26 + 2 + 21 + 2014 = ???

Judge Roger Vinson.  If you don’t know the name right now, it’s a name you’ll know by the evening news tonight (that plus more coverage of the upcoming storms in the Northeast – ugh.)

Judge Roger Vinson of Florida ruled today that it is unconstitutional to require individuals to purchase health insurance.  So far, two judges have ruled that it is unconstitutional – the first being Judge Henry Hudson of Virginia.  He is now joined by Judge Vinson who has taken things a step further stating that “…because the individual mandate is unconstitutional and not severable, the entire Act must be declared void.”

So far, twenty-six states have sued to block passage of the health reform bill.

And since the individual mandate (read “tax”) is viewed as the key point for the health reform bill to actually work…where does that leave us come 2014?

This is not a symbolic act by the GOP to vote down the legislation in the House.  This is much more than significant.  This is a federal judge stating that the whole bill needs to be thrown out because the individual mandate cannot be severed from the rest of the bill.  And he’s right.  If you take away the individual mandate, the bill that was passed will fail miserably.

I must say, I love this country.  The balance of power that makes the U.S. Government what it is spreads the decision-making amongst the three branches: Executive, Legislative, and Judicial.  This isn’t the government shutting off the Internet to quell uprisings. 

So far we know that the House voted to repeal.  We also know that in the very, very unlikely event that the Senate votes the same way (insert Nancy Pelosi laughter here), the President has already said that he would veto it.

But the Judicial branch may well be the wild card in this equation. My grammar school math tells me that 26 states is more than half of them.  My understanding of the conservative states means that we may soon see other judges making similar rulings to Judges Hudson and Vinson.

What does this all mean? Time will tell.  But I’m getting my popcorn ready now for the battle royal event that will likely occur in the Supreme Court sometime between now and 2014. 

Hmm…my hot buttered popcorn may be cold and soggy by then. Maybe I’d better just wait for the 2012 elections instead.

And what is the “21” number in the title you’re asking?  Why it’s the predicted snow fall north of Boston expected this week.  For those who aren’t from the area, it’s bad. I know this because the local media is measuring the snow fall in Shaq inches

Man, I wish it was being measured in Spud Webb inches instead. 

(For those non-NBA fans out there, Spud is the one on the left – #4 for Atlanta. The other guy, Manute Bol, was 7 feet, 6 and 3/4 inches tall.  That’s what’s next if we surpass Shaq inches, I guess.)

Now if you’ll excuse me, I’ve got to shovel out my driveway (again) so that when the time comes to pick up my hot buttered popcorn, I’ll be able to do it without getting stuck.

Can You Find Me Now?

Mobile technology in healthcare is booming.  Perusing the front page of Fierce Mobile Healthcare will show you that there are wellness apps for cell phones, cell phone-based health tracking for wounded soldiers, ECG smart phone apps, and iPad tracking apps for seniors.  According to NaviNet’s blog, there are already more than 6000 health-related apps in the iTunes store and by 2015 there will be over 500 million using health apps around the world.

Some of the big boys in the industry are pouring tons of money into this market – WebMD, Google, Apple…the list goes on and on.  

With many Americans ditching the old land lines and relying solely on a cell phone coupled with physicians needing to become more streamlined in their care of patients, it seems mobile healthcare is a prime target for continued growth.  In fact Health IT Analysts at Chillmark Research predict that by the end of 2014, this market will grow to $1.7 billion. 

There’s some concern over who’s vetting these apps.  But I have another concern: what the heck happens when you lose your phone?  What happens when your iPad is stolen?  What happens when there is a theft at a medical center?

In 2006 Advanced Wireless Solutions, a software firm based in Burbank, California, noted that more than 37 million cell phones are lost, stolen, or damaged every year in the United States.   Specific to theft, it’s likely that these numbers have risen since 2006 due to the economic downturn.

And what about the cost of a lost cell phone?  Just ask the Department of Mental Health and Addiction Services in Connecticut about it. Keep in mind the example in that link highlights only the charges for calls and downloads.  What if there were Protected Health Information (PHI) involved? It could cost even more – like someone’s job.

This does not include the hundreds of thousands (dare I say millions?) of dollars that will likely be spent in legal fees (trials, settlements, etc.) when (not if) PHI is jeopardized.  My guess is that the HIPAA police will come down hard on early offenders to encourage better security.

Now, I know there are now smart phones with GPS devices that can help locate a lost or stolen phone.  But not before data is stolen, I would imagine.  It’s like a Lojack device in your car. They’ll find the car, but not before your tires and radio has been removed.

Why am I pointing this out?  Because this is something we should all be aware of.  The use of health apps on mobile devices amongst the general public is still in an early stage and will continue to grow leaps and bounds in the coming years.  It is far too easy to download one of these apps to your cell phone without thinking of the risk if the phone is stolen. 

And if inter-connectivity in healthcare continues to grow, how difficult will it be for a tech-savvy thief to tap into your records using a stolen cell phone’s healthcare apps? If you thought identity theft was bad, just wait until your medical history is broadcast to the masses. 

Having charges rung up on your credit card is fixable.  There are protections against it.  But what if your history of mental illness or your chronic illness is made known to all?  There’s no taking that back. As Tom Waits says, “You Can’t Unring a Bell”.

(Employers with self insured plans, please take note – your HIPAA responsibility and compliance burden is greater than those of an employer offering fully insured plans.)

Perhaps vendors will put PHI/HIPAA warnings each time an app is downloaded. In fact, they should.  Leaving it to John and Jane Q. Public to police their own health data does not strike me as the most prudent approach. 

So another word to the entrepreneurs out there: figure out how to protect lost/stolen mobile devices from PHI theft and you’ll be a go-zillionaire.  And I hope you’ll remember the guy who gave you the idea.

By the way…with all of this talk of mobile device use in healthcare, does that mean I still have to turn off my cell phone when visiting a sick relative in the hospital?  Someone needs to explain to me how this is going to work.

Now if you’ll excuse me, I need to find the “Can You Hear Me Now” guy and see what his plan is to protect PHI.

The Benefits Package, 4th Edition, Up At Benz Communications!

As Jen Benz puts it, “The best articles from around the web on everything from healthcare reform to wellness” 

I couldn’t have said it better myself!

So here it is: 4th Edition of The Benefits Package complete with articles from Bob Merberg, David Harlow, Carol Harnett, Fran Melmed, Hank Stern, David Ballard, Evan Falchuk, Jason Shafrin, John Hollon, and Michael Cannon.

The Benefits Package has been hugely successful since Evan Falchuk rolled it out late last year on See First.

Keep it going! If you are a healthcare or benefits writer/blogger, submit one of your own articles!  Or simply share The Benefits Package with a friend!

Find A Happy Place

With the GOP mounting an assault on the Health Care Bill and the Senate being pushed to vote, writers and bloggers are having a field day writing about it. I figured it was time I joined in.

I read the other day on The Healthcare Blog that the assault may backfire if the GOP isn’t careful.  A good point, and something that should be watched closely.

The blogger, Robert Reich, continued saying that the individual mandate is the key point of the law with which the American public has a problem.  But it is also the most needed point as the young(er) people will even out the risk pool thus assuring a more evenly distributed risk.  If they’re in and then they back out, it will death spiral.

So why do young(er) people have a problem with the individual mandate?  Being the schmaaht fellow that I am, it didn’t take me long to figure out that they likely don’t have the money in addition to being forced to buy it.  And being forced to choose between buying groceries or buying health insurance isn’t a place they’d like to be. Neither would I.  Not to mention the fact that overall they’re probably feeling pretty healthy and don’t see the need.

However, the bill has been passed. 

So how can we all find common ground here? How could we find a happy place?

Let me state for the record that I am not a fan of the Health Reform Bill that was passed. Though there are some good (and needed) aspects to it (ex. no pre-existing condition limitations, no lifetime limits, change to Medical Loss Ratio or MLR, coverage for dependents age raised, improved preventive care coverage), it failed to adequately address what I feel is the most important issue in healthcare today – costs.

In short, we’re adding 32 million people to a system that already has problems controlling costs.  Not schmaaht.

This got me thinking again…thinking about a happy place.

Perhaps the HCR Bill wouldn’t be such a bad thing if the cost issue were addressed first. 

Young(er) people don’t want to be forced to buy health insurance because it’s expensive and they don’t have the money (maybe due to the economy they are unemployed). So if we did a better job of controlling costs, insurance would be more affordable.  If insurance were more affordable, then young(er) people would be more able to afford it.  If they were more able to afford it, then passing legislation requiring them to buy it wouldn’t be met with such opposition. And maybe, as an added bonus, if healthcare costs didn’t make up almost 18% of the GDP, maybe there would be more jobs.


Of course, I’m purposely and ridiculously over-simplifying. Or maybe it’s that I wrote the majority of this on a Friday afternoon a week and a half ago and am just now getting around to publishing it. 

But it does emphasize something.  Maybe our elected officials should have looked equally at the cost issue in addition to the access issue. 

I think a more effective approach would have been to make insurance more affordable and available (read: not tied to employment, promoting competition to drive down costs) for those who are unemployed with an individual mandate coming later (2014 or beyond).  Between now and then, the focus should be on cost controls while improving quality and outcomes. That, coupled with a government focus on creating jobs would put this country in a much better place to accept the individual mandate down the line. And don’t forget malpractice reform.

(Note: I’m not tackling the legality of the individual mandate as it relates to the Commerce Clause.  Others like Falchuk and Malkin have done a fine job doing this already.)

Here’s my analogy of the day: the bill has mandated that everyone has to drive and the government has built $50,000 cars for everyone in America to drive when the most that 10% of the population can afford is $25,000.  Oh, there is still the issue that there aren’t enough roads to get where folks need to go!

So a word to those in government (today and tomorrow): While you’re building the roads, be sure to focus on making the car affordable before you require that everyone drives – oh and make sure they’re built in America, because that helps create jobs, reduce unemployment, and allow more people to afford health insurance.

See?  Win-win for everyone!  We’ve found our happy place!

Now if you’ll excuse me, I need to co-sign a loan for a family member.  He’s being forced to buy a $50,000 car on a $40,000 per year salary. Man, I hope he doesn’t default on the loan…

Payment Reform, Dartmouth Atlas, and Entrepreneurs – Oh My!

This time around, it will be different. Right?  This isn’t capitation from the mid-90s.  No, this is risk-adjusted global payment tied to quality and outcomes.

Good. Great, even.  Heck, Massachusetts is on board. A number of the large insurers in Massachusetts have global payment contracts tied to their HMO providers.  In fact, the CEO of Blue Cross Blue Shield of Massachusetts, Andrew Dreyfus, is taking a strong stance with the hospitals and providers who do business with BCBSMA that aren’t currently participating in their Alternative Quality Contract get on board or else.

Clearly there is a push to change the current payment system.  The recent advent of Accountable Care Organizations (ACOs) is another vote in favor of payment reform.  By making doctors and hospitals eligible for shared bonus if they are “accountable” for the patient’s health, better outcomes will follow. (There may be an impact to patient choice, as well, but I digress).

So here you have a shift in how things have historically been done. It’s no longer business as usual.  It’s changing. And with change comes opportunity. 

I’m wondering if there are any business-minded professionals with entrepreneurial spirits that are looking at this push towards accountable care, global payments and the like and thinking, “Hmmmm….is there a way to game the system?”

Why, yes, there is!  Or at least there appears to be a way to stack the deck in your favor a bit.

Have you ever heard of the Dartmouth Atlas of Health Care? If not, take a look.  If yes, let’s continue with my example.

You are an entrepreneurial person with cash in your pocket and you want to invest in healthcare.  You decide to set up a new health center or hospital.  Providing you can get approval from the CON program in the area, one of the key considerations is where to set up shop.

Let’s go back to the map, shall we?  By searching a particular region one can look at a number of statistics such as hospital utilization, Medicare spending, hospital care intensity or physician utilization (to name a few).

Is it possible for a business-minded person to choose a location that would maximize his or her potential reimbursements under a global payment arrangement?  

Think about it.  If there is a region of the country that statistically and historically had a lower utilization of hospitals and doctors, fewer surgical procedures, high ambulatory care quality and strong patient satisfaction results…could one deduce that people in that region are not large consumers of care and, when they do, they are directed or geared towards less intrusive (read less costly) interventions?  AND the area has strong patient satisfaction and quality results?

Our entrepreneurial friend from my example would benefit from these new payment models due to better patient outcomes and better patient satisfaction results achieved through less intrusive and less costly healthcare interventions. Conversely, a doctor practicing in a high utilization area with poor outcomes may not view the push towards payment reform very favorably.

Does this sound far-fetched?  Maybe a little.  But the idea has merit. 

Is there a place in the United States, a Welltropolis filled with educated healthcare consumers who opt for less intrusive, less costly interventions before being put under the knife or being put on five different medications?

Is there a place where physicians utilize evidence-based guidelines for medicine more than another region?  A place with claims-based analysis of effective care helps determine what the next best step for appropriate medical care will be?

Boy I hope so. And I hope it’s within driving distance to my home.

Now if you’ll excuse me, I’m going to the bank to secure a loan to build a new hospital and figure out the best location for it.

In Good Companies, Volume I

Working at an insurance brokerage and consulting firm, I have the privilege of seeing some very innovative companies who work with clients at the firm.  I also do quite a bit of research myself on various health care companies – it only helps me to do my job as a client advocate better.  Some of what you’re reading below is research I’ve gathered on my own.

With that said, I thought it would be sort of neat to highlight some of these companies in a piece I’m calling “In Good Companies”. Here are a few in no particular order. If my blog does not do them justice, check them out for yourselves!

1)  WhiteGlove House Call Health:  If you thought the days of a visiting doctor were over, you’re wrong! Well, sort of.   If you don’t mind a nurse practitioner, then this company deserves a look.  Imagine this: when your child is sick, you may need to see the doctor.  If you work, then you need to get approval to leave work.  And then you have to go to the school to pick up your child.  Then wait in the doctor’s office.  And wait.  And wait.  Then, you’re seen, the child is given a work up, and the doctor recommends you fill a prescription. So it’s off to the pharmacy to wait…and wait…you get the point.  It’s basically a day off that you hadn’t planned.  But what if a nurse practitioner came to you?  Yes, came to your job or to your home.  After 5 pm.  When it was most convenient for you.  No loss of productivity. And the NP came with a bag of goodies (meaning the most common prescriptions) so that it can be filled right then and there.  Just pay the visit “co-pay”. But it’s not really a co-pay because this never even hits your insurance.  Wow.

2) Castlight Health: In an age of rising deductibles, patients are being forced to learn more about their own health costs.  The problem is that the data isn’t exactly easy to find.  Until now.  By working with employers and insurers, Castlight Health raises the curtain and shows its clients the wizard behind the curtain.  By using historic claims data, Castlight determines the actual medical costs based on the actual medical plan that the employer has. Talk about a need in today’s system!  Imagine this – you’re thinking about whether to have surgery, but you’re in a high deductible health plan (note: this service works best with this type of product) and you have no idea what your out-of-pocket will be.  Well, if that’s the case, go talk to your HR Director and ask them to call Castlight.  I think you’ll be pleasantly surprised.

3) Best Doctors:  I’ve heard them described as “a second opinion on steroids” but that description does not do them justice. With current payment models in today’s healthcare system, doctors spend less time with each patient and try to crank out as many patients in a day as possible.  Hey, it’s not their fault. They’re just trying to do the best they can in the system in which they work. But this can lead to mistakes…mis-diagnosis…that’s where Best Doctors comes in.  Give them a call and their team will take the time to view your diagnosis, your planned treatment, your medical records, your history, etc. to assure the recommended treatment plan is the best for you or to uncover a missed diagnosis. And this is just their InterConsultation model! Check out their website and learn more. And if you have time, check out the flash mob dance party too.

4) Hea!thrageous:  Technology is one of the biggest winners with the PPACA.  And here’s one company that’s jumping into the thick of things.  A personally connected healthcare company spawned from the Center of Connected Health, a division of Partners Health Care and founded by Brigham & Women’s Hospital, this organization transformed from an R&D company into a full-blown connected health care company.  They enable an individual to take meaningful and impactful action after having biometric data analyzed and then having an individualized wellness program put together…and delivered to you in the way that you choose (ex. cell phone).  Apparently real-time dynamic personalization makes a difference!  And Hea!thrageous is helping folks become healthier.

5) MedMetrics:  Ever hear the term PBM?  If yes, ever hear the term carve-in vs. carve-out?  Or AWP?  Or discounts? Or rebates?  Well, don’t feel bad if you don’t know what any of this means. But know that it contributes to your drug cost as your organization or your health plan probably uses a PBM for its prescription drugs and the PBM is making money somewhere.  This isn’t a bad thing necessarily. It’s just how business is done today.  Or…at least it was.  How about a not-for-profit PBM that partners with their clients to provide best-in-class clinical solutions to lower their client’s costs.  Oh, and they also provide 100% pass-through on drug pricing.  That’s right.  Transparency at its best.

That’s it for this inaugural “In Good Companies” blog.  If it goes over well, I’d like to do this again.  So if you work for an innovative health company and would like it showcased here, drop me a line!


[Disclaimer: I am not receiving any compensation or bonus from any of these companies to do this. This isn’t an endorsement of these companies based on personal or professional experience.  I do not speak for my employer.  This post does not influence client placement or recommendations to clients. I just think it would be neat to showcase some great minds and great companies at work.]

Benefits Package, 3rd Edition, up at InsureBlog!

What a way to start Monday morning!  Coffee, cereal, and the Benefits Package Blog Carnival!

Check out the 3rd edition of the Benefits Package, hosted this time around by the folks at InsureBlog.

You’ll read posts from Michael Cannon, Anne Freeman, David Williams, Evan Falchuk, David Harlow, Jen Benz & Ed Bray, George Van Antwerp, Kester Freeman, Keith McCurdy, and of course, Hank Stern!

Phew!  This list keeps growing!  If you want “in” next time around, be sure to get your post in! The next edition will be hosted by Jen Benz at Benz Communication – be sure to check it out!

Acronyms Beginning with “A”, Please

Perhaps you’ve heard of the term “ACO” or Accountable Care Organization.  And if you live in Massachusetts or are an avid follower of healthcare events, perhaps you’ve heard of the “AQC” or Alternative Quality Contract that Blue Cross Blue Shield of Massachusetts rolled out a few years ago to its providers.

There are some real similarities between them…and I’m not talking about the fact that both are healthcare-related acronyms that begin with the letter “A”.

First, a little bit of information about each of them…

In an Accountable Care Organization (ACO) providers will theoretically create teams of clinicians to manage patients and patient outcomes. (I say theoretically because ACOs are still in an infancy stage.  Some experts have ideas on what they should look like. But I digress). Providers will be eligible for shared savings based on their ability to hold down overall costs and meet quality goals which will lead to better outcomes.  The best outcomes will be achieved by managing each patient as part of a cohesive team that shares data and information and works together to achieve the best outcome.

If ACOs take hold, it would stand to reason that an ACO provider’s best chance at achieving the most favorable reimbursement is to manage the patient within their own team of doctors at their own hospitals to assure quality and control costs. Any movement to providers outside of the “group” would mean loss of control which could negatively effect payment of the shared savings.

With the Alternative Quality Contract (AQC) from Blue Cross Blue Shield of Massachusetts (BCBSMA) a hospital or physicians group enters into a new type of contract with BCBSMA.  It is a budget-based contract whereby the provider is given a global or fixed payment per patient which is adjusted annually based on health status and inflation.

In addition to the fixed payment, the provider has the ability to gain “substantial performance incentives tied to the latest nationally accepted measures of quality, effectiveness, and patient experience of care” (quote taken from the AQC website because I couldn’t think of a better way to say it).

By design it would appear that providers operating under an AQC arrangement will be motivated to control each patient’s care with providers in their facilities/groups who are also under the AQC to achieve quality “gates” and increase reimbursement.  The more control they have, the more easily they can manage each patient to the best possible outcome.

Both ACOs and AQC provider contracts are creative ways to align quality and payment, focus on the patient, and move away from the fee-for-service arrangement.  In theory, both are steps in the right direction.

But will there be any fallout?  I’m thinking yes.

When last I checked, the AQC contract applied to doctors contracted with BCBSMA’s local HMO products – local meaning Massachusetts HMO and New England HMO.  Applying it to PPO contracts was still in the works due to the challenge that a PPO model poses (no gatekeeper, ability to see any provider makes managing any single patient tricky…and paying the providers in an AQC fashion even more tricky). But if it is rolled out to PPOs, I would guess that a lot of health plans nationally will be watching it closely. And if it works the general concept, an AQC-like contract, will be adopted.

Also, Medicare beneficiaries are only going to increase in the years to come as baby boomers hit age 65.  If ACOs take hold, there will be an influx here as well.

So now you have a large number of patients managed under an ACO or AQC arrangement. Both allow additional reward for providers who increase quality and lower costs.  Both models tie additional payment to his/her ability to achieve such goals.  And let’s not kid each other – the hospitals and physicians who enter into these types of arrangements will be looking both at the increased quality as well as the additional compensation that is being dangled.

What happens when a patient wants to see another doctor who is either not under an AQC arrangement or not part of their ACO panel?

My guess is that a provider under an AQC arrangement will not be too thrilled about referring a patient to a provider who is not under an AQC arrangement as it could adversely effect the AQC provider’s reimbursement.

Similarly, an ACO provider will not be too keen on referring a patient outside of their ACO as this could adversely effect reimbursement.

I don’t believe there is a rule about whether or not a Medicare beneficiary assigned to a particular ACO will be allowed to move outside of that ACO.  My current understanding of the ACO rules/guidelines is that a Medicare beneficiary is allowed to choose any provider they’d like.

In reality, moving outside of an assigned ACO means less control for the provider and could impact their opportunity at shared savings. I’m wondering how long it will be before ACO providers are pressuring CMS to “dissuade” Medicare beneficiaries from moving outside of their assigned ACO.  (Read: apply an additional cost to the patient to move outside their ACO).

I will also not be surprised if health plan members managed by an ACQ provider will somehow find their wallets/purses lighter if they choose to seek care outside of the AQC provider’s walls.  AQC providers will look to protect themselves and negotiate this sort of clause into the contract.

Because when you mess with physician payments, there will be repercussions.  And a likely candidate in these scenarios will be patient choice.

I recently blogged about the effect on patient choice related to Tiered Networks.    Is it possible that ACOs and AQC-like provider contracts will have the same outcome as it relates to patient choice?

Time will tell.

Now if you’ll excuse me, it’s time for me to move my physician’s cheese and see what happens.