Like many Americans, I have been covered by employer-sponsored health plans for the entirety of my professional career. As such, the open enrollment period that has garnered so many headlines over the last few years has conversely been of little concern to me.

health-maze1That changed this fall when, for a variety of reasons, it was time for me to shop for an individual health insurance plan for 2017. “I’m young(ish), I’m very healthy, and I know the healthcare industry pretty well,” I said to myself months ago. “How complicated can this really be?”

Very much so, it turns out. Here’s a synopsis of the time and effort I put into choosing a health plan for 2017.

July: Emailed a friend who’s an independent contractor to ask for advice. He offered shopping suggestions and also forwarded some general price quotes. Forcibly removed jaw from floor after seeing the cost of the plans’ monthly premiums.

October: Read a primer on off-exchange and small-group market plans. Decided that “metal distribution,” in addition to describing the availability of on- vs. off-market ACA-compliant plans, would be a good name for a used record store.

Nov. 1: Logged onto MA Health Connector, the Commonwealth’s health insurance exchange (HIX), to get insurance quote. Discovered that I could not compare more than 3 plans at a time, which seemed counterproductive to the whole “it’s best to shop around” mantra of open enrollment. Also looked at the site’s Provider Directory to see if my PCP was covered, and the names of the plans in the directory did not match the names of the plans on the exchange. Sighed, then logged off.

Nov. 1: MA Health Connector sent a snail mail letter indicating that I qualify for coverage starting Jan. 1, 2017 but can only enroll if I had had a qualifying event – which is just plain wrong. Signed and ignored letter.

Nov. 4: Read another article about shopping for your own health insurance plan. Didn’t learn anything, unfortunately.

Nov. 4: Called current insurer to inquire about 2017 plans. After 15 minutes on hold, was told to go online even though the website said, in big letters, to call if you are a current member and you want to inquire about plans. Punched in my information, got some specifics about four plans available to me, and printed out a spreadsheet.

Nov 7: Emailed my accountant to ask about the tax deduction for individual health insurance plans. Only thought to do this after a conversation with a second friend with experience buying individual plans – ones much more complicated than mine, it turns out. Received news from my accountant that alleviated the sticker shock for the monthly premiums I faced.

Nov. 8: Went back to MA Health Connector to compare plans available there to plans available from current insurer – three at a time, of course – and started making a digital spreadsheet. Noticed that the Provider Directory was now up to date. Enlisted the help of a third friend who knows how to write formulas in spreadsheets so that I could project 2017 out-of-pocket costs for various health plans, taking into consideration if nothing happens at all, if I need to visit the ER, or if I need to go through physical therapy after hurting myself in a marathon. (Again.)

Nov. 19: Departed for a three-week vacation to New Zealand. This trip had been scheduled months in advance and was unrelated to the stress of researching insurance plans. (Mostly.)

Dec. 8: MA Health Connector sent a snail mail letter correcting the error it had made five weeks before to tell me that yes, in fact, it is open enrollment time, but I only have until Dec. 23 to enroll for coverage starting Jan. 1. Laughed, ignored the letter again, and wondered how much it cost MA Health Connector to print and mail both letters.

Dec. 14 and 15: Tried to purchase a plan, as the jet lag had finally worn off, only to discover that the MA Health Connector site was down. The next day, I saw a strange error when I logged in. I complained on Twitter and, to the MA Health Connector’s credit, received a quick response. (Darn browser cache.) Bought health and dental insurance. Pumped fist.

Dec. 21: Received two email reminders – one from the state, one from the insurer – to pay my bill. Did that, as it sounded like a good idea. Hadn’t paid right away because the site needed four hours to process my application before it could accept payment, and by then I was halfway through my celebratory dinner.

confused-300x199Dec. 22 and 23: Received one phone call to pay my bill, as well as two snail mail copies of my bill (one for health insurance, one for dental). Sighed and added the paperwork to the growing pile.

All told, I needed the help of three friends, one accountant, a spreadsheet, and tech support to choose a health plan for 2017. Meanwhile, one phone call to my 2016 insurer and two letters from my state HIX offered little reassurance and no help. All this for a plan I likely will not keep in 2018. But hey, at least the process built character, right?

A microcosm of a much larger problem

As healthcare enters its next and must uncertain phase of reform, the refrain of giving consumers more choice – in how (if at all) they are insured, where they receive care, and how they pay for that care, among other things – will likely ring louder than ever.

For choice to truly work, consumers need clear, concise information about what insurance (as well as care) will cost, along with professional assistance in deciding what is necessary, optional, or frivolous. My open enrollment experience demonstrates that, to date, none of this is readily available to even an informed consumer.

Choice in healthcare is helpful, and long overdue, but the industry’s efforts to empower consumers to make informed choices have been inadequate to the point of irresponsible. Improved price transparency, digital health services for comparison shopping, and better access to less expensive and more convenient care venues all remain the exception to the rule of monolithic care delivered in a fee-for-service system that makes more money when consumers don’t know their choices.

As I wrote in my first blog post for Chilmark Research roughly 18 months ago, healthcare reform has given consumers more sticks than carrots. In the short term, forcing consumers to make healthcare choices that others previously made on their behalf will only bring more sticks. Whether there are carrots on the end will depend on whether consumers have been empowered to make informed choices.

Stay up to the minute.

Supreme Court Upholds ACA Subsidies; Can We Move On Now?

Seal of the Supreme Court of the United StatesIn a 6-3 ruling this morning, the Supreme Court affirmed the legality of Affordable Care Act’s subsidized health insurance plans sold on The Court rejected the argument of the plaintiffs in King v. Burwell, who argued that the phrase “through an exchange established by the State” meant that subsidized insurance could only be offered through a state exchange.

“Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them,” Chief Justice John Roberts wrote for the majority. “If at all possible, we must interpret the Act in a way that is consistent with the former, and avoids the latter.”

The ruling represents a victory for the Obama administration and a defeat for Congressional Republicans, who have devoted considerable energy to their efforts to repeal the ACA. There are several other winners, too:

  • More than 6 million Americans no longer face the prospect of trying to pay for unsubsidized insurance. (The vast majority of those who purchased insurance on the federal and state exchanges qualified for tax credits.)
  • Health insurers won’t have to scramble to re-submit 2016 rates for ACA plans, which would have been the case if the Supreme Court ruled in favor of the plaintiffs.
  • The 34 states that declined to run their own health insurance exchange don’t face the politically difficult proposition of either spending millions of dollars to build an exchange or leaving residents without insurance subsidies.

There is now no doubt that the ACA train isn’t coming back to the station. Yes, the medical device tax faces repeal, and the “Cadillac tax” on high-priced plans may be next. Yes, Medicaid expansion seems to have hit a wall, with the two states that would most benefit (Florida and Texas) adamantly refusing to budge. Yes, the tax penalty for not being insured is still far too low to compel many “invincibles” to spend thousands on a health plan. Yes, and state exchanges could learn some lessons in user experience and basic website design.

However, for all its hiccups and challenges, the ACA is working. Among adults, the uninsured rate stands at an unprecedented 10.1 percent, according to the Urban Institute. The percentage of adults without insurance is even lower in the 30 states (plus the District of Columbia) that have expanded Medicaid. All told, an estimated 15 million Americans have obtained insurance thanks to the ACA since September 2013. And now the Supreme Court has upheld subsidized coverage.

Regulatory and legislative uncertainty will always loom over healthcare. The ACA will face additional challenges in the courts, in Congress, and on the 2016 presidential campaign trail. Additional aspects of reform and progress – shared savings, accountable care, meaningful use, and telehealth, to name four – will have to run in place until concrete guidance emerges from the Department of Health and Human Services. With today’s Supreme Court decision, though, one of the biggest clouds over the industry has lifted, and healthcare organizations can focus on their mission of delivering quality, efficient care with a bit less trepidation.

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 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.


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.


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