Can the Consumer Choose Wisely in 2014?

By Clive Riddle, January 3, 2014

The just released January 2014 issue of Medical Home News includes a profile of Paul Keckley, PhD, in which he is asked this question: “Looking back on your years as a health care analyst, what has been this country’s major achievement and what has been its greatest disappointment in terms of health care delivery?” His answer: “Greatest disappointment: the consumer is ignorant about the health system, even after all the fuss for and against health reform. Greatest positive: data-driven healthcare!!”

In August 2013, Kaiser Family Foundation released new survey results that the Wall Street Journal summarized as:  Consumers Remain Baffled By Health Law, Poll Shows. At the end of the year, things got no better. Consider findings from a December 2013 Consumer Reports survey of consumers regarding the Affordable Care Act which found:

  • 38% of respondents indicated they felt LESS informed over the course of the past month.
  • 48% thought the ACA established a government-run health plan
  • 36% thought the new law allowed the government to control their selection of doctors
  • 30% believed the law set up government panels that would dictate decisions about end-of-life care
  • One-quarter or less of respondents correctly identified the above as false statements.

But Paul Keckley’s point wasn’t just that consumers are confused about reform – rather that they are confused about the entire system, in spite of reform. And there a plethora of survey results previously cited in mcolblog postings to back that up.

George Van Antwerp, in blogging his 2014 healthcare predictions, posts that “consumer engagement in healthcare will continue to be the elusive Holy Grail.”

It is difficult to engage someone who is confused, and ignorant about the system. The consumer might feel as if they are in the scene at the end of Indiana Jones and the Last Crusade, confronted with a hundred different goblets, with only one being the true Holy Grail, as they try to navigate their health choices, and fear that the Guardian of the Holy Grail won’t be telling them that they “have chosen wisely.”


Ten Trends to Ponder for 2014

By Clive Riddle, December 20, 2013

These aren’t necessarily the top ten trends for the coming year, because the ranking of trends depends on the position of the stakeholder – in other words – in the eye of the beholder.  But below are ten trends worth pondering as one positions oneself for the year ahead:

Private sector co-opting of public healthcare policy.  Consider a number of the trends discussed below. What they have in common – an overarching theme – is that the private sector has co-opted public healthcare policy, and may have achieved a greater impact than the public sector in doing so. The ACA begat Medicare ACOs – but the commercial ACO arrangements are generating a groundswell of activity. The ACA’s centerpiece is the public exchange launch of 2014, but the private sector is paying an awful lot of attention to private exchanges. Ten years ago, HSAs and High Deductible Plans were policy driven – now they are market driven. The Stimulus drove Meaningful Use, but now that it’s become meaningful, the private sector is leveraging what to do with this new framework.

Commercial ACO Collaborations become commonplace. Soon health plans and provider networks may stop issuing press releases with each new collaboration because they are so commonplace, they just aren’t news anymore. Unlike their Medicare counterparts that are standardized arrangements, the commercial collaborations are customized, any one might argue about how many of them meet the definition of a true Accountable Care arrangement. Or perhaps they will simply erode the definition to the point where we end up calling them something else.

Private Exchanges Exceed Expectations While Public Exchanges Fall Short.  While public exchanges can drive much bigger numbers due to sheer numbers of the uninsured and underinsured, and the availability of subsidies, 2014 will find the level of impact and implications falling short of expectations as not as many of these population opt-in as expected, at least for now. This will also mean the dire predictions of ongoing glitches and budget shortfalls may not be as bad as predicted, because there will be fewer numbers for now compared to initial rosy projections. Meanwhile, private exchanges may very well exceed initial expectations for enrollment and levels of interest as 2014 takes shape.

Defined Contribution Drives Private Exchanges.  Defined contribution health plan arrangements were the buzzwords at the dawn of this millennium, but got left aside in the rush to account based and high deductible health plans in the consumerism movement. But now the stars are aligning for the return of the prodigal defined contribution son, as the driver of how most private exchanges are designed, and the driver of private sector interest in 2014 and beyond.

Is Everyone in a High Deductible Plan? There a lots a surveys with varying reported levels of HDHP penetration in the commercial sector – but this much can be agreed upon – all the percentages keep trending up… and up. Unfortunately, the account based plans that were supposed to accompany the HDHPs are missing in many employer sponsored plans, or at least the employer contribution is. Never the less, the trend for HDHP growth will continue.

Innovation, Transformation and Integration are the Words of the Year.  Like the old 80’s episodes of Pee-Wee’s Playhouse, with the word of the day that set off buzzers, Innovation, Transformation and Integration are the words for 2014… although they will in many cases, be words but not action at this point in time. But if your organization doesn’t yet have a Chief Innovation, Chief Innovation or Chief Integration Officer, look for them in 2014.

EHR Tipping Point Drives Innovation. Of course lots of physician practices still don’t have EHR. And a number who do aren’t all that interoperable. But still, the point has been reached where there’s gobs of stuff you can do with the level of electronic data and transmission that is now being generated – and this is going to continue to stimulate a plethora of new applications and solutions in a range of environments.

Analytics Extends Its Reach.  Analytics has become huge for so many sectors – healthcare may actually be a laggard. But make no mistake – analytics is where the action is in healthcare for 2014 if there is any hope in taming the beast of operational inefficiencies, resource management, and explosive costs.

The Further Evolution of Population Health.  Ten years ago the definition of Population Health was commonly held to be “the health outcomes of a group of individuals, including the distribution of such outcomes within the group” and was more prevalent in policy and academic circles. 2014 finds the scope and role of population health expanding and evolving, with strong involvement from the private sector.

Consumer Engagement Just Needs More Consumers to Get Engaged. In 2014, we will see the tools are there – apps, websites, outreach programs, incentive programs, plan design, you-name-it. The challenge we find ourselves in for 2014, is a number of surveys continue to demonstrate that large blocks of consumers remain unengaged, uninformed and fairly clueless about the delivery or the business of healthcare.


Pwc Top Healthcare Issues in 2014

By Claire Thayer, December 12, 2013

This week, PwC’s Health Research Institute (HRI) released its annual report on their top health industry issues. Trending as HRI’s top 10 issues for 2014 are:

To explore all of these important issues, start here!  Want to learn more, these and other key trends and issues impacting the business of health care throughout 2014 will be discussed at the 12th Annual Future Care Web Summit, scheduled for January 23, 2014 – the webinar is at 1:00PM.


Humana’s Vipin Gopal on Advancing the Frontiers in Predictive Modeling

By Clive Riddle, December 10, 2013

Vipin Gopal, PhD, Vice President of Clinical Analytics for Humana gave the opening plenary presentation last week during the Seventh National Predictive Modeling Summit in Washington, DC, providing an excellent overview of the current and future state of predictive modeling in healthcare.

Vipin summarizes the state of predictive modeling from his and Humana’s perspective as follows:

  • They have seen rapid evolution as a discipline over the past decade
  • There is newer and better software, data sources, hardware
  • There are a lot more applications
  • They have a deeper understanding of their members
  • There are now more efficient and effective delivery mechanisms for model output
  • Predictive Modelers will make a broader and deeper impact for in the coming years

Vipin offers as advice, these guiding principles for organizations deploying predictive modeling functions:

  1. Establish a set of "quick wins" to drive early results and build momentum
  2. Show results to bolster the business case behind making further investments
  3. Focus on the issues that have the most direct impact on the business
  4. Ensure that effort is placed on key strategic issues and pressing challenges
  5. Address challenges with underlying data
  6. Clean and streamlined data is an enabler for the creation of more effective and comprehensive analytical models

Vipin advocates that leading-edge analytics should encompass these themes:

  • Focus: Are we solving the right problems?
  • Nimble: Rapid analytics to respond to business needs
  • Cutting-edge Methods: State-of-the-art problem solving
  • Tools: Leverage advancements in the analytics marketplace
  • Optimize: Maximize output of analytic resources
  • Integrate: Systems approach to data, analytics and action
  • Real-time: Closing the feedback loop with the most recent data

What are the key components of predictive modeling in healthcare, according to Vipin? Three things that should all work towards improved outcomes, high engagement and reduced costs: (1) Integration of Data,

Action, and Analytics; (2) Infrastructure incorporating Consistent, comprehensive datasets, Cutting edge analytic tools, and Deployment to action; and (3) Talent (predictive modeling staff and outsourced vendors.)

Vipin notes that past modeling work primarily relied on claims data, while current work aggregates multiple data sources to create an integrated view of the member for consistent and rapid analytics.

So where are we headed with data sources? Vipin reviewed these Next-Gen sources:

  • Text Based (EMR; Nurses’ Notes; Call Center Transcripts)
  • Devices (Remote monitoring, Smart Phones)
  • Online Data (Social Media Data, Web Footprint)

And where are we headed overall? Vipin sees a broad range of applications, including Clinical, Marketing, 

Financial, and Fraud Detection. He sees us mining deeper data sources, driven by a need to know our consumers better, while deploying more efficient delivery mechanisms that incorporate real-time alerts and mobile devices.  The “Holy Grail” in all of this? Vipin says it is predicting and influencing consumer behavior; and we need to do this in an environment in which there is a proliferation of models and we hopefully will simultaneously see efforts to have them work in unison!


MCOL Blog | Fraud, Waste & Abuse Continuum in Healthcare

By Claire Thayer, December 6 , 2013

This week, Verisk Health posted a blog that identifies these three specific opportunities to help control costs and eliminate fraud, waste and abuse in healthcare:

  1. Tracking Durable Medical Equipment (DME)
  2. Assessing Lab National Coverage Determinations
  3. Improving Payment Accuracy on Modifiers 59 and 25

There's an interesting supportive infographic on the Verisk Health site that shows fraud, waste and abuse existing on a continuum and the level of intent a provider has to deceive – here’s a screen shot identifying the behaviors within the FWA continuum:

More details on these payment accuracy solutions are here.

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