Barefoot at HIMSS? Just Trying to Follow Dr. Google’s Orders

DrGoogle

If you see me in flip flop sandals, Vibram Five Fingers (VFF), or a barefoot-style shoe at HIMSS14 — please withhold fashion judgment. Since Jan 1, 2014, I have been performing a little “care management” on myself — as ordered by Dr. Google — and have been treating my sports injury by going about barefoot or minimally-shod.

Trusting Dr. Google over my Kaiser podiatrist (recommendation: prescription orthotics), and my Kaiser Sports Medicine Doctor (recommendation: wear a medical boot), was not easy. I was driven by: 1) pure desperation to get back to running, 2) A feeling that the KP system had nothing left to offer me, and 3) a high deductible health plan.

When my healthcare was paid for, and the doctor was all-knowing

I began running as a teenager and within a few years had developed posterior tibial tendinitis (pain and swelling along the inside of the ankle/foot). The podiatrist told me I had flat feet/over-pronated, and that I needed custom orthotics. I blindly trusted him, accepted his diagnosis as fact and was soon running again — pain-free and happy. Pre-Internet, I had no easy way (and no inclination) to really understand the biomechanics of running gait and why the orthotics fixed my symptoms.

A few decades later, I found myself again in a podiatrist’s office. I was suffering from some intermittent pain in my left ankle/foot, and assumed I needed the latest and greatest orthotics.

However, this time around I was no longer that oblivious teenager. I had read the book Born to Run and had also witnessed my husband suffer through various running injuries over the years — injuries that immediately disappeared after he started running in a VFF toe shoe.

I distinctly remember asking the podiatrist if there were any exercises I could do to strengthen my foot, negating the need for orthotics. He told me no, my problem was genetic, and that I would need new $300 prescription orthotics.

Turning to Dr. Google Instead of Dr. Kaiser

After running for several months in the new orthotics the pain came back ten fold. In order to simply walk, I began wearing an ankle brace in addition to the crippling orthotic. After 6 months of not running, I was in as much pain as ever, and was desperate.

During this time period (late last year), a perfect storm of events pushed me towards Dr. Google and healthcare consumerism.

I read The Story of the Human Body, by the “barefoot professor”, Daniel Lieberman of Harvard. Lieberman discusses how the habitual wearing of shoes since childhood deforms and atrophies the human foot — causing a host of problems including flat feet/overpronation. Lieberman also rails against the orthotics industry, describing how orthotics cause the foot to progressively weaken over time until wearers lose the ability to walk barefoot.

Feet

At the same time as I was learning about the deleterious effects of shoes on the human foot, I was transitioning into a high deductible Kaiser plan via Covered California. This meant that I would pay dearly for each office visit, and, at that point in time I didn’t feel like spending a dime on KP with regards to this injury. I very much felt (and still do) that I had been duped by both the orthotics maker, and the orthotics-salesman podiatrist.

In short, I had nowhere else to go except to Dr. Google, who was available for free, 24/7, instantly. Over a week I obsessively googled various keyword combinations. I found communities of barefoot runners, flat-foot sufferers, and numerous YouTube videos. Most helpful were the videos and blogs that described in detail, exercises to strengthen arches in flat feet. I also learned the important role of the big-toe in supporting the arch (in nearly all womens’ shoes, the big toe is pushed and squeezed to the side, causing the arch to oftentimes fall).

I formed a hypothesis that this barefoot stuff might cure my foot injury, and so on Jan 1, 2014 started slowly going barefoot as much as I could around the house and doing various foot and lower leg strengthening exercises. I wore VFFs and flip flops outside, and got rid of the ankle brace.

Testing My Barefoot Hypothesis, On a Sample Size of One

Wearing orthotics for so long, I hadn’t realized how weak my feet actually were. In going barefoot, I felt could feel just how feeble each tendon, ligament, and muscle was. At the same time (and despite the ongoing soreness), the post tib pain was subsiding. After 2 days barefoot I could walk without much pain.  7 days barefoot and the pain was gone completely. This was after 6 months of suffering.

Some other outcomes: My foot became noticeably wider, more muscular, and lo and behold I developed an arch in my foot. I have tried to prove these outcomes to myself by trying on a narrow shoe that used to fit but now does not, and by observing my footprint coming out of the pool — before it was a blob, now it looks like a normal footprint.

Disclaimer: yes, I am a sample size of one, this was a non-controlled study. I acknowledge that I too suffer from Optimism bias and Confirmation bias.  Also, I don’t yet have enough runs under my belt to know whether or not this barefoot transition will really enable me to run injury-free for a long time. (To date I have been able to run 4 miles at a stretch in the VFFs.)  I may get injured tomorrow but for now I am declaring victory.

Analysis: Why Didn’t Kaiser Care if I healed or Not?

Of all healthcare providers, KP as a capitated system should have cared about healing my foot and preventing the need for surgery. However, in this case KP acted completely episodically.

What about population health management outreach? I didn’t receive a single outreach from KP, checking in as to whether the orthotics worked or not. Not even a simple email. (Actually, I am naïve to expect this. KP is a smart actuarial organization and has made the calculation that this type of outreach is more likely to increase utilization for a generally healthy member. Not so for the sickest, most complex patients.)

What about care coordination? I visited a primary care doctor after the fact for a routine checkup. Why didn’t she ask me how my foot was doing? Maybe going through my (very short) medical record was too much to ask? Why then install Epic at $6B?  If this kind of basic care coordination isn’t being achieved within a closed, integrated system who has been on Epic for years and touted by many as the “gold standard” then how do we expect loosely integrated clinical networks to share data?

Note: In Kaiser’s defense, before I visited Dr. Google I did make one last attempt and had a phone conversation with a sports medicine doctor (no deductible charge) who wasn’t interested in talking about orthotics and told me the next step was a medical boot. I asked him about barefoot running and he didn’t disregard it as possibly helpful.

In Summary: Healthcare Consumerism Driven by Complex Factors

With this post, what I want to do is shed some light on the complex conditions driving healthcare consumerism today. In this case, my ACA high-deductible plan offered me some tough love and forced me to take control of my own health — though there are many use cases where these plans might backfire.

There is also the role of tech/IT therein. Aside from the obvious benefits and pitfalls of going to Dr. Google, this use case made me think deeply about just how far providers are from truly harnessing user-generated data. For example, KP in the far future might want to exploit my smartphone’s GPS data to predict if I am trending towards a sports injury in the first place.

I have also written this post as a small way of adding my voice to Dr. Google — I hope it can be useful to anyone who has suffered from similar injuries. You don’t always need to mindlessly believe a podiatrist who tells you that your feet are genetically defective and need to be propped up by an expensive orthotic.

I am now preparing to walk ~8 miles daily through those long hallways at HIMSS, and looking forward to it, though be forewarned, I may be not be wearing the most stylish shoe.

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What’s in Store for 2014?

zoltarThat time of year once again where we collectively look into our crystal ball, or throw the sticks or maybe even look at the coffee grinds dripping down the sides on our coffee cup to see what may be in the year to come. Making these predictions for the coming year is almost a rite of passage for any self-respecting analyst firm and what the heck, from our vantage point, we may have a slightly better view into the future than most.

So in keeping with some sense of tradition here at Chilmark Research, the following are our ten predictions for 2014, plus one (think of it like a baker’s dozen).

Meaningful Use (MU) stage two delay provides little relief to IT departments. Many breathed a sigh of relief when HHS announced that stage two timeline would be extended. Yet despite that extension, IT departments will remain overwhelmed in 2014 coping with a host of other initiatives, from ICD-10 to HIPAA compliance to preparing the organization for changing models of reimbursement and of course MU 2.

Best-of-breed solutions proliferate. Despite the desire to have as few as possible IT vendors and their solutions within an organization, department heads take it upon themselves to adopt new solutions as IT departments are not able to meet all the needs of the organization at this time, nor are EHR vendors capable of delivering new offerings in a timely manner. We anticipate analytics and care coordination to be high among list of adopted best-of-breed solutions. This will create its own host of problems several years hence.

Consolidation continues unabated in mid-market. Much to the concern of payers, large provider organizations will continue to purchase their smaller brethren to extend their reach and improve care coordination. Payers will fight back with lawsuits (monopolistic tendencies of providers) and by making their own acquisitions. Payers will be particularly attracted to the dual eligible market.

Bloom is off the rose as physician dissatisfaction with chosen EHR rises. OK, yes this is a no-brainer as we have been seeing discontent rise throughout 2013. But this discontent will escalate as smaller organizations increasingly realize that their EHR is ill-suited to address the needs of tomorrow in a value-based reimbursement world.

Limitations of deployed HIE becomes increasingly apparent. It’s one thing to put in an HIE infrastructure, quite another to embed HIE capabilities into clinician workflow, especially across a heterogeneous EHR community. Couple that with a growing realization among leading HCOs that to truly support clinicians at point of care, far more data is required to flow through the network and you end up with a lot of future head scratching as to where the real value realization will be derived from the HIE now in use.

Re-prioritization moves patient engagement to back burner. Despite the strong efforts of ONC/HHS to promote the concept of patient engagement, providers, no longer having the stage two gun to their head, will reset priorities on other, more pressing matters.

One third of stage one, MU-certified EHRs do not or choose not to certify for stage two. The HITECH Act created a false market for EHRs that led to the proliferation of vendors and their solutions. Unfortunately for many an ambulatory practice, their chosen EHR vendor will not have the resources to refine their product for stage two certification leaving smaller practices with the unenviable task of having to find a new vendor. Thankfully, a price war is anticipated as vendors look to build customer bases and subsequently valuations before inevitable acquisition.

Clinical analytics remains a hot, yet immature market. Leading HCOs are all clamoring for analytics to help run their operations and improve care delivery processes. But despite the high demand for such solutions, EHR vendors are still behind the curve in delivering such capabilities, the buyers still are not quite sure exactly what they want and rarely have the resources to begin asking the right questions. The best of breed vendors themselves struggle to keep up with market demand, leading to longer then anticipated deployment times.

Cloud-based EHRs become de facto standard for small, ambulatory practices. Pricing pressure will grow fierce in the ambulatory market and in an effort to lower cost of sales, shorten product lifecycles and improve customer service, ambulatory EHR vendors will move to cloud-based services for their solutions. Some push-back will occur over concerns of data governance and privacy. Physicians taking this path will need to review terms and conditions of such contracts carefully.

Payers increasingly become part of HIE fabric. In mid-2013, payers became increasingly involved in the HIE market partnering with leading providers in some communities to share data and improve care coordination. While providers have instinctively been reluctant to partner up with payers, the move to value-based contracts and the strong skills and critical data that payers can provide is forcing providers to re-evaluate their previous stance.

Healthcare.gov falls short – payers wring their hands. Healthcare.gov has far more sign-ups than detractors anticipated but falls short of administration goals, especially for the young and healthy. This leads to payers to continue wringing their hands over adverse selection of new enrollees and the likely higher risk profile as a result.

There you have it folks. Now let’s see how the year plays out and just how close these predictions are to reality come early 2015. Either way, never a dull moment in this market for the foreseeable future.

 

 

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Wellness Market: Too Many Chasing Too Little

CrowdHaving taken a hiatus from last year’s Health 2.0 event, was looking forward to this year’s event to see what may be new and upcoming among those looking to disrupt the status quo. Unfortunately, surprisingly little.

Health 2.0 a couple of weeks back had your usually cheery crowd of those who are looking to transform healthcare. As with past Health 2.0 events we have attended, hype was far out in front of market reality but that does not seem to deter the cheerleaders, which were again present with abundance among the some 1,700+ attendees.

Show Me Your Big Data – That’s what I thought, not so big after all
There was plenty (i.e., too much) talk about Big Data when in reality, presentations focused on relatively small datasets with little thematic similarity in any one session. For example, the Risk Assessment & Big Data session had Dell talking about genomics, Sutter Health talking predictive analytics for CHF, another about mashing up claims and clinical data and the last looking at risk assessment. At the conclusion of this session, nary a question was asked – audience confused. Another session on Big Data tools for Population Health Management (PHM) was cut short, thankfully, when the power died. Hard to say if it is the industry drinking the hype, this particular event (though experienced similar at HIMSS’13), or what but this silliness has to stop – we really need clarity, not smoke n’mirrors =- and don’t even get me started on PHM…

Track Me – Track You and no, I probably don’t want your data, at least not yet
In addition to riding the Big Data hype, the event also jumped on the hype surrounding the rapid proliferation of self-tracking, biometric devices now entering the market and all the great things that will come as a result of consumer adoption and use of such devices to monitor health. Not all are jumping on this band-wagon and for good reasons. There is no doubt that in time, such devices will be used by clinicians and patients together which will be the focus of a forthcoming Insight Report from Chilmark but our early research points to a number of challenges in the adoption and use of such devices in the context healthcare delivery.

There was again a plethora of solutions for price transparency. Some odd partnerships that are more opportunistic, for the partners, than providing value for the end users, e.g., the Dr Chrono-Box.net demo was so laborious I can’t imagine any clinician actually doing it. On the patient engagement front, plenty of new solutions on display and was particularly impressed with what Mana Health had build for the NYeHC patient portal contest. Simple, clean, straight-forward and intuitive to use refreshing.

Of course no Health 2.0 event would be complete without one of the large commercial payers taking the stage to announce their latest and greatest member outreach initiative. Two years ago it was Aetna with CarePass. This year it looked like it would be Humana until they were a no show – but Cigna was there with GO YOU Hub. First impressions of GO YOU: a fairly shallow pool in the health & wellness domain with lots of catchy phrases and colors – something your pre-pubescent daughter may like – but this adult quickly lost interest after four clicks

Health & Wellness Redux, Redux, Redux
And again, no Health 2.0 event would be complete without a gaggle of health & wellness solutions, the majority of which won’t be around by 2016.

There are now far more health and wellness solutions in the market than what the market can absorb. This situation is not likely to get better anytime soon as the numerous incubator/start-up accelerators continue to spew more of these solutions into the market every year. The only thing I can think of is that the barriers to entry must be exceedingly low, yet few of these companies realize that the barriers to adoption are exceedingly high and the market is on the verge of contraction.

The Big Squeeze
We are now projecting a significant level of contraction in the health and wellness arena as the broader market comes to grips with a shift in risk from payers to providers with providers ill prepared to accept that responsibility and the migration of many employees off of their employer plans and onto Health Insurance Exchanges (HIX).

This will create two challenges:

Providers are not accustomed to providing such solutions to their patients. While risk may shift to providers, provider adoption and use of such solutions to manage their patient populations is limited. When one adds in self-tracking devices, well…

…providers are struggling with the data dumps from their recently install EHR. The last thing they are seeking is another data source. Healthrageous is one example. A self-tracking wellness solution that was developed by provider Partners Healthcare, adopted in pilots by some big providers, failed to gain traction and was quietly sold to Humana. Not a pleasant outcome. If a provider organization can’t make a go of it through a spin-out, to the multitude of these health & wellness solutions think they can?

Second, we are at the very beginning of a massive shift of employers directing employees to HIX. Despite a fitful start, the use of HIX will grow overtime as a wide range of employers, but especially those in the retail and hospitality industries, direct their employees to these exchanges. Shifting employees to HIX reduces employer exposure (risk shifting) and will lead to decreasing interest and adoption of health and wellness solutions by employers.

Yet despite these challenges, the cheerleading at all Health 2.0 events and a questionable future, one thing that comes through every year is that there are a significant number of people that truly want to do something good, something meaningful to improve the sorry state that is our dysfunctional healthcare system, which we all struggle with at times. These are the people that attend Health 2.0, the ones willing to talk about the “Unmentionables”, the ones to project a vision of a better future for us all, the ones willing to take a risk. For that they should be applauded. But be wary as most will not be around three years hence.

But next time, can we actually have some front line providers in greater abundance to give us their take on all of this. Unfortunately, this event was sorely lacking in such, though it did have its fair share of various healthcare representatives – they just weren’t the ones from the front lines which is who we all need to be hearing from today.

Special thanks to Graham Watson for the image. Graham is easily the best cycling photographer in the world today.

And an extra special thanks to Cora who was there with me and provided a few tidbits of her own to this post.

 

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Crashes, Bugs, and Major Usability Issues at Covered California

I have spent the past few days struggling to apply for insurance on California’s HIX, CoveredCA. Early on in the application process I tried to withhold judgment, but have since learned that coveredca.com has a price tag of $360M, awarded to Accenture. And so I am feeling decidedly less generous and have penned this short note. I hope that details of my experience can be of benefit to CoveredCA, Accenture, and anyone in the state considering applying for insurance.

System Slows to a Halt (Oct 9th)
I started out by checking a few news and twitter sources, which reported that the initial kinks with CoveredCA had been worked out. However when I began the application process the system was unbearably slow. I waited easily 30 seconds for every form submit. Eventually, I was presented with a cryptic error message when the system finally crashed: Oracle Access Manager Operation Error”.

The (very nice) woman I spoke with at the CoveredCA call center confirmed that the site was down. However, this news was absolutely under-reported. There were a few tweets that noted the system failure, but that was it. Notably, @CoveredCA remained silent on the issue.

I gave up staring at the Oracle error message, and the next morning (Oct 10), logged back in at 5am thinking I would beat peak web traffic. At 5am the site was still down, this time for “scheduled maintenance”.

I eventually completed my application later in the day… overcoming several usability hurdles and bugs along the way… as detailed below:

Major Usability Issues Encountered

  • Lack of login link. Why is their no login link on the landing page? It is completely non-intuitive to click “start” when I really want to just login and continue my application.
  • Security questions gone wild. These were so bizarre. There were 5 different security questions with 5+ question dropdowns each. One example: “What is your funniest friend’s last name?”
  • Children…are not adults. If a person has been identified as a child why am I still bombarded with adult-centric questions about that child, e.g. “has this person submitted a tax return.” Why should I ever be given the option to assign a child to be the parent of another child?
  • Family relationships. There has to be a better way to identify family relationships than the all-permutations-approach used. I’m sure this problem has been long solved — what does TurboTax do here? CoveredCA and its partner Accenture seems to have completely ignored industry best practices.
  • Going back and forward through application. It is absolutely unclear how to go “back and forth” in the application workflow easily.
  • Family member health status. Absolutely weird UI for specifying how many family members have high healthcare/high medication needs — need to click plus (+) and minus (–) boxes.
  • How do I verify my income? At one point in the application workflow, it was specified that I had to verify my income before I could fully qualify for health insurance. I still do not how I am supposed to do this — no instructions given and no email follow up.

Major Bugs Encountered

  • Bug #1: editing previously entered data. After I was nearly done with the application process, I tried to edit some of my husband’s citizenship details.  When I clicked the ‘edit’ button next to his name I was taken back to the wrong family member’s form. I could find no other way to edit my husband’s contact information.
  • Bug #2: going “back” in application. After I was unsuccessful at editing my husband’s information, I was taken back several screens in the application and had to click “continue, continue, continue,… ” many times to get back to where I was.  At this point I became resolute to never try to “go back” in the application process ever again.
  • Bug #3: health plans search. When shopping for health plans I tried to search for health plans by both physician and hospital. I typed in “Kaiser”… and… no results found! Pretty shocking considering that Kaiser-Permanente is the largest, fully integrated insurer-provider in the country with headquarters in California. How could they miss this is beyond my imagination.

I am not one who wants to see CoveredCA fail, and I appreciated @CoveredCA responding to my tweets — albeit giving general assurances that the web team is “working on” the problems. I hope these problems can be resolved quickly (but doubt it).

Unfortunately, by spending $360 million of taxpayer dollars for Accenture consulting services and producing this kind of product, CoveredCA is giving plenty fodder to those that want HIX, and general healthcare reform, to fail. One really has to wonder, were those dollars well spent, and if there is any clause in the contract to hold Accenture’s feet to the fire until they get this fixed. Lastly, If anyone can tell me how I am supposed to verify my income then I would be much obliged.

 

 

 

 

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Looking at Healthcare Through Payer Lenses: Part Two

Payers, as with the rest of the healthcare industry, have a lot on their plate right now. Healthcare reform, via the Affordable Care Act (ACA) continues its march forward despite legal and political uncertainty. Struggling to define the payer role in Accountable Care Organizations (ACOs), understanding the impact of Health Insurance Exchanges (HIXs) on their business (McKinsey survey results likely have many payers wondering how to market to what may be an enormous uptick in individual purchasers of coverage – something that most are ill-prepared for), and how to better engage consumers/members in proactively managing their health are a few of the top issues that were addressed at the AHIP Institute last week.

But when one sits back and reflects on the AHIP Institute – all of the sessions, all the discussions, the chatter in the halls, underlying messages within the message, the exhibit hall – it boils down to three key themes that this sector of the healthcare industry is grappling with, which much like the three stages of meaningful use, build upon one another:

  • Establishing Trust
  • Engagement
  • Collaboration

Establishing Trust
Health insurers have a major image problem and they know it. Providers don’t trust them, consumers don’t trust them and who knows, maybe even their spouses don’t trust them. Without that trust it is extremely difficult for payers to engage providers and members at a deeper level to improve overall population health and lower their risk exposure (MLR=medical loss ratio).

With the passage of the ACA, payers are now looking at the prospect of at least 30M more members (a significant portion Medicaid) joining their ranks. The 30M estimate could easily be tripled if McKinsey’s research (see above link) is indeed accurate. This creates a two-fold challenge for payers:

  1. How to market to these potential new members through a state-sponsored and run HIX. Payers do not know how to market to a market of one as they are more accustomed to marketing to employers or through brokers to reach that end consumer. Payers need to develop strategies that will assist them in attracting new members through these exchanges and one would imagine that ideally, a payer would prefer to attract the healthiest consumers on the HIX to join their ranks, again to lower MLRs. Successful marketing begins with establishing trust in a given brand and with a consumer trust ranking for payers that is towards the bottom, payers have a long road ahead of them.
  2. How to ensure that these new members receive appropriate care when they need it and not have them turn to the local, and the far more expensive, Emergency Room (ER). Many of these new members are unaccustomed to having a primary care physician and have typically gone to the local clinic or ER for care. Ensuring that these new members receive effective, value-based care will require close collaboration (and education) not only with the new member, but more importantly, the care community in which that new member resides. Payers will need to establish a higher level of trust than they have today with that care community, be they ACOs, Patient Centered Medical Homes (PCMH), clinics, you name it to develop value-based care models. With a gapping shortage in primary care, that will only be exacerbated with ACA, very creative approaches are needed to develop these new care models and trust is often a foundational element to the creative process.

Engagement
If and when trust is established, the next stage is engagement and for payers it appears that such engagement is sporadic at best. Sure, there are many examples where payers have established partnerships with provider organizations, but it has not been easy. As stated in Part One of this series, Blue Shield of California worked closely with Catholic Healthcare West to establish an ACO model that worked for both parties. This effort took four long years to accomplish which makes one wonder: if Kaiser-Permanente wasn’t beating up both parties in the market, would this ACO even exist?

Payers need this type of deeper engagement with providers to develop new models of care but do they have the time, do they have four years for each significant ACO they wish to establish in a given community/region? With 2014 a short 2.5 years away, one would have to logically conclude: No, there is not enough time. Payers will certainly take lessons learned from initial efforts, but definitely need to accelerate engagement of the provider community. But where is that engagement? While there were representatives of provider groups in attendance at AHIP Institute, AHIP’s failure to put such representatives on the stage to talk of their experiences and what they, the provider community seeks from payers is shocking almost to the point of disbelief.

Not sure if the payers are anymore successful on the member side but with an increasing number of future members being individuals, payers need to seriously rethink their consumer engagement strategies, which today rank dead last of major industries surveyed. Yes, most payers have a PHR offering for their members. Yes, most payers are seeking to engage members via calls to those with a condition. But is any of this gaining traction, engaging consumers/members in a meaningful way to help payers reign  in ever rising healthcare costs? Sure doesn’t look like it and payers will never make it to Stage 3 if they do not get members and providers engaged.

Collaboration
Collaboration is the final Stage 3 for payers. It is the nirvana of deep and meaningful collaboration between all stakeholders to improve healthcare delivery in the US – a new delivery model that reigns in costs, equitably distributes risk, and ensures accountability. This is a very elusive goal that the payer sector, which AHIP represents, is not even close to achieving today.

While a large portion of the “collaboration problem” can be laid at the feet of this industry sector, in all fairness, payers are not completely to blame. Providers, while by and large well meaning, do have some in their ranks that are less so and unnecessarily drive up costs. On the consumer side, for far too long consumers have not been held responsible for taking better care of themselves. There is very little personal, consumer accountability in today’s healthcare system but that is changing, will need to change if we as a nation wish to truly grapple with the extremely serious issue that we can no longer afford the healthcare system (system used loosely as it is hard to call the US healthcare industry a system) that we have today. As one of the keynote presenters, economist Laura Tyson so eloquently put it:

We do not have a debt problem in the US economy, we have a healthcare problem.

Without deep, meaningful collaboration among all stakeholders the debt problem we face today will seem a mere pittance to what we will face in the future. Payers can play an extremely important role in that collaboration but they have some very hard work yet to do to establish trust in the market and then engagement. Based on what we heard and saw at this year’s AHIP Institute, payers are seriously behind in these efforts and at times almost seem oblivious to just how critical these efforts are to their very survival.

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Looking at Healthcare Through Payer Lenses: Part One

Attending the annual health insurers confab (AHIP Institute) last week gave one some insight as to the challenges this part of the healthcare industry is facing. There were plenty of sessions on addressing data analytics for everything from population health management to fraud, a number of other sessions on consumer engagement, disease management, health & wellness, and of course the ever ubiquitous sessions on Accountable Care Organizations (ACOs).

But what pervaded many a discussion, panel session, and even keynotes was the level of uncertainty in the market today. Though the Affordable Care Act (ACA) was passed and signed into law, its future is anything but certain. There is both legal and political uncertainty. Legal in the numerous lawsuits that have been filed, particularly regarding the individual mandate that will ultimately be a Supreme Court decision. Political in that numerous politicians and some presidential contenders have built a portion of their platform on repealing ACA. Such uncertainty makes it extremely difficult for payers and employers to effectively plan for the future. Regardless, there were a few key areas that seemed to attract the most attention: ACO, Consumer Engagement & HIX.

Following are some quick snapshots:

Accountable Care Organizations (ACOs): Plenty of talk on this subject, primarily from the consulting firms who seemed to have run most of the sessions at AHIP. Payers have been experimenting with the model for some time now, well in advance of CMS’s NPRM. In one session, Blue Shield of California (BS-CA) talked about their ACO with Catholic Healthcare West. A very challenging relationship that took 4 years to iron-out and stand-up the ACO and the only reason they kept at it: Calpers was supporting them with an enrollment of 40K new members and Kaiser-Permanente was beating the hell out of both of them in the market. More competitive necessity. This may foretell future attempts and challenges to move to this model. One other important point expressed many times over regarding ACO: data exchange is an ACO’s life-blood.

Consumer/Member Engagement: Numerous sessions drilled down on how payers will market to and serve their members in a deeper, more meaningful fashion but it all sounds just so superficial. Sure, payers are indeed trying to engage the consumer (marketing to new prospects via HIX – payers are really struggling here) and provide consumers with information they can use to make better “value” choices. There are also the ubiquitous efforts of payers to promote health & wellness and institute various disease management programs. Yet based on the sessions attended, seems more like a lot of hand waving and not convinced payers are seeing any meaningful traction in truly engaging their members.

Health Insurance Exchanges (HIX): In accordance with the ACA, a State must have its HIX operational by Jan. 2014. Each State in the country will have their own, slightly nuanced HIX to meet the needs of their citizens and in compliance with their laws. There is no commercial off the shelf (COTs) solution so each exchange will be a separate, custom build. The big winners here are consulting/system integrator (SI) firms (e.g., ACS, CSC, Deloitte, etc.) and they were out in force at this event. They are going to make a killing first standing up these HIXs and then of course keeping the HIX up and running over the years to come. The big challenge, however, is that these exchanges are slated to support Medicaid recipients and most States’ Medicaid IT infrastructures are so outdated that they need to be rebuilt. Even more $$$ to those SI/consulting firms.

What may have been the most bizarre aspect of this event was simply its isolation from the rest of the healthcare sector. This was a very insular event. There were no consumers/members giving presentations or keynotes on what they are looking for from this industry sector. There were few if any providers or representatives of provider organizations talking (either in sessions or keynotes) about what they were looking for from payers, how they wish to engage them, work together to improve health outcomes, improve the value of healthcare delivered.

All very, VERY strange.

If this sector of the healthcare industry is truly interested in improving the quality and value of healthcare delivered, it has its work cut out for them. In our next post we’ll delve into the three overarching challenges payers face with the coming changes brought about by ACA. Small hint, start with trust.

Addendum:

Consulting firm Perficient was also in attendance and wrote about the ACO issue as well that is worth a read.

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