Healthcare

It seems that there are many in the general public who feel that universal health care will answer all the cumulative issues which has caused the current state of health care crisis in America today.  However, before anyone rushes into a “cure all” solution, there needs to be an understanding what universal healthcare is, how it will work for America, and further debate as to whether universal healthcare really is the right answer or if there are better ways for the government to spend taxpayer money towards a different kind of healthcare model.

First at a macro level, let us define what universal healthcare is, as there are several different models.  One model is where the government owns and maintains a national health program similar to what you might see in Canada or England.  Other models, which include having a choice of health insurance carriers, are also something which can be considered, such as what the US is using today for Medicare Advantage programs.

At a more micro level other considerations to universal healthcare need to include membership and premiums, benefit structure, access to care, reimbursement for services received and quality of care initiatives.

Membership and premiums:  How is the cut-off for membership defined and who will pay what?  As George Will pointed out on 06.14.2009 ABC’s “This Week”:
WILL: Donna [Brazile], you talk about the 46, 47 million uninsured. Fourteen million of them are already eligible for other government programs and haven’t signed up. Ten million are in households with household incomes of $75,000 a year and could afford it if they wanted to. Furthermore, an enormous number in that 47 million are not American citizens. Sixty percent of the uninsured in San Francisco are not citizens.

The media throwing around a number of uninsured is not substantiated nor validated.  One of the first things needed to be done is to determine who needs health insurance, who are they (citizen or non-citizen) and what type of premium structure needs to be put in place?  Is the government willing to suggest that everyone living in the US be entitled to subsidized healthcare?

Benefit structure:   The benefit plans offered by private insurances varies from carrier to carrier.  It is one of the differentiators and marketing tools that private insurers use. In addition each state has a list of mandates as to what must be included as part of the base coverage.  According to the Council for Affordable Health Insurance (CAHI), by the late 1960s, state legislatures had passed only a handful of mandated benefits; today, CAHI has identified more than 1,900 mandated benefits which in many cases unnecessarily impact the cost of care.
Most people do not equate buying health insurance to car insurance, but in many ways it is very similar.  The more benefits you want to add to your car insurance, the more it is going to cost.  The same is true of healthcare insurance, regardless who is underwriting the policy; be it a private carrier or the government.  Having universal healthcare will not necessarily mean having unlimited benefits.  Medicare, for example, just started covering prescriptions drug (and not at 100% either, but with a very large “doughnut hole”).

Access to care:  For most people with either private or public insurance, access to doctors and care is pretty straight forward.  They call their family doctor or specialist and are able to get an appointment within a reasonable timeframe.  One of the biggest arguments against universal care is that it will lead to rationing of care, which is a debatable point.  However, one thing that universal care will need to define is the number of primary care physicians to specialists.  In the US today the number of primary care physicians to 100,000 people is approximately 90 whereas the number of specialists to 100,000 people is 189 .  Another way to look at this is: In the US, the ratio of PCPs to specialists runs about 30/70, while in other developed countries it is typically around 70/30.
 One of the ways to reduce cost is to have a very strict gatekeeper model to specialist care.  Does this mean rationing?  Some may define it as such.  However, given today’s model in the US, it can be argued that specialists are over-utilized without the significant outcomes to backup what the health care system is spending for specialist care .

Provider Reimbursement:  For providers who participate with multiple health plans in today’s model, must keep a small army just to submit and reconcile claims.  The contracting structure which has evolved over the last 30 years has only added to the complexity and frustration within the system.  With a universal health care model, it is assumed then that there would only be one entity which would set reimbursement rates, and that would be the government, similar to what Medicare does today.  While some of Medicare’s rules are complex, they are also standardized, which means that there would be only one way a provider would need to submit a claim, thereby potentially reducing the office staff needed or billing services needed to maintain status quo.

Quality of Care:  For the sake of argument, let us imagine the benefits and provider contracting have been standardized and that there is little differentiation to be had for insurance carriers on this front.  However, one area that could grow and become a differentiator for plans is how they help to manage the health of their members and what type of quality programs they offer.  With the funds that they would save on not have to build so much custom processes to administer benefits and provider contracts, these funds could be re-directed to enhance Quality of Care programs to ensure members are following protocols and building more predictive models for intervention as apposed to reactive models.  There has to be a reason why America spends so much money on health care, but according to international organizations studying outcome, America lags behind all other industrialized countries in terms of outcomes.  The question then becomes: Are we spending our health care dollars on the right things?

Conclusion:  There is no “cure all” solution.  For those touting the wonders of universal healthcare, beware, everything comes with a price.  You cannot have the open access, fee-for-service model with unlimited access to specialist that is in existence today as the universal healthcare model.  The government will go broke.  What everyone needs to understand is that compromise is needed on all fronts, not just by the insurance carriers. Medical science has evolved tremendously since the 1930’s when healthcare insurance was first really introduced to this country.  Unfortunately, insurance did not keep up with technology and we are now spending about 17% of our GDP on healthcare. It is now time to play catch-up, and start a revolution which will provide basic, affordable, high quality healthcare to those Americans who need it without breaking the bank to get there. 

How can this be achieved?  The first and biggest step is towards standardization.  For anyone who is involved with HIPAA Transactions and Code Sets or NPI and has sat through round-table discussions, one of the concepts that come up over and over again is that it is too expensive to implement standards. The goal is to be simply compliant, but not change the current process.  Instead of the government looking to try to insure everyone (and again here is the big question of how do we define “everyone”?), perhaps what they should be doing is looking at how to incentivize payer and provider organization into becoming truly standardized.  Once standardization happens, cost will be reduced and money can flow back into the system with more of a focus on quality.

Posted by Alison Schambach at 06:05 AM | Permalink | Comments (0) | TrackBacks (0)

As recently as a month ago, we might have compiled the multiple healthcare reform bills in search of common themes to prepare for likely changes to come.  Who would have supposed that successfully managing a health insurance organization would require that we become political pundits?  As the conversation unfolds, its resemblance to a dialogue is quickly dissembling into a conflict based on the loudest and last word spoken rather than on the merits of any given proposal. Terms are morphing, healthcare reform is being recast as health insurance reform. Our industry had approached the table with significant contributions, including a willingness to forego benefit exclusions based on pre-existing conditions in the context of a marketplace where effectively all lives are health-insured.  Health insurers are now being cast (by those who oppose reform) as the villain solely responsible for wasteful healthcare costs.

While we witness conflicts currently devolving into an argument that is becoming personal, it’s a good time to recall the hierarchy of conflict. Whether or not the nation can apply it to restore a healthy conversation on reform; I’ve witnessed many capsized ideas and projects where the failure of parties to engage productively had been misconstrued and escalated as personality conflicts when in fact the disagreements lay elsewhere.

When seeking common ground to achieve effective change, the groundwork needs to begin with common goals. Are we going North or are we going South? Healthcare reform goals that have been given a great deal of air time include: expanding health insurance coverage to a greater portion of the population; improving the quality of healthcare; reducing the costs of healthcare. In the case of the multiple healthcare goals, concurrent implementation seems contraindicative. Expansion of the number of people covered runs headlong into notions of reducing cost. Does improving quality also increase cost? If more people are covered, will quality of care suffer?  The building blocks to meet these multiple, seemingly contradictory goals are the inter-related incentives and constraints of public and private funding, benefit and product design, marketing and sales, network design and management, medical management policies, and the costs and benefits of quality customer service. Without the foundation of an agreed-upon set of goals, no other conversation is productive or possible. While healthcare reform goal-themes we’ve heard are relatively finite and usually common, I suspect our national dialogue has not fully resolved the objectives that will find commitment from all parties. Where parties don’t recognize the goals are mis-aligned, the arguments may be misconstrued at a personal level. “They never listen,” “they don’t understand,” become common refrains.

Once goals are in alignment; proper planning addresses the strategies and tactics to achieve the goals. Even our agreement on compass heading will not stand in the face of our holding different ideas on the best approaches as to how to get there. In the case of healthcare costs, are they really attributable solely to any of: wasteful and redundant services and tests? Exorbitant case settlements driven by greedy lawyers?  Imprudent use of expensive emergency room settings for routine care?  Rising insurance premiums?  When disagreements revolve around strategy and tactics, accusations degenerate to statements like, “They’re taking the wrong approach,” and “they have the wrong idea.”

If we can agree on the spectrum of strategies and activities to achieve our goals, then the next forward step depends on our agreement to engage in change within specific roles. I’m sure you’re familiar with the metaphors for these problems. “Nobody’s minding the store,” “Too many chefs,” are expressions relating to the absence or over-abundance of leadership providing vision, direction, encouragement, organization, and support.  Complex change depends upon many roles, each played well, from leadership, project management, to the rank and file. The complexities of the inter-related component goals proposed for healthcare reform call for clearly defined responsibilities and roles. “They’re not doing their part,” “They’re trying to run my division,” “I don’t trust them,” will otherwise become commonly heard refrains.

The most unfortunate end-point for breakdowns in goals, strategies, and roles is the misperception that these failures are personal in nature. Nay-sayers and spoilers, without contributing thoughtful solutions, resort to personal insults and vindictiveness. Comments erode to, “They’re all idiots.” Truly personal conflicts are actually rare, if we take the time to seek the other hierarchical layers of conflict and commonality, we often find the root source of disagreements lies in misaligned goals, strategies, or roles.

With respect to accelerating your organization’s ability to respond to whatever changes may come: listen for conference room comments and water-cooler dialogue. They may provide clues as to where your projects are misaligned and off-track.  Remember to begin alignment work from the top: Goals, Strategies, and Roles.

With respect to the national debate, insist and contribute to the dialogue at a more productive level. It will be our only hope to identify, design and accept desirable change, and to discern, honor, and retain aspects of healthcare services delivery and funding that work.

Posted by Rob Eichler at 05:16 AM | Permalink | Comments (0) | TrackBacks (0)

Enough has been said and written (some in our own blogs here) about how HIPAA 5010 should be seen as “business transformation”. It’s okay to view it as a transformational program as long as you have the extra money and the time to implement one. If you don’t have either or only one of the two, I’d say stay focused on to the compliance aspect and what I like to call the “tactical opportunities” or the low hanging fruit.

The ground work has been done for you by CMS – just by complying with what CMS is asking of you, you’ll be able to interact with your trading partners using a more standardized transaction format. You’ll end up with less number of partner specific companion guides to maintain and reduced need to create new ones. You’ll also improve your payment cycle and customer service, by carrying out inquiries and responses electronically. 

5010 provides you with many new pieces of information you didn’t have in 4010. You can still achieve compliance without processing this information internally, but these are opportunities for you to quickly improve your process efficiency. For example, with 5010 payers will be able to readily determine the additional paperwork available at the physician’s office. You probably need multiple back and forth transactions/phone calls to gather that information currently. Similar changes can be squeezed into your HIPAA 5010 program plan easily, with returns immediately post implementation and you’ll breakeven in the very short term.

Lastly, I’m not saying that no strategic opportunities exist with HIPAA 5010 transition. If you have an ailing front end system that takes a fortune to maintain and is plagued with scalability issues, this is the right opportunity to re-engineer that to a modern scalable platform. In any case, you’ll need to pick your battles wisely. In these days of short supply of money you don’t want to run out of money too soon, more so because ICD-10 is also knocking at your door!

Posted by Vijay Kumar B at 05:03 AM | Permalink | Comments (1) | TrackBacks (0)

It is simply amazing, how things change within a short span of time, in an industry that is traditionally considered highly static. Take the example of Enterprise Performance Management (EPM).

It was but a year ago that everybody in the provider segment, and their aunts, were trying to figure out how to solve the dilemma posed by the P4P and similar mandates. People in power (vendors included) were shouting at top of their lungs about the injustice of it all. After all, how could anybody put a price tag on quality care. Once their throats got parched and eyes started watering, they got around to finding best ways to maximize their returns in face of the “unjust” restrictions imposed by a “tyrannical” CMS. And all of a sudden, the water went off the boil. Nobody, and I mean nobody, could care less about the P4P measures anymore. Programs were shelved, people reassigned, budgets slashed.

So what happened?

Did all the underlying data collection issues evaporate all of a sudden on a steamy July night? Or the clinical processes automatically became self-efficient? Or all the providers secretly swore an oath to trust each other’s findings and not order wasteful and redundant procedures? Or, for that matter, they found a new floor cleaner that ensures nobody slips on an ER floor. Just spray it and forget about all penalties arising out of involuntary falls. Maybe that is my path to richness, but I digress.

Well, the correct answer is …………….. US elections.

With the elections came a small matter of $20B for ARRA and all bets were off. Nobody could give a hoot about the piddly little 4% penalties associated with pilot KPIs. After all we are talking 7-8 figure dollars associated with ‘Meaningful Usage”. Everybody was (and I believe, still is) rushing to Washington. Out goes the attempt to reduce costs and increase care through enforced and standardized clinical pathways, and in comes the attempt to share the information among caregivers as the first baby step, which should have been the case to begin with. One first learns to crawl and then run, with possible exception of Mr. Usain Bolt.

So, back to the titular question…. Does US healthcare industry need EPM? The answer, in my opinion, is a resounding YES. ARRA or no ARRA, $20B or no $20B, the bottom line still remains that till the time the provider sector does not have a hard look at their clinical practices, there is not going to be much improvement in quality of care and neither would be there much reduction in cost of care. $20B can take you only so far.

Especially once the hoopla of the EMRs die down and most providers get connected electronically, it will be much easier to maintain a standardized way of doing things irrespective of whether the hospital is Mass General or Beth Israel, irrespective of whether the doctor is John Smith or Joanna Smith. In addition, it will be much easier to weed out the black sheep too. Not too many places (or should I say, files) to hide with the good old computer cranking out the reports on a remote printer in CMS’ offices. So then what? How does it impact my choice for using EPM or not?

Well, as a wise man once said, ‘You don’t wanna take a knife to a gun fight’. Would you, as a provider, not be interested in acquiring all proactive tools that you could lay your hands in your battle with regulatory bodies who are hell-bent on using some of their own tools to monitor you to the minute? You bet, you will be. And there my friends, comes the proactive EPM tools to the picture.

An EPM tool that can alert you within time for you to take corrective action for a potentially payment-impacting variance in pre-ordained clinical pathways would pay for itself the first time you submit a 100% compliant HEDIS report. Can anybody hear those bonus checks leaving CMS’ headquarters? An EPM tool that can weed out the chronic violators and procrastinators among your clinical staff, would be worth its weight in Gold, especially if it could be configured to be a behavioral modification tool rather than a simple punishment artifact.

So, my response to all those doubting Sams is, just wait. Wait for another year or so and then see if the whole EPM gravy train does not come around again.

Posted by Rajiv Sabharwal at 07:42 AM | Permalink | Comments (1) | TrackBacks (0)

Organization departments have tendency work in silos and Healthcare Providers are no exception to this.  A leading insurance provider firm in USA was venturing into a new business in Canada and the IT team was busy working on the system requirements for the new business. The CIO sought this opportunity to make maximum out of the capital budget to invest in latest rules engine and custom application development. There was no consideration given to the revenue targets onto this new business or ROI on the IT system investment. Out of curiosity when I asked the CIO, his response was “ROI clouds the mind in any decision making. My priority is to ensure work for my team and have the systems in place to support business. It’s for business SMEs to extract maximum out of the system. This is what I call working in silos of departments by achieving individual department goals.

How many CEOs get a 360 view on the operations? Point me to any hospital which claims to understand:
• How much is my utilization cost vs the reimbursements I am getting for those utilizations?
• How much is my ALOS vs the reimbursed ALOS ?
• How many hospitals have a handle on the asset, staff, equipment utilization rates before investing more capital to increase capacity to meet demand?
• Which are the top 20 % areas that are leaking revenues for my hospital, which if plucked can bring 80% improvement in revenue leakage ?
• How much is my reporting tool investment, cost of ownership vs the returns/benefits I am deriving from it?

Data analytics is a very powerful tool that has the least penetration in hospitals. Hospitals invest in transactional products that help them to meet there day to day needs and look at analytics as mere post facto reporting tool to meet regulatory and payer compliance means. Little focus is given in understanding from the past data, trends, areas of improvements.  Moreover data availability in silos of departments makes it more difficult to relate a complete episode of care. The competing transactional vendor products across departments with very little interoperability capabilities adds to this. The current ARRA stimulus package with stress on the meaningful use of electronic record is step in right direction. For providers who currently don’t even have the transactional records captured electronically would need to invest in EMR.  But for those who already use transactional systems to capture day to day data should focus on data analytics around the record. Enterprise performance management tools are light weight analytics platform, which have pre built interfaces to extract transaction data from leading products and apply & present out of the box rules around clinical, operational & financial key performance indicators. These tools present real time performance of the hospital, breaking the silos and also  bring in built in intelligence based on statistical models applied on the past data of the hospital to improve efficiency, identify outliers and suggest corrective actions. They also come in with predictive modeling capabilities for hospitals to make informed data based decisions around its short & long terms capital investment needs.

Hospitals should not wait for full fledge definition of “Meaningful use of electronic record”. Those who have EMR should look at innovative ways of using the electronic data captured to decrease the healthcare cost. Investing in enterprise performance management tool is a low hanging fruit that can be easily explored.

Posted by Nilesh S Pai at 07:15 AM | Permalink | Comments (0) | TrackBacks (0)

Will the Henry Ford of healthcare emerge from the current effort to truly lead the reinvention of the US system?  Not even 100 years ago, Henry Ford refined the assembly-line concept and completely transformed the automotive industry from a highly-specialized, one-off, craft-based culture into an industrial juggernaut based on fanatical process consistency, data-driven driven decision-making, and product standardization.  Costs fell almost immediately to unforeseen lows.  Access to automobiles became available to everyone.  Solid, competent, reliable service delivered to everyone.  Isn’t this what we all crave for our Healthcare system?

I believe that true business model re-invention is at hand.  Over the last few years, I have observed a growing sub-culture within the Hospital community that is exploring, and in some cases embracing, various elements of modern manufacturing systems theory.  Department Heads are implementing concepts like Straight-Through-Processing, Kan-Ban, and Lean Manufacturing.  Six Sigma Black Belts seem to be relishing the fresh new ground to plow they find within Hospitals.  Several world-renowned Hospitals employ High-Performance Work Cells, lifted from modern manufacturing, to deliver best-in-class patient care at surprisingly low costs.  Of particular notice is the innovative Narayana Hrudayalaya cardiac hospital in Bangalore (www.narayanahospitals.com) that has fully adopted the concept of ‘mass-production healthcare’ wherein world-class services are provided to the general population at very low prices by keeping volumes high, processes in control, and service variability limited.  President Obama has recently visited the Cleveland Clinic to understand their modern methods of Hospital management.  But this sub-culture must emerge from the shadows and be thrust into the mainstream.

Supporting this growing movement is an emergent set of tools and techniques that transcend traditional data management to provide Real-Time Forecasting and Decision Making, Real-Time Process Monitoring and Management, and Advance Resource Management.  These techniques are being employed to solve some of the most difficult business management issues in a Hospital such as eliminating sources of revenue leakage, enabling Just-in-Time inventory management, managing clinical workflow compliance, and optimizing resource allocation across an enterprise.

I have observed the growing desire on the part of hospitals to transform how their businesses are being run.  I am observing the invention of a new class of tools to support this transformation.  Our government is providing the political environment to facilitate real change. 

What we need is a new Henry Ford to emerge from this new environment to lead from the front.

Where are you Dr. Henry Ford, MD, MBA?

Posted by Mark Brownlee at 05:42 AM | Permalink | Comments (0) | TrackBacks (0)

The Experience;
Americans enjoy freedom and rights, as our “Founding Fathers” intended and indeed guaranteed in the Constitution. The right to choose our healthcare facilities, physicians and the insurance coverage or not that funds those is considered sacred to many. When “Choices” are threatened by politicians and an imposing alternative is offered we take notice and speak out.

Several months back I was fortunate that exceptional healthcare was available when I needed attention. The facility of my “Choice” treated me with my general practice physician and a specialist with my history documented by each. After a disagreement with the specialist regarding a contradiction of facts, I opted to change course and re visit a major Dallas based facility and specialty group that had delivered excellent care in the past through “Evidence Based” medicine. My “Choice” was important to allow a change of course when I felt uncomfortable with the existing plan of action.

The One thing;
As I detailed in my July blog entry, “Heal Me”, we expect a physician to see us in a timely manner, take time to understand our feelings, touch us with a thorough examination and then heal us with a well thought out “Care Plan”. In my opinion, and having a “Choice”, I was not getting this kind of care from my specialist originally so I chose to change the plan and seek better treatment. What a concept!!

The Complication;
As I orchestrated the change in care, it was necessary for me to notify each organization, The Hospital, General Practice Physician and Specialist to send (fax) my medical records to my new care giver. This required dealing with 3 different offices each with their own set of rules governing HIPPA compliance and release of data.

Conclusion;
If these Physicians and Hospital provided an Electronic Health Record (EHR), Personal Health Record (PHR) and each jointly participated in Care Planning and Execution of that plan this change in plans could have been a seamless move. The value to the patient and organizations faced with this logistical nightmare is clear. Many say that “Technology is not the Answer” but in this scenario that repeats itself over and over each day, technology is a big step towards enhancing quality and safety standards as well as efficient transfer of knowledge with access to critical data.

Posted by Gary O. Claytor at 04:18 AM | Permalink | Comments (6) | TrackBacks (0)