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Tag: THCB Marketplace

Disruption breaking out over at Scott Shreeve’s place

Clayton Christensen's publisher is pressing me to read The Innovators Prescription and then interview him. Sadly I haven’t had the time to pay the book the attention it deserves. Messrs Kuraitis & Kibbe already did a review on THCB and probably said what I’d say, which was that like several other Harvard Business School profs, they got the problem right but the solution wrong. I’m on record from a couple of years back saying that Christensen’s guns are aimed in the wrong direction.

But to be fair my criticisms are pre-publication. Scott Shreeve has a great interview with Christensen’s co-author Jason Hwang (the late Jerome Grossman is also a co-author). and in this interview several of the incentive issues which concern those of us who understand how innovation gets stopped in health care, are addressed. Well worth reading.

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Univita buys Enurgi (with a little explanation about the future of long-term care…)

Univita is a new play from a strong executive team led by former Anthem CEO Ben Lytle. Post Anthem, Lytle and his son Hugh founded Axia, a wellness company, and sold it to DM industry giant (albeit a small giant among dwarves), Healthways.

Now they’ve bought Enurgi which has established a platform for caregivers to manage in-home care over the web. (FD, Enurgi was founded by my friend Chiara Bell). Scraped straight from Univita’s website, here’s what they say they’re going to do:

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Saving Health Care, Saving America

So far, Congress’ response to the health care crisis has been alarmingly disappointing in three ways. First, by willingly accepting enormous sums from health care special interests, our representatives have obligated themselves to their benefactors’ interests rather than to those of the American people. More than 3,330 health care lobbyists – six for every member of Congress – contributed more than one-quarter of a billion dollars in the first and second quarters of 2009. A nearly equal amount has been contributed on this issue from non-health care organizations. This exchange of money prompted a Public Citizen lobbyist to comment, “A person can reach no other conclusion than this is a quid pro quo [this for that] activity.”

Second, by carefully avoiding reforms of the practices that drive health care’s enormous cost growth, Congress pretends to make meaningful change where little is contemplated. For example, current proposals would not rebuild our failing primary care capabilities, which other developed nations depend upon to maintain healthy people at half the cost of our specialist-dominated approach. They fail to advance the easy availability and understandability of information about care quality and costs, so purchasers still cannot identify which professionals and organizations are high or low performers, essential to allowing health care to finally work as a market. They do little to simplify the onerous burden associated with the administration of billing and collections. The proposals continue to favor fee-for-service reimbursement, which rewards the delivery of more products and services, independent of their appropriateness, rather than rewarding results. Policy makers overlook the importance of bipartisan proposals like the Wyden-Bennett Healthy Americans Act that uses the tax system to incentivize consumers to make wiser insurance purchases. And they all but ignore our unpredictable medical malpractice system, which nearly all doctors and hospital executives tell us unjustly encourages them to practice defensively.

Most distressing, the processes affecting health care reflect all policy-making. By allowing special interests to shape critically important policies, Congress no longer is able to address any of our most important national problems in the common interest – e.g., energy, the environment, education, poverty, productivity.

Over the last four years, a growing percentage of individual and corporate purchasers has become unable to afford coverage, and enrollment in commercial health plans has eroded substantially. Fewer enrollees mean fewer premium dollars available to buy health care products and services. With diminished revenues, the industry is unilaterally advocating for universal coverage. This would provide robust new revenues. But they are opposing changes to the medical profiteering practices that result in excessive costs, and which often are the foundation of their current business models. And these two elements form the troublesome core of the current proposals.

Each proposal so far contemplates additional cost. But we shouldn’t have to spend more to fix health care. Within the industry’s professional community, most experts agree that as much as one-third of all health care spending is wasted, meaning that a portion of at least $800 billion a year could be recovered. There is no mystery about where the most blatant waste is throughout the system, or how to restructure health care business practices to significantly reduce that waste.

Make no mistake. A failure to immediately address the deep drivers of the crisis will force the nation to pay a high price and then revisit the same issues in the near future. It is critical to restructure health care now, without delay, but in ways that serve the interests of the nation, not a particular industry.

Congress ultimately must be accountable to the American people. The American people must prevail on Congress to revise the current proposals, build on the lessons gleaned throughout the industry over the last 25 years, and directly address the structural flaws in our current system. True, most health industry groups will resist these efforts over the short term, but the result would be a more stable and sustainable health system, health care economy and national economy, outcomes that would benefit America’s people, its businesses and even its health care sector.

Finally, the American people should demand that Congress revisit and revise the conflicted lobbying practices that have so corroded policymaking on virtually every important issue. Doing so would revitalize the American people’s confidence in Congress, and would re-empower it to create thoughtful, innovative solutions to our national problems.

Brian Klepper is a health care analyst and industry advisor. David C. Kibbe is a family physician and a technology consultant to the industry. Robert Laszewski is a former senior health insurance executive and a health policy analyst. Alain Enthoven is Professor of Management (Emeritus) at the Stanford University Graduate School of Business.

A whole lot more Medicaid, but there’s a catch

It looks like the stimulus package is going to spend a whole lot more on Medicaid AND subsidize the purchase of COBRA for laid off workers. Unlike the “let them eat cake” brigade who’ll decry this as extending welfare to the worthless, I have no problem with it. So long as it really is only a temporary measure,

But let’s be clear—Medicaid is dumb public policy. It’s divided between paying for care for the poor and paying for mostly long-term care for the elderly and chronically disabled, and also has subsidies for hospitals in poor areas thrown in. Then it has S-CHIP as its bastard relation. Furthermore, while the Federal government giveth, the states (which are broke but can’t borrow—California alone is $45 billion in the hole!) are by necessity going to have to take away.

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CEOs’ Urgent, Shared Commitment to Change

2008_GaryKaplan

A few weeks ago, I joined five of my peers in health care leadership throughout the country to help launch Health CEOs for Health Reform, a coalition dedicated to transforming health care and creating a more sustainable health system. 

In mission, we committed to moving past policy concepts toward a detailed blueprint that would reconcile legislative goals with operational realities of the health care system. Our goals are lofty and the challenges immense. What struck me in recent months, with the current state of the economy, is the tremendous sense of urgency we all feel and the confidence we have that now is the time to truly transform health care. 
 

I read Michael Millenson’s post The Inevitability of Health Care Reform: This Time, the Politics Have Changed with great interest and personal reflection. What is different this time around? What do I think a handful of health CEOs can really do to change a system entrenched with waste and cost that does not add value to our very customer – the patient? 

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Five “Shovel-Ready” Health Care Reforms

Microsoft Health Vault’s leader Peter Neupert has a wonderful blog post that makes two important points really well. One message is that health care reform is about the outcomes, not the technology. We should think expansively about which technologies to invest in, based on the results we want to get.

The other message is the economic stimulus package is different than the reform effort. It is moving at hyper-speed through Congress, and it may be difficult for staffers and other advisors to sort through and incorporate what may seem like opposing Health IT views against a backdrop of traditional ideology and extremely forceful special interest lobbying.

Even so, there’s consistency among the health care professionals who worry about these issues all the time. Peter unexpectedly discovered that the messages of his fellow panelists from the Health Leadership Council, the National Quality Forum, the Permanente Federation and the General Accounting Office were remarkably in sync with his own testimony to the Senate Health, Education, Labor and Pensions Committee.

Congress is about to make some big moves in health care that will require immense resource expenditures but, depending on what we pay for, may or may not bear the fruits we hope for. They should move carefully. Not all health care reform has to be labyrinthine. Not all ideas must require huge cost or take years to come to fruition and gain market traction. There are relatively simple actions that are available now, and that the Obama Health Team could tackle to effect tremendously positive, immediate impacts on the system.

Of course, right now the Health IT industry is focused on the promise of a huge stimulus windfall that would be dedicated to their products. But the opportunities we describe below follow principles that have broad support among students of the health care crisis. Two would change the way we pay for health care services, tying payments to documented results. Three are based on how we pull together and make use of the data that can drive clinical and financial decisions, and they overlap, though not perfectly, in their potential. Still, if any system adjustments can be passed through policy initiatives that focus on what’s best for the common rather than the special interests, these should be among the most straightforward.

Payment
Re-Empower Primary Care
There is general agreement that primary care is in crisis, the result of years of abuse and neglect by the medical establishment and by CMS. In simple terms, the primary care/specialist ratio in the US is 30/70. In all other developed nations, its about 70/30. And our costs are roughly double theirs.

We should allow primary care physicians to do the jobs they were trained for, changing their roles from “gatekeepers” to “patient advocates and guides.” We should immediately start financially rewarding them for collaborating with specialists to manage patients throughout the full continuum of care. Keep in mind that, as the Dartmouth Atlas and other studies have made clear, most health care waste is concentrated in the sub-specialties and in inpatient settings, incentivized by a fee-for-service reimbursement system that rewards more procedures, independent of their utility.  One very thoughtful approach to invigorating primary care has been advanced by Norbert Goldfield MD and colleagues.

Of course, truly re-empowering primary care will require more than just paying primary care physicians more. Higher reimbursements will help them afford to spend more time with each patient, yes, but PCPs also need help acquiring tools that can help them better manage those patients. And they need the authority to work collaboratively with specialists. Challenging, but certainly doable and important!

Changing America’s current imbalance between primary and specialty care should drive significant downstream waste from the system, dramatically improving quality and reducing cost.

Increase the Incentives For Programs That Tie Payment To Outcomes
Projects like the CMS/Premier Hospital Quality Incentive Demonstration (HQID), in which 250 participating hospitals got 1-2 percent bonuses for achieving quality improvements, have clearly demonstrated that incentives work. The hospitals that pursued the incentives made greater strides in quality improvements than their peers who did not work toward the incentives.

But we need to make the financial incentives large enough to drive real paradigmatic change. Too many programs offer incentives that are trivial in the minds of providers. Does it make sense for physicians in small, busy practices to rework their office flows to try to meet the challenges associated with hitting targets in exchange for a 1 or 2 percent financial bump, tied to a fraction of their patient population?

Now that there’s no question that incentives work, we could easily give these programs teeth by raising the incentive antes to 15 or 20 percent, while also demanding commensurate levels of savings. And we should go in, understanding that the goal is to drive out unnecessary care, and create expectations that,  by managing better upfront, the total spend will be lower.

Data

Establish a National All-Payers Database
Data sets, including those comprised of health care claims, must be large to generate credibly useful information.

But health care is financed through many different payer streams and by many players within each stream.  Nearly all treat their data as proprietary, and information remains fragmented. So, for example, physicians rarely receive useful information on their complete pool of diabetic patients: instead, they get small slices of data from each payer, each analyzed using a different proprietary methodology. Or, we fail to accumulate adequate sample sizes to identify which treatments, interventions, drugs, devices, health plans, physicians or facility services provide the best value.

But merging those data across payers and making the aggregated set freely available would create the basis to identify true evidence-based best clinical and administrative results. Based on hundreds of millions or billions of records, we might be able to credibly identify which professionals, services or approaches most consistently produce the best results within value parameters. The data set would always be building, providing an always slightly-new base for answering our most difficult questions. Together with the analytical tools that are also becoming stronger and more refined, the potential is vast.

Of course, health plans, always politically formidable, might fight tooth and nail to maintain the competitive advantage they believe is inherent in their data. But health care is a special enterprise, with objectives that are ultimately rooted in the common interest, so they have no real excuse to refuse this. And health plans, like the rest of us, would gain access to much larger data sets that can be mined to advantage.

There also are precedents here. Several states have already begun to establish all-payer databases. At a June 2008 meeting, a presentation on Maine’s experience highlighted 3 fundamental, telling principles that are challenges to any effort.

1. Nobody wants to pay to develop and manage the database.
2. Nobody wants to contribute their data to the database.
3. Everyone wants the aggregated data that develops in the database.

The solution: make it a national effort, paid for by CMS, and with mandatory participation, user fees, and open access to the data.

Create Uniform Nationally Accessible Disease Registries

Many physicians have come to appreciate the value of disease registries. Registries allow clinicians to count all active patients with distinct conditions, e.g. hypertension or diabetes. They can track characteristics within a patient subset, e.g. diabetic patients on a particular medicine. They can monitor and stratify patient status and progress within each group, and generate reminders and alerts to assure guideline level care. And they can identify trends in performance and, with relative ease, get a sense of what works and what doesn’t.

Even so, many registries are still in silos, meaning that the sample sizes remain small and that the parameters that define the registries’ characteristics often vary between implementations.

What we need are freely available, Web-based registries with easy data entry and easy querying capabilities. The impact on our management of patients with chronic illness, who consume 70 percent of our health resources, would almost certainly be powerfully positive.

Release Medicare’s Physician Data
Nearly a year and a half ago, the consumer advocacy organization Consumer Checkbook sued the US. Department of Health and Human Services (HHS) for the Medicare physician data in four states and DC. HHS argued that physicians have a right to privacy, even though, in the case of Medicare and Medicaid, they are vendors taking public dollars, and even though hospitals do not enjoy the same protection from scrutiny. In August 2007, the court held with Checkbook, and on the AMA’s “advice,” HHS promptly appealed, locking up the data for the duration of the Bush Administration.

The large commercial health plans have traditionally considered their claims data proprietary and so have not made their data sets publicly available. Self-funded health plans, administered by Third Party Administrators (TPAs), develop sizable data sets but have resisted collaborating, and have also not expressed an interest in making their data available.

So for those outside the health plan community, there are few, if any, data sources with sample sizes large enough to accurately evaluate and profile physician performance. This is significant, since studies have shown that there can be profound differences, 6x-8x, in resource consumption (i.e., cost) between the least and most expensive physician (within a specialty and market) to obtain the identical outcome.

In other words, not all doctors perform equally. While more patients are paying out-of-pocket for a larger portion of care, there is still virtually no credible information to guide their physician choices.

The American people could quickly learn which physicians within a specialty and a market consistently get the best outcomes at the lowest costs if Medicare physician data were made publicly available. Releasing these data would also put pressure on physicians everywhere to understand their own numbers, and to improve if their performance values are lacking.  We see this as beneficial to the great majority of physicians who seek excellence in their work.

Smoothing the Way

American health care is a vast enterprise in which millions of professionals and hundreds of thousands of organizations vie for an ever larger portion of what has historically been an always growing resource pool. The chaos and dysfunction that has developed in health care is largely due to two system characteristics. One is the fee-for-service reimbursement system that has rewarded more rather than the right care. The other is a lack of transparency that prevents us from knowing and understanding performance, even when that performance is dangerous: what works and what does not, which approaches are high and low value, who does a good job and who does not.

The five action steps outlined above would allow us to better identify the problems and opportunities in our health system, as well as the strongest solutions to drive decision-making. Then they would leverage that information to create strong incentives for the right care, organically changing the dynamics of care and reimbursement and, to the degree possible, smoothing the transition required to heal the way we supply, deliver and finance care in America.

Confessions of a Cultural Anthropologist: The Cause and Cure of High Health Costs

Today’s medical students are being inducted into a culture in which their profession is seen increasingly in financial terms. Add in such pressures as the need to pay off enormous debts, and it is not surprising that students’ choices are dictated by the desire to maximize income and minimize work time.

Pamela Hartzband, MD, and Jerome Goodman, MD
“Money and the Changing Culture of Medicine”
New England Journal of Medicine, 1/08/09

I have a confession to make.  I think the cause of high American health costs is straightforward, but it is not simple. It is American culture in general and the physician culture in particular.  There is nothing wrong with this, and I point no fingers.

The Way We Are
It is our culture.  It is the way we are, the way we’ve been for 232 years. It is our distrust of government and high taxes. It is our want to be free to choose. It is our belief in for equality of opportunity for access to the latest and best of care.

It is the notion, stemming from frontier days and conquering of the West,  that action speaks louder than words, that if you do something specifically, it is better than doing nothing generically. “Don’t do nothing, do something,” as the saying goes.Continue reading…

New NRC Report Finds “Health Care IT Chasm,” Seeks New Course Toward Quality Improvement and Cost Savings

Like the Institute of Medicine’s (IOM) 2001 counterpart report, “Crossing the Quality Chasm,” a new report from the National Research Council of the National Academies is complex, full of new ideas assembled from multiple disciplines, and is likely to have seminal importance in framing public policy from now on. “Computational Technology for Effective Health Care:  Immediate Steps and Strategic Directions” was released last Friday, January 9, 2009 in draft, but there is so much to comment on that I think it’s wise to begin with a quote from the committee that sums up the central conclusion:

In short, the nation faces a health care IT chasm that is analogous to the quality chasm highlighted by the IOM over the past decade. In the quality domain, various improvement efforts have failed to improve health care outcomes, and sometimes even done more harm than good. Similarly, based on an examination of the multiple sources of evidence described above and viewing them through the lens of the committee’s judgment, the committee believes that the nation faces the same risk with health care IT—that current efforts aimed at the nationwide deployment of health care IT will not be sufficient to achieve the vision of 21st century health care, and may even set back the cause if these efforts continue wholly without change from their present course. Success in this regard will require greater emphasis on the goal of improving health care by providing cognitive support for health care providers and even for patients and family caregivers on the part of computer science and health/biomedical informatics researchers. Vendors, health care organizations, and government, too, will also have to pay greater attention to cognitive support. This point is the central conclusion articulated in this report. (emphasis added)

It would be difficult to find a more sober indictment of US health care IT policy and implementation over the past decade than what is contained here.

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Now, Sleepless in San Francisco

Having returned from Seattle, the persistent itching from the sand-fly bites of Roatan has awakened me at 5 a.m. So I’m commenting on three pieces of news, which I’ve commented on before here and at Spot-On.

First, United HealthGroup has introduced two new things this week. One is is a consumer portal/WebMD competitor called myOptumHealth, which gave a sneak preview (and was a sponsor) at the Health 2.0 Conference in October.

At first blush I like the look of what they’ve pulled together, although the about us section doesn’t exactly tell you much about who owns Optum! But the really interesting product United launched this week was aimed right at me. It’s an option to repurchase your individual health insurance without being re-underwritten and rejected.

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Fibroid Tumors: What You Need to Know

In her just published 8th book on women's health, Biologist Winnifred
Cutler takes the terror out of fibroid tumors.  In HORMONES AND YOUR
HEALTH: A SMART WOMAN'S GUIDE TO HORMONAL AND ALTERNATIVE THERAPIES FOR
MENOPAUSE
, she writes:

     "Fibroids are about as common as freckles.  They are benign and
occur in more than 70% of reproductive-age women."  ***Fibroids should
not be confused with cancer or a risk of developing cancer.

Dr. Cutler recognizes that unwanted bleeding caused by fibroids
understandably alarm women and scare some to rush into surgical removal
of the fiborids, or worse, of the entire uterus i.e. an  unneeded
hysterectomy (which Dr. Cutler generally opposes.)

Importantly her new book alerts women to the "turf battles" among
various medical specialists competing for the business of fibroid
treatment and the 4 effective treatments if they are causing problems.
She shows women which specialists are trained to perform which
procedures.

An important theme throughout her book is encouraging women to:
-Take Command

If you having a problem with fibroids, I hope you will seriously study
the information presented here. Your informed, dignified command of the
facts can profoundly affect the solutions you seek and find. Don't be
in a rush to get the process over with. Every surgery provides fodder
for future medical problems. Surgery is dangerous. Reject the attitude
of, "when in doubt, cut it out."

To learn more read  Hormones and Your Health: The Smart Woman's Guide to Hormonal and Alternative Therapies

     ************

Leading medical experts praise this book:
"Winnifred Cutler's message is clear, precise and correct that women
have choices as far as hormone therapy is concerned and they are in
charge."

-Dr. Alan De Cherney, MD., Editor in Chief of the medical journal Fertility and Sterility.


"Excellent"

Dr. John Sciarra, MD, PhD, past president International Federation of Gynecology and Obstetrics

We hope you will visit the Athena Institute for Women's Wellness website to learn more about Dr. Cutler's new book and research;

http://www.athenainstitute.com/hormonesandyourhealth.html http://www.athenainstitute.com/mediaarticles/moremag2.html

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