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THCB Gang, Episode 12

Episode 12 of “The THCB Gang” was live-streamed on Friday, June 5th from 1PM PT to 4PM ET. If you didn’t have a chance to tune in, you can watch it below or on our YouTube Channel.

Editor-in-Chief, Zoya Khan (@zoyak1594), ran the show! She spoke to economist Jane Sarasohn-Kahn (@healthythinker), executive & mentor Andre Blackman (@mindofandre), writer Kim Bellard (@kimbbellard), MD-turned entrepreneur Jean-Luc Neptune (@jeanlucneptune), and patient advocate Grace Cordovano (@GraceCordovano). The conversation focused on health disparities seen in POC communities across the nation and ideas on how the system can make impactful changes across the industry, starting with executive leadership and new hires. It was an informative and action-oriented conversation packed with bursts of great facts and figures.

If you’d rather listen, the “audio only” version it is preserved as a weekly podcast available on our iTunes & Spotify channels a day or so after the episode — Matthew Holt

Lasting Lessons From Health Care’s ‘Money Back Guarantee’ Experiment

Ceci Connolly
Matt DoBias

By CECI CONNOLLY and MATT DOBIAS

When it comes to money back guarantees in health care, it’s often less about the money and more about the guarantee.

That’s the biggest takeaway shared by two organizations—Geisinger Health System and Group Health Cooperative of South Central Wisconsin (GHCSCW)—that separately rolled out closely-watched campaigns to refund patients their out-of-pocket costs for health care experiences that fell short of expectations.

Both programs started as a way to inject a basic level of consumerism into a process long bereft of one. In fact, as consumer frustration over medical costs rise, a money back guarantee has the potential to win back a dissatisfied public.

But like many experiments in health care, the effort produced some unexpected results as well. Instead of a rush on refunds, executives from both systems said their money-back pledge served even better as a continuous-improvement tool, with patients providing almost instantaneous feedback to staff who felt newly empowered to address problems.

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Health Plans Need to Go Farther To Get Us Through the COVID-19 Crisis. Employers Can Encourage Their Cooperation.

Brian Klepper
Jeffrey Hogan

By JEFFREY HOGAN and BRIAN KLEPPER

Among its less appreciated but more worrisome impacts, COVID-19 threatens to destabilize America’s health care provider infrastructure. Patients have largely been relegated to sheltering at home and, to avoid infection, are avoiding in-person clinical visits. The revenues associated with traditional physician office visits have been curtailed. Telehealth capabilities are gradually coming online, but are often still immature. The concern is that many practices will be financially unable to keep the doors open, compromising access and healthy physician-patient relationships.

Health plans have become health care’s bankers, controlling the funding that fuels larger care processes. Health insurance companies and health plan administrators rely on networks of doctors and hospitals to deliver health care services. They also rely on premium payments from employers to administer and pay for health care. In conventional fee-for-service, pay as you go arrangements, providers are paid after they have delivered care services. The stability of this approach, of course, assumes an unhindered flow of patients receiving care.

When the stability of that flow is disrupted, as it has been with COVID-19, physician practices become vulnerable. Solving that vulnerability would give members access to critical services – primary care, specialty care, urgent care and pharmacy coordination – during this epidemic. Without these resources, members will be forced to turn to overburdened hospitals, where they risk increased COVID-19 exposure.

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Will Your Health Plan Tell You That It Can Save Your Life?

By MICHAEL MILLENSON

At kitchen tables everywhere, ordinary Americans have been grappling with the arcane language of deductibles and co-pays as they’ve struggled to select a health insurance plan during “open enrollment” season.

Unfortunately, critical information that could literally spell the difference between life and death is conspicuously absent from the glossy brochures and eye-catching websites.

Which plan will arrange a consultation with top-tier oncologists if I’m diagnosed with a complex cancer? Which might alert my doctor that I urgently need heart bypass surgery? And which plan will tell me important information such as doctor-specific breast cancer screening rates?

According to Matt Eyles, president and chief executive officer of America’s Health Insurance Plans (AHIP), insurers over the last decade have made a “dramatic shift” to focus more on consumers.  That shift, however, has yet to include giving members the kind of detailed information available to corporate human resources managers and benefits consultants (one of my past jobs).

What’s at stake could be seen at a recent AHIP-sponsored meeting in Chicago on consumerism. Rajeev Ronaki, chief digital officer for Anthem, Inc., explained how the giant insurer is using artificial intelligence to predict a long list of medical conditions, including the need for heart bypass surgery. Information on individual patients is passed on to clinicians.

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Scaling Health Insurance Disruption | Ali Diab, Collective Health

By JESSICA DAMASSA, WTF HEALTH

Ali Diab, CEO & Co-Founder of Collective Health, wants to talk about healthcare affordability and the fact that consumerism doesn’t really exist when it comes to healthcare because we don’t really have a functioning market. The “Real” buyers — from the federal government to large employers — have no idea what things cost in traditional health plans and are making healthcare purchases for their constituents without full price transparency. So, what has he and Collective Health learned now that they’re 6 years into trying to offer these buyers an alternative to that traditional health plan experience? Nothing is more complex than health insurance innovation, but Collective Health is making significant headway and, according to Ali, has made it past the “homicide phase” of being a digital health startup.

Filmed at HLTH 2019 in Las Vegas, October 2019.

Jessica DaMassa is the host of the WTF Health show & stars in Health in 2 Point 00 with Matthew Holt.

Get a glimpse of the future of healthcare by meeting the people who are going to change it. Find more WTF Health interviews here or check out www.wtf.health

THCB Spotlights: Matt Cox CMO of Lumeris

Today THCB is spotlighting Lumeris which creates a platform to help set-up and develop health plans and manage care delivery for patients. Working with its associated medical group Essence, Lumeris has been creating actionable steps to reduce Medical Cost Rates (MCRs) and is now taking that process to other health systems that want to set up Medicare Advantage plans. Lumeris is working with 12 health systems and is growing rapidly. Recently, Lumeris partnered with Cerner to bring their product to market.

Matthew Holt interviewed Matt Cox, Chief Marketing Officer at Lumeris to find out the details.


Adjusting for Risk Adjustment

Risk adjustment in health insurance is at first glance, and second, among the driest and most arcane of subjects. And yet, like the fine print on a variable-rate mortgage, it can matter enormously. It may make the difference between a healthy market and a sick one.

The market for individual health insurance has had major challenges both before and after the Affordable Care Act’s (ACA’s) risk adjustment program came along. Given recent changes from Washington, like the removal of the individual mandate, the market now needs all the help it can get. Unfortunately, risk adjustment under the ACA has been an example of a well-meaning regulation that has had destructive impacts directly contrary to its intent. It has caused insurer collapses and market exits that reduced competition. It has also led to upstarts, small plans and unprofitable ones paying billions of dollars to larger, more established and profitable insurers.

Many of these transfers since the ACA rules took effect in 2014 have gone from locally-based non-profit health plans to multi-state for-profit organizations. The payments have hampered competition not just in the individual market, which has never worked very well in the U.S., but in the small group market, which arguably didn’t need “help” from risk adjustment in many states.

The sense of urgency to fix these problems may be dissipating now that the initial rush for market share under the ACA is over and plans have enough actuarial data to predict costs better. There has been an overall shift to profitability. But it would be a serious mistake to think that just because fewer plans are under water, the current approach to risk adjustment isn’t distorting markets and harming competition.

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WTF Health | Oscar’s Schlosser on Consumerizing Health Plans, post-ACA & pre-Amazon/JPM/BH

WTF Health – ‘What’s the Future’ Health? is a new interview series about the future of the health industry and how we love to hate WTF is wrong with it right now. Can’t get enough? Check out more interviews at www.wtf.health

Having formerly worked for a health plan, I geek out over health plan innovation as IMO it’s the underpinning of the true disruption of health care. When the incentives change, everything else will change too…

So when I met Mario Schlosser, co-founder & CEO of Oscar Health at Health Datapalooza, I may or may not have asked him to sign my Oscar insurance card. (Yep, I’m a member.)

Our chat focused his push to continue driving health plan innovation amid the deterioration of the ACA and his plans for Oscar’s latest $165M round. His goal: make the payer “an interface and enabler of new kinds of technologies.” Is that even possible?!

Around 4:15 minute mark we find out if he’s been tapped for advice from the Berkshire Hathaway/Amazon/JP Morgan health alliance as they take on their own challenges disrupting health insurance.

Holier Than Thou Doctors

flying cadeuciiI can recall it like yesterday.  It was 2004, and I had become the CEO of Blue Cross & Blue Shield of Rhode Island.  I was in the middle of my annual physical with my long-standing primary care physician, Dr. Richard Reiter (true).  Dick Reiter is my age and is an old school doc.  He caught my cancer before it got too serious, and had been yelling at me about things like cholesterol, stress, and exercise for years.

During a lull in the exam, I turned to him and asked, “Dick, I’m the CEO of Blue Cross.  What do I need to know?”  He paused, looking down.  Then his cheek started to twitch.  I actually saw him lose his temper for the first time in 25 plus years.  “Jim, you want straight?  What the bleep are you doing to us?  A monkey can do a colonoscopy and yet they make four times what we primary care doctors make.  What you are doing is a disgrace.”  He was some pissed!!

I then had lunch with Dr. Al Puerini, a highly regarded PCP of 30 years with a full practice.  I asked him how much he netted before taxes, and when he told me, I was appalled.  He made some aside about it not being about the money, but it IS in part about the money.  He also told me about how difficult it was to recruit new PCPs in RI.

Those two encounters started me down my path of alarm about the future of primary care.  Rhode Island is a small (40×30 mile, one million population) microcosm of the country.  While we have our accents and quirks, and people still think we’re overrun by the mafia, we’re not all that much different.  Just wicked smaller.  Our PCP population was aging and shrinking rapidly.  The best and brightest from Brown Med School and others of its ilk were decidedly not swarming into primary care.  Practices could not recruit new members.  We were, and still are, in a crisis that is nation-wide.

And it didn’t stop with just the poor PCP reimbursement.  PCPs cannot survive financially without untoward volume.  This has all sorts of negative consequences.  Moreover, on the totem pole of respect, PCPs do not seem to rank high for reasons that I simply cannot fathom.  It seems that the more “miracle machines” a physician uses, the more respect he or she gets.  While the poor PCP does what we in the billing world refer to as “E&M” (Evaluative and Maintenance).  The look-you-in-the-eye, known-you-for-years sort of thing.  In other words, taking basic tests and extrapolating health trajectories.  Wading into gray areas.  Knowing the patient and her family, and making informed prognoses.  All difficult stuff.  Not something that shows up on an LED screen.  Ahhhh….judgment and perspective.

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Confessions of a Health Plan CEO

flying cadeuciiThe fact that I was once the CEO of a health insurer may cause you to read this with some skepticism.

I invite and challenge your skepticism.  And I will do my very best to keep this piece strictly factual and not stray into the ambiguities that necessarily accompany complicated matters.

So bear with me.

Health insurers are not popular.  No one wants to go to the prom with us.  We have been vilified by no less than the President of the United States.  Heady stuff.  Let us see if this vilification and what I call the cartoonization of insurers has served us well in the healthcare debate.  I think it has not, because for reasons I hope to make clearer, it has taken the focus away from the real causes of our cost and quality nightmares.

Health insurance started in the Depression with the Blues, although they were not at first called that.  They typically were formed by hospitals (the Blue Crosses) and physicians (the Blue Shields), so that some payment for services rendered might be, well, “insured.”  Provider self interest cloaked in the public interest.  Perhaps there was alignment.  And there was a Depression going on after all.

At first, the role of the health insurer was strictly financial.  The insurer financed all or a portion of covered health services, and far, far fewer services were covered then than today.  That’s all an insurer did or was expected to do.  It was not there to manage doctors or hospitals or patients or anything else.  Originally, this financing was done through “indemnity” plans, which allowed patients to see anyone they wanted, and paid a set dollar amount per service or per day of hospitalization (e.g., $50/day of hospitalization).  Thus, if you chose a more expensive provider, the difference was on you.  Insurers back in the day did not negotiate reduced fees with providers (“fee discounts”).  It was much more civil then.

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