When envisioning what public insurance exchanges of the future can and should look like when it comes to technology and structure, one only needs to look at the successful private exchanges that have paved the way over the past several years.
This experience has taught those who administer private exchanges that open enrollment—the phase that the federal government’s Health Insurance Marketplace is struggling through currently—is only the beginning. Public exchanges could benefit from lessons already mastered by private exchanges—starting with open enrollment but extending to even more complex technology-based transactions.
There are 10 scenarios that vendors must be able to handle.
1. Life Events. In today’s individual Health Insurance marketplace, consumers can generally add or drop coverage for themselves or their dependents anytime they want. In other words, it’s a relatively “rule-free world.” In January 2014, that world changes to look more like the current group health marketplace in which many rules are defined by the federal government’s existing tax code (e.g., Section 125) and HIPAA requirements, and consumers must select and “lock in” their coverage once a year for the following 12 months, unless they experience a qualified life event.
As a result, each qualified life event – e.g., marriage, divorce, birth of a child, loss of spouse’s coverage and many more – must be configurable within the Exchange technology to enforce the appropriate rules. For example, if a person gets married, is that person allowed to drop coverage or change plans and carriers? How about with the birth of a child? Or with a loss of spouse’s coverage? For a truly scalable Exchange technology, thousands of scenarios must be configured in advance to enable consumers to make enrollment choices online without administrator involvement.
Continue reading “What Public Insurance Exchanges Will Look Like 5 Years From Now”
Filed Under: Uncategorized
Tagged: Health Insurance Exchanges, Health Plans, Open Enrollment, Robert Gallun, the business of healthcare
Dec 4, 2013
His emails arrive at night and land like scud missiles. He is an Old Testament retired CEO who is appalled at the state of America and as a thirty year healthcare system veteran and dutiful son, I am expected to interpret the complicated tea leaves of the Affordable Care Act ( ACA) and warn him if Armageddon (any form of change) is imminent. He needs three hours notice to hide his coin collection.
Today, his instant messaging is in large case font; He has forwarded an email that was forwarded to him from a friend of a friend of a friend – all retirees convinced that our current President is an operative for a hostile foreign government. I have to give high scores to his email chain author for his/her detail, veracity and creativity. Many of the stories are purportedly authored by retired Generals, Navy Seals, and in one case, a dead President.
I often scroll down these emails to see if I can find its genesis and author – perhaps it is Karl Rove or someone incarcerated for white-collar crime.
The email offers me “the truth about Benghazi” or a grainy photo of the President giving out nuclear codes to Al Qaeda operatives behind a District of Columbia Stop & Shop. I am not always inclined to believe these missives but I love my Dad and his loyal concern for America. At 83, his draconian solutions are not always politically feasible and carry a decent chance of arrest if one actually tried to act on them. However, he has a 140 IQ and understands economics.
Continue reading “The T-Rex Takes on Healthcare Reform”
Filed Under: Uncategorized
Tagged: Michael Turpin, Obama administration, The Affordable Care Act
Dec 4, 2013
Healthcare.gov appears to be working much better, at least in enabling individuals to select plans. And some of the state exchange web sites appear to be improving their functionality too. Some have heralded these advances as providing hope that the Exchanges will be able to meet the enrollment projections on which the economics of insurance without medical underwriting in part depend. But do these claims stand up to the cold light of mathematics? Not very well.
Here’s the headline:
A close look at the numbers shows that the pace of enrollments from here to the close of open enrollment needed to meet projections is high in every state, even those touted as successful, and almost impossibly high in many. Given the incredibly slow start in most jurisdictions, it will not just take a little pickup over the next few months to achieve the projected and needed number of persons in the Exchanges. It will take a miraculous last minute stampede. Since miracles seldom occur, the result may be two different stories of the Affordable Care Act: a few states in which the Exchanges proved from the start to be a somewhat stable mechanism for providing health insurance without medical underwriting but a significant number of other states in which the results for at least the first year represent a large failure.
News appears to be breaking out that the federal exchanges enrolled about 100,000 in November. This is being heralded as somewhat of a success compared to the 26,000 who enrolled in October. And, of course, enrollment figures from healthcare.gov are difficult to assess due to the actual and feared dysfunctionality of the web site. But one way to look at this is to consider what has to happen between December 1, 2013, and March 23, 2014, the close of open enrollment to make projections. The states that are dependent on healthcare.gov need about 4.84 million enrollees by the end of that period if the nation is to meet the goal of having 7 million enrolled in the Exchanges by the close of open enrollment. If, right now, there are about 126,000 enrollees in those states, we are just 2.5% of the way there.
The pace of enrollment on healthcare.gov will need to increase by a factor of about 20 in order to meet goal. In absolute terms, healthcare.gov needs to be enrolling about 42,000 people per day. And while perhaps not every single one of those people need to enroll for the system to succeed, the 7 million enrollment goal isn’t just a mere wish. There are, as I and many others have noted potentially serious consequences to the stability of insurance markets if the figures fall well short, even in several states.
Continue reading “In Which Your Author Does the Math”
Filed Under: Uncategorized
Tagged: California, Connecticut, Enrollment, Exchange, Healthcare.gov, November, Seth J. Chandler, Texas, The Affordable Care Act, The States
Dec 2, 2013
I’ve read a number of reports in recent days gushing over the progress Covered California is making leading the nation in signing up people for Obamacare.
But, I am having trouble understanding how the numbers should make anyone gush with enthusiasm.
Covered California, the state health insurance exchange, has a goal of enrolling 500,000 to 700,000 subsidy eligible Californians by March 31, 2014.
Covered California just announced that it would proceed with its original plan to cancel 1.1 million existing individual policies (their estimate)––80% of them by December 31. Covered California also just said that 510,000 of them would qualify for a subsidy.
The only place a Californian can buy a policy with a subsidy is on the Covered California state exchange.
So, it would certainly seem that the only way those 510,000 people can continue their coverage and get a subsidy is to sign-up on the California health insurance exchange––80% of them by December 23.
So, if only the canceled policyholders who are subsidy eligible replace their canceled policies Covered California will make the lower end of its entire 2014 enrollment goal. Doesn’t sound like much of a stretch goal for them.
Besides the 1.1 million who have lost their policies because of cancellation, Covered California has estimated that 5.3 million Californians are uninsured and eligible to purchase coverage on the state exchange––about half with subsidies.
Continue reading “Trying To Make Sense of the Covered California Numbers”
Filed Under: Uncategorized
Tagged: Covered California, enrollment numbers, Robert Laszewski, Subsidies, The Affordable Care Act, The States
Nov 25, 2013
I’ve recently written about healthcare.gov and the lesson that going live too soon creates a very unpleasant memory.
As I work with healthcare leaders in Boston, in New England, and throughout the country, I’m seeing signs that well resourced medical centers will struggle with Meaningful Use stage 2 attestation, ICD-10 go live, HIPAA Omnibus Rule readiness, and Accountable Care Act implementation, all of which have 2013-2014 deadlines.
People are working hard. Priority setting is appropriate. Funding is available.
The problem is that the scope is too big and the timeline is too short.
What are the risks?
Continue reading “Fine Tuning the National Health IT Timeline”
Filed Under: Uncategorized
Tagged: Accountable Care Act, HIPAA Omnibus Rule, HIT, ICD-10, John Halamka, Meaningful Use Stage 2, National Health IT Timeline
Nov 20, 2013
This past weekend, I attended Cyberposium at Harvard Business School where I was invited to speak on the Healthcare Technology panel. Cyberposium is one of the largest MBA student-run tech conferences in the country and typically gets around 1,000 attendees — students, industry professionals, press, and VCs. This year was no different.
The atmosphere was buzzing. There’s always a certain energy at these events, and when you’re surrounded by individuals who are passionate about innovation and the curiosity and sense of possibility that come with it, it’s an exciting place to be.
The morning’s keynote featured Bill Clerico, CEO of WePay (a competitor to PayPal in the online payments space). Bill told us about his motivations for starting WePay, their journey to raise $20M, and how he and his team worked relentlessly to scale the organization.
His two big takeaways on what it takes to be a successful entrepreneur, especially if you’re just starting out: 1) you have to be scrappy and 2) you have to have maniacal focus on the customer (both when you acquire and service them). I couldn’t agree more. Personally, it was a reminder that as we grow bigger at CareCloud, we can never lose sight of our entrepreneurial roots.
After the keynote, I headed off to the Healthcare Technology panel. On the panel, I was joined by HCIT folks from Activate Networks, athenahealth, HealthTap, and Operating Analytics. Our panel was moderated by Zen Chu, serial healthcare entrepreneur and founder of MIT’s H@cking Medicine program (who earlier in the day, told me about a startup he recently invested in called Figure1 — think of it as a Pinterest for doctors).
The 50-minute discussion focused on the future of healthcare, from the impact of reform to emerging business models and trends in HCIT investing. As I think back on the panel and dozens of conversations throughout the day, a few things stood out:
1) Big data’s a big deal: Our panel immediately jumped into big data, with one of the more interesting discussions around what’s needed to reach the promised land called population health. For me, it’s about starting with a platform that can easily house both patient and claims data. You can’t have one or the other, you need both – especially as providers take more financial risk for care delivery.
More critically, as you build analytics on top of that, the platform needs to be scalable, have enough horsepower to aggregate and analyze all the information, and is interoperable so you can bring in new data sets from different sources (think genomics or the quantified self). The combination of storing administrative, financial, and clinical data in a powerful, cloud-based system is what we have at CareCloud today and in my view, is a critical enabler for big data going forward.
2) Selling to doctors is hard: During the panel, an audience member (a new HCIT entrepreneur) asked what’s the best way to sell to doctors. As a marketer, we work to connect with practices every day – helping them navigate through the pain of declining reimbursements, while easing their struggle with poorly designed HCIT. In my view, it’s a twofold solution.
First, it’s having a simple, flexible business model like SaaS-based pricing that makes finances easier on practices. Secondly, it’s developing products with “design thinking” from the start. You can build all the Meaningful Use features into your EHR, but if you’re making the doctor’s life harder and she can’t go home to see her family, you’ve failed. Usability has always been an obsession with us at CareCloud, and that’s why I’m so encouraged by the great work of our product teams, led by Edwin Miller, to make the fastest, most user-friendly HCIT solutions out there.
3) Engaging patients is even harder: Throughout the day, there was a lot of buzz about wearable devices like FitBit, mobile health apps like Ginger.io, and physician networks like HealthTap. While the growth of these tools is exciting, it made me realize how siloed all data is and how hard it will be to get patients to take action (I, for one, don’t walk an extra mile when Jawbone Up tells me I’ve hit less than 10,000 steps on any day).
Perhaps it’s linking all this disparate data into a patient portal so it reaches doctors and EHRs, incentivizing doctors on care planning (not just care delivery), or simply having patients pay a greater share of their healthcare spend. However, in my view, a combination of integration and incentives are required to reduce the physician/patient asymmetry.
Continue reading “Posts of Note: The 2013 Harvard Business School Cyberposium”
Filed Under: Uncategorized
Nov 7, 2013
Health and Human Services Secretary Kathleen Sebelius will testify before the House Energy and Commerce Committee this morning. Her testimony comes the week after Healthcare.gov contractors testified before the same committee and a day after the head of the Centers for Medicare and Medicaid Services testified before a different House committee.
Here’s what you need to know.
1. Where to watch the hearing, which began at 9 a.m. EST:
Live coverage via C-SPAN.
2. Read Sebelius’ prepared testimony. Politico calls it more of the same:
Sebelius’s eight pages of prepared testimony for the House Energy and Commerce Committee matches nearly word-for-word testimony delivered by CMS Administrator Marilyn Tavenner to Ways and Means on Tuesday.
In both written statements, the officials acknowledge that the website hasn’t met expectations but say the administration is taking major steps to improve it.
Neither testimony includes an apology for the bungled launch—but Tavenner verbally apologized at the hearing Tuesday morning.
Clay Johnson (@cjoh), who advocates for open source information in the federal government, annotated the testimony on Rap Genius, with questions and comments.
3. Get familiar with the background. Sebelius gave an interview to CNN’s Sanjay Gupta last week in which she had this memorable exchange:
Gupta: The president did say that he was angry about this. I mean do you know when he first knew that there was a problem?
Sebelius: Well, I think it became clear fairly early on. The first couple of days, that —
Gupta: So not before that, though? Not before October 1st?
Sebelius: No, sir.
Gupta: There was no concern at that point here in the White House or at HHS?
Sebelius: I think that we talked about having — testing, going forward. And if we had an ideal situation and could have built the product in, you know, a five-year period of time, we probably would have taken five years. But we didn’t have five years. And certainly Americans who rely on health coverage didn’t have five years for us to wait. We wanted to make sure we made good on this final implementation of the law.
And, again, people can sign up. The call center is open for business. We’ve had 1,100,000 calls. We’ve had 19 million people visit the Web site, 500,000 accounts created. And people are shopping every day. So people are signing up and there’s help in neighborhoods around the country, that people can have a one-on-one visit with a trained navigator and figure out how to sign up. So people are able to sign up.
I wondered at the time if Sebelius’ answer left a little wiggle room. I expect Republicans on the committee will pursue this.
4. Digest media reports. You can definitely expect that Sebelius will be asked about a CNN report yesterday that Healthcare.gov’s lead contractor warned the administrator well before the Oct. 1 launch of major problems. Read the documents.
CNBC suggests these six questions for her:
—What did you know, when did you know it, and who told you?
—Did you ever consider not launching Oct. 1?
—Why has no one been fired?
—What does all this cost?
—What contingency plans do you have?
—What are the enrollment numbers?
TPM offers what it calls seven legitimate questions for her.
And the Washington Post says that “the embattled secretary of health and human services will submit to a quintessential station of the Washington deathwatch.” Gotta love Washington.
Charles Ornstein is a senior reporter at ProPublica and past president of AHCJ. An earlier version of this post originally appeared on his tumblr, Healthy buzz.
Filed Under: Uncategorized
Tagged: Charles Ornstein, Healthcare.gov, Kathleen Sebelius, The Affordable Care Act
Oct 30, 2013
A commentary in the current issue of the British Medical Journal (BMJ) suggests that saturated fat is not really so bad after all. The article has the media buzzing, with headlines exonerating saturated fat sprouting like mushrooms throughout cyberspace and print media alike. My most recent Google search of “saturated fat” limited to news retrieved 20,000 sites.
Since the new paper is just a commentary — one doc’s opinion — and not a new study, and since this opinion has been asserted many times already, I’m not sure I really get the reaction. But hey, I just work here. Let’s deal with it.
Is it, in fact, time to absolve saturated fat? No, it’s not. But then again, it was never time to demonize it in the first place. I will lay out my case that we are ill-served to think of saturated fat as either scapegoat or martyred saint.
1) Ancel Keys was never really wrong.
The case against saturated fat, its implication in the development of atherosclerosis, inflammation, and chronic diseases, notably heart disease, involves a vast expanse of research over many years by thousands of researchers around the world. But dealing with all of that in this column would be a terrible bother, so let’s just blame it all on Ancel Keys. Keys was certainly among the first to emphasize the association between saturated fat intake and heart disease.
The temptation to absolve saturated fat comes along with a temptation to indict Dr. Keys of crimes against dinner. But, Ancel Keys, while perhaps not quite right, was never really wrong.
Keys looked at rates of disease around the world and correctly noted that heart disease was more common in societies that ate more meat and dairy. His mistake may have been to look past that dietary pattern for the “active ingredient” in it, which led to the convictions of dietary cholesterol, saturated fat, and to a lesser extent overall dietary fat.
There’s much that could be said about this. Whole columns could be written about dietary cholesterol, dietary fat, and saturated fat and ways we went wrong. In fact, I — along with innumerable others — have written just such columns. Simply click the inserted links.
Continue reading “Sorry. Saturated Fat is Bad For You. Or More Accurately — It’s Complicated. Let’s Review the Evidence…”
Filed Under: Uncategorized
Tagged: Ancel Keys, British Medical Journal, David Katz, Nutrition, Obesity, saturated fat
Oct 25, 2013
At least two-thirds of the perpetrators and victims of gun violence are males under the age of 30. What else do they have in common? They live in neighborhoods with high crime rates and low family incomes, they knew each other before the violence broke out, they usually aren’t employed.
But there’s another commonality these young people share which isn’t often mentioned in discussions about gun violence and crime.
It turns out that the part of the brain that controls processing of information about impulse, desire, goals, self-interest, rules and risk develops latest and probably isn’t fully formed until the mid-20s or later. And while adolescents and young men understand the concepts of ‘good’ versus ‘bad’ as well as older adults, they tend to let peer pressures rather than expected outcomes guide their behavior when choosing between risks and rewards.
Take this neurological-behavioral profile of males between ages 15 to 30 and stick a gun in their hands. The brain research clearly demonstrates that kids and young adults walking around with guns understand the risks involved. Whether it’s the NSSF’s new Project ChildSafe, the NRA’s Eddie Eagle or the grassroots gun safety programs that have expanded since Sandy Hook, nobody’s telling the kids something they don’t already know.
So what can we do to mitigate what President Obama calls this ‘epidemic’ of gun violence when the population most at risk consciously chooses to ignore the risk? I suggest that we look at what communities have done to protect themselves from other kinds of epidemics that threatened public health in the past.
And the most effective method has been to quarantine, or isolate, the area or population where the threat is most extreme. It worked in 14th-century Italy, according to Boccaccio in The Decameron. Why wouldn’t it work now?
Last month the city of Springfield, Mass., recorded its 12th gun homicide. If the killing rate continues, the city might hit 15 shooting fatalities this year, a number it actually surpassed in 2010. This gives the city a homicide rate of 10.2 per 100,000 residents, nearly three times the national rate. Virtually all the violence takes place in two specific neighborhoods bounded by Interstate 291 and State Route 83, and all the victims are between 15 and 30 years old.
Continue reading “If Gun Violence is a Health Epidemic, Can We Quarantine It Like a Virus?”
Filed Under: Uncategorized
Tagged: at-risk youth, crime, gun violence, Mike Weisser, Population Health, public health
Oct 20, 2013
Earlier this month, the editors of THCB saw fit to post my essay, “The End of the Era of Coronary Angioplasty.”
The comments posted on THCB in response to the essay, and those the editors and I have directly received, have been most gratifying. The essay is an exercise in informing medical decisions, which is my creed as a clinician and perspective as a clinical investigator.
I use the recent British federal guideline document as my object lesson. This Guideline examines the science that speaks to the efficacy of the last consensus indication for angioplasty, the setting of an acute ST-elevation myocardial infarction (STEMI). Clinical science has rendered all other indications, by consensus, relative at best. But in the case of STEMI, the British guideline panel supports the consensus and concludes that angioplasty should be “offered” in a timely fashion.
I will not repeat my original essay here since it is only a click away. The exercise I display is how I would take this last consensus statement into a trusting, empathic patient-physician discourse. This is a hypothetical exercise to the extent that little in the way of clear thinking can be expected of a patient in the throes of a STEMI, and not much more of the patient’s caring community.
So all of us, we the people regardless of our credentials, need to consider and value the putative efficacy of angioplasty (with or without stenting) a priori. For me, personally, there is no value to be had rushing me from the “door to the balloon” regardless of the speed. You may not share this value for yourself, but my essay speaks to the upper limits of benefit you are seeking in the race to the putative cure by dissecting and displaying the data upon which the British guideline is based.
There is an informative science, most of which cannot deduce any benefit and that which deduces benefit finds the likelihood too remote for me to consider it worth my attempt. A hundred or more patients with STEMI would have to be rushed to the catheterization lab to perhaps benefit one (and to harm more than one).
Continue reading “The Great Coronary Angioplasty Debate: Giving Patients the Right to Speak”
Filed Under: Uncategorized
Tagged: cardiology, doctor/ patient relationship, informed medical decision making, NICE, Nortin Hadler, Patients, PCI, STEMI, stents
Oct 19, 2013