in 1998 when MHQP first starting reporting on patient experiences of care, patient experience was not considered a core measure of quality.  MHQP’s statewide collection and reporting of patient experience helped draw national attention to the importance of listening to patients, and in 2001 the IOM introduced the concept of patient centered care as a key element of quality care in the Crossing the Quality Chasm Report.

Kindred organizations to MHQP have arisen around the country over the last couple decades. How do you relate to them?

MHQP was one of the first regional health improvement collaboratives (RHICs) to be founded in the country. Gordon Mosser (founding CEO of ICSI in Minnesota) and I organized the first meeting of regional collaboratives in 2004.  As a founding member and past Board chair of NRHI (the Network for Regional Healthcare Improvement), it has been very gratifying to see so many new RHICs being established.  There are now more than 40 across the country.  I have been told by many of the younger RHICs that MHQP was a role model for them when they were first starting out, and I take great pride in that.

What does the future hold?

Great question, and one I have been reflecting on as we have been looking back on our first 21 years. One of the biggest challenges (and one of our greatest failures as a health care system) has been that we have not done a good job engaging our patients as a resource to help us improve outcomes. In many cases we have actively refused to seek input from patients, and when given feedback we have ignored it.  We are now trying to make a 180 degree shift on this, to better engage patients in the co-production of solutions, and it is not easy because it requires a shift in mindset.  I believe that MHQP’s two decades of experience capturing the patient voice and integrating that voice into care improvements positions us extremely well to support our practices and healthcare systems as they embark on this journey.

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By healthcare business consultant David E. Williams, president of Health Business Group.



from Health Business Blog https://healthbusinessblog.com/2016/10/11/mass-health-quality-partners-21-years-young/
via A Health Business Blog

Friday, October 7, 2016

Is radiology doomed?

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Which path to take?

The radiology profession is a famously paranoid lot, often worried about encroachment on imaging from non-radiologists, competition from teleradiology, reimbursement squeezes, and more. Auntminnie.com is a good place to go to observe how these worries play out.

The latest article, Will machine learning turn radiologists into losers? is a case in point. It reports on a New England Journal of Medicine article that asserts that machine learning will replace radiologists. Images will be sent straight to algorithms, bypassing radiologists completely, they say. There are differences of opinion on how soon this will happen, but an appreciation that once the electronic tools are good enough they will be preferred.

As a patient I’m all in favor of faster, more accurate, and cheaper interpretation of images and if that means there’s no future role for radiologists, so be it. But actually what I hope is that radiologists start to assert themselves as diagnostic quarterbacks, helping to organize and analyze information from pathology, genomics, lab tests and physical examinations. They can work with teams of clinicians in new ways, to speed diagnosis and treatment decisions.

I am aware that some enlightened radiology leaders are already thinking in these terms. I hope the fears spurred by the development of machine learning will accelerate the movement.

Image courtesy of Stuart Miles at FreeDigitalPhotos.net

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By healthcare business consultant David E. Williams, president of Health Business Group.



from Health Business Blog https://healthbusinessblog.com/2016/10/07/is-radiology-doomed/
via A Health Business Blog

Health Wonk Review is up at Managed Care Matters

Managed Care Matters hosts an alliterative edition of the Health Wonk Review (Pre-election pundit ponderings!) which you are bound to enjoy.



from Health Business Blog https://healthbusinessblog.com/2016/10/07/health-wonk-review-is-up-at-managed-care-matters-18/
via A Health Business Blog

Sunday, October 2, 2016

Boston Children’s gets the go-ahead. I’m quoted

From the Boston Globe (Children’s gets green light for hospital expansion, with conditions)

Massachusetts health regulators said Friday that Boston Children’s Hospital should be allowed to go forward with a $1 billion expansion project, a recommendation that seeks to support one of the state’s premier hospitals without undermining efforts to control medical spending.

The staff at the Department of Public Health recommended approval of the plan to build an 11-story building in Longwood and an eight-story outpatient clinic in Brookline.

Here’s my quote:

“DPH seems to be trying to satisfy everyone here, including taxpayers, health insurers, [Children’s Hospital], and competing hospitals,” said David E. Williams, president of Health Business Group, a Boston consulting firm. “The conditions DPH lays out may help achieve these goals, but it is hard for a government agency to manage the hospital market so tightly.”

Children’s plan to use its expanded capacity to draw patients from out of state and overseas is consistent with the hospital’s overall strategy. DPH appears to accept Childrens’ explanation, but wants assurances that MassHealth patients will not be displaced and that Childrens will not attempt to lure well insured, healthier patients away from local competitors.

Ironically, DPH seems to be fighting the last war. After all it was Partners, not Children’s, that expanded widely within the local market. Meanwhile Children’s big recent acquisition was in New York, New Jersey and Connecticut not Massachusetts.

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By healthcare business consultant David E. Williams, president of Health Business Group.



from Health Business Blog https://healthbusinessblog.com/2016/10/02/boston-childrens-gets-the-go-ahead-im-quoted/
via A Health Business Blog

Friday, September 30, 2016

Justifying EpiPen pricing, once again

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Back with more

I enjoyed Medical hackers create $30 DIY EpiPen in defiance of corporate greed over at inhabitat. The Four Thieves Vinegar collective cobbled together an “EpiPencil” from an auto injector for insulin, a hypodermic needle, and epinepherine. It’s a pretty cool trick but it proves nothing about EpiPen pricing nor does it help real patients.

Actually, it unwittingly reinforces the points I made in my very unpopular EpiPen may still be too cheap post, which is that the pricing of EpiPen has almost nothing to do with the cost of its parts.

Consider these caveats about the DIY EpiPencil from the inhabitat post:

However, it is worth mentioning that many experts have voiced concern about the EpiPencil and warned that it’s not advisable to try to create a piece of medical equipment at home – it can be difficult to ensure the correct dose is being administered, the epinephrine inside is delicate and might lose its effectiveness if stored this way, and of course, if someone were to create the device without paying close attention to hygiene, it could become contaminated. A miscalibration of the device could even cause the medicine to be injected into a vein, which can have dangerous side effects.

To recap, here’s what you’re paying for when you buy a real EpiPen:

  • The ability to send your kids to school, playdates, summer camp, hikes, and restaurants with reasonable confidence that they’ll survive an allergic reaction
  • An auto-injector that works. Remember, Twinject was rejected by the market for being clumsy, Auvi-Q was recalled because it could administer the wrong dose, and Teva’s autoinjector was rejected by FDA for “major deficiencies”
  • A device that many, many people know how to use: school nurses, babysitters, passers-by. That means someone is likely to be there to help you if you need it. Good luck with getting someone to learn how to use your EpiPencil in an emergency, even if somehow it worked as advertised

EpiPen’s maker, Mylan has done a lot of sleazy things, which I don’t defend, and as a result they may well deserve the opprobrium that is being directed at them. But I stand by my argument that EpiPen is not $2 of epinephrine and a syringe. Instead its a differentiated solution that provides plenty of value to users.

If someone can come up with something better and cheaper, please do!

——-

By healthcare business consultant David E. Williams, president of Health Business Group.



from Health Business Blog https://healthbusinessblog.com/2016/09/30/justifying-epipen-pricing/
via A Health Business Blog

Friday, September 23, 2016

Public option pops up again

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Where do we go from here?

The so-called “public option” is back on the table. According to Politico there’s a “feud” between liberal and moderate Democrats about the wisdom of such an approach. That’s an overstatement, and really it doesn’t even matter if they are fighting about it or not.

Health insurers have a problem, which is that it’s hard for them to prove that they add value. Does all their utilization management, network development, formulary administration and price negotiation improve cost, quality and patient experience enough to justify the extra administrative costs and hassles they impose on the system? It’s an open question, and one that health plans have a hard time answering convincingly.

Since the Affordable Care Act (ACA) passed, health plans haven’t really had to address this fundamental question. With all the new regulations, marketplaces, and mandates, customers and plans have been busy getting themselves into compliance and learning and testing out the new system. No one has really asked the question about whether we need plans or not.

ACA health insurance marketplaces in some parts of the country are seeing less competition than is ideal as some health plans give up. Aetna gave the feds the middle finger by announcing plans to exit exchanges in retaliation for the government’s opposition to the company’s mega merger plans. The exchanges are fixable but opponents in Congress prefer to let them die if possible rather than fix them. However, this passive aggressive approach to the exchanges could ultimately backfire if it means the government sponsors a “public” competitor to give people choice.

For some, opposition to the ACA is ideological. They don’t like federal mandates, or expanding access to birth control, or they just don’t like Obama. But opposition to the public option is more about business considerations than ideology. Apple wouldn’t be worried if the government started making smartphones, but health insurers are worried about whether they can do a better job than Uncle Sam.

And let’s face it, a government option brings us a big step closer to a single payer system under which insurance companies would essentially be out of business.

Health plans don’t have to worry too much today about single payer or even a public option. Even Senate Democrats can’t agree, so it’s unlikely a public option will make it through Congress. But give it another 10 to 15 years and we’ll see.

Image courtesy of Stuart Miles at FreeDigitalPhotos.net

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By healthcare business consultant David E. Williams, president of Health Business Group.



from Health Business Blog https://healthbusinessblog.com/2016/09/23/public-option-pops-up-again/
via A Health Business Blog

Thursday, September 22, 2016

Health Wonk Review is up at Colorado Health Insurance Insider

Times flies when you’re blogging away. And believe it or not Colorado Health Insurance Insider has turned 10 years old. Blogger Louise Norris rises to the occasion with a comprehensive and compelling edition of the Health Wonk Review.

Although, if the beloved Cavalcade of Risk of blessed memory were still running, they might have a word or two to say about the safety of the candles on that cake!



from Health Business Blog https://healthbusinessblog.com/2016/09/22/health-wonk-review-is-up-at-colorado-health-insurance-insider-13/
via A Health Business Blog

Wednesday, September 14, 2016

LBJ would think walking meetings are pretty lame

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Don’t talk to me about walking meetings

The Wall Street Journal continues to go soft on us. I just read about “walking meetings,” which are just what they sound like: conducting meetings while walking around. According to the Journal, these meetings are great for combating obesity and diabetes, and improving creativity. With meetings, phone calls and emails taking up more than 90 percent of the workday for some people (consultants like myself included), the Journal touts studies purporting to show the benefits of wandering around at work.

Walking meetings aren’t really new. Kaiser’s Dr. Ted Eytan touted the idea on my blog five years ago.

Sure it’s good to get moving, and taking a walk can be just the thing to clear one’s head, but when I’m in a meeting I’m usually taking notes and often viewing documents. Many meetings are confidential and sometimes they involve 10 or more people. So IMHO most serious meetings are not suitable for walking.

When I was an economics student at Wesleyan in the 1980s, professor Stanley Lebergott told me about a pretty crazy job interview his colleague Douglas Cater had with Lyndon Johnson at the White House –swimming nude in the pool and having to keep up with Johnson while trying to answer questions. Although I believed my professor, you might not, so here’s how it’s recounted in Jack Valenti’s memoirs:

I’ll never forget the day LBJ brought Doug to the White House to sort of interview him. ‘Let’s go for a swim, Doug. Okay with you?’ said the president. Well, of course it was, so Doug, Bill Moyers, and I followed the president to the swimming pool. Doug’s eyes almost popped out when LBJ, Bill, and I threw off our clothes and jumped into the pool, nekkid, as we say in Texas. After a moment’s hesitation, Cater stripped and plunged in, too.

As we splashed around, the president began chatting with Doug about his ideas for making the Johnson administration more effective. I daresay, many of us have been interviewed in odd places, but as Doug said later, ‘Nothing compares with my waterlogged birthday suit interview with the president.’

Compared to this, walking meetings are nothing. Can’t the Journal find something more inspiring or scandalous to write about?

By healthcare business consultant David E. Williams, president of Health Business Group.



from Health Business Blog https://healthbusinessblog.com/2016/09/14/lbj-would-think-walking-meetings-are-pretty-lame/
via A Health Business Blog

Thursday, September 8, 2016

Health Wonk Review: Back to School Daze

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Ah Labor Day! A final blush of summer before jumping back to work and into the school year. Here’s a pretty serious set of posts as you settle back in to the fall routine.

The opioid epidemic

Managed Care Matters tells tales from the front lines of the opioid epidemic. Not pretty. Not pretty at all.

Health Affairs Blog shares insights on the development of a “safe space and medical monitoring to prevent overdose deaths” in Boston. This excellent post describes the observation and treatment facility (which is not a supervised injection facility) and lays out five policy lessons learned to date.

Insurance and the Affordable Care Act?

The Obamacare insurance exchanges are in somewhat rough shape, but as Wright on Health explains, there are some pretty straightforward fixes. Politics (as usual) is likely to get in the way.

If you were somehow under the illusion that Health Care Renewal was a fan of managed care mergers (and for-profit, managed care companies in general) this week’s post should erase any doubt. In fact, it’s a trip down memory lane from the early 1990s formation of Aetna and its merger with US Healthcare to today’s politically motivated withdrawal from the exchanges to retaliate for the government’s opposition to a new mega-merger.

Oh boy. Insurance is about spreading risk, but you have to be pretty darn to big to spread around the expense of a $1 million/month chronically ill patient. That’s what Wellmark is having to do, and InsureBlog says good for them, it’s insurance working the way insurance should.

Ready for the fourth Obamacare open enrollment period, coming up in November? Healthinsurance.org has a guide to what’s new.

Technology and population health

Is that the best we can do?  HealthBlawg does not think health systems deserve credit for leveraging Uber to get people to their appointments. Telemedicine is the way to go, instead.

Population Health Blog, on the other hand, applauds the potential of personalized, tech-enabled approach to diet.

Like HealthBlawg, The Hospital Leader wants to focus on social determinants of health to keep people out of the hospital.

Drugs are pricey

Healthcare Economist describes various value frameworks that can help life sciences companies evaluate and justify the value of innovative approaches.

I made a few new enemies at Health Business Blog with my contention that EpiPen prices may still be too low.

And Health System Ed rounds out the wonkery with a post on drug prices, EHRs, and the Affordable Candidate. Big topics all!

A hopeful finish

Workers Comp Insider shares a firefighter’s miracle: a face transplant after sustaining severe burns.

Image courtesy of Stuart Miles at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.



from Health Business Blog https://healthbusinessblog.com/2016/09/08/health-wonk-review-back-to-school-daze/
via A Health Business Blog

Friday, September 2, 2016

Are men comfortable with female physicians? Other factors to consider

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Nuzzel showed me that my friends have been sharing a new athenainsight: Are male patients comfortable with women doctors?  The post uses athenahealth billing data to demonstrate that male patients are less likely to return to female physicians than they are to male physicians, but for female patients the sex of their doctor doesn’t make a difference.

Athena’s conclusion is that men may be “less enthusiastic than women about seeing physicians of the opposite” sex. The article links to a Quora exchange, where all the respondents indicate that as patients they are equally comfortable with women as they are with men.

These findings are interesting, but I don’t think they tell the whole story.

When my long-time primary care physician retired I looked for a new doctor. I believe in the value of long-term relationships so wanted to pick someone I could be with for 15 years or more. I wanted someone affiliated with my preferred health system, with excellent clinical and at least decent communications skills, and around my age (late 40s).

My retiring physician recommended a female colleague in a practice close to where I live, who fit the bill. He had been involved in her training and had worked with her.

Like the Quora respondents, I was comfortable with being examined by a female physician. As I’ve written, I’m also comfortable being examined by a physician who is a friend.

But, although it was further down my list of criteria, I did have the sex of the physician somewhere on my list of factors. Why? Because at least on average, men work more hours and retire at an older age, making them more likely to be available to patients when needed.  One survey showed that 44 percent of female physicians worked part time, compared with 22 percent of men. Another showed 25 percent of women compared to 12 percent of men.

My personal experience reinforces those statistics. The recommended primary care doctor works part-time. Other  female physicians my family sees have taken time off to care for sick family members and attend to other family issues. One retired in her 40s to take care of sick parents. Working less or taking time off doesn’t make them bad doctors or bad people –quite the contrary, it may even keep them fresh or help them stay connected with patient needs– but it does have an impact on availability and longevity of the relationship.

In the end I chose the female primary care physician my retiring doctor recommended, and I plan to stay with her. But I’m also adjusting my expectations about primary care. For one thing I’m focused more on the relationship with the overall practice, rather than just with my personal doctor.

The practice seems to do a reasonable job of working together as a team, and I hope this will serve its patients as well or better in the long term than the more traditional and familiar one-on-one doctor/patient relationship. If it doesn’t turn out that way then my likely next step is to switch to a concierge practice rather than seek out a male physician.

Image courtesy of stockimages at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.



from Health Business Blog https://healthbusinessblog.com/2016/09/02/are-men-comfortable-with-female-physicians-other-factors-to-consider/
via A Health Business Blog

Friday, August 26, 2016

EpiPen may still be too cheap

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Good stuff, cheap

Pick up a newspaper or surf the web and you’ll find story after story taking Mylan to task for EpiPen pricing practices. The list price of a 2-pack has soared from about $100 to $600 over the past decade. The price is deemed too high and the rate of increase is considered particularly unconscionable.

Let me offer a brief counterargument:

  • EpiPen is worth the price. A $300 pen regularly rescues children from anaphylactic shock that would otherwise be fatal, offering them the chance to live to 100 instead of dying at 10. (About 20% of patients need a second dose, which is why these devices are sold in 2-packs.) Meanwhile drug makers charge hundreds of thousands of dollars per year per hemophiliac, tens of thousands or more to give a cancer patient a shot at a couple or few more months of life, and thousands per year to modestly lower the chance of a heart attack. Within that context, and in absolute terms, EpiPen is indeed a bargain.
  • People are complaining that they pay hundreds of dollars per year –or more if they have multiple packs– for something they hope never to use. But they should acknowledge that they are actually using EpiPen even when they never dispense the drug. EpiPen is what lets them send their children on playdates and be comfortable with them away at school and summer camp, go out to restaurants, and take hikes in the woods.
  • EpiPen is worth a lot more than its current and former competitors. According to the Washington Post, Twinject left the market in 2012 and was considered clumsy and unappealing compared to EpiPen. Auvi-Q was recalled last year because it could administer the wrong dose. Teva’s autoinjector was rejected by FDA this year for “major deficiencies.” How many parents would be willing to trade down to save a few dollars on these? Anybody?
  • The failure of Adrenaclick to catch on despite a lower price, distribution through Walmart and a good review from Consumer Reports demonstrates that Mylan has done a lot with EpiPen over the past decade to earn its price premium and high market share. In particular, EpiPens are now close to ubiquitous in schools thanks to clever marketing, effective lobbying, and public health campaigns. School nurses know how to use them, babysitters know how, and so do siblings. When an emergency strikes and seconds count, the familiar tools are at hand, and people are ready to act. It doesn’t really feel like the moment to learn about Adrenaclick for the first time!
  • In effect, Mylan has created a public health support system around EpiPen. I’ll go ahead and make myself even more unpopular by saying that this system justifies the big price increases. When you buy EpiPen in 2016 you’re not just getting the product like you were in 2007, you’re benefiting from the whole system. Although the product itself hasn’t changed, EpiPen is more valuable now than it used to be, and Mylan has justifiably reaped the rewards.

EpiPen is far from perfect. For example, it needs to be stored within a tight temperature range and protected from light.  The pens have to be replaced annually. Other companies are working on EpiPen alternatives, and I’d like them to have a financial incentive to do so. A cheaper EpiPen could be nice, but I’d rather see something that’s better (easier to use, more effective, more stable), even if the price is higher. The current attacks on EpiPen are unfortunate because they discourage investment in these types of innovation.

Before you dismiss these arguments and call me an industry hack, I’ll point out that I have advocated for drug price regulation since 2006. But EpiPen is not the place for the government to intervene.

Image courtesy of Sira Anamwong at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.



from Health Business Blog https://healthbusinessblog.com/2016/08/26/epipen-is-still-too-cheap/
via A Health Business Blog

Thursday, August 18, 2016

Surprise, surprise! Exchange customers are price sensitive

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Uh oh. Another big national health plan, Aetna has decided to pull back from the individual health insurance marketplaces (aka exchanges) deciding they can’t make money because customers are focusing on price, not brand name. The headlines give a sense of it:

Cost, Not Choice, Is Top Concern of Health Insurance CustomersNew York Times

Customers’ Laser-Like Focus on Plan Prices Is Causing Concerns in Health Insurance MarketKaiser Health News

The articles quote insurance executive and experts claiming that “price competition has turned out to be much more cutthroat than anyone expected” and that “people signing up for [broad network, big employer style coverage offered by the big name national health plans] are less healthy –and more expensive to treat– than anticipated.”

Hah!

As I have written before (Good riddance: United finally gives up on ACA marketplaces):

Health plans thinking of competing in the marketplaces should say this to themselves a few times before diving in: “Exchange business is price sensitive business. If we can’t compete on price we might as well stay home.”

The exchanges do have problems. For example, insurers are limited to charging older people 3x what they charge younger ones, whereas actuarially it should be more like 5x. The problems are eminently fixable, except that opponents of the law still want it to fail. As for Aetna, specifically, it seems they are retaliating against the feds after the government announced its opposition to Aetna’s merger plans.

Nonetheless, why would we measure the success of the exchanges by whether the big, fat brand name health insurers can make money? Exchanges allow customers to compare plans on an apples-to-apples basis and they are deciding that there’s no big reason to pay higher prices. Some health plans are thriving on the exchanges by negotiating hard with providers (Medicaid oriented plans like Centene and Molina) or by having local market knowledge and density (Blue Cross Blue Shield of Florida  –which has almost as many Obamacare customers in Florida as Aetna has in the whole country).

Here’s the real problem for health plans: they have largely failed to demonstrate that they add significant value. Aetna, United and their ilk don’t accomplish a lot compared with Joe’s health plan. And even when they do add value, they still add large administrative costs and inefficiencies to the system that may outweigh their benefits.

The Affordable Care Act has actually given health plans a new lease on life, by herding in new groups of individual customers and by imposing whole new sets of standards and rules. Health plans fear a so-called “public option” because it could reveal that commercial plans don’t bring much. And as unlikely as it seems now, it’s quite possible that the failure of commercial plans to demonstrate value could lead us eventually to a single-payer system.

Ideally, I’d rather not see single payer. If some of the plans were a little more ingenious and capable they could actually prosper in the exchange business, in ways that would boost their success in the commercial market as well. In particular, there are opportunities to better manage the way specialty care is delivered and paid for, by emulating the approaches used by the most efficient and innovative specialists. This would drive down the overall cost of insurance and improve care for patients.

Plans could also be more creative and resourceful in helping providers take risk or even full capitation.

Meanwhile, Aetna will struggle to grow. After all, the US is moving toward marketplaces and government coverage. Aetna, not Obamacare or the exchanges, may turn out to be the big loser here.

Image courtesy of Stuart Miles at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.

 



from Health Business Blog https://healthbusinessblog.com/2016/08/18/surprise-surprise-exchange-customers-are-price-senstive/
via A Health Business Blog

Health Wonk Review is up at Healthcare Economist

Healthcare Economist hosts the Short and Sweet Edition of the Health Wonk Review blog carnival. Here you’ll find posts on health insurance, mental health, pharmaceuticals, physician pay and value measurement.

I’ll be hosting the next edition at the Health Business Blog. Have a post to submit? Use the contact link at Health Business Group to send it my way.



from Health Business Blog https://healthbusinessblog.com/2016/08/18/health-wonk-review-is-up-at-healthcare-economist-14/
via A Health Business Blog

Friday, August 12, 2016

Medicare and the end of racial segregation in healthcare

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The story of how Medicare ended segregation in healthcare settings is a pretty remarkable one. Temple University Professor David Barton Smith’s  The Power to Health: Civil Rights, Medicare, and the Struggle to Transform America’s Health Care System brings the events of 50 years ago to light.

“In four months [government bureaucrats] transformed the nation’s hospitals from our most racially and economically segregated institutions to our most integrated,”he writes. “A profound transformation, now taken for granted, happened almost overnight.”

In the early 1960s healthcare was even more segregated than the economy as a whole. In Southern states there were separate hospitals for whites and blacks; there were separate waiting rooms in physician offices, with black patients seen last.

The 1964 Civil Rights Act prohibited racial discrimination in programs that received federal funds. But when Medicare was enacted in 1965, no one really took the provision seriously. After all, the Brown v. Board of Education decision a decade earlier had not led to rapid progress in school desegregation.

And yet Wilbur Cohen and a small team from the Social Security Administration and Public Health Service put together rules that prevented hospitals that discriminated from receiving Medicare funding. Learning their lesson from the failure of Brown’s “all deliberate speed” language, which had let school segregation fester, the team decided to enforce the rules from day 1.

Since hospitals couldn’t afford to forego Medicare, desegregation was achieved in a matter of months. Imagine that.

Image courtesy of podpad at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.



from Health Business Blog https://healthbusinessblog.com/2016/08/12/medicare-and-the-end-of-racial-segregation-in-healthcare/
via A Health Business Blog

Monday, August 1, 2016

MGH marketers take on Boston Children’s

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The doctor will see you now –and forever

I was driving along in Boston last weekend when I heard an intriguing radio advertisement for MassGeneral Hospital for Children, the pediatric division of Massachusetts General Hospital (MGH).

MGH is a world famous hospital, but when it comes to pediatrics it’s much smaller, less well known, and lower ranked than Boston Children’s Hospital –the #1 rated children’s hospital by US News.

I thought MGH picked a clever angle for the ad: highlighting a patient with Crohn’s disease who was diagnosed at age 10 and is now an adult. The message: illnesses that occur in childhood may need ongoing care into adulthood. Therefore why not start with a hospital that cares for children and adults? Boston Children’s isn’t mentioned, but it’s the clear target.

The Crohn’s example is not accidental. It’s a fast growing illness among kids, and it lasts for life. I don’t have the data but my sense is that it must be a highly profitable line of business for hospitals because of the frequent surgeries, endoscopy, and use of biologic drugs. (I would have been surprised if they had uses a common but non-lucrative disease like diabetes.)

The transition from a pediatric to adult gastroenterologist is an important step on the patient journey. A bad transition can be stressful and even lead to worse health outcomes. I’d be interested to learn what processes MGH has in place to make the transition smoother for its patients than what Children’s can offer. (I’ll have to research that.) It’s also unclear how highly to weigh this factor when choosing a place for a child to be treated, especially if that child might move away for and after college.

I don’t want to sound too cynical on this. In my own experience, I’ve seen physicians from Children’s and MGH –including in gastroenterology– collaborate closely to help one another’s patients. If you have a child with inflammatory bowel disease and live near Boston, count your blessings.

Image courtesy of kdshutterman at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.



from Health Business Blog https://healthbusinessblog.com/2016/08/01/mgh-marketers-take-on-boston-childrens/
via A Health Business Blog

Friday, July 29, 2016

Smoking and the ACA

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The Affordable Care Act (ACA) has created a wonderful laboratory for studying the impact of changes in healthcare policy. One of the more interesting papers on the topic appears in the latest Health Affairs (Evidence suggests that the ACA’s tobacco surcharges reduce insurance take-up and did not increase smoking cessation). (You’ll need a subscription to read the full article.)

Health plans can’t charge higher prices to people who are sicker, but they can tack on surcharges of up to 50 percent for tobacco users. States can limit or ban the surcharges, and some do. Not surprisingly, people subjected to high surcharges are a lot less likely to purchase insurance, especially because the way the surcharges work has a very significant impact on their out of pocket costs.

Beyond the headlines, there were several additional findings:

  • When smokers faced no, moderate or high surcharges rates of smoking cessation were unaffected
  • Low surcharges significantly reduced the degree of smoking cessation
  • Young smokers were much more likely than older smokers to be deterred from health insurance coverage by the imposition of surcharges
  • Surcharges were typically higher than the extra medical costs incurred by smokers

These findings have some interesting implications:

  • If the goal of the surcharge policy is to get people to quit smoking, then it doesn’t seem to be working very well. The least effective approach of all is to impose low surcharges. The authors speculate that the low surcharge smokers may feel they are being fairly charged and therefore don’t have an incentive to change. This is like the parents who are more likely to pick up their kids late from day care when a small fine is imposed
  • Surcharges knock younger people out of coverage disproportionately, which may destabilize the risk pools since younger people are generally more profitable than older people
  • The rising penalties for not purchasing insurance may not have much effect on smokers who face surcharges. Many low or moderate income smokers will be exempt from the penalties because the premiums –with surcharges– are deemed unaffordable
  • Patients with mental health problems are being discriminated against because they have much higher smoking rates than the general population. (I have been making similar arguments since 2007)

The authors mention in passing that high surcharges may encourage people to quit in order to obtain affordable coverage. They also note that the smoking surcharge isn’t always apparent on the exchanges, so smokers may not understand that they are paying more or how much.

I’d like to see the law tweaked to make the financial consequences of smoking more apparent to smokers. Surcharges could be displayed more explicitly, and the bar for being exempt from the insurance coverage requirement could be raised. Exceptions could be made for those with a mental health diagnosis.

These changes won’t necessarily be easy to achieve. Congress so far shows no signs of being willing to improve the law –though that may change if the Democrats retake Congress. Another issue is that tobacco use is generally self-reported for exchange customers, so we don’t know how many people are classifying themselves as non-users when in fact they are not.

By healthcare business consultant David E. Williams, president of Health Business Group.



from Health Business Blog https://healthbusinessblog.com/2016/07/29/smoking-and-the-aca/
via A Health Business Blog

Friday, July 22, 2016

Health Wonk Review is up at Medicare Resources

The latest Health Wonk Review blog carnival is posted at Medicare Resources. There’s a Republican National Convention theme, so be prepared!



from Health Business Blog https://healthbusinessblog.com/2016/07/22/health-wonk-review-is-up-at-medicare-resources-4/
via A Health Business Blog

Wednesday, July 13, 2016

Drinking while grocery shopping. Is pot next?

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Where did my grocery cart disappear to?

Amazon.com seems to be unstoppable. It’s grabbed the lion’s share of the e-commerce market, turned other retailers into mere showrooms for shoppers who then purchase online, discarded list prices in favor of its own internal comparisons, and turned Prime Day into a new national shopping holiday. Little buttons around the house can be pressed to reorder staples, and voice commands to my Amazon Echo can summon goods to the home.

Supermarkets are now in Amazon’s sights. I’ve received come-ons lately for Amazon Fresh.

But instead of quaking in their boots, some supermarkets are taking a page from the casino playbook and offering inexpensive alcoholic beverages to customers. From the Wall Street Journal (Supermarkets Invite Shoppers to Drink While They Shop):

At nearly 350 Whole Foods locations nationwide, shoppers can carry open beverages out of the bar area and around the store as they shop around. Some stores have added cup holders to their shopping carts or placed racks around the store where shoppers can place empty stemless wine glasses. In some Texas locations, the $1 cans of beer rest in ice-filled buckets labeled “walkin’ around beer.” “When customers find out that they can sip and shop, a lot of times it’s a lightbulb moment,” Mr. Kopperud says.

Take that Jeff Bezos!

As just about everyone knows, alcohol lowers inhibitions and is more or less guaranteed to boost retail sales. Impulse purchase anyone?

But let’s fast forward this story just a bit. With the movement toward the legalization of marijuana for recreational purposes –which I oppose– it’s just a matter of time before these same stores start opening marijuana boutiques at their entrances, featuring a wide variety of tasty edibles. For Whole Foods they will likely be organic, gluten free and artisanal.

You can bet the munchies will contribute to a healthy boost to the average sale!

Come to think of it, these two ideas aren’t mutually exclusive. A walkin’ around beer and a marijuana edible sounds pretty darn attractive.

Ok, Amazon. What’s your reply?

Image courtesy of iosphere at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.



from Health Business Blog https://healthbusinessblog.com/2016/07/13/drinking-while-grocery-shopping-is-pot-next/
via A Health Business Blog

Friday, July 8, 2016

Dialysis and its discontents

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For the good of the patient, of course!

If you want to understand what ails the US healthcare system, look no farther than the dialysis industry. A recent New York Times article (UnitedHealthcare Sues Dialysis Chain Over Billing) provides a pre-made case study.

In brief, a chain of dialysis clinics (American Renal Associates), pushed poor people out of government coverage and into private insurance with UnitedHealthcare so that the clinics could bill $4000 per treatment rather than $200. A patient advocacy group (American Kidney Fund), paid the patients’ insurance premiums using funds donated by American Renal. United is suing American Renal for overbilling.

So who are the good guys and who are the bad guys here?

From what I can see in the article (and there’s always more to the story) it looks like both American Renal and American Kidney are to blame. But to understand the motivation for their behavior, we have to look at the politics and economics of dialysis.

Dialysis is a life-saving treatment for people with impaired kidney function, but it’s expensive. Medicare is mainly a program for the elderly, but it also covers the disabled and people with end stage renal disease (i.e., dialysis patients) regardless of age. That entitlement was added way back in 1972 to make sure patients didn’t drop dead for lack of funds for dialysis. Medicare coverage kicks in over time, so people with commercial insurance use their plans first before shifting over to Medicare. Once on Medicare they are still responsible for a portion of their costs unless they are poor enough to qualify for Medicaid.

So officially the government pays for dialysis, but does it really do so in practice? In fact what happens is that government reimbursements from Medicare and Medicaid are so low that clinics would go out of business if they had to rely solely on those payments. The clinics make up for the losses by charging high –or even extortionate– rates to private insurers, hence the 20x difference in reimbursement cited in the article. As a result, the clinics make more than 100 percent of their profits on their few commercial patients. From a financial standpoint, the commercial patients are the only patients the clinics cares about.

Meanwhile, the clinic business is essentially a duopoly between Fresenius and DaVita, which is why commercial rates can be so high. Interestingly, the few remaining independent players like American Renal are sometimes even more aggressive than the big boys. (There is an interesting analogy here with Martin Shkreli, who got into trouble for taking big pharma pricing tactics to their logical extreme.) Interestingly if you look at the American Renal website you can see that their real customer is the nephrologist; patient-centric they are not.

What about the American Kidney Fund? It seems like a good guy for paying the insurance premiums for ESRD patients. But its funding overwhelmingly comes from the two big dialysis companies who get a fantastic return on investment, since insurance premiums are much much lower than the reimbursement the companies get back for dialysis treatments. The two big boys basically split the market, so they are certain to benefit from their own contributions. More ESRD patients with commercial insurance means a lot more profit. In fact, if you want to understand just how closely American Kidney is tied to the dialysis business, it’s instructive to learn that patients who get kidney transplants and hence no longer need dialysis are not eligible for American Kidney subsidies!

For a small player like American Renal it’s a different story. They can’t just donate to American Kidney and expect to get a benefit, since most of the value will flow to their big competitors. American Renal’s strategy appears to have been to target specific patients for insurance coverage who would then become American Renal patients. That’s an obvious no no. But hey, they probably figured their own intent wasn’t really any different from what their big competitors were doing and they thought they could get away with it.

Incidentally, analogues to American Kidney operate in other disease areas, particularly for diseases where there are just one or two expensive drugs available. The drug companies pay the premiums and more than recoup their investments via reimbursed drug sales.

So I say good for United for taking on American Renal and American Kidney. But I also note that they –and the other health plans– are still too scared of retaliation to go after the industry heavyweights.

Image courtesy of Sira Anamwong at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.

 



from Health Business Blog https://healthbusinessblog.com/2016/07/08/dialysis-and-its-discontents/
via A Health Business Blog

Wednesday, July 6, 2016

Scaling up bundled payments: Interview with Loopback Analytics CEO Neil Smiley

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Neil Smiley, Loopback Analytics CEO and Founder

Neil Smiley is CEO and Founder of Loopback Analytics, which supplies tools to providers to manage bundled payments. I asked him to comment on the growth of bundled payments and the role of analytics.

Why are hospitals hesitant to adopt bundled payment options?  What strategies can long-term care providers take to encourage bundled payment adoption on a large scale?

In most cases, a hospital’s financial responsibility ends upon patient discharge.  Bundled payments significantly lengthen the care episode, making hospitals responsible for the costs of downstream care partners.  The shift to value-based reimbursement from our current environment of fee-for-service represents a sea-change for the industry.  Decades of business practices, clinical relationships, payment structures and core competencies are being reevaluated in light of this new payment model.  Such evaluation and reflection takes time, and we are starting to see leading organizations embrace this challenge as an opportunity to develop differentiating capabilities.

Long-term care providers can help accelerate this process through proactive engagement with their hospital colleagues.  Hospitals will need better data from their post-acute care partners to have confidence that they can consistently deliver efficient care and strong clinical outcomes.  The long-term care providers that can demonstrate these capabilities pave the way for hospitals to better understand, trust and rely on the broader care delivery pathway they must manage with bundled payments.

What are the main benefits patients will reap from bundled payments?  

Bundled payments have the potential to significantly improve patient outcomes through better care coordination across providers and care settings.

Under a fee-for-service payment model, there is little financial incentive to help ensure a patient makes a successful transition to skilled nursing after an acute care stay, or ensuring that patient successfully transitions home after leaving a skilled nursing facility.

Under bundled payments, there is now an aligned incentive with providers across care settings to ensure transitions are clinically successful and financially efficient.  Patients are likely to get more help in navigating multiple silos of care, when participating providers are financially responsible for the cost of poor outcomes.

What factors are holding back scalability of bundled payments options?

Broader scalability of bundled payment options will be paced by the availability of accurate and timely data from network participants and workable frameworks for sharing risks and rewards among bundled payment partners.

At the national level, CMS has relayed its intention to aggressively advance pay-for-value reimbursement models, with bundles being a prominent example.  Ready or not, the expectation is that bundles will quickly expand to include additional conditions and broader mandated participation.

At a health system level, first movers that have invested in the tools, competencies and partnerships needed to succeed in bundle configurations will be courting more bundle opportunities to take advantage of their lead in the market.

What is the role of analytics in bundled payment? Can you provide an example?

Advanced analytics are absolutely essential to success in bundled payments.

Bundled payments require that different providers across the care continuum come together to consistently deliver a clinically successful and financially efficient episode of care.  Without deep knowledge of potential partners’ strengths and weaknesses, a bundled payment manager stands a poor chance in creating a winning network.

CMS provides data to healthcare systems, ranging from high-level quality ratings to detailed, individual claims records.  With effective application of data analytics, these sources of information, combined with data from network partners can be used to create the most effective care delivery network possible.

How will analytics advance over the next 5 years? 10 years? How do you measure progress?

Looking towards the future, we expect a pronounced shift from retrospective, historical analytics to prospective, predictive analytics.  The former allows healthcare systems to accurately assess their current and historical states, and is an essential component for improving operations.  The latter allows healthcare systems to avoid costs and adverse clinical events before they even occur.  The availability of real-time health data will continue to grow with the proliferation of digital monitoring devices. Machine learning and predictive algorithms are already establishing themselves in matching patients with appropriate resources based on a diverse set of data markers.  We foresee significant expansion on this front in the coming years.

With so many analytics solutions vendors out there how do you distinguish yourself?

Loopback Analytics puts analytics into action.  Loopback has an integrated technology platform that allows our clients to move from investigatory analytics to data-driven interventions, through a platform  that provides a closed loop feedback system to ensure executed actions achieve the expected impact.

It is only through such an integrated solution that healthcare organizations can be assured that the problem is understood, the appropriate actions executed and impact quantified.

By healthcare business consultant David E. Williams, president of Health Business Group.



from Health Business Blog https://healthbusinessblog.com/2016/07/06/scaling-up-bundled-payments-interview-with-loopback-analytics-ceo-neil-smiley/
via A Health Business Blog