Your Healthcare Lexicon for 2015 from A to Z

by Clive Riddle, January 9, 2015

Accountable Care Arrangements in Medicare, Commercial and Medicaid flavors

Big Data in healthcare parsed with Analytics

Collaboration between providers and purchasers

Deductibles loom large with continually increased consumer cost sharing

Engagement by purchasers with consumers and with providers

Federally Facilitated Marketplaces may or may not be able to provide future subsidies (see “K” & “S”)

Generic Drug prices are on the rise

Health Insurance Exchanges (Marketplaces) both public and private

Innovation Officers abound in health systems trying to transform how they do business

June is when we should find out what SCOTUS has to say about the next item (see “K”)

King vs. Burwell looms large on the Supreme Court docket

Long Term Care continues to be largely ignored while boomers age away

mHealth technology advances on all fronts

Narrow Networks are being deployed in Exchanges and elsewhere

Obamacare somehow remains the politically charged umbrella term for all things Affordable Care Act

Population Health Management has been embraced in the mainstream of plans and health systems

Quality Measures are being transformed with advances in analytics and reporting capabilities

Republican control of Congress ensures continued chipping away at the Affordable Care Act

Subsidies for public exchange enrollment are threatened (see “F”, “K” and “R”)

Tax Filings now require healthcare coverage information,

Uninsured are the topic of conversations of health plan marketing departments and political pundits

Value Based Purchasing is being sought by almost every purchaser

Wellness Programs for employers are being significantly scrutinized for effectiveness

X-Prizes in healthcare are on the rise with Innovation initiatives (see “I”)

Young Invincibles reluctant to signup for healthcare coverage (see “U”)

Zebras – may be easier to find in healthcare with advances in Big Data and analytics (see “B”)


The Convenience Truth

By Kim Bellard, December 17, 2014

The U.S. Mint reports that it now costs 1.7 cents to make a penny; nickels are slightly better, costing "only" 8 cents to make the 5 cent coin.  This is economics the way health care practices it.

According to Christopher Ingraham of the Washington Post, we could save $100 million annually by eliminating both coins.  Or we could change the metal composition to make them cheaper, but that would create havoc with vending machines.  So we just blithely chug along, mostly because we've always had them and the businesses that revolve around them don't want to change.

See how this is like health care?

What made me think about this was a recommendation from Britain's National Institute of Health and Care Excellence (NICE).   They now say that midwife-led birthing units are safest, and advised more women to consider them for low risk pregnancies.  They believe this could account for as many as 45% of live births.  Moreover, they think home births are just as safe as births in a hospital.  The Netherlands is considered the leader in home births, at a little under 25%.  The U.S. has 1.36% home births.

The literature -- often drawn on Netherland's data -- generally supports the NICE recommendation, but not everyone is convinced. It would be very easy to weigh all the factors, and conclude that even a relatively small increase in risk is not something you'd want to take for your own baby, and opt for the "traditional" OB/hospital delivery.

This is where the penny analogy starts to really apply.  These decisions on risk reduction are not without financial consequence.  A vaginal delivery with no complications averages about $10,000, whereas a birthing center costs under $2,500, according to Childbirth Connection.  I assume home delivery is less expensive.

In a piece for The New York Times, professor/physician Aaron Carroll notes that the ACA-created Patient Centered Outcomes Research Center is explicitly prohibited from considering cost effectiveness.  Its website says: "We don’t consider cost effectiveness to be an outcome of direct importance to patients."


In theory, value-based purchasing will help us address these decisions.  In practice, though, most of the value-based purchasing arrangements I am aware of -- and that certainly is not an exhaustive list -- reward providers whose outcomes are simply what we'd hope for, may penalize them slightly for disappointing results, and are indifferent about if the care could have safely been done elsewhere for less.

I'm beginning to think that trying to reshape our health care system through value-based purchasing, cost-effectiveness, or even greater transparency may not work.  The "killer app" may not prove to be any of those high-minded strategies but rather a much more basic one: convenience.

Indeed, one of the earliest urgent care chains attributes its inspiration to the example of McDonald's.  We are, after all, the nation that invented fast-food, decided even that wasn't fast enough and so invented drive-throughs, which we use for over half of our fast food.  We liked the convenience of them so much that we've extended the approach to banks, car washes, pharmacies, even weddings and  funeral homes.  The concept of drive-throughs itself is rapidly being supplemented and even superseded by mobile apps, allowing consumers not to even have to get in their car.

Health care cannot ignore these consumer demands for more convenience.

Walgreens' chief medical officer recently noted that: "The idea of convenience ... is really becoming a dominant theme in health care."  It's no coincidence that Walgreens has been investing in in-store clinics, has a 24/7 Pharmacy Chat option, and just rolled out a direct-to-consumer physician virtual visit app, similar to American Well's Amwell service.  Not to be topped, Kaiser is now offering EMT home visits, in addition to its array of in-office and virtual visit options.

Our traditional approaches to care delivery have revolved around convenience for the providers, not the consumers.  Many consumers, especially younger ones, find ridiculous the notion that they have to call for an appointment that may end up weeks away, go to an office or facility that may not be close, only to wait there with sick people, and perhaps be sent to some other office or facility for more services.  They'd rather get their care via their mobile devices and/or in their home, and the technology is increasingly allowing that for many health concerns.  

We've come to recognize that health care is one of the few industries where technology typically not only doesn't lower costs but usually adds to them.  Maybe, though, expecting providers whose revenue is at stake to focus on cost-effectiveness is asking too much of them.  Focusing on convenience shouldn't be.

Focusing on convenience is simply a way to make sure we're focusing on the consumer (AKA "patient").  Isn't that supposed to be the point?

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting


Pitfalls with Health Care Provider Data

By Claire Thayer, December 11, 2014

A U.S. Senate Committee investigation report finds that Medicare paid 478,500 claims attributed to deceased physicians, totaling up to $92 million, from 2000 to 2007. The U.S. Postal Service reports that at least 25-30% of the demographic and contact information for health care providers changes every year. The cost of bad or outdated provider data is estimated at $26 billion annually. These and other data points are featured in MCOL’s infoGraphoid this week:

MCOL’s weekly infoGraphoid is a benefit for MCOL Basic members and released each Wednesday as part of the MCOL Daily Factoid e-newsletter distribution service – find out more here.


The Age of Discontinuity

By Cathy Eddy, December 8, 2014

Newt Gingrich and David Nash

On December 2, I was invited to be on a panel at a Health Care Executive Forum in Washington DC that was sponsored by the Academy of Managed Care Pharmacy. David Nash, MD, MBA, dean of the Jefferson School of Population Health facilitated discussions about:

  • Population Health and the Insurance Marketplace (my panel) 
  • Narrow Network vs Value Network: Where’s the Greater Value? 
  • Specialty Pharmacy & Biosimilars: Improving Population Health?  

One of the most interesting aspects of the day-long discussion was the morning keynote by the Honorable Newt Gingrich, the author of the Contract for America and Speaker of the House when the Republicans took both the House and the Senate in 1994 – a political point in time that parallels the recent 2014 election.

He referred to one of his mentors Peter Drucker and a book he wrote in 1968 called “The Age of Discontinuity.”  I’ve read some of Drucker’s work and always found it to be very insightful, but I hadn’t heard about this book, so I looked it up and found this summary:

Drucker begins by examining four major areas of obvious discontinuity:

  1. The explosion of new technology and its resultant new technology 
  2. The development of knowledge as a result of mass education and its impact on work, life, leisure and leadership
  3. The social and political realities of the new industries
  4. The change from an inter-nation economy to a world economy. 

He was writing this in a time before cable TV, the internet, cell phones or the fall of the Berlin Wall. But I do remember 1968 as a year of political unrest in this country.

However, Drucker's framework for discontinuity is very relevant today and especially to the challenges that are facing the health care industry. Here are some of my take-away perspectives from the discussion we had in DC:

  • We are trying to leverage and integrate multiple forms of technology as part of our approach to care. The smart phone, which is with people now 24/7, will become the monitoring and informational tool of choice in the future.
  • As healthcare pushes the “consumer” to become more self-governing, the value of information as a driver of behavior continues to grow, while at the same time the expectation is for more services, but at a lessor cost.
  • ACA – what happens next? The direction and degree to which the new Congress can change the current health care law is uncertain. The impact of a Supreme Court decision on subsidies can impact millions on the exchanges run by 
  • How will the instability of the rest of the world impact the US economy and spending demands, while an increasingly large portion of the federal budget is going toward healthcare expenditures?

Although it is clear that healthcare has the attention of leaders in business, state government, Congress and the Supreme Court, it is as yet unclear how that attention will change our industry in the future.

The health insurance industry by definition manages risk, but in this “Age of Discontinuity,” it is hard to plan for some of the risks that are coming our way. Hold on - 2015 looks to be an interesting year.


What’s In a Name?

By Clive Riddle, December 3, 2014

Wellpoint is now Anthem. The re-titling of the national health benefits company was publicly announced months ago, the new corporate website has been designated as, and the change from the New York Stock Exchange ticker from WLP to ANTM became effective today.  

WellPoint Health Networks and Anthem merged in 2004, with WellPoint assuming the corporate name of the merged company. Why the name change back to Anthem ten years later? It’s mostly about branding. Joseph Swedish, Anthem’s President and CEO tells us “the change to Anthem will help us better communicate our values and simplify the way we connect with our associates, consumers, investors, and the communities we call home.” Simply put, the company has lots of products around the nation branded as Anthem. They have none branded as WellPoint.

So why did they take the WellPoint name in the first place? Branding may have been less the issue at the time than negotiations between two large BBCBS for-profit corporations. The corporate headquarters went to Anthem’s Indianapolis, but with the WellPoint name. WellPoint’s Leonard Schaeffer got the title Chairman of the Board; Anthem’s Larry Glasscock took the title President and CEO. A telling sign of the shifts in competing corporate cultures and recognition of the branding issue would have been in 2009 when the flagship from the WellPoint camp, Blue Cross of California, assumed the trade name Anthem Blue Cross.

The era of corporate names that are independent of the subsidiary divisions and products seems to have faded as branding is deemed more essential.

As we dig around through the graveyard of bygone healthcare names, the branding issue is forever complicated by mergers, acquisitions, spinoffs and scandals. 

Humana once was a hospital company that developed a health plan division, back when corporate integration of healthcare was in vogue in the 1980’s, before falling out of favor in the 1990’s and re-discovered this decade. Humana’s hospital division was spun off as Galen Healthcare, which was acquired by Columbia, which merged with HCA to become Columbia/HCA, and finally just HCA (Hospital Corporation of America), partially to simplify branding, and perhaps more to re-brand away from the Columbia identity after a Medicare fraud scandal in 1997.

Tenet was once National Medical Enterprises, becoming Tenet in 1995 partly to re-brand after large acquisitions, but motivated to distance from the NME name after scandals with NME’s Psychiatric hospitals division.

In New York, Group Health Inc. and Health Insurance Plan of New York merged in 2006, under the corporate name EmblemHealth. Eventually, the corporate name became branded as a product name. Such strategies - to deploy the corporate name in branding - have become much more prevalent during this decade.

But then there is Regence, the Pacific Northwest BCBS company who in 2011 announced their new corporate name would be Cambia Health Solutions, while the health plan products are still branded Regence.  So what’s in a name – and in 2024 will Cambia pull a WellPoint and re-title themselves as Regence?

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