HIMSS blogger meet-up is on.
Sunday, February 25, 2007Time: 08:00 PM (right after the HIMSS Reception)Location: Mulate’s (Cajun restaurant and bar located right across from the convention center) — thanks to Tim Gee for this arrangement
Come meet Shahid Shah, Tim Gee, John Sharp, and guess whic one of the lurkers at the bar is really MrHISTalk….
This is so important that I’m flying in especially from London for it. Hope to see you there!
The Brits have decided that in at least some regions their hospitals are going to try American style P4P
Health bosses have announced a plan to reward hospitals for low death and infection rates and few readmissions. NHS North West said it was piloting a scheme where cash bonuses are paid to hospitals following the success of a similar programme in the US. Trusts will compete for a total pot of £1.5 million, with any ranking in the top 10 per cent or 20 per cent getting a share. Initially, payments will be made for treatments for heart failure, pneumonia, heart bypass grafts, and hip and knee replacements. But critics said people would expect hospitals to be prioritising safe care anyway.
Don’t forget that on the primary care side they’ve been well ahead of anyone else. Although that’s had it’s issues too. The first year the GPs beat their targets so easily, they’ve made lots more money then the government thought they would.
This is the transcript from my recent podcast with WorldDoc CEO Rahul Singal transcript.
Matthew Holt: Hi. It’s Matthew Holt, at The Health Care Blog, and we’re back with another podcast. This time, I’m talking with the C.E.O. of a very interesting company, which has its fingers in multiple pieces of the health-care system. I’m talking today to Rahul Singal, M.D., who is the president and C.E.O. of WorldDoc. Rahul, how are you today?Rahul Singal: Doing fine. Thanks, Matt. Good afternoon.
Matthew: WorldDoc is based in Las Vegas, just to let the people listening know. I saw Rahul there at a conference a week or so ago. I’d kept tabs on WorldDoc a little bit in the last couple of years, but I wanted to find out a bit more about what was going on. But a number of interesting health care stories are coming out of Las Vegas. I suspect that both those stories and the roles of WorldDoc are not so well known. Anybody going to your website would see that you’re involved in a bunch of different things: strategy analysis, software, personal health records, pharmacy benefits management. To tell the people listening, what does WorldDoc do and what are your main lines of business?
Rahul: WorldDoc is in its seventh year of operations. We started with 14 board certified specialists. We now have 20. We have the single vision of trying to educate and empower consumer end users about their health before seeing a doctor. So we created a web based software system that helps people understand their acute care problems, things like a cough or red eye or stomach pain, "What’s wrong with me? What can I do to make myself better?" Acute care is one of the things. Preventive health. "Hey, I just turned 40 years old. What tests do I need? How can I maintain a healthy lifestyle? Am I at risk for a heart attack?" Then chronic conditions, things like when you know you have high blood pressure or diabetes or high cholesterol. We teach people about their goals, how to talk to their doctors, how to get to their goal.
We do this all in a software based system, created by the 20 board certified specialists.
Matthew: That’s one part of your business. As you know, there have been plenty of companies over the last decade or so who have created software programs to do some parts of some of that, but you guys seem to have made a real business of it. So what have you been selling, who are your customers, and what kind of services are you selling?
Rahul: Our core customers are self insured employers and their payers. The self insured employers are the true purchasers of health care. Their payers are independent third party administrators or regional health plans, which market to these entities, and then their consumers and end users use them.
Our core web based system comes with a 24 hour nurse line. One of the things that we’ve been able to do is import pharmacy and medical claims into our care engine, so that the pharmacy claims can be done within 24 hours of a claim fill. That means that, if I have diabetes and you have high blood pressure, and we each fill a prescription, then, the next day, the WorldDoc system might message you and say "Hey, for your high blood pressure, do you know what your goals are? Here’s the medication. You may want to talk to your doctor about this alternative, which will save you $1,000 a year."
Matthew: Let’s get down to a more granular example. Let’s say I’m one of your customers who is an employer, and I’m working with a TPA to administer a regional health plan or a TPA to administer my employee benefits. Maybe you want to pick a real example, of one of your employer customers. How does it actually work? What are the pieces that you’re supplying to them? What are the pieces that they’re really looking for?
I understand that a smaller TPA may not have done what some of the larger health plans have done and created their own online consumer health experience, as it were. Perhaps they’re looking to you to provide that. What is the value proposition? What are the reasons for which they will engage WorldDoc?
Rahul: On the health risk assessment side, where organizations profile a population’s risk, there’s a lot of examples in the industry in which an employer or a health plan will incentivize a population to fill out a health risk assessment. We do that as well, it works great.
However, we go a few steps further, so that, if, on the basis of pharmacy claims, we know that 500 people may have diabetes, and we’ve done this with Coast Resorts, a casino here in Las Vegas. These 500 people that were on a diabetes claim file, out of a total population of about 7,000, were sent one letter, which invited them to come to the WorldDoc website and fill out a diabetes report card. About 150 people did that.
What’s fascinating is that these 150 people, whom we taught to know their numbers, put in their cholesterol levels, their hemoglobin A1c, and blood pressures, and we created a profile of "Hey, am I at goal?" Simultaneously, we sent this to the employees’ doctors, and we had that in our database. What we showed, within six months, was that these people that participated, that their blood sugars improved to the same degree as they would have if a nurse had phoned them at home. So, we believe, for working age people, commercial people, "Get on the same page with your doctor, reach your goal." This study was published in the Journal of Managed Care about a year ago, and really empowered end users to take better care of themselves.
This time apparently Hollywood Presbyterian is at it.
Over at Spot-on I’m writing about a not very health care topic A brief history of football violence.
Only a few months after winning the World Cup,
Italian football is in crisis – again. Last year a referee-tampering
scandal sent Series A champions and Italy’s most famous club Juventus
to the barren wastelands of Serie B. Last weekend Italian football was
shut down after a policeman was killed by a crowd in a Series A game in
Sicily.
Currently a 17-year-old is the main suspect. And the government has reacted strongly. Apparently only six stadiums are going to be allowed to reopen
any time soon. The others lack the suddenly required safety features
(including close circuit TV) which they’ve supposed to have had for
several years. This includes Italy’s most famous arena, the San Siro in
Milan which is shared between the two giant Milan clubs, AC and Inter.
Anyone who’s ever seen the briefest scenes of Italian football
on TV will probably have been astonished by the huge fluorescent
purpley-red flares set off by the fans standing behind the goals . They
usually are lit when their team scores, but in some cases they’ve been
used to disrupt games. The most notable case was in the semi-final of
the European Champions League played in San Siro Stadium between the
two Milan clubs. Inter were losing, then had a goal disallowed, and their fans threw flares onto the field. One hit the AC Milan goalkeeper.
The game was halted, then abandoned, and later awarded to AC Milan (who
went on to lose the final to Liverpool). Inter’s penalty was the
proverbial slap on the wrist – they were forced to play their next 4
home games in an empty stadium. Go on, continue …
Dr. Eric Novack is an orthopaedic surgeon practicing in Phoenix, Arizona. A frequent contributor to THCB, he has been following the recent debate over universal insurance with a growing sense of disbelief. Eric is also the host of The Eric Novack show, which airs every Sunday
on KKNT 960 AM in Phoenix. You can find an archive of his recent shows here.
Wow. Wow. The Rocky Mountain News, in an editorial today, writes what many of us have known for a long time:
As the clamor for a universal (meaning: single-payer) health-care system rises, one factoid needs to be discredited: the notion that the federal administration of medical services would be dirt cheap.
"\[T]he overhead for Medicare," says Dr. Stephen Rous of Brown University, a single-payer advocate, "is 1 percent to 2 percent. The overhead for various private insurance plans (HMOs, etc.) is 15 percent to 25 percent."
Not so fast. Medicare indeed reports administrative costs of less than 2 percent – it claimed $5.2 billion in costs and paid $273 billion in benefits in 2003. But those figures don’t include the costs of paying claims and tracking down fraud – those are accounted for by the Justice Department and other federal agencies, not Medicare. Nor do they include the building costs and taxes paid by insurance companies, doctors and private hospitals.
The Council for Affordable Health Insurance, a free-market think tank, pegged the actual cost of Medicare compliance at 5.2 percent. And since Medicare spends more than twice as much per recipient as the average private health provider, $6,600 vs. $2,700, the gap shrinks even more.
Even the council pegs overall private costs as more than those for Medicare. But as the debate over the proper medical system for Americans moves forward, the least we can ask for is an honest comparison of the sort the council attempted.
At a time when I am becoming skeptical about our ability to have an honest debate about healthcare, it is nice to see occasional rays of sunshine.
Up, comprehensive and a quarter of a century old: it’s Health Wonk Review at HealthBlawg. Plus it puts THCB in its (rightful) place!
Jess Parks co-founded VISICU, Inc, was a partner at Accenture, and most recently was COO of Aveta, Inc., a Medicare Advantage plan. Jess thinks that, if he hasn’t solved it, he’s at least figured out the problem of irrational technology adoption in health care. See if you agree:
This past week I read two interesting articles that, when taken together, illustrate one of the most fundamental problems in today’s US health system. The first article was Ron Winslow’s piece in the Wall Street Journal: “The Case against Stents: New Studies Hint at Overuse”. Winslow writes that the explosive market adoption of drug-eluding cardiac stents has been well out in front of hard scientific evidence supporting stents’ efficacy for large swaths of the population with cardiac disease. The second article was by David Leonhardt in the New York Times: “What’s a Pound of Prevention Really Worth?” Leonhardt chronicles the experience of Dr. Arthur Agatston, the South Beach Diet doctor. Dr. Agatston has built a medical practice that focuses on prevention of heart attacks in patients with cardiac disease, and has achieved some remarkable outcomes.
So what’s the “fundamental problem”? Our medical system has delivered billions in profits to the providers of stent treatment for cardiac disease (with suppliers, hospitals, and cardiologists all benefiting), while Dr. Agatston’s practice is virtually the only one of its kind, and loses money because the preventive medicine he delivers is inadequately reimbursed. The two articles illustrate the powerful and pervasive incentives for our healthcare system to allocate resources aggressively and disproportionately to profit-making activities. They also highlight the sub-optimal alignment between the potential for profits and the potential to drive the key outcome we all desire for our healthcare system – namely a healthier life lived for all.
Now don’t get me wrong, we need the profit motive in health care. Profits drive innovation, change, and operational discipline – there is no substitute and we would not have our system’s continuing stream of life-saving advances in treatment were it not for the profit motive. In fact, I’d argue that all the world’s nations benefit from the profit motive in US healthcare (yes, they are free riders!). And our system does make significant efforts to align profitability and desired societal outcomes through regulation, e.g. the FDA, provider licensure, underwriting regulations, the orphan drug act, etc., etc., not to mention the Hippocratic Oath. However, the alignment we have achieved falls short of what we need: insurers still cancel policies, the poor still have markedly reduced access to services, information exchange standards still do not exist, and we still suffer from countless wrong-headed resource allocations – paying more for amputation of feet than for regular preventive podiatric examinations of diabetics who are at high risk, more for invasive end-of-life heroics than for preventive community or home-based monitoring of at-risk elderly with chronic disease. I could go on.
There are major opportunities all around us to improve health outcomes, and these opportunities are obvious to all market participants. However, they will continue to sit latent and unfunded – because activities that do not increase insurance profits (today) or provider/supplier reimbursement (today) simply do not get funded and/or adopted by our healthcare markets, no matter how efficacious they might be. I know that many feel that the growth of so-called “disease management” programs sponsored by insurers are an example of how markets are working to align profit and outcomes. Sadly, I disagree, but that is another topic.
If we consider a list of key contributing factors to greater health for our society, the misalignment becomes very evident. Here is the list:
1. Risk identification (that is, identifying risks while there is still time to mitigate them)
2. Behavior modification (patient behavior)
3. Affordable access to healthcare delivery services
4. Identification of best practice in healthcare delivery operations (e.g. medical research, public health research, health services research)
5. Consistent adherence to acknowledged best practice operations within the clinical AND non-clinical components of healthcare delivery
6. Development of superior healthcare treatments (diagnostics, drugs, devices, supplies, procedures).
So I will ask the rhetorical question: in which category will an innovation be rapidly adopted by the healthcare market? The answer is clearly #6 – new healthcare treatments – because suppliers and providers can easily and directly make profits from introduction of superior treatments. And since all industry participants compete for resources, those that offer a clear and rapid return on investment command the majority of the healthcare market’s discretionary capital resources. If you were a venture fund with $1 million to invest, would you put it to work researching a new breakthrough treatment for breast cancer, or would you fund health services research on reducing nosocomial infections in hospitals via improvements in nursing assistant hygiene? Even non-profit charitable organizations (taken collectively) tend to allocate resources disproportionately to treatment R & D, primarily because this is where the greatest and loudest demand is coming from.
To make matters worse, success has driven industry behavior into a rut (albeit a well-greased one). Because the profits available from new treatments are so significant, the supplier / provider industry has over years invested billions to develop an industry-wide infrastructure for promoting and adopting new treatments. From the IRB to FDA approval to physician detailing to payer reimbursement the path to adoption is so well-tread that alternative promotion efforts for other types of solutions seem “unofficial”. If you are competing with this market adoption engine for physician or institutional attention, you have a very hard road ahead of you, even if your solution has good profits to offer.
For example, take #4 or #5 on my list. There are many operational process modifications – in many cases enabled by technology – that can make profits and improve outcomes for hospitals or home health providers or any other provider under PPS reimbursement. However the barriers to development and widespread, consistent adoption of these modifications are very high:
There is in most cases no entity, let alone industry segment, that directly or significantly profits by market adoption of operational process improvements (some consulting firms promoting the change process may profit indirectly), so there is no investment in a cross-industry scaffolding for market adoption (despite their incredible value, I don’t consider organizations like the Institute for Healthcare Improvement or NCQA to be very effective in promoting adoption). As a result, every institution has to mount its own internally developed and internally funded effort for promoting and implementing the solution.
Rather than “adding” an element of care delivery, technology and process changes often focus on avoiding waste, redundancy, and/or inappropriate utilization, raising the burden of proof for efficacy and ROI significantly higher and making the solutions a target for patients, advocates, lawyers and physicians
Return on investment is complex, hard to measure, and usually delayed; in comparison to the ROI of learning/equipping to do a new procedure, doing it, and getting paid, or replacing a supply item that costs $10 per use with one that costs $8.
Imagine if stents were presented to the market this way: “Hey, Mr. Hospital Medical Director, IHI says you really ought to convince your cardiologists to use drug-coated stents instead of referring their patients for bypass; they do have better outcomes for some patients… oh, there’s no payment for them, and you may lose some bypass volume, but we think it’s best practice…and almost forgot, you have to buy a two years’ supply of them and train the cardiologists before you get started.” Absurd, right? But that’s the message that many promoters of technology and process innovations are delivering today!
This is bizarre, but both Wal-Mart and the SEIU want the employer-based health insurance system to end. So apparently today they’re going to agree about that. Of course as Wal-Mart has a completely fungible workforce, any attempt to make it pay for its employees health care either via a pay or play system, or by increasing taxes, will lower its profits. And so it has vigorously opposed any pay or play attempts, and has forced the rest of its unionized. health-benefits providing grocery competitors more or less into its line of thinking.(See this old chestnut about Wal-Mart vs Costco on that score).
So that the SEIU and other unions have backed them into a corner on this means one of three things . Either Wal-Mart is worried about its public image of being a dreadful employer. Or that it’s genuinely worried that its employees not having health insurance lowers their productivity. Or that it believes it can back a universal insurance plan that means someone else (presumably the taxpayer) will pay for its workers to get insurance and thereby get the issue off its back.
You can guess which one I think it is.
At iHealthbeat, the ever wonderful Jane Sarasohn Kahn tells you more than probably ever needed to know about NEPSI–the Allscripts et al backed free ePrescribing initiative.
BTW, if you use the words eRx apparently you don’t mean ePrescribing but you mean this company instead. Or at least that’s what their lawyer Mr Swindle (I shit you not) said in his letter to me. Pity that said word has been used to mean ePrescribing since well, well before the foundation of said company, and certainly before it got a trademark on it in 2001. But it’s good that said company is rich enough to pay high-priced lawyers to write stupid letters. I suspect that they’re not so pissed with me, as with these companies and government agencies—whom people have actually heard of—using the term!
Talk about fleas claiming that they own the dog! I’m thinking of trade-marking the term eIdiot.
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