Entries in Trends & Strategies (102)


The State of the Uninsured and Health Insurance Coverage

The State of the Uninsured and Health Insurance Coverage

by Clive Riddle, February 23, 2018


The National Center for Health Statistics has just released updated health insurance coverage estimates from selected states using 2017 National Health Interview Survey data.  Here are seven things to know about their findings for the first 9 months of 2017:


1.     28.9 million (9.0%) persons of all ages were uninsured, not significantly different from 2016, but 19.7 million fewer persons than in 2010.

2.     12.7% of adults aged 18–64, were uninsured, 19.5% had public coverage, and 69.3% had private health insurance coverage.

3.     4.4%  of adults aged 18–64 (8.6 million) covered by private health insurance plans obtained their coverage through the federal or state-based exchanges.

4.     Adults aged 25–34 were almost twice as likely as adults aged 45–64 to lack health insurance coverage (17.3% compared with 9.2%)

5.     4.9%  of children aged 0–17 years, were uninsured, 41.9% had public coverage, and 54.6% had private health insurance coverage.

6.     The percentage uninsured decreased significantly for all age groups from 2013 through the first 9 months of 2017, ranging from –6.2 percentage points for ages 45–64 to –10.7 percentage points for ages 18–24.

7.     43.2% of persons under age 65 with private health insurance were enrolled in a high-deductible health plan (HDHP) compared to 39.4% in 2016


However, as a warning sign that 2018 may see slippage in these insurance coverage, the Minnesota Department of Health just issued an ominous press release, indicating that “last year Minnesota saw one of its largest, one-time increases in the rate of people without health insurance since 2001. The uninsured rate rose from 4.3 percent in 2015 to 6.3 percent, leaving approximately 349,000 Minnesotans without coverage.”

It's About Time

It's About Time

By Kim Bellard, February 16, 2018


Chances are, the sun isn't directly overhead for you when it is for me.  That's why for most of human existence time was a local matter.

Nowadays, we have time zones that span the globe, and we have clocks so accurate that satellites have to 
take into account relativistic time-dilation effects. Technology made the change possible, and necessary. 

Health care should learn from this.


It used to be that local time was good enough.  The village clock served your purposes.  It was the railroads that made this impractical.  People wanted to know when trains would arrive, and when they'd leave.  More importantly, if they weren't coordinated, trains traveling in different directions might -- and did -- run into each other.

We treat health care much like we used to treat time. That is, it is largely local.  How it is practiced in one community may not be how it is practiced in the next community, or even the next hospital or physician practice within a community. . 

The care you get will depend on, of course, what is wrong with you, but also on 
which physician you see.  Very few dispute that there is significant variation in care, or that it is probably bigger than it should be.  But there's not much evidence that it is getting any less. 

We accept these variations because, well, that's how it has always been.  We accept them because we think our personal situation is unique.  We accept them because we trust our local experts.   

We accept them for all the same reasons we used to accept that time should be local. Technology has made it both necessary and possible that we move away from this attitude.

It is necessary because the scope of the problem is clear.  As Propublica put it in a 
recent expose of unnecessary procedures: "Wasted spending isn’t hard to find once researchers — and reporters — look for it." 


Almost twenty years ago the Institute of Medicine estimated as many as 98,000 hospital deaths annually due to medical errors.   More recently, medical errors have been estimated to be the third leading cause of death in the U.S. 

Yes, moving away from "local" health care is necessary.

The good news is that it is possible.  We have the technology to consult with physicians who don't happen to be local, such as through telemedicine.  It is possible to get the "best" doctor for our needs, not just the closest. We have artificial intelligence that can analyze all that data plus all those medical studies that no human can possibly keep up with.  It is possible to come up with the "right" recommendations for us.   

We have to stop thinking of health care as local.  The information it is based on is not.  The people who are best able to apply that information to our situation may not be.

If I get a driver's license, I don't have to get another one when I drive to another state.  If I get on a plane, the pilot doesn't have to have a pilot's license from each state he/she lands in, or flies over.  But if I want to use a doctor who is in a different state (or country), that doctor needs a license from my state.    

We've always justified such licensing by states wanting to ensure the safety of their citizens, but drivers and pilots can put those citizens at risk too.  It's not really about risk; it's 
more about controlling competition

There is irrefutable evidence that local health care is rarely what is going to be best.  It might not be bad care, but most likely it's only going to be average. 

Maybe we're willing to settle for that.  I'm not.

Time for a change.


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


AmazonBerkshireJP Healthcare: Think About Kaiser

AmazonBerkshireJP Healthcare: Think About Kaiser

By Clive Riddle, February 1, 2018


After Amazon, Berkshire Hathaway and JPMorgan Chase issued their press release this week regarding their employer based healthcare partnership, healthcare stock portfolios went into a tailspin and a lot of smart people have had something to say about what this venture might become. But where there is consensus is that what we do know is what we don’t know, as right know the venture is a dot to dot healthcare coloring book where no lines have been connected yet and we haven’t even been issued our crayons.


The press release, while void of details, espouses technology solutions. Learned speculation surrounds their replacing PBMs, going whole hog into self-insurance, promoting telemedicine and much more.

The New York Times quotes Segal Group’s Ed Kaplan: “Those are three big players, and I think if they get into health care insurance or the health care coverage space they are going to make a big impact.”


Paul Demko in Politico writes that Amazon's new health care business could shake up industry after others have failed. But while citing some optimism, he also reports that ““ ‘We’ve seen these deals before,’ said Sam Glick, a partner in the health and life sciences division at Oliver Wyman. He cited Walmart and Intel as two companies that have sought to provide health care for employees while cutting out the insurance middleman. ‘It’s not news that jumbo employers are frustrated with escalating costs and lousy experiences in the health care system.’ “


A great tweet from Yale Health Economist Zach Cooper tells us "I do hope Amazon, JP Morgan, & Berkshire succeed. Health care is wildly inefficient However, it’s a bit like Mayo Clinic, Cleveland Clinic, and Partners Health coming out and saying they don’t like their computers so they’re going to form a new IT company."


An Axios post by Sam Baker cautions “A new health care behemoth? Not so fast.” He reminds us “We don't know what they're even trying to do” and that “other big companies have tried something similar.”


While like Sam Glick, we can point to less than stellar results from a number of other corporate forays into this arena, if we peek further back into time, we can also point to Kaiser, whom Sam Baker mentions in his post.


Let’s take the wayback machine to 80 years ago: In 1933, Sidney Garfield MD establishes prepaid plan to fund care for his Contractors General Hospital and clinic providing care to workers on the Los Angeles Aqueduct. In 1938 Henry J Kaiser recruits Dr. Garfield to establish prepaid clinic and hospital care for his Grand Coulee Dam project in Washington. In 1942, at the request of Henry Kaiser, Dr. Garfield expands program to Kaiser-managed shipyards and Kaiser’s steel mill. In 1945, Permanente Health Plans opens to the public in California, in addition to serving Kaiser employees.


Kaiser and their clinically integrated health care is often cited now as an example of a better system than much of the rest of American healthcare. Perhaps Amazon et al should take a long look at the Kaiser experience, and consider directly providing some levels of care enhanced by technology, instead of just relying on technology alone.


Everything in Healthcare Is Design

By Kim Bellard, January 27, 2018

I've been thinking a lot about health and communities lately. But I keep coming back to Dr. Bon Ku is doing at JeffDESIGN.

I am somewhat late to this game.  Dr. Ku co-founded JeffDESIGN three years ago, as a "college within a college".  Since then it has received local, regional, and national attention.  Dr. Ku has done a TEDx talk on their efforts.  So I'm not exactly breaking new ground here.

More importantly, though, they are.

Basically, the goal of JeffDESIGN is to teach medical students "to apply design thinking to solve healthcare challenges." As obvious as that might seem, they believe it is the first such program in a medical school.

Their Health Design Lab is located in a former bank vault.  It looks more like a start-up than a medical school classroom, full of configurable tables, computers, whiteboards, even 3D printers. 

Students get to take on actual problems in the healthcare system, develop solutions, prototype them, and perhaps see them put into use.  Dr. Pugliese told NextCity:  "These kids are all going to graduate as physicians, and they’re going to have a whole new language that nobody who’s ever graduated from a med school has had before."

That's pretty cool.

Dr. Ku is by training an ER physician, and his experiences there shaped his views of the broader forces impacting health.  And, remember, this program -- and, presumably, this point-of-view -- is unique among medical schools.  It shouldn't be.

We simply don't think enough about design in healthcare.  Not the right designs, for the right reasons.  In a a podcast for Knowledge@Wharton, Dr. Ku complained that:

We settle for design mediocrity, like I said. When we design hospitals, we should want to design the best and most beautiful building which happens to be a hospital, but instead, we design mediocre buildings.

He went so far as to say: "most of us don't realize that everything in health care is design."

Think about that:  Everything. In. Health.  Care. Is. Design.

The problem that JeffDESIGN has, through no fault of its own, is that even if all physicians were similarly trained, physicians can't change everything that needs to be redesigned (or, as some would say, actually designed) -- not in healthcare and certainly not in our society. The problems go much deeper.

Too many designers are designing only within their bubble, and no matter how well designed that bubble is, all-too-often they don't think enough about how their bubble overlaps with the others.  Our health is impacted by everything we touch and interact with, and many of those interactions are not designed with our health in mind.  

Design thinking in healthcare isn't about making the process of getting medical care easier, although it should do that too.  Design thinking in healthcare should be about making the process of being healthy easier.  That's a much taller order of magnitude, and that's what Steve Downs meant by wanting to build health into the "operating system" of our daily lives.  

Dr. Ku would agree: you don't have to be trained as a designer to use design thinking.  Dr. Ku boils it down: "I think at the core of human-centered design or design thinking is deep empathy for the end user.”

Certainly anyone working in or around healthcare should have that.

Patients aren't the end users.  People are.  Care is not the end result.  Health is.  Let's design for them and for that.  If you don't have that kind of empathy, maybe you should be doing something else.

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


Ten Large Objects on the Highway to Healthcare in 2018

By Clive Riddle, January 5, 2018

We find ourselves suddenly situated in 2018. How did that happen? Where did 2017 go, and for that matter, 2016 and its younger siblings? A Meat Loaf ballad once lyricized how Objects in the Rear View Mirror Appear Closer Than They Are. With apologies to AC/DC - on the highway to healthcare, here are ten large objects that demand our attention to stay focused on the road ahead and not in that fabled rear view mirror:

Merger Mania

In 2015 three health plan mega mergers were hatched, but only the Centene-HealthNet one made it out of the nest, and no other mega deals immediately followed suit. Will the late 2017 CVS-Aetna and hospital mergers such as CHI-Dignity signal more major activity in 2018, such as the rumored St. Joseph-Ascension merger? The answer should be a big yes for hospitals and other providers. In the health plan arena, look for additional players to pursue out of the box approaches such as CVS-Aetna (see below.)

CVS/Aetna and Multi-Level Integration

CVS will become a distribution center for applicable Aetna products. Aetna will become a distribution system for CVS products. CVS will further build upon its base retail clinics to become a direct care delivery system for Aetna. It’s a different kind of integrated delivery system than traditional hospital-medical group-health plan integrated systems, but integration it is, all the same, at multiple levels.

Amazon and the Decline of Retail Pharmacies

Especially coming off the holiday season, we read reports on the continuing rise of online shopping and decline of brick and mortar retail. Mail order pharmacy has been around for decades but has been focused on maintenance meds. Now that Amazon has mastered rapid on-demand delivery and has filed for pharmacy licenses in various states, and can deliver the other non-prescription products typically purchased at retail pharmacies – the rush is on. Major retail pharmacies will try mightily to enhance their own online offerings or partnerships.

Consumer Embrace of Technology

Private practice physicians aren’t so wild about the demands of EHR, and are skeptical at times about all things new bright and shiny, but numerous surveys indicate consumers are enthusiastic about the range of advances in healthcare technology that touch them. Consumers have plenty to be grumpy about in healthcare – but their embrace of technology will continue to drive demand for telehealth, e-visits, apps, portals, wearables, and new treatment options.

Searching For Value in Value Based Care

In the business of healthcare, we love to give birth to innovative approaches in healthcare delivery and payment arrangements, and after a honeymoon period, we tend to eat our own. Studies are published that indicate the new approach doesn’t deliver on results. A chorus of naysayers rises. And then we rightly or wrongly move on to something else. Health Affairs recently published a study concluding that Medicare ACO program savings were more the result of patient selection than care efficiencies. Other studies have begun to question various value based care arrangements. Given the growing popularity of value based care, and the intrinsic notion that the proposition makes sense, there is much at stake for value based stakeholders to continue to demonstrate the true value in their arrangements.

All Things Healthcare CyberSecurity

Hackers are as plentiful and resilient as crabgrass. Healthcare provides fertile hacking ground. The challenges in cybersecurity will grow larger, not smaller in 2018. More data breaches, and ransomware and other intrusions will occur and disrupt. A greater portion of healthcare resources will have to be deployed from every budget.

Deploying Social Determinants of Health

SDOH has been around for some time, but in 2018 it will be put into practice for population health initiatives by healthcare organizations and health plans on a significantly wider scale, driven by analytics and innovative new approaches.

Ho-Hum Impact of Trump Health Insurance Reforms

Moving insurance plans offerings across state lines and promoting association health plans won’t make much of a dent in the individual health insurance market in 2018. Don’t count on these initiatives to drive much business.

The Certainty of Uncertainty

Uncertainly was the word of the year in 2017 as the ACA teetered on a year-long tightrope. The tax reform individual mandate axe further muddies the water, as well as threatened Medicaid funding and more in 2018, but then there are the November 2018 elections, and who knows what that will bring.

Fulfilling the Promise of Analytics

SDOH is just one of a spectrum of initiatives that analytics is driving that wouldn’t have been feasible in their current form earlier this decade. Analytics is helping to shape solutions for the Opioid crisis, healthcare identify management, and interventions throughout population health, readmissions management, complex case management, to name a few. Serious analytics requires no small sum of resources and scale, but the returns are mounting and will bear even more fruit in 2018.