Healthcare Talent Transformation

Health Insurance 101: A Primer on Where We’re Going for Those of Us Who “Remember When”

Peggy Salvatore, HealthSystemEd.com

Back Then:

When I turned 18, my parents did what all my friends’ parents did: they cut us loose to start paying for our own stuff. Even those of us who went to college were
supposed to kick in and help carry the load – we got jobs on weekends and in the summer to help out with expenses.

I paid my first health insurance bill for myself before my 20^th summer. The bill from Blue Cross and Blue Shield was for $59.60 a month.  My parents had always been self-employed and paid our family health insurance premium every month, “just like our mortgage. It wasn’t anything we even thought about, it wasn’t optional. You have to have health insurance,” my mom said.

Having grown up with that kind of thinking, I paid my own health insurance every month. 

Later On:

When I had kids, health maintenance organizations (HMO) became popular and I could take all my babies for their doctor visits for $5, shots included. I lost some of the choice of providers I had back with Blue Cross and Blue Shield, but the HMO was good, solid coverage. When a baby had to go to the hospital, it was covered. When a child needed surgery, it was covered. And those trips to the emergency room for stitches from falls, they were covered, too. We had comprehensive coverage from a strong corporation that gave my husband good union benefits. We had great suburban providers near our home.

Insurance companies charged us, or our employers, what they needed to charge us to cover the cost of care, including whatever shots and drugs we needed, and to make enough to cover administrative overhead. The money they spend on care for their members is called the Medical Loss Ratio (MLR); from an insurer’s perspective, when you have to pay out, it is a loss.

Typically, insurance companies paid about 80% to 85% of their premiums in MLR and the rest to administration.  Health insurance companies charged rates based on the profile of the customer, so when I was young and healthy, my rates were low. When we had a family, rates went up. And as we are getting older, our premiums are rising. It makes sense; those things are determined by actuaries who do underwriting and determine the likelihood that you will draw on your insurance for care.

Back in the day, employers paid benefits to attract and keep good workers, and the coverage was good. Private sector coverage was distinguished from public sector coverage such as government-subsidized Medicaid plans. Medicaid was available to people who were seriously ill and indigent, and you had to meet very strict income and asset limits to qualify.

Where We Are Going:

Today, with all health insurance coming under federal regulations, the distinctions are blurred between private and public coverage. Under the provisions of the new health reform law that fully kicks in next year, health insurers are required to take all comers, and charge premiums for mandated packages. Actuarial tables be damned, Scarlett! Insurers must cover mandated populations with mandated packages and deliver mandated services in ways that are friendly to the population. Premiums will be subsidized with public funds based on income according to a sliding scale. And by the way, remember that MLR where insurers’ liabilities determine what percentage goes for overhead and administration? That percentage is mandated now, too.

When insurance is mandated for everyone, when packages are written according to law and not according to what is logical according to age and utilization, when the amount you can spend for administrative expenses is mandated, the basis for the whole concept of insurance is undermined. It’s like defying the laws of gravity.

When health insurance is written while ignoring the logic of actuarial tables and underwriting principles, it isn’t really insurance anymore. The government is just mandating that a private, third party pay for healthcare for its citizens, and premiums will be subsidized by the government for those who can’t pay. The third party becomes an extension of carrying out the government rules for who is covered, what they get, and even whether they get it.

Yes, those of us who have been watching managed care since the mid-90s have certainly seen that insurance companies have been “rationing” care under depth and breadth of coverage in contracts with employers and private individuals all along. However, it is a rationing system that the purchasers have agreed to within those private contracts. If I get denied coverage, the insurance company can point to the plan that I bought (i.e., the private contract which I entered into with them) and show me that benefit wasn’t included in the coverage I purchased from them.

Within that private contract framework, the insurance companies had discretion regarding  the customers with whom they entered into contracts. Some health insurance companies chose to deal in the private insurance market and contract mostly with large employers. Others became specialists in government-subsidized programs like Medicare or Medicaid. They built their premium pricing structure and contracts around their selected markets and the amount of risk they chose to assume with certain populations.

Now What?

Under health reform, insurance companies are regulated so they have to write packages according to federal regulations, offer insurance to mandated groups, and charge rates that under normal underwriting rules defy the laws of simple arithmetic. Some interest groups would have us believe that insurance companies are evil entities that should not be in the business of healthcare; that they are profiting from premiums and denying care because they are the third party standing between the patient and the provider.

In reality, they have assumed the lion’s share of the responsibility in case you have a catastrophic illness, and they also cover preventive care like vaccines because, if for no other reason than simple good business sense for them, it is cheaper to prevent a disease than to treat it. Based on that logic, most health insurance companies are concerned about keeping their members healthy. And when they are mandated to cover certain populations and conditions, they are going to be even more concerned about keeping those populations healthy.

When I was paying $59.60 a month for Blue Cross and Blue Shield, it was wholly voluntary on my part and theirs. I chose them as an insurer and they agreed to write coverage for me. I went to the doctor when I was sick and they held up their end of the deal and paid 80% of my bills. I’m not sure what the business model is going to look like when that contractual arrangement is no longer voluntary by either the patients or the insurance company. I suspect it will get expensive for both parties, as the covered populations will not be chosen by the insurance company as part of their business strategy, and the members will be getting a mandated package of services that they will be required to pay for.

It doesn’t sound exactly like a government-run healthcare system, but then again it doesn’t not sound like a government-run healthcare system, either. And it makes me wonder, armchair health economist* that I am, at what point we just cut out the middle man and eliminate the charade.

*For the record, even though I am a self-declared armchair health economist, I have had the privilege to watch this from a professional perch for awhile. In one particular meeting in the late 90s, academics and government think-tankers gathered to figure out how to rewrite the tax laws to encourage coverage within the free market system. If you are looking for a mental image, think Upton Sinclair’s The Jungle.

The Economic Lessons of mHealth

Dr. Michael Koriwchak, www.wiredemrdoctor.com

The recent HIMSS 2013 meeting witnessed the emergence of mHealth as a significant component of health information technology (HIT).  The meeting offered 35 educational sessions on mHealth. One of the meeting’s keynote speakers, Dr. Eric Topol, predicted a revolution in health care based on smartphones.  Connecting a smartphone to a currently available bio-sensor allows anyone to monitor and share with a physician his vital signs, heart rhythm, sleep patterns or blood sugar, and soon other physiologic data as well.  Eventually these systems will include software that will enable laypersons to interpret data and determine when physician involvement may be appropriate.  The way each of us will learn to interpret our own body’s data will become a natural extension of the way we now interpret our own “internal body cues” and symptoms.

Meanwhile, progress within the more established parts of HIT has ground to a standstill. At the HIMSS meeting results of a provider survey conducted by the American College of Physicians and AmericanEHR Partners were presented.  Among over 4000 surveys the percentage of clinicians that were “very dissatisfied” with their EMRs has increased by 10% from 2010 to 2012. 39% of EHR users would not recommend their EHR to a colleague (up from 24%).  Satisfaction with EMRs has clearly deteriorated since the 2008 pre-Meaningful-Use study published in NEJMthat showed 93% of physicians were satisfied with their EMR.  In the physician blogosphere the leading EMR story last week was about a physician class-action lawsuit against an EMR vendor who allegedly sold defective software and then abandoned the product.  Outside of mHealth there is not a lot to cheer about in HIT right now.

Why is mHealth growing so fast while the rest of HIT is stalling? There are many reasons but three important reasons bear discussion.

First, most mHealth projects don’t take on every patient at once.  An mHealth project designed, for example, to monitor congestive heart failure patients at home addresses only that population of patients and providers associated with a single diagnosis. A project with such a narrow, focused scope has a greater chance of success than a typical EMR project which must cover every patient and every physician regardless of diagnosis.

The other two reasons illustrate an important economic lesson. At the moment mHealth is a relatively unregulated industry. Any startup company can acquire a bio-sensor and/or write a mobile app for a smartphone and be off and running.  There are no Meaningful-Use-type regulations that require all mHealth apps to operate a certain way or meet a minimum set of requirements.  Barriers to entry are relatively low.

Third, many mHealth projects are marketed directly to consumers and are paid for directly by consumers.  The just-released Samsung Galaxy S4 smartphone has a suite of built-in mHealth apps and available biosensors to monitor sleep, calories burned, heart rate and (Samsung implies) blood glucose.  Consumers will purchase this phone like any other – with their own money.  There are no third party payers involved.  That means no insurance approval, no complex coding and billing, no politics ….so far less overhead and far more flexibility and speed.  All you have to do is build a quality, useful product.

mHealth currently operates in a free market where products can be designed any way their creators choose. Their target customers choose what products to buy – or not to buy at all – and how much to pay.  Many of these products will fail, but the ones that succeed may indeed revolutionize healthcare as Dr. Topol predicts.

EMR vendors, burdened by Meaningful Use requirements, have little bandwidth left to address customers’ real needs.  As Meaningful Use requirements and EMR certification raise the barrier to entry into the market, the market is increasingly dominated by the largest vendors at the expense of the smaller ones.  As competition is suppressed product quality and customer service both suffer. Given the AmericanEHR survey results it is no surprise that EMR vendors are now marketing to current EMR users who are unhappy with their present system. There are certainly plenty of those.

Unfortunately the freedom mHealth enjoys may soon come to an end.  The FDA’s upcoming release of its final regulations of mobile medical applications is expected soon.  These rules will likely impose an approval process similar to those already in place for drugs and conventional medical devices.  One source estimates the cost of this approval process for a single mHealth product will be as high as $24 million.  While that estimate seems high, there is no doubt that the cost of compliance will have a detrimental effect on the mHealth marketplace.  Costs will go up dramatically, smaller companies will be forced out, and true innovation will slow as mHealth companies expend most of their resources on compliance.  Those products that survive to reach FDA approval will no doubt seek third party payor reimbursement.  With that will come loss of price transparency, driving up costs even further.  The mHealth market will become as bloated and ineffective as the rest of the health care system.

Will the mHealth revolution survive?  Time will tell.

Dr. Mike Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship and Residency at Vanderbilt University Medical Center. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. Dr. Koriwchak has been working with information technology since 1977. In medical school, he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 30 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care. 

Transparent Healthcare – It’s Here: Get on the Bus or Get Runover

Jonena Relth, TBD Consulting

I’ve done some “unscientific” surveying of the issue of Transparency in Healthcare and was surprised by what I found. While we often blame the older docs of being inflexible and holding back in the transparency arena, I run across docs of all ages who know that healthcare delivery must change. There are the gutsy docs willing to put their heads above the fray and open themselves up to scrutiny by their peers and patients. They ask the hard questions, pressing for why we’re still teaching and practicing medicine the same way. They ask the question of why we don’t review our standard procedures using Lean methodologies to see how medical professionals can save time and money and improve patient care.

As with any change, there are those individuals that still need to be brought over to the “light side.”  Forgive my Star Wars analogy… There are still MANY doctors, old and young, who still have the “I went to medical school and thus know more than anyone else in the room. I like what I do now and don’t want healthcare to change – or at least don’t want my work to change.”

I don't have much advice for how to change the attitudes of the second group, except to:

• Keep the drums pounding…in a nice way of course. 
• Allow naysayers to stand back and watch the changes happening around them but not too long.  At some point, they will need to get on the bus, or the changes will pass them by.

Medical School Experiences that Show Leadership Transparency

Medical students experience both types of leadership: Transparent and Autocratic.  They see firsthand transparent leadership from some docs’ autocratic leadership from those docs unwilling to open up and flex, even a little, to allow the students learn from the docs’ personal experiences that would bring the subjects to life.  Yes, students are taught to memorize, assess quick, make quick decisions, but that's a different topic to address later.

As a trainer and teacher, I love to hear of times when professors share the good, the bad and the ugly with their students.  It’s from these real-life experiences that the “light bulbs” turn on around the room. These professors show a transparency that shows they are “real people” working at a complex job with many variables. It helps give the students a better idea of what practicing medicine will be like from them after their LONG training journey.

Don’t jump to conclusions here, I’m not suggesting breaking HIPAA laws, just doctors showing a bit of vulnerability.

Unfortunately, in medical school, the time is so short to teach the students all the theory and science needed to practice medicine, instructors in the classroom and hospital use an autocratic teaching style to get through as much of the content they can. There isn’t time to allow for much “self-discovery” or independent thinking. That will come later when they have more experience under their belts.

Signals that Change is Not Easy for MANY

In our EMR/EHR consultancy, we see the flexible doctors willing to attend training whenever it is convenient for the organization.  The inflexible doctors are the ones that still want to be trained one-on-one. My opinion is that these physicians don’t want "transparency" because they don't want others to know what they don’t know. It would bump them off their know-it-all pedestal and down with mortal men.  You can’t blame them.  I’m not being flip – honest.  No one wants to be treated by a doctor who they think doesn’t have all the answers and thus can’t cure them. Patients choose to be treated by docs they perceive to be “the” experts. What’s sad is that these same docs and patients are kidding themselves.  No one can know everything about every topic – even in their particular specialty.  A very skilled doctor may know more than the next 20 people, but new information is found every day and no one has the time to learn everything new every day and keep up with their patient load.

I have the utmost admiration for those who choose the medical field as their choice of profession. It is often a lonely, selfless job that keeps practitioners away from their families and forces them to trade “personal time” for being on call at night, weekends and holidays.  It is, however, time for all healthcare professionals to take a good look and accept that our world, our patients and healthcare delivery are changing. Hopefully more healthcare professionals will choose improved, transparent, care delivery by involving others, especially holding patients ultimately mutually accountable for our own care. 

It’s not a one-way street – patients need to change, as well.

The time is now that patients must start taking responsibility for how we treat our bodies and learn how they work. Ok, so in a perfect world, patients would know that "we are what we eat" and also know that we all need exercise and a will power to avoid things that harm our health.  If we do this, doctors will have a much easier time treating our illnesses and helping to make us healthier. Sounds logical to those of us "A" type personalities, but we have a long way to go to get here!

Please share your experiences with us about doctors – young and not so young – who are modeling transparent healthcare.  I know they are out there.  If you are a champion of transparent healthcare, please let us hear from you so we can learn from you!

Here’s a short list of my current transparent healthcare heroes. These docs are in the trenches speaking out for reforming healthcare delivery. They have all earned the right to be heard.

And folks, leadership is where it has to begin! 

• Dr. Michael Koriwchak; Read one of Michael's blog posts: MD – Techy Doc Who Puts Patients’ Needs First
• Dr. Stephen C. Schimpff; Read one of Stephen's blog posts: Innovative Technologies Can Markedly Enhance Safety or check out his book: The Future of Health-Care Delivery: Why It Must Change and How It Will Affect You
• Dr. John Toussaint

Then there are the holdouts… but we’re working on ‘em! 

Jonena

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Transparency Inside and Outside Healthcare Walls - No one wants an "F"!

Is Obama Killing Healthcare?

Hal Alpiar, www.BusinessWorks.US

Doctors know where they've been, but they don't know where they're going! Today's medical professionals are strapped to a rudderless ship at sea that's being sucked into a raging storm.

Some politicos would have us believe that the scandalous fifteen-thousand-page Obamacare program (and when, by the way, was the last time anyone you know read 15,000 pages of anything?!) need not be such a shocking insult to healthcare consumers because after all, it helps “less fortunate” people to get medical care.

Steamrollered through an inept Congress, Obamacare appears to have little if anything to do with the realities of healthcare. Instead, Obamacare hints at having everything to do with the crippling economic and personal freedom limitations brought on by the relentless White House pursuit of dictating increased government controls on American lives.

The end result? We will definitely end up with fewer competent physicians.

And those who remain will clearly not be providing adequate care –regardless of competency– because of the restrictions Obamacare piles on top of the restrictions already imposed on them that limit their ability to deliver meaningful health services.

But computerization is what tightens the noose around healthcare necks, some say. Not so. The mismanagement and misappropriation of administrative computerization advances by interfering and uninformed government misfits and ignorant insurance providers is what is at the root of today’s healthcare delivery shortcomings.

The de-humanizing of humanizing services is the characterization that uninformed and manipulative individuals, agencies, and organizations have wrought as they’ve twisted administrative computerization advances into shortcut invasions of patient and physician privacy. Have we lost even having thoughts of human dignity?

When “DOCTOR’S ORDERS” becomes “DOCTORS ORDERS” (as in orders issued to doctors by the White House) to conduct patient gun ownership surveys to build a bigger “Big-Brother-Watching” database universe designed to gain yet more government control, do you think this might possibly get just a bit in the way of doctors performing healthcare services?

Of course EMR (electronic medical records) and EHR (electronic health records) have succeeded at putting patient care over paper care. But are these important advances enough to be really helping doctors to know where they’re going?

And the Internet has fully armed healthcare consumers to be better prepared to understand and manage their own healthcare issues, to be more informed about diagnostics and treatments, and to work more productively with their doctors. But are these advances enough to be able to really help doctors to know where they’re going?

The whole lean organization, lean management fad (where did Quality Circles go?) may be a solution, but is not THE solution. It is simply a band-aid acknowledgement that things have gotten so bad, we can no longer afford for the physician to spare a minute or two extra with each patient and patient family to help heal, and help ensure and reassure a sense of well-being.

More dollars are saved. Care is more efficient. But –at the ultimate point of care– doctors don’t get to spend more time with their patients, so is this increased efficiency really enough to help doctors know where they’re going?

Being preoccupied with efficiency necessitates lower levels of individual healthcare delivery. And last time I looked, healthcare was a profession dedicated to individual care. Perhaps it’s time to redefine the word “care”? The bottom line is that doctors are literally trapped.

Adherence to rules and regulations designed to increase control over their skills and abilities to earn livings commensurate with their training and societal value is squashing the very lifeblood out of healthcare. And Obamacare will surface as the culprit when it’s too late to matter — unless enough small business owners and practice administrators and doctors start to make waves

. . . NOW.

Employee vs. Employer Choice of Physician Revisited: Additional Commentary on How Best to Incorporate Medical Tourism into Workers’ Compensation

Richard Krasner

Further research into the topic of Employee vs. Employer choice was prompted by a phone call I received over a week ago from an attorney in New York who handled workers’ compensation cases and is a consultant to carriers and businesses on workers’ compensation, group health and disability insurance, cost-containment, claims investigation and claim preparation. The call got me to think about what I had previously stated in my earlier post on the subject of employee vs. employer choice, and to my amazement, new research found that New York State allows employees, and not their employers, to choose the treating physician. I corrected my error in the original post, but decided that a further clarification and elaboration was needed.

Needless to say, when I came across a study by the Texas Department of Insurance comparing state workers’ compensation systems, I found more information, and decided to expound upon my previous writing. What I found was not just that there is employee vs. employer choice, but that choice of physician is determined by six additional categories. The first category is employee choice of physician. The second category is selection from a list prepared by the appropriate state agency. The third category is selection from a list maintained by the employer. The fourth category is employer choice. The fifth category is employer’s choice may be changed by state agency, and the final category is a after a specified period of time, choice falls to the employee.

As seen in Table 1, thirty states allow some form of employee choice of doctor, while twenty states allow some form of employer choice of doctor. This is important to bear in mind, for the purposes of incorporating medical tourism into workers’ compensation, as 60% of U.S. states allow employees to make the initial choice, and only 40% of U.S. states allow employers that choice, as seen in Figure 1, so that in order to incorporate medical tourism into workers’ compensation, it will be necessary to get employees to agree to it before getting their employers, or their employer’s carrier to do so.

Figure 1 – Pct. of Employee/Employer Choice

Table 1 – State-by-State Comparison of Statutory Provisions Relating to Choice of  Treating Doctor

Source: Texas Department of Insurance, Workers’ Compensation Research Group, Comparison of State Workers’ Compensation Systems, 2004.

Note: * If an employer and/or insurance carrier has a managed care arrangement for workers’ compensation, then injured workers are required to choose a treating doctor from within the employer’s or carrier’s network.

Note: ** If employer has designated at least two Health Care Organizations (HCOs), then the timeframe that an employer has to choose the treating doctor is normally extended.

Broken down even further into the three categories mentioned above for employee choice, as well as for employer choice, 24 states allow employee to have initial choice, which represents 80% of all states that allow employee choice. Four states allow the employee to select from a list prepared by the state agency, which is 13% of all thirty states, and three states allow employees to choose from a list maintained by their employer, which is 10% of all the employee choice states, as seen in Figure 2.

Figure 2 – Pct. of Employee Choice Categories

Ten states allow employers to choose the treating physician. Three states allow the employer’s choice to be changed by the state agency, and seven states allow the employee choice of doctor after a specified period of time has elapsed. As shown in Figure 3, half of the twenty states that allow employer choice, or 50%, allow for initial employer choice. The other 50% is split between states that allow the state agency to change the employer’s choice (35%), and the states that allow the employee to choose after a specified period of time (15%).

Figure 3 – Pct. of Employer Choice

To further complicate the matter, one state in the employee choice category, yet unknown, allows the employee to choice their treating doctor if they can prove that they or a family member has a record of previous treatment with a particular doctor. As shown in Table 1, five states allow workers to choose their doctor if the employer or carrier does not have a managed care plan; otherwise they have to choose from within the network. Seventeen of the employee choice states have unlimited choice of treating doctor, but are not ascertained in the report.

It would appear that in order to incorporate medical tourism into workers’ compensation, it would be useful for any facilitator or other entity such as an employer or carrier, to carefully read the statutes in each state they are conducting business in and have considerable workers’ compensation claims that might benefit from the lower surgical cost and quality issues medical tourism affords. To not do so would be foolish, and would create a great deal of confusion and doubt as to the whole efficacy of medical tourism, which would be a terrible mistake for the employee, his employer and the insurance carrier.

Richard Krasner has worked in the Insurance and Risk Management industry for more than 30 years in New York, Florida and Texas in the Claims and Risk Management spheres, primarily in Workers’ Compensation Claims, Auto No-Fault and Property & Casualty Claims Administration and Claims Management. He has experience in Risk and Insurance Business Analysis, Risk Management Information Systems, and Insurance Data Processing and Data Management. Received my Master’s in Health Administration (MHA) degree from Florida Atlantic University in Boca Raton, Florida in December 2011. I am looking for new opportunities that will utilize my previous experience and MHA degree. I am available for speaking engagements and am willing to travel. Contact Richard or read Richard's blog.

Employee vs Employer Choice of Physician: How Best to Incorporate Medical Tourism into Workers’ Compensation.

Richard Krasner

One of the obstacles to incorporating medical tourism into workers’ compensation is the issue of Employee vs. Employer choice of treating physician. State Workers’ Compensation laws recognize four different categories of choice of physicians, Employer Only, Employer/Insurer, Employee/Employer and Employee Only.

Employer Only is self-explanatory; Employer/Insurer means that either the employer or his insurance carrier can choose the treating physician for the claimant. Employee/Employer means that the employee has the choice to choose the treating physician, or failing to do so, gives that right to his employer. Employee Only means that the employee can choose his physician.

Among the fifty states and the District of Columbia, a slim majority of states allow some form of employer choice as described above, and as indicated in Figure 1. As seen in Table 1, choice of physician is marked by an ‘X’ under each category for all fifty states and the District of Columbia.

Figure 1

Table 1

The percentage of states for each category is shown below in Figure 2, the majority of states, 48% recognizing Employee choice, but if you add together the Employer Only, Employer/Insurer and Employee/Employer categories, the majority of states would favor employer choice in whole or in part.

Figure 2

What this all means for medical tourism is this, the best approach to take in implementing medical tourism into the US workers’ compensation system is to get employers to choose it as an option for their injured employees who will need secondary treatment, i.e., surgery that would be more expensive in the U.S., but at a much lower and more reasonable cost and better quality in fully accredited hospitals in medical tourism destinations.

For self-funded employers, especially those already using medical tourism as an for their employees health care plan, doing the same with their workers’ compensation claims will allow them to realize considerable savings in workers’ compensation costs, as they are ready realizing in their health care costs. Employers, who are getting coverage on health care for their employees through the commercial market, will want to approach their workers’ compensation carriers to get them on board with a medical tourism option. Some commercial insurance companies that provide both health care coverage and workers’ compensation coverage would be the best companies to work with in this regard.

If there is some resistance on the part of employers and their insurers because of state workers’ compensation laws, then a concerted effort to amend, remove or change these laws will need to be considered, not just by a few companies, but across the board in the business world. To do anything less would be to allow the status quo to continue and to see medical costs for workers’ compensation claims to rise even higher when there is a viable and reasonable alternative available, within a relatively short distance from the US mainland in Central and Latin America, the so-called “rising stars” of medical tourism.

Richard Krasner has worked in the Insurance and Risk Management industry for more than 30 years in New York, Florida and Texas in the Claims and Risk Management spheres, primarily in Workers’ Compensation Claims, Auto No-Fault and Property & Casualty Claims Administration and Claims Management. He has experience in Risk and Insurance Business Analysis, Risk Management Information Systems, and Insurance Data Processing and Data Management. Received my Master’s in Health Administration (MHA) degree from Florida Atlantic University in Boca Raton, Florida in December 2011. I am looking for new opportunities that will utilize my previous experience and MHA degree. I am available for speaking engagements and am willing to travel. Contact Richard or read Richard's blog.

 

Five Ways of Achieving Patient Engagement: Part 1: WITHOUT Technology

David Scher, MD, DLS Healthcare Consulting

If one looks at communications revolving around healthcare these days, whether emanating from political, healthcare economics, clinical, or technology spaces, the term patient engagement is invariably found as one of the cornerstones of the conversation.  This is no more evident than in the digital health technology space. One would think that patient engagement is only possible by hitching a wagon to the technology horse.  I would like to explore the issue with two posts, the first devoted to non-technical considerations and the second examining best practices of technology utilization in this regard.

1.     Listen to the patient.  Patient-physician communication is the basis for much of what transpires during the tenure of the professional relationship.  Lack of good communication has been cited for medication nonadherence.  William Osler, the father of modern American medicine famously stated that the patient will tell you the diagnosis with the narration of the history. Given the fact that most office encounters today last 15-20 minutes and that patients have comorbidities requiring attention, it is no wonder why many times they are not heard.  The physician is looking at the computer screen clicking off checks. The system is no longer geared towards human interaction and this creates a recipe for poor care, even if unintended.  This is why direct care or concierge medicine is becoming popular.  Both physicians and patients are returning to communicating in this setting. Other solutions need to arise to promote communication. Providing patients with pre-visit guidance in order to organize their thoughts and concerns might help.

2.    Motivate your staff to be as patient-focused as you are. Office and hospital staff should reflect the provider’s patient-focused approach to care. Many times they are too task-oriented and forget there is a patient who is the reason behind those tasks.  If the staff takes on the mindset of a stakeholder in the patient’s care and not just performing a job, the result will be a happier patient. Patient satisfaction surveys (an important part o the future healthcare landscape) will reflect this aspect of the care.  Patient-centered professionalism should be the goal of all ancillary staff.

3.    Demonstrate to the patient that you are an advocate.  Going to bat in front of an insurer for a patient who really needs a specific drug or procedure is something I always felt good about. Spending time on such matters is something physicians years ago (dating myself) went into the field thinking they would have to do.   However onerous, it is what patients need docs to do in critical moments. And patients do very much appreciate this. It is what made me feel good going to sleep at night.

4.    Show them your personal side.  Social media is a great way for providers to show their personal side.  This is not to say that personal interactions with patients should take place one on one, but a way in which patients see the personal (and hopefully appropriate) side of their healthcare professional.  I believe Twitter is a better forum for this than ‘friending’ between a provider and patient on Facebook.

5.    Individualized self-management.  Patients will partner with providers in their treatment plans with different levels of enthusiasm.  Some patients will require more support than others (motivational and material) and this should be discussed. Discussing patient engagement early on in the relationship is important.  It should also involve a caregiver who might be the one participating in the engagement on a larger scale. A provider who embraces co-management and is seen as both a partner and supporter of the patient will be appreciated.

The above might seem obvious to most people, but in today’s discussions surrounding patient engagement, the humanistic aspects of achieving this are lost in the vision of technology magically transforming how patients react to their medical conditions and to their healthcare providers.

David Lee Scher, MD,FACP, FACC, FHRS, is Founder and Director at DLS HEALTHCARE CONSULTING, LLC advising digital health companies and their partnering institutions, companies, and providers.He is a former cardiac electrophysiologist with over 25 years in patient care. He leverages his experiences as a major clinical trial investigator, human subject research committee chair, Medicare committee member, and medical device industry consultant and key opinion leader in advising clients on best product and business development practices and adoption of digital health technologies He travels worldwide speaking to professional organizations and the general public on topics related to remote patient monitoring and digital health. Board Certified in Internal Medicine, Cardiovascular Diseases, and Clinical Cardiac Electrophysiology, Dr. Scher was a pioneer adopter of remote patient monitoring. He was named one of the ten cardiologists to follow on Twitter and author of one of the ten best healthcare technology blogs. . He is senior medical adviser at Happtique. As chair of Happtique’s Blue Ribbon Panel, he oversees the certification process of health apps.dlschermd@digitalhealthconsultants.com

Five Reasons Why Self-Insured Companies Need Mobile Health

David Scher, MD, DLS Healthcare Consulting

According to 2011 research by the Employee Benefit Research Institute, workers for companies with self-insured health plans make up 58.5% of workers with health coverage compared to 40.9% in 1998. The increase has been consistent over time. This percentage varied by state, from 30.5% (Hawaii) to 73.8% (Minnesota). This number was 10.8% for companies with ten or fewer employees to 86.3% of companies with 1000 or greater employees. It is very interesting to note that in Massachusetts, a theoretical model for predicting the full effects of the ACA, the percentage of self-insured company workers has risen dramatically in small (50-99 workers) companies from 54.4% in 2006 to 67.2% in 2011 and in large (1000 or more) companies from 74.1 to 86.4%. Therefore, it is likely that the percentage of self-insured company workers will rise even more in the coming few years ahead. Regardless of the size of the company, the cost of healthcare is critical to the bottom line. In a previous post, I discussed why payers are critical to mHealth adoption. However, mHealth is critical to payers as well. And as seen above, self-insured payers are a big piece of the puzzle. I’d like to discuss reasons why mHealth is good for self-insured companies.

1. mHealth tools encouraged by a company show the worker is valued. The potential benefits of mHealth tools in the form of apps and portals remains to be demonstrated in this setting. However, the offering of tools which promote health, fitness, and self-management conveys a tie stronger than just an employer-employee relationship. It is for this reason that health insurance companies have embraced patient portals and health coaches.

2. mHealth tool utilization in employee health plans sets examples for customers and clients. Demonstrating the company’s progressive (in the non-political sense) approach to healthcare might make for good marketing to clients and customers, whether they be other companies or individual consumers. One imaginative approach would be for the company to offer some of these tools to its clients or customers.

3. mHealth tools will result in more productivity. According to the Met Life Caregiving Cost Study (often quoted today though it dates to 2006), the total estimated cost to employers for all full-time, employed caregivers is $33.6 billion annually and the average cost per employee/caregiver annually is $2110. If these employees had apps which allowed them to communicate with healthcare providers, allowed them to get test results of the patient, afforded them the opportunity for a short video smartphone or other telehealth consultation at the place of work, or for them to receive actionable alert alarms from sensors their loved ones wear, the price of lost productivity could plummet dramatically. In addition, employees themselves would benefit physically from mHealth tools which improve their own lifestyles thereby decreasing the impact of or even potentially preventing chronic diseases.

4. mHealth tools can integrate with other mobile platforms. If a company already has mobile tools for work itself, integrating mHealth apps is not a big leap. It will fit in with work flows or at least the adoption of mobile tools for other purposes. What about a reminder timed to pop up at break time to take a walk instead of chatting at the cooler, or to take the stairs prompted by a meeting reminder?

5. mHealth apps will create happier employees. Healthier employees are happier. Employees are happier if their family members are benefitting from the tools. Some of these tools have associated social communities and employees can increase bonding if they take part in them. Utilization of these types of tools or creating employee health social groups based on them might improve employee satisfaction and teamwork.

While the adoption of mHealth technologies has obvious potential benefits to all, the self-insured company offers unique challenges which are great opportunities for worthwhile products. The workplace also affords an interesting research environment for mHealth apps. They can be evaluated from many outcomes perspectives. Health coaches employed by traditional insurance companies are too costly for smaller self-insured companies. Apps offer convenience and more options. Different sectors will require apps more specific to workers with unique health challenges based on occupation. The marketplace is there. I challenge companies with quality solutions to step up to the plate.

David Lee Scher, MD,FACP, FACC, FHRS, is Founder and Director at DLS HEALTHCARE CONSULTING, LLC advising digital health companies and their partnering institutions, companies, and providers.He is a former cardiac electrophysiologist with over 25 years in patient care. He leverages his experiences as a major clinical trial investigator, human subject research committee chair, Medicare committee member, and medical device industry consultant and key opinion leader in advising clients on best product and business development practices and adoption of digital health technologies He travels worldwide speaking to professional organizations and the general public on topics related to remote patient monitoring and digital health. Board Certified in Internal Medicine, Cardiovascular Diseases, and Clinical Cardiac Electrophysiology, Dr. Scher was a pioneer adopter of remote patient monitoring. He was named one of the ten cardiologists to follow on Twitter and author of one of the ten best healthcare technology blogs. . He is senior medical adviser at Happtique. As chair of Happtique’s Blue Ribbon Panel, he oversees the certification process of health apps.dlschermd@digitalhealthconsultants.com

Do you use your computer or mobile device to research your healthcare questions?

Jonena Relth, TBD Consulting

I was a bit surprised that the newest Pew study shows that consumers are not flocking the Internet now more than in the last 12 years to research their health issues. 

As someone who is on the computer more hours a day than I'd like to admit, I can't think of a better way to start my research than to go to WebMD, Google, etc., to help me get my thoughts together and decide if I should "start panicking now" or wait until I confirmed my self-diagnosis with my Doc. Seriously, the Internet is here for our use, but it will never replace my Doc and her opinions! We should only visit reputable sites to conduct our research.  For my health, Wikipedia will probably not be the place I'll start or end my medial research...

More surprising in the study is the amount of diminishing sites created for consumers to compare drugs and medical treatments. I can only speculate on their demise, but I'd put my money on pressure from "the powers that be" and/or financial issues. 

Health data is complicated, often confusing and not always easy to find.  If access to content on comparison sites were free, I believe that consumers would flock to the sites. There is always the good 'ol American advertising avenue that the site owners could use to earn the all mighty buck so they'd keep the data up to data.

1) Take a look at the Pew study Pew: 35 percent of US adults are online diagnosers and let me know what you think.

2) Do you use your computer or modile device to research your healthcare questions?

Jonena

TBD Consulting has a proven track record for ensuring staff and physician adoption of EMR/EHR system implementations as well as Lean Healthcare. Whether you need assistance to create a training department or organizational change department, help your existing training organization meet the needs of the ongoing changes, or simply need "extra hands" to meet your deadlines or ROI goals, please contact Jonena. She and her qualified staff are here to assist you with your organizational development, coaching and training initiatives.

It’s Nice To Be Back or The More Things Change, The More They Stay The Same

Peggy Salvatore, MBA

After a hiatus, it’s nice to be back in the rotation in the Healthcare Talent Transformation blogging fold. Thank you, Jonena.

In scanning the headlines to find the latest news and reports on health IT, it is clear that while health IT uptake is moving along nicely since I last blogged here almost two years ago (!), actual health IT *integration* is slogging along.

On the plus side of the ledger, the feds have doled out millions in Meaningful Use incentives to Medicare and Medicaid doctors who bought patient record software and met some abbreviated version of compliance with Meaningful Use criteria. On the minus side of the ledger, the Meaningful Use criteria had to be abbreviated so providers could qualify for the incentives.

Just why is that? Two answers leap to mind. Either a.) the Meaningful Use criteria are too stringent to be met in the timeframe required or b.) providers and software are not prepared to meet them. My money is on a and b. An outtake from an article on Meaningful Use Stage 2 in the December 27^th edition of InformationWeek Healthcare explains:

Nearly half -- 47% -- of hospital and health system leaders are "somewhat confident" of their ability to meet the Meaningful Use Stage 2 requirements, according to a new KPMG survey. The respondents included 140 healthcare executives who completed a webcast poll.

In addition, 36% of the survey respondents said they were "confident," 4% said they weren't confident at all, and 11% didn't know what their level of readiness was to meet the criteria, which are part of the government's electronic health records (EHR) incentive program.

When asked to identify the biggest challenge in complying with the standards, the largest group of respondents (29%) cited training and change management...

… Jerry Howell, a principalin KPMG's healthcare consulting practice, in an interview with InformationWeek Healthcare…said he and his colleagues weren't surprised that so many respondents saw training and change management -- rather than technical aspects of implementation -- as their top challenges in Meaningful Use Stage 2. "We always felt reasonably confident that the leading software vendors would successfully create the technology capabilities to meet the Meaningful Use requirements," he said. Also, he noted, the transition from Stage 1 to Stage 2 is mainly about "using the technology effectively. That's contingent on the processes and people being right, which is all about change management."

The message in this blog feels as familiar as a favorite old sweater. The old sweater is this: Until we provide training to move providers up the curve to adopting health IT in a meaningful way (there’s that word again), we’ll be overlaying 21^st Century solutions on a 20^th Century mindset. And it will take a generation, instead of a few quick years, to integrate a fully functional electronic patient record system into our healthcare system, leaving us to continue to grapple with the inefficiencies and duplication that our paper-based system begets.

A vignette from a recent experience with a family member’s emergency care made it clear that things aren’t quite moving apace as we’d like to believe. A member of my family had a serious health scare over Thanksgiving, one that led us to seek an opinion at a top – some might say *the* top – healthcare institution in the US. We filled out paperwork on clipboards at several visits to inpatient and outpatient facilities. The provider did not have access to the records of the other caregivers in this person’s life in another state, and there are at
least three relevant ones, so they relied on us to provide that information either from memory or physically contacting them and providing it ourselves. We carried paper files from another “modern” facility to this hospital. We required a paper prescription to be carried in our pockets for an MRI back home, after which the physical MRI film had to be sent overnight via FedEx to be read at said top healthcare institution by their expert. Huh?

I am going to say something that nobody at the General Accounting Office wants to hear, let alone the people at Health and Human Services, which is that you just spent hundreds of millions of taxpayer dollars encouraging use of electronic patient record systems that aren’t quite ready for primetime by providers who aren’t quite ready to use them.  We’re peering over a fiscal cliff and staring at spending this money all over again sometime in the future on systems that are fully integrated by providers who are game to make them work.

It’s nice to be back.

Update: New government numbers out today show we've spent more than $10 billion in EHR incentives so maybe we can add an editor's note to the blog in the interest of accuracy.