A Few Quick Thoughts on Amazon, JP Morgan, & Berkshire Hathaway Tackling Health Care

When I recently wrote about The Year of the Partnership, this is not quite what I had envisioned. But wow – what an announcement!

I put pen-to-paper on a few quick thoughts. Here it is:

  1. I love that these big players are seeing what those of us in health care have known for a while – something needs to change (and soon). When three bigs converge on the problem, it’s exciting.
  2. The solution is going to come from the employer side. Not policy makers.
  3. The size and money that these 3 players have makes me think there will be dis-intermediation. They’ll go direct to provider (a concept generally known as direct primary care). They’ll also negotiate direct contracts with pharmacies (or develop their own pharmacy – heaven knows they have the distribution). Check the stock price of CVS and ESI.  They’re scared (and they should be). I was also educated recently by Brian Klepper who wrote an article that discussed this same topic. Until reading it, I had not known that Berkshire Hathaway had a medical stop-loss division. Interesting…
  4. How will these companies use existing Amazon/Whole Foods infrastructure to reach consumers?  This intrigues me and the possibilities are interesting. Imagine going to buy your groceries, and taking a moment to get a check up while you’re there.  Since primary care in the US is so important, I see this as a very real possibility.
  5. I hope they pay attention to the social determinants of health as they attack this.  Not everyone buys their groceries at Whole Foods, banks with JP Morgan, or has an Amazon Prime account.
  6. Innovation and technology are key – it will be interesting to see what tech is used/created here. I’ll be watching this closely.
  7. Leadership is even more important.  Throwing money at a problem doesn’t solve it. Who do these players bring in to lead this charge?  I’ll be watching this even more closely.
  8. They have their work cut out for them.  One of the large challenges in health care today is “The System” – I’ve blogged about this before.  If these big 3 players have to work with the existing infrastructure of patient data, claims data, etc. then interoperability will prove to be as big a hurdle to them as it is to the rest of us.
  9. I think these companies want to make a significant dent in health care, but spinning off one (or more) successful health care businesses is where the future takes these guys. Think of it as a giant petri dish that can conduct huge experiments on their own gigantic base of employees. If it works there, they spin it off into mainstream US health care system. Wouldn’t it be neat to see these big three companies challenge entrepreneurs throughout the world to get involved in solving the problems in health care?
  10. Sorry to end on a bit of a downer, but when you’ve work in the biz as long as I have, you are cautiously optimistic (at best). I am excited about the prospects of what could happen, but I’m also reminded of the sobering facts and history of entrepreneurs and other companies trying to make a dent in this behemoth.  So my fingers are crossed here, but I’m trying not to get my hopes up too high.
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The Year Of The Partnership

(Alternative Title: The Three “P”s – Point of Service, Platform, Partnership)

Over the last few years, the digital health space has seen a lot of new entrants, a lot of deals, and a lot of money invested.  The recently released report from Rock Health summarizes this nicely.

2017-Funding-Report_Digital-Health-Funding.001-1200x752(Graph from Rock Health’s “2017 Year End Funding Report: The end of the beginning of digital health” report).

This is great news for those of us in the space – entrepreneurs keep coming up with ideas to help impact the health care space.  Investors have money and an appetite to invest.  Buyers of the solutions still have an appetite to try new products and services.

Many of these vendors offer point of service solutions – meaning the product or service meets a specific need vs. a broad array of needs. An example of this would be a weight loss tool or a diabetes management service.  It serves a singular purpose.

By comparison, platform solutions are designed to provide a number of services. A wellness platform could cover weight loss, exercise, nutrition, challenges, rewards, smoking cessation and other services. A disease management platform may tackle diseases such as asthma, diabetes, congestive heart failure, coronary artery disease, depression and others.

I’ve not counted the number of recent entrants that offer point of service solutions vs. those that offer a platform solution, but based upon my own view of the landscape, we’re seeing more point of service solutions.

Is this a bad thing? Not necessarily, but it does pose a challenge to the customer.

Lets assume that a startup vendor is offering a diabetes management solution to self-funded employers.  The customer in this case is the self-funded employer.  And lets assume that the employer may already have a disease management vendor handling diabetes as well as other conditions.  This disease management program may be something the employer purchased on their own or it could be part of their medical insurance carrier’s offerings – meaning it’s being paid for already.

But if the point of service solution is a better option (perhaps due to the fees at risk, or the solutions impact on the employees with the disease), then the employer is stuck paying more money for the startup vendor in hopes that the medical savings will offset their spend on the solution.

Then take into account that there are a multitude of point of service solutions in the diabetes management space.  The equation gets more complicated.  Now consider more point of service solutions are bringing other disease specific solutions to the market.

The vendor landscape for the customer becomes quite crowded and blurry.

Up to now, I’ve discussed point of service solutions and platform solutions.  How does the last “P” – partnership – fit into this crowded picture?

When I speak to early stage digital health companies offering a point of service solution, we inevitably discuss who their “customer” is.  Is it the health plan?  A hospital? A self-funded employer?  The employer’s benefits advisor?  I suggest a new customer – an existing point of service vendor or platform vendor.

What is often overlooked, and what I predict will happen more in 2018 and beyond, is the partnership model.  Organizations that offer a platform solution will reach out to point of service solutions (or vice versa) to bring a best-in-class platform offering comprised of point of service solutions.  Or two complementary vendors will announce a partnership like the recently announced Solera Health and WellDoc partnership or the Springbuck and Healthjoy partnership. The self-funded employer will benefit from a consolidation of strong point of service solutions in a one-vendor platform thus making it easier for the benefits team at the employer to manage the vendor while deriving maximum benefit for the services being offered.

I attend a lot of events with startups and VCs and typically the speakers are asked for a prediction for the future.  With this in mind, I’m predicting 2018 (and maybe 2019) to be the year of the partnership.

Let’s see how many of these things pop up this year…

 

Innovation Isn’t the Challenge – It’s “The System”

The world is constantly evolving and innovating – it’s sometimes hard to keep up as an individual.  A year or so ago I did not have apps on my cell phone to pay parking meters, but now it’s available in most places in Boston. I have friends who have children in little league and there are apps to update game times and locations or send notices about practice cancellations.

Health care is a business that is not immune to innovation, though some would argue the obstacles we’ve created for ourselves in health care are making this industry immune to innovation.  Lack of interoperability and access to meaningful data, complex provider contracting and reimbursement, fragmentation – “The System” has a way of fighting against progress, I’m afraid.

Yes, I used quotes around “The System”.  How does one define “The System”?  It is the legacy technology, processes, and thinking that has led to (and perpetuates) the fragmented delivery system we use today.

While working at a former job, I was struck by “The System” and a how it creates obstacles to every day innovation. There was a strong push for telemedicine visits in lieu of office visits.  The vendor said it would save money, but the employer wanted proof of its impact.  How did “The System” fight this?  At the time, there were no ways to code telemedicine visits – they only showed up as office visits in claim files – thus no way of measuring adoption or potential cost avoidance of the new tele-health programs.  “The System” – 1.  Innovation – 0.

How about this article?  “The System” is enough to make even the most forward-thinking, “can-do” entrepreneur re-think his or her entry into health care.

“The System” is a formidable opponent to innovation.  But it won’t win.  In fact, it can’t win.

I’m struck by the push for machine learning and artificial intelligence in health care and even more curious to see how the coming advances will change “The System”.  Some say it will occur fast. Others say 3-5 years or longer.  My guess is that the “fast” adoption will not be quite as noticeable or impactful as some are saying.  The real impact will be felt when innovations are used to re-create, re-invent and, in some cases, replace existing systems and processes.

In any case, I’m hopeful that the innovations coming in health care will not let “The System” get the best of them.  Innovation will find a way and will lead to a better future for all of us.

“Exchange” Is Becoming A Dirty Word

Did someone just say the “E” word?

The world of insurance and employee benefits has changed immensely in the last few years.

After the passage of the Affordable Care Act, the word “exchange” was all the buzz.  To some extent, the concept of an exchange had existed for years, but the ACA brought it to the forefront of insurance and employee benefits.  “Obamacare” was being discussed and debated and each state was faced with the challenge (or opportunity – depending on how you looked at it) of establishing a state-based exchange or defaulting to a Federal model.

The public sector was not the only area seeing the emergence of the “e” word.  The private sector saw two main flavors of exchanges gain popularity – the first being large consulting house benefit exchanges and the latter being tech companies empowering small to mid-market brokerage firms as well as insurance carriers with technology designed to enable a better user experience when purchasing insurance.  This included decision support tools, cost calculators and other tools along with the employee’s choice of insurance plans.  Tech companies saw an opportunity to inject a much-needed dose of innovation (or at the very lease, 21st century technology) to a sleepy old process.

And the word “exchange” was being thrown around as much as Tom Brady throws a football in the 4th quarter of a game when the Patriots are trailing.

So here we are – 2017. What has changed?

Many federal and state exchanges saw a dip in enrollment.  [Note that some did see increases this past year]. Exchange-empowering tech companies are being bought and sold.  Both public and private exchanges aren’t seeing the types of enrollment originally predicted (though there is still time, I suppose). And saying the “E” word may get your mouth washed out with soap.

I have had conversations with executives at some of the national insurance carriers and each one is questioning the popularity of exchanges. Most are questioning their continued participation. Others are questioning if exchanges will even survive.

This shift can be attributed to low enrollment or the election of President Donald Trump and the Republicans now positioned to make good on their “repeal and replace” threat regarding the ACA.  Despite the vast differences between public and private exchanges, the ACA = exchanges and therefore the private exchanges are guilty by association.  These, in my opinion, are not a major reason for the souring of benefits consultants and HR workers to exchanges.

So what is it?

Let me back up a moment.  What, exactly, is an exchange?  Depending on who you ask, you’re likely to get multiple answers.  And rightfully so. There are a number of models out there.  I daresay that the most simplified definition is technology-enabled (or technology improved) employee benefits enrollment that often times comes with more employee selection than historically seen and – maybe – some components of employee engagement and cost savings that, arguable, are in their infancy. As a Senior Vice President of Sales at a Massachusetts health insurer recently reminded me, the move from defined benefit to defined contribution is also the staple of a private exchange.

Now we have more technology and more choices. But has it really changed anything? Are costs going down?  Is the health of an organization’s employees improving?  Or has the exchange technology, though improved, added costs without saving money?  Currently, I think we’re looking at increased cost without enough improvement. I would argue that the health insurers I’ve spoken with feel the same. Yes, many employees have bought down to high deductible health plans, but without the necessary tools to become stronger health care consumers, the impact on health status and cost is unlikely to be impacted.

With any new trend, it needs to deliver on its promises. And the promises were mixed, depending on which type of exchange you were talking to.  The initial models that were rolled out are being tweaked, improved, changed.  And though enrollment in private exchanges is not what was projected, they’re still very much alive. They’re not going anywhere.

My prediction – the models we see today will be improved.  There will be more consolidation.  The remaining dominant designs will need to move onto their next iteration. There is only so much that can be done around the “shopping experience” so the shift will be towards engagement – and rightfully so.  And with engagement will come the tools for members to become better consumers of health care. And that (hopefully) will lead to improved health and lower costs.

We may see the word “exchange” be retired or replaced by some other name, but the promise of exchanges will continue to evolve.

 

 

What Still Needs To Change

Regardless of the uncertainty regarding the Affordable Care Act and the Republican’s “repeal and replace” cry, there’s something that has been missing in health care.

Engagement.

I’ve written about this in the past and it continues to be an issue.

The ACA, passed with the support of the Democratic party, moved us down the path of universal coverage. Health and Human Services (HHS) stated in early 2016 that 20 million people now had coverage under the ACA. This doesn’t include the 2017 open enrollment numbers as we’re still in open enrollment. Having more people covered is a good thing.  Yes, there’s a question about adding people to a system that can’t control costs, but from a health standpoint, having insurance is arguably better than not having it (especially if you have a medical condition of some sort).

The Republican party has not yet agreed upon one approach, but they have options.  One item I’ve noticed is the push for transparency – the ability to know what you are paying for when you consume health care.  This is also an area that needs a kick in the pants.  It’s maddening to go to a health care provider and, while at the registration desk, agree to pay for any out-of-pocket expenses – WITHOUT KNOWING WHAT THEY WILL BE.

As maddening as this is, I still say that getting covered and having transparency doesn’t do anything without…say it with me…engagement.

I can have health insurance coverage. I  can have tools that let me see what things cost.  But if I don’t actively engage in my health – and I’m talking all facets of health – then problems remain.

So how would I define engagement?  I suppose there are many ways, but let me start with this:

Knowing how to choose the right health plan for you and your family, eating healthy, staying on a medication regimen when prescribed, questioning treatments prescribed by your doctor to prevent over-treatment, exercising, arming yourself with information before seeking care, utilizing all the great tools that employers offer to their employees to manage their health, understanding your chronic condition and actively managing it, knowing when to go to ER vs. urgent care vs. telemedicine visit, etc. etc. etc.

Yes, there’s a lot here.  But it’s our duty as consumers of health care to engage in our own health.  That’s not a small order, I know.  And sadly, a great deal of engagement is missing.

Understanding the Past, Building the Future: Health Care – from Xerox HR Insights Blog

I’m very excited to share a post from my employer related to the past and future of healthcare.

To celebrate our 100th anniversary, the consulting practice leaders from the UK, Canada, and the United States were asked the following three questions:

  • How have things changed in their fields in the past 100 years?
  • What are the biggest challenges they – and their clients – are about to face?
  • What’s the most exciting thing they speculate is coming along?

My friend and global health practice leader, Hope Manion, wrote a piece for this and she was kind enough to mention me.  She and I discussed some of these topics prior to her writing her piece – I’m pleased to have helped!

What’s Transparent Is This – Engagement Is Missing

Last week, The Journal of the American Medical Association (JAMA) released the results of a price and transparency study.

Though I do not have access to the full study, I read the brief excerpt including this:

Conclusions and Relevance:  Among employees at 2 large companies, offering a price transparency tool was not associated with lower health care spending. The tool was used by only a small percentage of eligible employees.

Anyone else have a “whoa” moment after reading this? (I’m guessing it will only be the health care geeks out there who have this moment.)

With the continued rise of high deductible plans and the push towards consumer directed health (where a member/patient takes a more active role in shopping for and consuming health care services), the need for a cost and transparency solution was a market need eventually met by a number of organizations.

Coupled with the exchange phenomenon – both private and public – and it appeared the market would be drawn to such tools in droves.  But as this study shows, people are not using the tools.

Should we be surprised at this conclusion? No, we shouldn’t.

We can push transparency and we can offer incentives. We can conduct payment reform and change how we pay for healthcare. We can insure the entire country and set up national work groups to look at quality, efficiency and costs. And perhaps tools and services will be brought to the market to help in these areas.

But if the patient doesn’t get engaged, then you may (still) see a consumer make a poor decision by not questioning a referral to a particular doctor or hospital. You may (still) see a patient select the lowest quality, highest cost hospital for a particular condition.

Engagement has been missing – and it appears it still is. Until we have an engaged health care consumer, price and transparency tools (along with anything else brought to market) will continue to see low utilization.