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In January 2013, LIMRA reported that 90% of industry executives it had surveyed believe that insurance companies will continue to form strategic alliances with “non-traditional organizations” to expand distribution. The example cited was MetLife’s trial alliance with 200 Wal-Mart stores. Then Accenture’s “Customer-Driven Innovation Survey” found that more than two-thirds of customers would consider purchasing home, auto and life insurance from businesses other than insurers—23% were open to purchasing from online service providers like Amazon or Google (which acquired auto insurance aggregator BeatThatQuote.com way back in 2011 in the UK).

Amazon has proven leadership as an e-commerce distributor, while Google is seen primarily as an information organization, so I would like to elaborate exclusively on the compelling reasons for insurers and Amazon to create a distribution model to match ever-evolving customer demands.

Customer demands

Every information source and every analyst report on insurance in the recent past points to changes in customer’s preferences. Generation X, Generation Y and Millennials prefer doing business with companies that provide:

  • Convenience of on-demand buying and self-service, predominantly through digital channels such as web and mobile.
  • Personalization of product and service delivery, including helping the customer choose the right product.
  • Building trust through transparency in pricing, simplified products and clear articulation of benefits.

So, insurers must innovate in personalizing products, providing transparency in the value of products and services and demonstrating excellence in on-demand distribution. Innovation must also touch “moments of truth” such as claims and policy changes. It is also critical that the distribution lifecycle should be an iterative process to consistently review the value of benefits and help customers fine tune the products and services they purchase.

Continue reading “Can Amazon Dominate In Insurance, Too?”

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EMR adoption is skyrocketing, in no small part due to government incentives. The office of the national coordinator lauds this hockey-stick curve as a success. Advocates promise electronic records will improve patient care, reduce mistakes, and save healthcare costs. At the same time, doctors love to complain about implementation cost and poor usability. How can we reconcile these differing opinions? The truth is they are describing very different technologies. EMRs, the way they are implemented now, will not accomplish these goals. In fact, early adopters can become stuck at a rudimentary level of functionality, and the extensive feature lists described by meaningful use criteria fail to address the most basic needs for patient care.

I have been at medical institutions at different levels of technological development. Each has a different attitude toward the EMR; for some its loathing, others longing. Some devote resources to try to improve it, but others give up. I realized the parallels with Maslow’s Hierarchy of Needs, people are motivated to attain something only after their very basic needs have been fulfilled. So are EMRs good or bad? Well, it depends on where you are on the hierarchy.

The figure above describes the steps to building a technology infrastructure that will lead to improved patient care. Yes, incentives help us achieve some very basic needs, but the problem is that decisions and investments we make now will determine the ceiling as well.

Continue reading “Maslow’s Hierarchy of Health IT”

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flying cadeucii

To control the nation’s overarching fecundity the government of India raised mass awareness of condoms; the chief effect of which were a load of giggling school boys and a load of giggling school girls. Further, in an initiative by Sanjay Gandhi, vasectomies were performed, nearly en masse, through a mixture of cajolement, economic incentives and coercion.

The fertility curve remained unbent.

Then along came color TV. Paul Ehrlich’s doomsday prophecies were forestalled. I know correlation is not causation, let alone abstinence. I’m just saying.

Policy is a strange and lucky beast. It can survive its futility. It is not so much occasionally inept as often incidental. And it has the epistemological luxury of not being easily falsifiable: i.e. it’s hard to prove that it was not responsible for the effect for which it was instituted.

Can you prove that it was not condoms but color TV that derailed India’s logarithmic fecundity? Good luck randomizing to the television arm.

Yes I can hear you muttering “ahem seatbelts.” This is not to say policy never achieves its desired aims. It’s to say that it’s not easy to distinguish policy’s true successes from pseudo successes.

Continue reading “The Cost Curve Probably Won’t Bend Downwards. But That’s Ok.”

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Users and non-users of electronic cigarettes (e-cigarettes) have many legitimate questions about these nicotine-delivery devices. E-cigarettes represent a nearly $2-billion-a-year industry, and one that’s growing exponentially. The number of young people trying e-cigarettes doubled from 2011 to 2012, according to the Centers for Disease Control. So it is natural that so many people are interested in the health consequences of using e-cigarettes.

Research from the Department of Health Behavior at Roswell Park Cancer Institute has documented the impact of first-, second- and third-hand exposure to e-cigarette vapors. Our most recent research, done in collaboration with scientists from the Medical University of Silesia in Poland, offers insight into the user’s exposure to carcinogenic carbonyls.

The e-liquids used in e-cigarettes are primarily composed of glycerin and propylene glycol. We set out to find out what chemicals are generated during use of e-cigarettes, particularly at variable voltages. Some devices allow the user to adjust the voltage to increase vapor production and nicotine delivery.

We found that when e-cigarettes were operated at lower voltages, the vapors that were generated contained only traces of some toxic chemicals. These chemicals included the carbonyls formaldehyde, acetaldehyde, and acetone. However, when the voltage was increased, the levels of these toxicants also significantly increased.

The novel finding of our study is that the higher the voltage, the higher the levels of carbonyls. Increasing battery output voltage leads to higher temperature of the heating element inside the e-cigarette. Increasing the voltage from 3.2 to 4.8 volts resulted in increases of anywhere from 4 times to more than 200 times the exposure to formaldehyde, acetaldehyde and acetone. The levels of formaldehyde in vapors from high-voltage devices were similar to those found in tobacco smoke.

Continue reading “Electronic Cigarettes: What’s in the Vapors?”

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Screen Shot 2014-06-19 at 11.04.40 AMACO, MSSP, BPCI, HIE, CQM, P4P, PCMH, yadda, yadda, yadda … The litany of acronyms describing changing P&D (excuse me, payment and delivery) models can sometimes numb the senses. But it would be unwise to allow the latest healthcare jargon to lull you into an AIC—an acronym-induced coma, for which I believe there is a new ICD-10 code—because the world might look a lot different when you snap out of it.

Little debate exists that the U.S. healthcare system needs to transition from turnstile medicine to value-based care, from a predominantly fee-for-service payment model to one that emphasizes accountability for population health. This, of course, is not a novel concept, so the biggest challenges relate to how we get there. As many skeptics have argued, the same dynamics have existed before – unsustainable healthcare costs and too little value for our money – so the Talmudic question arises: Why is this era different from all other eras?

  1. EHRs have changed the playing field completely
  2. Reporting of comparative performance is now embedded into the delivery system
  3. We understand the centrality of patient engagement
  4. Today’s incentives reward greater accountability and value

There are some fundamental differences compared to, for example, the environment that existed in the 1990s when some experts believed managed care would change the underlying cost structure of the health care system. A majority of providers now have implemented electronic health records (EHRs) and an increasing number are – or soon will be as a result of Stage 2 “Meaningful Use” – able to exchange clinical data across network and vendor boundaries. The expectation that quality measurement will be used for holding providers accountable has taken root and most health care organizations regularly submit standardized performance data to public and private payers, purchasers and independent accrediting bodies. Providers increasingly recognize that their success in population health management relates to their ability to effectively engage with their patients in collaborative relationships.

Continue reading “Be Prepared: Beyond the Alphabet Soup of Value-Based Care”

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Jeff GoldsmithSometimes big game hunters find frustration when their prey moves by the time they’ve lined up to blast it. That certainly appears to be the case with the health policy target de jour: whether providers, hospital systems in particular, exert too much market power. A recent cluster of papers and policy conferences this spring have targeted the question of whether hospital mergers have contributed to inflation in health costs, and what to do about them.

Hospitals’ market power appears to be one of those frustrating moving targets. The past eighteen months have seen a spate of hospital industry layoffs by market-leading institutions, and also a string of terrible earnings releases from some of the most powerful hospital systems and “integrated delivery networks” in the country. These mediocre operating results raise questions about how much market power big hospital systems and IDNs do, in fact, exert.

The two systems everyone points to as poster children for excessive market power-California-based Sutter Health and Boston’s Partners Healthcare, both released abysmal operating results in April. Mighty Partners reported a paltry $3 million in operating income on $2.7 billion in revenues in their second (winter) quarter of FY14. Partners cited a 4.5 percent reduction in admissions and a 1.6 percent decline in outpatient visits as main drivers. Captive health insurance losses dragged down Partners’ patient care results. Sutter did even worse, losing $22 million on operations in FY13 (ended in December), — compared to a gain of $697 million in FY11 — on more than $9.6 billion in revenues.  A 3 percent decline in admissions led to FY13 revenue growth of 0.9 percent (that is, nine-tenths of one percent), against 7.3 percent in expense growth.

These results were not atypical. After Sutter, the second most powerful health system in the West, Seattle-based Providence Health and Services, had $37.7 million in operating earnings in FY13 — compared to $239 million in 2011 — on $11 billion in revenues and essentially flat admissions. While some of these results were clearly affected by Providence’s take-over of the failing Swedish Health System in Seattle, there were broad declines in revenue growth across the system. Henry Ford Health System in Detroit, one of the nation’s first hospital-based integrated delivery networks, lost $12 million on operations in FY13 (before some one-time accounting changes), on $4.6 billion in revenues, and hadonly $75,000 in total system revenue growth. Expense increases of 2.6 percent effectively wiped out earnings.

Continue reading “How Much Market Power Do Hospitals Really Have?”

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Brian-KlepperBy BRIAN KLEPPER
One of America’s most enduring mysteries is why the organizations that pay for most health care don’t work together to force better value from the health careindustry.We pay double for health care what our competitors in other developed nations do, but studies show that more than half of our annual health care spend – equal to 9% of GDP or our 2012 budget deficit – provides zero value. Every health care sector has devised mechanisms that allow it to extract much more money than it is legitimately entitled to. Health plans contract for and pass through the costs of products and services at high multiples of what any volume-based purchaser can buy them for in the market. Medical societies campaign for excessive medical service values that Medicare and commercial payers base their payments on. Hospitals routinely over-treat and have egregious unit pricing. There are scores of examples.Decades of these behaviors have made health care cost growth the most serious threat to America’s national economic security. Medicare and Medicaid cost growth remains the primary driver of federal budget deficits. Over the past decade, 79% of the growth in household income has been absorbed by health care. Health care’s relentless demand for an ever-increasing percentage of total resources compromises other critical economic needs, like education and infrastructure replenishment.Health care costs have been particularly corrosive to business competitiveness. Three-fourths of CFOs now report that health care cost is their most serious business concern. Commercial health plan premiums have grown almost five times overall inflation over the past 14 years. Businesses in international markets must overcome a 9+ percent health care cost disadvantage, just to be on a level playing field with their competitors in Australia, Korea or Germany.The health care industry’s efforts to maximize revenues have been strengthened by its lobby, which spins health policy to favor its interests. In 2009, as the Affordable Care Act was formulated, health care organizations fielded eight lobbyists for every Congressional representative, providing an unprecedented $1.2 billion in campaign contributions to Congress in exchange for influence over the shape of the law. These activities go on continuously behind the scenes and ensure that nearly every health care law and rule is structured to the industry’s advantage and at the expense of the common interest.Health care is now America’s largest and most influential industry, consuming almost one dollar in five. Only one group is more powerful, and that’s everyone else. Only if America’s non-health care business community mobilizes on this problem, becoming a counterweight to the health care industry’s influence over markets and policy, can we bring health care back to rights.

Continue reading “How Business Can Save America From Health Care”

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Lately, stories about outbreaks seem to be spreading faster than the diseases themselves. An outbreak of measles in Ohio is just part of an 18-year high of U.S. cases. Meanwhile, polio continues to circulate in Pakistan, Afghanistan, and Nigeria, while spreading to other countries, like Cameroon, Equatorial Guinea, and Syria, leading the World Health Organization to declare a “Public Health Emergency of International Concern” last month.

The Role of Globalization

As recent threats of H5N1, H1N1, and MERS attest, the increasingly global nature of infectious diseases presents serious risks. Foreign tourists, Americans returning home from international travel, immigrants, and refugees can all expose countries to disease.

With modern transportation shuttling people and products to nearly any part of the world in a matter of hours, the volume of these comings and goings is unprecedented. In 2008, approximately 360 million travelers entered the United States, which also takes in about 50,000 refugees annually.

It should be unsurprising, then, that the Ohio measles outbreak started when unvaccinated Amish missionaries visited the Philippines, then returned home. Infected persons spread the disease to others within their largely unvaccinated communities. The last naturally occurring U.S. outbreak of polio occurred in similar fashion: An outbreak in the Netherlands spread to Canada in 1978, then to the United States the following year, all among unvaccinated Amish populations across four states.

Compared to the United States, nations experiencing social unrest and political conflict face even more serious obstacles to preventing infectious disease.

Strife can interrupt routine vaccination campaigns, as is largely happening with polio. For example, the largest numbers of polio cases last year were in Somalia and Pakistan. Refugees and other displaced populations without health care access can create fertile settings for disease spread, especially if they’re not protected by vaccination. Health workers involved in vaccination campaigns can become targets of violence. And in some areas—Nigeria, for example—religious leaders haveconvinced their followers that the polio vaccine is a biological weaponpromulgated by the West.

For the most part, the United States doesn’t face these barriers. In America, vaccination is more of a choice. Unfortunately, some Americans are putting themselves, their families, and their communities at risk by choosing not to get vaccinated. If those who opt out of vaccination travel to areas where diseases are more common or come in contact with individuals arriving from such areas, they’ll be at risk of becoming ill from otherwise preventable diseases. Continue reading “An Outbreak of Outbreaks”

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Health care for veterans has been all over the news.  At the same time, the DoD is moving to procure a replacement EHR system.  So it seems there is no time like the present to review a recent RAND case studies report entitled “Redirecting Innovation in U.S. Health Care: Options to Decrease Spending and Increase Value.”

The case studies include a chapter comparing America’s two most broadly deployed EHRs:  The VA’s VistA and Epic.  The tale RAND tells is not one of different EHR technologies, as both VistA and Epic both employ the MUMPS programming language and file-based database. Rather, it is about how different origins, business models and practices have dramatically influenced the respective systems.  As the report itself says, the contrast offers “useful insights into the development, diffusion, and potential future of EHRs.”

VistA

VistA, “the archetype of an enterprise-wide EHR solution,” supports the Veterans Health Administration, “the largest integrated delivery system in the United States.” Initial VistA development was a collaborative, distributed, grass-roots effort where individual VA medical centers built out new clinical functionality on a common platform.

In the mid 90’s, VistA became the instrument of change at the VA.

The pace and scope of EHR adoption increased dramatically under the leadership of Dr. Kenneth W. Kizer, who served as the VA’s Undersecretary for Health from 1994 through 1999.  Dr. Kizer considered installation of a major system upgrade to be a core element in his effort to transform the organization … Continue reading “How Does the VA’s Technology Rate Against Other EMR Vendors?”

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flying cadeucii

Three of the five largest private health insurers in the US – UnitedHealthcare, Aetna, and Humana – have decided to follow the lead of the Centers for Medicare & Medicaid Services (CMS) and release their payment information to the public. According to Bloomberg News, this data will include 5 billion individual medical claims and $1 trillion in spending.

Releasing payment information by governmental and private health insurers is an important step towards transparency. Providing researchers with access to the details of health insurance payments is an unprecedented and long-awaited opportunity to gain insights into the drivers of rising healthcare costs. Although I share the enthusiasm of many other researchers for analyzing this valuable data, I am also concerned with unanticipated consequences that may arise with unrestricted release of sensitive and complicated healthcare insurance data to the public.

Reputation of Physicians

The performance of physicians, as some of the most reputable and highly specialized professionals of our society, cannot be evaluated only based on their insurance billing history. To the untrained eye, the abnormalities in insurance charges may seem unjustifiable. Deep expertise in the medical domain is required to investigate all of the underlying causes of the abnormal prescriptions, medical procedures and equipment utilizations. Accusing physicians of malpractice or misconduct based on hasty analysis of this data and without careful examination of the unique medical context in each case, would be unfair to those who deliver medical care to patients.

Continue reading “The Side Effects of Releasing Public Health Insurance Data to the Public”

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