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John Irvine

The Land of Milk, Honey and Low-Priced Health Insurance

Not long ago we received our first signs that all may not be well in the land of milk, honey, and low priced insurance, i.e. the ACA insurance exchanges.  Many insurers, including some of the largest in each state, have requested double digit rate increases, with some asking for raises that exceed 30 percent. A casual review of these requests suggests that the increases are largest in areas where the premiums were initially lowest. If these increases are approved, it will mean dramatically higher payments for enrollees, and escalating tax bills for the rest of us.  This is particularly true when the premium hikes affect the lowest priced “silver” plans available in the market (as the subsidies are tied to premiums for the second cheapest silver plan). Of course, the premium increases might backfire on insurers, but only if enrollees opt to switch to cheaper plans.

However, we have grave doubts about whether this will be the case. If participants in the exchanges behave like enrollees in employer-sponsored plans, then it seems unlikely that there will be much switching out of plan. This is a natural consequence of the way the exchanges work, combined with well documented inertia on the part of health insurance enrollees.

What is this inertia?  Academic research performed here at Northwestern University and elsewhere convincingly shows that employees are reluctant to switch health plans, even if they stand to save $2000 or more without sacrificing quality or access.  In addition, a pair of studies of Medicare Part D prescription drug plans also demonstrate that consumers switch plans infrequently and those that switch do those mostly in response to changes in the design of their own plan (i.e., are their preferred drugs on formulary) rather than in response to the relative financial attractiveness of theirs versus competing plans.

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Bridging the Gap between MUS2 and Patient Engagement Through Appointment Reminders

MaloofMedical technology has undergone dramatic changes in the last 10 years. Right now, I make and cancel appointments, get prescriptions filled, look at test results, pay bills and email my doctor—all from my computer. I track multiple health markers on my cellphone, and am proactive about my preventive screenings. I am the definition of an engaged patient.

But, I know how the system works from the inside out. The question for most doctors is how to teach patients to be more engaged with the convoluted, fragmented, and confusing healthcare system. They are asking this because they are struggling to meet Meaningful Use Stage 2 requirements.

Most docs complain that the 5% patient portal requirement is unfair because it is out of their control. Maybe it is, or maybe there are smarter ways to work the system in their favor that they just don’t know about.

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Health DataPalooza 2015: The Download

flying cadeuciiHealth Datapalooza once again lived up to its reputation as the liveliest and most eclectic health IT confabs of the year.  Energetic and sleek young entrepreneurs mingled with government bureaucrats, academic types, consultants, current and former ONCers, a smattering of providers, app developers, data geeks, and patient advocates at this year’s conference, held in Washington D.C. June 1 to 3 with about 2,000 in attendance.

Although the speeches, app demonstrations, and panel sessions broke little new ground, that’s not the point.  The point is to maintain the excitement, optimism and commitment, to update the vision, showcase the creativity, and extol the virtues and power of data-driven care improvement.  Perhaps not as the solution to all the health system’s woes, but a fair share of them.

I didn’t discern a dominant theme, but amid the ra-ra and fun there was a good amount of hand-wringing around these issues:

1. Failure to engage the vast majority of consumers/patients in their own care—with data, medical records and Yelp reviews in hand.  Some two-thirds of providers attesting to stage 2 meaningful use reported that not a single patient had requested their data or records.   Continue reading…

What India’s Teleradiology Market Teaches Us About the Future of Medicine

Teleradiology has the same effect on radiologists as Lord Voldemort has on Muggles. It’s the feared end point of the commoditization of imaging, with Rajeev in Bangalore outpricing Rajeev in Chicago for reading follow-up CTs for lung nodules.

But despite the fears of U.S. radiologists, their counterparts in India have more pressing things on their mind.

“U.S. radiologists think that Indian radiologists are [itching] to steal their jobs. We have plenty of work in India,” reassured Dr. Sumer Sethi, director of TeleRad Providers of New Delhi.

A tech-savvy blogger, Sethi founded TeleRad Providers in a flash of inspiration and an appreciation of market forces.

“There is unimaginable competition in private medical imaging in New Delhi,” he said.

A new radiologist wishing to set up shop in one of India’s metropolitan areas faces large upfront costs: There is little discount for a 1.5-tesla MRI scanner. This means one must have abundant spare change floating around — or ancestral wealth. And once the shop is set up, the aspiring radiology entrepreneur embarks on a long and uncertain road toward establishing reputation and market share.

Employment models in the U.S., such as partnership tracks and buying into a practice, are not generally available to Indian radiologists. The alternative to entrepreneurship is working as a salaried employee for a corporate hospital, private imaging center, or government hospital. That was not the career pathway for Sethi, whose teleradiology practice is a pure fee-for-service model.

“It’s a low-cost operation,” he explained. “We read from home.”

An elegant model

The costs of an Indian teleradiologist are certainly low. Sethi does not have to deal with intermediary agents. There are no concerns about using the wrong billing code, and there are no separate state licenses to acquire. The model is elegant in its simplicity. He gets a study, renders a report, and gets paid.

However, the low operating costs belie the actual effort that is required of Sethi to grow his practice. He negotiates with hospitals directly. Being an entrepreneur means recognizing the need for teleradiology, and persuading others of the need and its solution.

Most of Sethi’s clients are hospitals in tier 2 and tier 3 cities in India, the equivalent of Dayton, OH. The hospitals have the machines and patients but not always the radiologists.

“We mostly plug the gaps in the rota at these places,” Sethi said.

This must mean that the radiologists at these centers welcome his efforts, I surmised.

“The scrutiny of our reports is intense,” he said. “This does not mean all our reports are overread. But were we to miss something, we could lose the contract, as the local radiologists would say, ‘See, this is a report from a teleradiologist.’ I tell my team that we must be at the top of our game, always.”

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How to Out-Argue Your Doctor with Data

Your doctor believes he’s “patient-centered” because he wants to provide the the treatment he thinks you need as quickly as possible. Or as the fictional Dr. Heart tells his chest pain patient right after recommending a stent, “As it happens, I can do the procedure for you next week. Does that work for you?”

Before giving in to the gurney, what questions should patients ask? One data-driven script was presented in skit form at the recent Health Datapalooza 2015 meeting in Washington, D.C. The drama was light-hearted; the clinical and financial issues underlying it are not.

Dr. Heart was played by Glyn Elwyn, a theater student-turned-family practitioner recognized as one of the world’s leading researchers in patient preferences and values. Casey Quinlan, a writer and activist widely known for her unfiltered expression of those preferences and values, played the patient.

In the skit, a persistent Quinlan keeps pestering the doctor with questions about what a stent will accomplish that changing her medications won’t. At first glance, a stent sounds appealing because it props open the blood vessel. What could be better? However, when Quinlan asks directly about the effect of meds versus stenting on preventing a heart attack, the doctor admits that data show medication lowers the odds but stenting does not.

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Productivity? In Healthcare?

Obamacare is built on the assumption that healthcare can be more productive, that we can squeeze more health per dollar out to the system that is built to give it to us. Practically everything I write is based on the same idea — big time. I believe we could do healthcare better for half the money we pour into it now.

There is a widely-cited theory that this is fundamentally impossible, popularized by William Baumol, a New York University economist, in a 2012 book, The Cost Disease: Why Computers Get Cheaper and Health Care Doesn’t. Baumol trades on the idea that healthcare is mostly the individual labor of highly trained professionals (doctors, nurses, and technicians) whose labor cannot simply be baked into machines and software. So we can’t expect healthcare to become any more productive, especially as healthcare keeps getting more complex.

We can’t both be right. What’s the daylight between these two radically different points of view?

I believe that the Baumol argument assumes many things that are simply not true. These include:

o  We are using doctors and other personnel at their highest and best use (when in fact we waste masses of clinician time on documentation and other processes that do not add value at all, let alone value that only they could add)

o  The goal against which productivity should be measured is provision of healthcare processes, such as how efficiently one can do a gall bladder removal or an uncomplicated birth (as against, say, improvement in health of patients and patient populations)

o  There is not much wasted motion within those processes (when in fact there is a great deal wasted, as anyone who has applied lean manufacturing principles to healthcare processes has discovered)

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How I Built a Health App In Six Hours, Got 2.3 Million Downloads and Got Acquired

Creating A Story

Rewind back to May 2013 and I was co-founder of a music app startup called Discovr. We had managed to achieve over 4 million downloads, raised over $1m and were perceived as ‘successful’ (unfortunately things didn’t end up that way) in our home town of Perth, Australia.

It was very common for people to come up to me and ask what the magic was to make a successful app. We’d fudged our way through and somehow made something people wanted to download, but could I recreate it?

I was lucky enough to be reading an advance copy of the amazing book The Fortune Cookie Principle which really opened my eyes to storytelling and products.

I was also inspired by reading this advice from the One More Thing conference about how to write a press release. Surely it’s impossible to stand out with a press release like that?

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A Few Thoughts on “Culture” in Healthcare

The big news in Boston healthcare last month was the announcement that Tufts and Boston University Medical Centers were calling off their proposed merger.  The Boston Globe wrote:

“Although they did not specify why the deal fell apart, the hospitals were apparently unable to overcome differences in culture, mission, and strategies for the future, analysts said. Culture always trumps strategy,”said Ellen Lutch Bender, president of the consulting firm Bender Strategies LLC.

I don’t know any of the details about the proposed merger, and certainly can’t tell you if the deal made sense.  But it also wouldn’t be the first partnership that failed due to perceived incompatibilities in organizational culture.  In fact, one of the great healthcare case studies in business school is about the ultimately failed merger of Stanford and UCLA health systems– a marriage that came apart after two years.  The cause, according to the Stanford Alumni Magazine?

The venture’s biggest downfall may have been that it never managed to bind the two institutions together with a common culture.

I’ve been thinking a lot about the concept of culture in healthcare.  You hear the term used frequently– generally to describe either some sort of social incompatibility between one group and another.  Besides mergers, the other time you hear the term used is to explain poor operational performance at healthcare organizations.   People in healthcare often finger “culture” as the explanation for a litany of disappointing outcomes, failed initiatives and poor performance.

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