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HEALTH PLANS/TECHNOLOGY: AHIP impressed with itself yet again, with UPDATE

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Long term THCB readers will know the the term “AHIP report” tends to put me in a just a little bit of a tizzy, given the generally shoddy “research” they’ve been foisting on those of us who bother to read the PR wires.  For that matter the mention of AHIP’s President’s name tends to drive me equally bat-shit, given the tissue of half-truths, crass ill-informed generalizations and self-serving platitudes that tend to emerge from any document with “Ignagni” as author. And it looks like they’ve done it again.

You may believe that America’s health plans aren’t exactly hotbeds of delightful consumer experiences. And you’d be right. While any corner store in the world can take your credit or ATM card and whisk your info to your bank and back, the majority of health insurers still send out paper ID cards to their members, which get photocopied at the doctors office. Most have customer service systems that only allow the poor sap on the phone to see one claim at a time for the member trying to piece together a series of care encounters. Hardly any allow their members to access their own information in a useful manner integrated with other medical information (Empire, Group Health in Seattle, and a few others being honorable, but recent exceptions). And they all still send out EOBs which require a masters degree in accounting BS to decipher. In fact probably only hospitals and doctors are worse.And of course they’ve continued this ineptitude while their prices to their consumers have increased at a rate of 10% a year for more than half a decade.

But have no fear.  Despite consumer reputation ratings that are in the tank, according to the latest AHIP report on its insurer members’ activities are going great guns. In fact the very title is that  Through IT, Companies ….Achieve Impressive Results in Quality, Ease of Use, Cost, and Efficiency.

Read it and weep. For example, I’m particularly impressed by the example from my health plan Blue Shield of California which, bless its heart, has been at least trying on some of these tech issues. They’ve been trying to promote Relay Health’s physician email service to their members and to California’s 60,000 odd physicians. The report details their great strategy. The last number I heard was that after 5 years of trying, only 1,000 had signed up. My doctor was one of them, but when I sent him an email, 3 months later I got one back saying that my application to email him was rejected!

I can’t complain about a series of case-studies about health insurers trying to get better at this IT and customer service stuff. There may be some useful stuff in here. But how about calling it “Through IT, health insurers achieve impressive results in managing to stay in business and increase their margins while denying their clients what’s been seen as standard practice in every other industry for years…..but are now getting around to slowly thinking about changing”.  That would be closer to the truth — although telling the truth may be a dangerous habit for AHIP to adopt.

UPDATE: Arien Malec from RelayHealth has sent me what he terms a few corrections which indicate that RelayHealth has been slightly more successful than I stated, and I promised him that I wouldn’t mention how much cash RelayHealth has burned since its inception! Here’s Arien’s points:

1)     The current number is 3000 physicians in CA who are fully up and running with RelayHealth

2)     We (and BSC) are working medical group by medical group to bring on physicians, concentrating on primary care providers, so the denominator of 60,000 isn’t quite fair

3)     The first few years of the BSC relationship with RelayHealth were mainly focused on a trial of clinical messaging, not a wide scale rollout, so “5 years of trying” also isn’t quite fair (more like 2 years of active wide scale deployment).

 In the East Bay, Sacramento, and some parts of SoCal, penetration among primary care providers is pretty good; in other areas, there are holes. That’s the reality in trying to get adoption in this business… If we look at the measure of “how many Hill Physicians primary care doctors are up and running with RelayHealth,” the picture looks much more favorable.

 As for BSC’s role here, they obviously can’t “roll out” this program to all of “their” physicians, because this is an industry of small boutique businesses that aren’t owned by anyone.

Finally, with regard to your own doctor, we’ve had some issues with doctors who got set up before they were willing to accept online patients. I’m sorry that happened in your case, but it shouldn’t be taken as representative of the program as a whole.

 The larger point still stands, but in an industry where change is this hard, it’s not quite fair to knock those organizations that are at least trying.

Now it’s good news that something is happening, but it’s evident that the four most important functions of the “personal health record” view that the bigger provider groups (like Group Health of Puget Sound, Partners, etc) are offering their clients online are a) appointment scheduling, b)drug prescription renewal request c) email communication with the doctor, and d) access to lab results, rather than the actual ability to look at the health record per se. Survey data going back to the 1990s shows strong demand from patients for these exact services. Given that RelayHealth (and for that matter in the dim distant past Physicians Online) has offered these functions to physicians on an ASP basis for several years at almost no cost to them and requiring no change to their basic day to day activities, it tells me that they’ve felt no incentive to offer these services to their patients. And 3,000 is better than 1,000 but not by too much. And what have the plans done?  When the plans wanted to actually make doctors change their behavior they can. When back in the 1990s when Blue Cross wanted to receive claims electronically, they mandated the change to their doctors and wouldn’t pay them for non–electronic claims.  That got the docs to change in a big hurry. You get the impression that the insurers don’t care about their doctors improving their online services to their members nearly as much, as there don’t seem to be any penalties for the doctors who don’t sign up and/or don’t use the service if they do. Frankly to this point the majority of IT support from insurers to doctors seems to be PR-inspired (like Wellpoint’s useless $40m computer giveaway) rather than trying to enable them to deliver better services to their patients.

Still I’m a big fan of RelayHealth and I really am not slamming them—the insurers  and the doctors, I’m not so impressed with.

TECH: Mark Gaynor on sensor network

Mark from Boston is building a sensor based application that talks HL7 (open standards) to all systems so that an air ambulance company (Boston MedFlight) can gather data in advance of hospital admission.  Thus they need to build a sensor gateway. All the filtering (how many times you get information per minute from the sensor) can happen in the gateway or even in the application (so doesnt need to be in the sensor). Data mining can be done later. They’ve also built some of their own monitors and have allowed Welch-Allen and others to connect.

On top of the sensors they need an application, and they are building a GUI  which shows the body etc, and will probably be run on a tablet PC to be used in the helicopter. But of course this data requires context (e.g. depending on the patient state…what if the patient is pregnant, a child, on certain meds?) and so they are building a rule processing system that prompts for the rules (that Med Flight mostly already has). Eventually they want this data to be mined and so they want to be able to collect it….again all open source standards. So their sensors are running TinyOS (sensors open source operating system). There’s a GPS in it too, so they can track location. They also want applications to exchange data — SOAP (better but incorrectly known as “web”services) in order to get these distributed pieces to exchange data. Here’s a chart of their infrastructure.

 

Figure 1: iRevive interface between field, 10-blade server

Data


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TECH: Cindy LeRouge on using claims data in PHRs

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Cindy LeRouge is from Washington Univ in St Louis, and has been working with Wellpoint on a study of integrating claims and chart data….there is some chart-type data (i.e. lab tests) around so some chart elements (electronic) can be put together.

Insurers are not yet seeing costs savings or consumer push for this, but there might be a competitive first mover advantage (if you can delay first mover as much). Insurers would like to see some chart data (e.g. getting lab data or blood pressure for DM). So there are reasons at the margin for plans to do this (although I might have to pick a fight with her later about this!). So out of claims they can start to generate reports that patients can view, and emergency rooms.

Running a test in Missouri, which will integrate data from certain hospitals in Missouri, and will eventually allow Wellpoint claim data to post back into some hospital forms and reports.

Oh, but of course the internal data at Wellpoint is a mess, so that data scrubbing issue remains a problem…and legal is getting in the way.

And then what about moving records between plans (UPIN and all that)? Do we go to a credit bureau-type reporting structure?

And why would providers want to share their chart data? (Good question!). Why are they going to the brain damage of working with providers to get that part of the chart in? Apparently there’s something in the chart that they need for UM that they can’t get out of the claims (but it’s not in the attachment either). And it’s all been driven by the marketing department.  Strikes me that the Blues yet again need more consulting help!


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TECH: Mary Jo Deering

Mary Jo Deering is  the director for Informatics Dissemination, National Cancer Institute’s Center for Bioinformatics; she has (self-professed) been around health informatics in DC for quite a while!

The big problem they face is that there is a divide between health care practice and clinical trials. Only 3–4% of cancer patients are in clinical trials, and all trials are delayed because of enrollment. But there is no general EHR which people can be matched with.  Right now neither the eligibility critieria nor the patient information are standardized. Can this be done thru a PHR instead? Maybe. They are putting together cancer centers to try to match all types of data form the big NCIs to make the loop of all information, on a standards based information infrastructure. (The caBIG initiative)

She tracks this all back to NCVHS talking about PHRs in 1996, with their report in 2001 being a catalyst for the NHIN movement. It distinguishes person, 050909l3

provider and populations so she has provider and personal centric views.

Then there are syntactic interoperability (can the machines talk) and semantic interoperability (does the language mean the same). NCVHS has recommendations for standards on semantics in a Sept 2005 report. AHIC is trying to get people to concentrate on a “clipboard”.  But the capacity for interoperability is not the same as actually having information exchanged. Reluctance to share data is a continuing problem, not least for incentive and business reasons. But nonetheless data standards and getting them worked out is the

Mary Jo says instead of building from where we are, why not build the working model of the vision? And then see if that motivates people.

She’s fabulous BTW, and I hope to engage her some more.

 


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TECH: Motorola’s view of seamless health

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Jose Lacal is from Florida, and they have lots of hurricanes there (and there’s a reason for that!). Motorola has built a seamless health record (basically a CRM system that has all the information, built on the mobile device). You can use a cellphone to download iTunes, to pay parking meters, etc, etc. So if the phone is trustworthy enough for those guys, than it’s more secure than the PC. OK, but he thinks it should live on the phone…(I assume that it’s backed up somewhere?)

Then he wants the “iPod of personal health”—bring it all in including meidcal guidelines via RSS feeds, information from hospital information systems, etc, etc. All in one place.  Wants to focus on chronic improvement. Wants to empower mom as the chief medical officer.

Thinks that some big org will host it. (Banks, Quicken, Google, USPS). This is a prototype


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TECH/POLICY: Steeve Kay on integrating disability via PHRs

More from the conference. Steeve Kay is the founder of QTC, a disability company which provides outsourced evaluations. Given the problems in figuring out who’s disabled and who’s not, you can see why they care about getting these records electronic. Meanwhile, a private equity firm just bought his company, so he’s obviously convinced someone else that it’s a good business! Yet another little niche in the health care world where plenty (plenty!) of money is flowing around.

Steeve says that medical treatment is provider centric, medical disability is payer centric — and there are lots of payers. It’s about $350 bn total on the health care side (public and private) for medical care for disability, plus another $200 bn for cash payments to the disabled. There’s about 10,000 claim centers in the US who are involved in allocating money, and that includes about 250,000 people working as claims administrators (of various types) with some 10 m claims a year. (I may have that number wrong—Mapping this system is damn confusing!)

These all need evidence to process and judge a disability claim. Most of that needs to come from a medical record, and the legal custodian of the medical record for disability is the payer, while in the medical world it’s a provider. And the disability payer needs to do a bit more to make that complete.

And of course not much has been thought about how these different parties access medical records in an electronic world. His 2 key questions are can we standardize billing codes for disability? And is evaluating disability a practice of medicine.


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TECH/POLICY: Disability and PHRs

David Stapleton (from Cornell Univ Inst for Policy Research) is here to talk about disability. He says that we spend over $200bn on disability (via Medicare, SSI, and Medicaid) and the process of getting people onto disability is totally broken (Determination takes forever, and appeals take even longer). Much of that problem is due to the fact that there is no easy access to the medical record, and then if they actually get the record, figuring out what’s in it is hard, and the information may be biased because the provider is somehow colluding with the applicant (Imagine that in health care!), or applicants may withhold information early, and then produce it later. (If you let the consumer have control of the PHR, then they’ll fix the record to make it favorable to them to qualify for SSI!)

So if there was national PHR then the applicants could give these records out and they’d theoretically be available, accurate and complete! But funnily enough he thinks that disability is not the right place to target EHR development…and given the complications in that part of the world….yup! So why is he here? This conference (and in fact the sponsor of the center) are from a disability management company, hence the role of disability is coming up more than you might suspect! Still it’s a pretty interesting part of the system that we don’t hear about much, and it takes a lot of dollars. And if there was a national, reliable PHR with adaquate rules to get into it — and people trusted the government which Helga Rippen just told us they don’t — then management of the disabled population across programs could dramatically benefit in many ways, but we’re not holding our breath!


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TECH: Personal Health Records–a conference

I’m at a conference with a bunch of academics at Claremont graduate school, all about the Personal Health Record. Helga Rippen, who’s been hanging out in health care IT for a while, and is now buried somewhere in HHS is up and talking now. She’s telling us that people are very concerned about privacy. (I think I’ve heard this before somewhere…and you know that I don’t think that it’s the main problem)

IMGP5585 Allegedly this will all be up on video/podcast/multi-media sometime soon. 

HOSPITALS/POLICY/TECHNOLOGY: More on the dodgy practices of the GPOs

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Via Health Care Renewal, a great article on the ongoing scandals of the GPOs in the Fort Worth Weekly. It’s long but well worth a read.

Essentially the GPOs, on behalf of the hospitals, agree to pretty much exclusive contracts with big suppliers (BD, formerly known as Becton Dickinson, is singled out in the article) and lock out competitors from the hospital markets they control. The hospitals pay over the odds for their supplies, and then bill that back to their clients (who include lots of government agencies). So we all pay. Meanwhile the GPOs get administrative “fees” from the suppliers, which they in turn pass some of back to the hospitals. And it’s a fair bet that very little of that is reimbursed back to the end payer. Does this remind you of any other part of the health care business?

It does to the Congress which has been investigating GPOs for a while now with precious little result. Luckily the current Administration seems not to mind dubious business practices from monopoly sellers, well not if the company has close connections with certain politicians.  Whether the local authorities or the civil courts will be so kind seems less likely given the records of judgments in the article.

Meanwhile, while BD is being bashed it is also being accused by an ex-employee of stiffing the US government by refusing to sell it needed needles, when it has huge stockpiles in Europe. Apparently BD was also illegally trading with Iraq—something that other well connected companies seem to do with impunity.

A doctor twice promoted by medical device maker BD alleges he was illegally fired after repeatedly complaining about serious company breaches in safety, quality control and ethics, including deliberately keeping off the market syringes that could have stretched the supply of flu shots during the 2004 vaccine shortage. In a lawsuit filed Wednesday, Dr. Zeil Rosenberg also alleges that BD, formerly known as Becton Dickinson, refused to upgrade its shoddy clinical studies quality control system, illegally copied a syringe made by another company, and twice tried to ship syringes to Iraq in 2001 without government authorization. Rosenberg’s objections to the Iraq shipments halted them until proper approval was obtained, the lawsuit states.

TECH: M&A in the Healthcare IT world reviewed

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For those of you that want a recap on 2005’s market action in health care IT so far, it’s worth reading equity analyst Ben Rooks on M&A in the HealthCare Informatics top 100. Essentially there’s a lot of M&A going on compared to recent years, mostly because of the realization that the big boys are going to play in health care IT as the gap between medical imaging and clinical software continues to shrink. Go over and read it for more details.

However, Ben is too kind to note that the " Top 100" (PDF) has been wrong as often as it’s been right in the past few years. For example it still doesn’t rank Siemens as a top 100 health care IT company, even though SMS was consistently over $1 billion in sales when it was acquired in 2000. The acquisition may not have gone well, but it didn’t go that badly! And in the list GE’s total health care IT revenue mysteriously dropped dramatically this year, as they noticed that they’d been counting a lot of medical imaging revenue in the “IT” category, and it went from being number 1 to being number 12. However, it looks like they’ve got the same problem this year with Philips, which certainly isn’t as big an IT player as it is an imaging and monitoring player. And how come Dell is on the list at number 11, but IBM isn’t there at all?

Basically the list has no consistency as to who’s selling hardware versus software versus imaging versus PACS versus IT. But that’s OK, if you want to find out what’s really going on behind the data clutter, you just need to ask me nicely….(although sadly unlike Healthcare Informatics I ain’t giving it away!)

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