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CIGNA and Me

• 17

By Vik Khanna

I have a challenge for CIGNA CEO David Cordani.  Sometime this week, pick up the phone and be a secret shopper.  Call your customer service team and ask them the same thing I asked them on a Friday not long ago: does my plan cover and reimburse for flu shots, and at which participating providers in my area?  This is managed care and wellness 101.  Just not at CIGNA.

Customer service rep A says shots are covered and reimbursed, but she cannot confirm any place in St. Louis as a par provider that would bill the plan directly for payment.  Her stubborn refusal to grasp the meaning of “par provider” was infuriating.  She repeatedly reads a list of potential providers (all national companies, such as Walgreens) and then tells me I must call each location to discern its billing practices.

Wrong.  Just plainly and simply wrong because they’re all signed to national contracts.  Then, while both my German Shepherds headed for cover in another room, she hung up on me.  (I was angry but never profane or malevolent.)

Undaunted and now even more frustrated, I call customer service again.  Customer service rep B says: shots covered fully and each location noted previously is a par provider that will accept assignment.  Done, right?  Not yet.  Customer service rep A calls me back.

She has not, however, learned anything in the intervening 15 minutes, as she returns to her home base of ignorance with the accuracy of a GPS.  Finally, I demand a supervisor.  With the supervisor comes enlightenment and lower blood pressure.

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Is Healthcare.gov the Future? I Ask a Futurist

• 8

By Charles Ornstein

Ian Morrison is a health care futurist. Companies, trade groups and nonprofits call on him to speak about trends in health care and offer prognostications of what the future brings. I’ve heard him speak a few times and his knowledge and sense of humor drew me in right away.

Last Friday, I tweeted a story written by Anna Gorman and Julie Appleby,friends at Kaiser Health News about hundreds of thousands of consumers receiving cancellation notices from their insurance companies on account of the Affordable Care Act. I was surprised to learn that Morrison was one of them.

I emailed him to find out more. This is what he told me: Until 2011, Morrison paid for his health coverage from a company on whose board of directors he served. The company was sold and he was insured through COBRA until this March. As he tells it, Blue Shield of California “didn’t want a badly behaved 60 year old Scotsman,” so he got coverage through a preferred-provider organization offered by the insurance company Health Net through a Farm Bureau program.

“No kidding,” he says, he’s no farmer.

Two weeks ago, he received a letter canceling that plan for reasons similar to those cited in the Kaiser story. He subsequently applied for coverage—not through Covered California, the state’s new health insurance marketplace, but directly through Blue Shield. Because of the Affordable Care Act’s ban on discriminating based on pre-existing conditions, the insurer must take him.

Here’s a Q&A I had with Morrison by email (edited for clarity with his approval).

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.Gov Prices May Not Add Up

• 5

By The THCBist

A THCB Reader in Michigan writes:

“The rates listed on the Healthcare.gov/Michigan site are inaccurate “estimates.”  Being unable to apply on the website due to glitches, I simply go on the site to view plans for my husband and me.  Based on our locality, “estimates” shown are about $250 – $600 for bronze and silver plans.  We even see some gold plans for about $460.

But when I telephone the insurance companies (Aetna, Humana, BCBSM, HAP) for details and quotes, suddenly the costs of the same plans are $950 – $1750!  Obviously, the “estimates” are disingenuous, probably reflecting prices that are available only to very young adults with no medical history.

An estimate is not an estimate unless it is close to what the final price is expected to be, not one-half or one-third the final price. Insurance companies need to list the estimates on the .gov website by range, rather than a single rate.  For example, if a policy can be sold for as little as $250 or as much as $950 depending on the particulars of each insured, that policy estimate needs to read $250 – $950.  Until insurance companies do this, they are, effectively using a bait-and-switch sales technique, which is illegal.”

If you’ve had a bad or good experience attempting to buy health insurance on the state or federal exchanges, we’d like to know about it. E-mail us at editor@thehealthcareblog.com.

Health 2.0 Europe: Creation Healthcare’s Daniel Ghinn

By Harriet Messenger

Harriet Messenger – How has social media transformed our lives? And how do you see it transforming health care?

Daniel Ghinn – Social media is transforming our lives in so many ways. I think all the benefits we’re getting through social media are now happening in health care. For example, social media is great for connecting people who share experiences, this is greatly beneficial in health care – whether it’s bringing patients together or building strong communications between health care providers.

It enables us to learn from one another, to get support and to share ideas in ways that would never have been possible in the non-digital communities that we lived in before the explosion of digital.

HM – Who is using social media? Is it patients, health professionals, pharmaceutical companies?

DG – To some extent it is probably a reasonable generalisation to say everybody, but in so many different ways. Patients, I believe, led the digital health revolution. Patients coming together, collaborating, sharing experiences and learning from each other on how to connect with other diverse areas.

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Health 2.0 Europe: Med Digital’s Felix Jackson

• 1

By Harriet Messenger

Harriet Messenger – New technologies are allowing pharmaceutical companies to be in direct contact with patients. How is this transforming the industry and what are the opportunities and the pitfalls?

Felix Jackson – Nothing has really changed with regards to how pharmaceutical companies can interact with their patients. We’ve always been able to provide information for patients. In fact it’s a regulatory requirement that pharmaceutical companies provide patient information. What’s changed is that the digital framework enables them to do this much more conveniently online and much more powerfully. The places that I’m seeing theses changes are places like disease awareness, where pharmaceutical companies are using digital awareness to raise education and information about a certain disease and when to go and seek treatment from a doctor. Also in their support of patients post prescription. So when a patient is prescribed a drug and needs detailed information on that drug, pharmaceutical companies are doing quite a lot of work to provide that information digitally.

HM – And are there pitfalls to this at all?

FJ – Yes, one of the problems with digital, is that it is very global and so traditionally the pharmaceutical companies are regulated on a geographical basis, by country, and traditionally that has been quite easy to control, handing out leaflets in a specific geography. Now with the Internet, if you put something online it can be accessed from all sorts of different parts of the world and that can cause issues. However, I don’t think those problems are that major. If you think it through, it’s about how you are aiming and targeting that activity and if you’re aiming at UK patients and filter websites in the UK then it’s very easy to control, or at least easier than some companies worry about.

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In Medicine, More May Not Be Better

• 4

By Haider Javed Warraich, MD

The dull whir of the computer running in the background seemed to have gotten louder as the patient fell quiet. She was a young woman, a primary-care patient of mine, seeking a referral to yet another gastroenterologist. Her abdominal pain had already been checked out by two of the city’s most renowned gastroenterologists with invasive testing, CAT scans and endoscopic procedures.

But she wasn’t satisfied with her diagnosis — irritable bowel syndrome — or the recommended treatment and wanted a third opinion. I tried to reason with her but failed to convince her otherwise. Even when I acquiesced and gave her the referral, she walked out visibly unhappy. I sat there listening to the whirring, feeling disappointed.

Physicians love being liked. They also love doing their jobs well. With other incentives, such as monetary returns, dwindling, the elation we get from satisfying a patient as well as providing them good care is what still makes being a doctor special. But is keeping patients satisfied and delivering high-quality care the same thing? And more important, can patients tell if they are getting good care?

Policymakers certainly think so. In fact, under the Affordable Care Act, Medicare, and Medicaid hospital reimbursements are now being tied to patient satisfaction numbers.

But the association between patient satisfaction and the quality of care is far from straightforward, and its validity as a measure of quality is unclear.

In fact, a study published in April and conducted by surgeons at the Johns Hopkins School of Medicine showed that patient satisfaction was not related to the quality of surgical care. And a 2006 study found that patients’ perception of their care had no relationship to the actual technical quality of care they received. Furthermore, a 2012 UC Davis study found that patients with higher satisfaction scores are likely to have more physician visits, longer hospital stays and higher mortality. All this data may indicate that patients are equating more care with better care.

Although patients and their physicians generally have similar goals, that is not always the case. As a resident, who is not paid on a per-service basis, I have no incentive to order extra testing or additional procedures for my patients if they’re not warranted. But one study found that physicians who are paid on a fee-for-service basis and therefore have an incentive to deliver services — needed or not — are more likely to deliver these services (such as an MRI for routine back pain).

On top of that, as another study found, they also are more liked by their patients. It is no wonder then that the number of patients with back pain, one of the most common reasons for physician visits, are increasingly being overmanaged with MRIs and narcotic pain medications.

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Darwinian Health IT: Only Well-Designed EHRs Will Survive

• 14

By Edmund Billings, MD

Remember the Ford Pinto and the AMC Pacer, aka the Pregnant Pinto?

Both serve as reminders of an in era in which the American auto industry lost its way and assumed drivers would buy whatever they put on the lot. Foreign competition, primarily from Japan, filled the void created by American apathy for quality and design, and the industry has never been the same.

Admittedly, the comparison of cars and EHRs is less than apt, but health IT also assumes healthcare will buy what we’re selling because the feds are paying them to. And, like the Pinto, what we’re selling inspires something less than awe. In short, we are failing our clinical users.

Why? Because we’re cramming for the exam, not trying to actually learn anything.

Myopic efforts to meet certification and compliance requirements have added functionality and effort tangential to the care of the patient. Clinicians feel like they are working for the system instead of it working for them. The best EHRs are focused on helping physicians take care of patients, with Meaningful Use and ICD-10 derivative of patient care and documentation.

I recently had dinner with a medical school colleague who gave me insight into what it’s like to practice in the new healthcare era. A urologist in a very busy Massachusetts private practice, he is privileged to use what most consider “the best EHR.”

Arriving from his office for a 7 PM dinner, he looked exhausted, explaining that he changed EHRs last year and it’s killing him. His day starts at 7 AM and he’s in surgery till noon. Often double or triple booked, he sees 24 patients in the afternoon, scribbling notes on paper throughout as he has no time for the EHR. After dinner he spends 1.5 to 2 hours going over patient charts, dictating and entering charges. What used to take 1 hour now requires much more with the need to enter Meaningful Use data and ICD coding into the EHR.  He says he is “on a treadmill,” that it should be called “Meaningless Use,” and he can’t imagine what it will be like “when ICD-10 hits.”

My friend’s experience is representative, not anecdotal. A recent survey by the American College of Physicians and American EHR Partners provides insight into perceptions of Meaningful Use among clinicians.

According to the survey, between 2010 and 2012, general user satisfaction fell 12 percent and very dissatisfied users increased by 10 percent.

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The Doctor Returns Bearing Data.

• 13

By Rob Lamberts, MD

I have felt from the start that this practice model is far better than the one I had in my former life, including:

  1. Better experience for the doctor
  2. Better experience for the patient
  3. Better care quality
  4. Savings for the patient and for the system.

The last one on the list is the hardest to prove, and I am potentially getting someone to gather concrete numbers for patients who followed me from my old practice to see if their overall health expenditures are down from before I started this practice.  This will take time, however, and I am not sure the sample size is large enough to account for the normal variations (either in my favor or against).

Yet some anecdotes from the recent past suggest the answer, giving evidence of significant savings, both financial and life quality, that my patients and their payors get.  This is an important case to be made to both the patients (who want to know if their $30-60/month is worth it) and payors (who could financially benefit from promoting this practice model).  I realize that this does not constitute a proof of concept, but it is not without meaning.

PATIENT 1.  MEDICARE.  AGE: 90+

Pt had a head injury and came to my office wondering if they should go to the ER.  I assessed the mental status did an exam, determining that this was not necessary.  Set up imaging study that day (CT without contrast) which came back negative.

In my old office, the nurse who answered the message would have immediately suggested going to the ER, not checking with me on this.

Cost: CT without contrast as outpatient – cash price $300, not sure about negotiated price.

Savings: Avoided ER with head injury work-up.  Cost: ?  (More than $300 by far).

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Why Calling it a “Tech Surge” May Not Be the Best Idea in History

• 18

By Brad Feld

Now that our federal government is back at work and the short term debt ceiling thing is resolved, it should be no surprise that the news cycle is now obsessed with Obamacare and its flawed implementation. Over the weekend I must have seen a dozen articles about this online and in the NY Times, and then I woke up this morning to a bunch of new things about the Healthcare.gov site underlying tech, how screwed up it is, and what / how the Health and Human Services agency is going to do to fix it.

The punch line – a tech surge.

To ensure that we make swift progress, and that the consumer experience continues to improve, our team has called in additional help to solve some of the more complex technical issues we are encountering.

Our team is bringing in some of the best and brightest from both inside and outside government to scrub in with the team and help improve HealthCare.gov.  We’re also putting in place tools and processes to aggressively monitor and identify parts of HealthCare.gov where individuals are encountering errors or having difficulty using the site, so we can prioritize and fix them.  We are also defining new test processes to prevent new issues from cropping up as we improve the overall service and deploying fixes to the site during off-peak hours on a regular basis.

From my perspective, this is exactly the wrong thing to do. Many years ago I read Fredrick Brooks iconic book on software engineering – The Mythical Man-Month. One of his key messages is that adding additional software engineers to an already late project will just delay things more. I like to take a different approach – if a project is late, take people off the project, shrink the scope, and ship it faster.

I think rather than a tech surge, we should have a “tech retreat and reset.” There are four easy steps.

  • 1. Shut down everything including taking all the existing sites offline.
  • 2. Set a new launch date of July 14, 2014.
  • 3. Fire all of the contractors.
  • 4. Hire Harper Reed as CTO of Healthcare.gov, give him the ball and 100% of the budget, and let him run with it.

If Harper isn’t available, ask him for three names of people he’d put in charge of this. But put one person – a CTO – in charge. And let them hire a team – using all the budget for individual hires, not government contractors or consulting firms.

Hopefully the government owns all the software even though Healthcare.gov apparently violates open source licenses. Given that, the new CTO and his team can quickly triage what is useful and what isn’t. By taking the whole thing offline for nine months, you aren’t in the hell of trying to fix something while it’s completely broken. It’s still a fire drill, but you are no longer inside the building that is burning to the ground.

It’s 2013. We know a lot more about building complex software than we did in 1980. So we should stop using approaches from the 1980s, admit failure when it happens, and hit reset. Doing a “tech surge” will only end in more tears.

Brad Feld is the managing director at the Foundry Group. This post originally appeared at his site, FeldThoughts.

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