Health Business Blog

The Imaging e-Ordering Coalition is a group of medical imaging-related companies that are striving to have electronic ordering of diagnostic imaging coupled with e-prescribing as part of the Federal government’s incentives for health information technology adoption. A not-so-hidden objective of the Coalition is to counter the influence of Radiology Benefit Managers (RBMs). From a June press release:

According to the Coalition, e-Ordering prevents many of the potential issues associated with radiology benefit managers (RBMs), which are organizations employed by some healthcare insurers to manage utilization and costs associated with high-tech diagnostic exams.  Concerns with the RBM model include regulatory oversight and a manually burdensome “prior authorization” system whereby physicians must receive approval before ordering an imaging service.  Under prior authorization, patients are often denied the imaging studies their physicians believe are warranted, are steered towards lower-precision tests that may not provide needed clinical information, or are forced to wait days or weeks to receive vital imaging services.  e-Ordering, on the other hand, provides physicians real-time, electronic access to pre-exam, case-by-case decisions that are linked to published, evidenced-based clinical studies and are tailored to a patient’s specific circumstances.

I spoke today with Scott Cowsill, co-founder of the e-Ordering Coalition. In addition to Scott’s role with e-Ordering he is an employee of Nuance Communications, one of the Coalition members. Other members include the American College of Radiology, Center for Diagnostic Imaging, Connecticut State Medical Society – IPA, GE Healthcare, Insight Imaging, Life Image, Medicalis and MedCurrent.

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David Williams interviews e-Ordering Coalition founder Scott Cowsill Play Now | Play in Popup | Download

Three years ago in Hooray for Hospitalists I described how a good hospitalist program works and how common problems can be avoided through the use of call centers and well-developed and implemented protocols. Today I received a disturbing comment from Eleanor, that I thought deserved to be featured as a main post. Here it is:

Hospitalists caring for my elderly mother never contacted her PCP to find out why he admitted her (to come off Coumadin so that a test of ascites fluid could be done). Instead they doubled her dosage of Lasix and kept her on Coumadin for 5 days hoping that the ascites would “go away.” It took five days of leaving messages before I could find one to talk to, and I demanded that he call her PCP. Finally he did call the PCP, took her off Coumadin and did the test. She was so weak from the 12-day hospitalization (PCP said it would be “three or four days”) that she had to go to a short-term rehab facility. Hospitalists had taken her off Coumadin so didn’t put Coumadin on the list of her meds when she was transferred to the rehab facility. Took me three days to realize she wasn’t getting it and to get her back on it. Hospitalists could not put her back on it because she had been released from the hospital. Rehab’s attending physician could not do it because she had no medical history indicating a need for Coumadin. PCP had no authority at hospital or at rehab center. Unbelievable! Hospitalists wouldn’t talk to me (health care proxy) because Mom was “lucid.” But she is also blind and almost deaf so their explanations of proposed treatment were useless. She was never an “informed patient” and never gave “informed consent” to anything. She was terrified, and I was, too.

Another story: A friend’s elderly husband had chronic diarrhea and incontinence for many months. When he was admitted to an ER for a possible stroke, the hospitalists put him on a prescription-dose of laxatives. Laxatives? For a possible stroke?? In a patient with chronic bowel problems? What were they thinking? Who are these people? Where are they trained? The theory of hospitalists may be excellent, but we need educated, competent, “common sense” physicians filling that role. Those are qualities that the family PCP brings to patient care and they’re sadly lacking with the hospitalists we’ve encountered so far.

These are pretty bad situations. I wish the solution were as simple as banning hospitalists. Unfortunately I’ve heard similar stories about hospitals that don’t involve hospitalists, and not every PCP is as responsive, useful and competent as we might like. As I’ve said before: Going to the Hospital? BYOMD.

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Laika’s MedLibLog hosts the latest Grand Rounds, complete with a bonus section.

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This is the second half of the transcript of my recent podcast interview with MEDecision CEO and founder David St. Clair. Part I is here.

David Williams: There’s been quite a demonization of the health insurance industry as part of the debate about health care reform and in particular challenging whether health plans actually add value or whether they’re just focused on making money in a way that doesn’t help people.  I’m curious about what your view is on the right role between the private and public payers and how MEDecision helps those health plans add value.

David St. Clair: I think that the word demonization is a very apt one in terms of the debate. I have to admit publicly that I am a staunch Democrat, but I’ve been tremendously disappointed by the language that’s being used in the health care reform by both sides, but by the Democrats in particular.  If you think about the nuance that President Obama used in talking about issues of race and in his speech in Cairo, his outreach to the Muslim community around the world.  He understood issues of nuance.  He was very, very clear that those are very complicated issues and things aren’t simply good and evil and black and white.

Unfortunately as soon as we came back domestically and started talking about health care, all of a sudden there was good and evil and all that sort of stuff.  My experience over the last 21 years has been that the insurance companies have clinical staffs who are absolutely committed to trying to improve the quality and affordability of care for their folks.  They were doctors out in the community.  They’ve been nurses in hospitals.  These aren’t people who are bean counters that our good friends in politics like to point to.  These are caring clinical folks who are trying to figure out what’s best.

There are many, many instances where there is a very viable debate going on between the treating physicians and the clinicians at the health plan and I actually think that’s a very healthy thing today.  What we’re really focused on is trying to make sure that those people are acting on the same basic information.  That’s why we’re so adamant about sharing what the health plan knows about a particular patient with the physician and with the care managers, so then at least we can have conversations about what is in that patient’s best interest.

When I think about the role of public payers versus private, it’s a very complicated issue, but my view is that virtually all of the innovation in health care has come out of the private insurance sector, not the public one.  Look at Medicare and Medicaid, with the possible exception of the Medicare use of DRG’s for paying hospitals.  Everything around disease management, everything around quality assurance, everything around case management came out of the private sector.

So if we set up an environment where there are going to be significant incentives for people to shift to a public payer because the public payer has the opportunity to use the force of law around pricing,  I think that’s going to diminish the amount of innovation that we will see in a time when we need it most.  So I think there has to be the balance.

Obviously there are a lot of private insurers out there who are dealing with the Medicaid population. There were a bunch of private insurers who were dealing with Medicare, Medicare Advantage, but once again we’ve sort of gutted their reimbursement model so it remains to be seen how many of those stay in business.  There seems to be a back and forth argument with government depending on who is in charge.  In my experience –and it’s a pretty broad set of experience now with very senior people in the health insurance companies– they all want health reform. The only argument these days is what are the specific elements of that reform?  But unfortunately a lot of the discussion is: ‘Well if you’re not for my form of reform, whatever that might be, even if I’ve chosen not to define it clearly, then you must be against reform,’ and that’s simply not true. I’m hoping as we go forward we can get away from that demonization and realize there are people of very good will, people with great amount of experience on all sides of those issues that really do have a common goal, which is to improve the quality and affordability of care and accessibility to that care for everyone in this country.

Williams: One of the things that the health plans had been big on in recent years was disease management.  Yet some of the leading companies like Healthways and LifeMasters have fallen on hard times recently.  Does that mean that the health plans aren’t interested in disease management or that these companies just haven’t met the needs?  How should we interpret that?

St. Clair: There are a couple of different ways to look at that.  Some of the disease management companies tried to disintermediate the health plans by going directly to their big customers. That’s a difficult role to play for a long time when you’re essentially then competing with people who have far more resources at their disposal.  So some of that you can think of as competitive retribution, where if you’re one of those disease management companies that has been goring me and changing the relationship between me and my big customers, I might be out to get you.

But I think the bigger issue in the long term is actually very analogous to the discussions around the electronic health record and the fact that in order for us to improve the quality of care, we have to ultimately integrate information from a multiplicity of sources about an individual patient so that you end up with one central record.  Most of the DM companies, in order to protect their business, felt they needed to create yet another silo of clinical information about the health plan’s members rather than being fully integrated with the care management or health management process that a big player like a Blue Cross Blue Shield plan is using and then periodically, maybe we’ll send you a data update that tells you what’s going on.

That put these big health plans in a bad position.  If somebody is admitted to the hospital tonight who was talking to a health plan’s DM vendor that afternoon, they have no clue what that conversation was about because there is no real time integration of that information.  Also if they’re trying to generate reports for their employers and really understand what’s going on, they’ve only got bits and pieces of the information rather than all of it.  So we’ve been advocating to the DM companies for quite some time that they use us, because we have such a large footprint particularly in the Blue Cross Blue Shield world, that they use us as that integration point so that we can fully integrate the work that they are doing with the systems and the databases that our customers use to manage care. We can integrate it not only from a data perspective but also a work flow perspective so that we can route cases back and forth across enterprises. Unfortunately in some cases for business model purposes they were very reluctant to do that.

Now to a certain extent the chickens are coming home to roost because these large Blue Cross Blue Shield plans are using our tools and our clinical content and our workflow engine to bring all those services back, because they don’t feel that they can get properly provide service if in fact they end up with this dislocated system.  Going forward, I still firmly believe that no health plan, disease management vendor, hospital or physician is going to ever be best of breed themselves at everything.  There’s going to always be a rather robust market as new ideas come to the forefront and people are trying things of one sort or another, there is going to be a robust market for people to be able to integrate a particular set of services on a fully integrated basis from data and work flow into their capabilities.

There is no employer out there that says to a payer, ‘I need you to do it all yourself.’ But employers are asking, ‘Why aren’t you integrated?’  If you’re doing diabetes and asthma management on this individual you might have two vendors that are doing that and they’re not coordinated.  What’s going on?  That to us is the biggest issue.  The ecosystem out there of all the vendors, all the new ideas integrated together that I think payers and consumers will have a better shot at improving the quality and affordability of care.

Williams: I’ve been speaking today with David St. Clair, CEO and Founder of MEDecision.  David, thanks again.

St. Clair: Thank you very much.  I enjoyed it.

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This is the first part of the transcript of my recent podcast interview with MEDecision CEO and founder David St. Clair.

David Williams: This is David E. Williams, co-Founder of MedPharma Partners and author of the Health Business Blog.  I’m speaking today with David St. Clair, Founder and CEO of MEDecision.  David, thanks for your time today.

David St. Clair: You’re very welcome.  I’m looking forward to it.

Williams: Tell me about MEDecision.  What is the company and what is it that you offer?

St. Clair: MEDecision is a 21 year old company that provides health care management solutions used primarily by private insurers and government plans to manage care for about 50 million people in this country.  We have a couple of main product categories.  One is called Alineo, which you can think of as an electronic medical records system with full clinical decision support.  It’s used by the clinicians who actually work for the health insurance company doing quality assurance and case management and disease management.  Then we have a product called Nexalign, which is a multi payer connectivity solution.  Think of it as an electronic health exchange product.  It essentially helps automate a number of the processes that health plans have used for years, but I think more importantly going forward it also is a full blown health information exchange that allows us to share the same clinical history on an individual with that individual themselves, with their doctors, and with their care managers.

We have a set of solutions that we talk about as being ‘simple, smart, and state-of-the-art.’ That matters because a number of those attributes are very important for consumers and for health plans.  On the simplicity side, we help consumers navigate what can sometimes be an overwhelmingly complex health care system. We’re able to deliver summary information to a patient’s doctor or to the patients themselves.  It’s a good summary of the data that’s available on that particular individual so we try to make that very easy to use.

The ‘smart’ side is really about knowledge flow.  We’re trying to help information move around the health care system, always centered on the patient and their best interest. That knowledge is ultimately much more important than the underlying data. We have an instance where we’re looking at an individual patient with 61 pages worth of paid claims data.  That volume of information will be essentially inaccessible by anyone who is trying to make a decision about that patient.  It’s just too much of it.

The ‘state-of-the-art’ part speaks to the technology we’re using to help our systems be integrated into the broader health care ecosystem. It also addresses the clinical content that we provide to our customers, doctors and others in that we always have to stay abreast of evidence based medicine to make sure that the information we’re providing is appropriate for this individual.

MEDecision, after 20 years of independence and a brief history as a public company, was acquired last year by the fourth largest health plan in the country; Health Care Services Corporation.  They are the largest non-investor owned health plan and own Blue Cross Blue Shield of Illinois, Texas, New Mexico, and Oklahoma.  Their strategy is about simplicity, affordability, and accessibility.

Our technologies are used to provide the science.  The clinicians provide the art to make health care systems simpler. Ultimately by improving the quality of care, we’ve improved the affordability of that care.  The accessibility side is about the technologies we use to try to engage consumers in their own health care.  We are not a believer in single portals, but rather in trying to create ways to deliver the same information to individuals whether they’re physicians or other providers or patients themselves, where they want to meet us.  We don’t try to force them.  We don’t try to coerce them into one particular way of acting.  We give them a broad variety of choices.

Williams: How do you think about this patient that you referred to with  60 plus pages of claims data? How do you expect that patient to interact with the system?  What is their role and what can you do for them beyond simplifying things so that they can get some grasp on it?

St. Clair: I think one of the challenges in discussing health care these days is getting people to think about the right sorts of individuals benefiting from this.  So if you look at someone who has 61 pages worth of paid claims (by the way in a two year period) that person has, if I remember correctly, something like nine different medical conditions and was taking something like 18 different medications, was seeing nine different physicians over the course of the last year or so. This is somebody who is a huge consumer.

They are in the sickest half a percent or one percent,  which consumes 15% to 20% of the health care costs.  It’s a huge drain.  Those individuals quite don’t care a whole lot about their health record.  They need it to survive.  They’re essentially so overwhelmed by trying to take care of themselves that we don’t expect them to interact highly with our systems.  We do however need to make sure we can reach out and give them information and give them reminders, but we don’t expect them to be spending a whole lot of time on the computer trying to figure things out because they are simply too ill to be doing that.

But if you look at the next 19%, I think there are lots of opportunities where consumers can get more engaged.  The challenge is how one does that because typically the people who are not at all ill don’t have any interest in thinking about health care or their health care record. It really is only those folks who have an active illness of one sort or another. Many of us are accustomed to essentially relinquishing control to our physicians. There is a big cultural change that we have to go through and that’s one of the reasons that we believe very strongly that we have to take every opportunity we can if a consumer indicates an interest in engaging in their own health care in some sort of a system or PDA or something of that nature.  We ought to be trying to respond to that, to encourage that use in the future.  I think there is going to be a significant change over the next five to ten years in terms of who gets involved with what kinds of interactions around their health.

Williams: You use a lot of claims information from health plans. If I think about claims that I’ve seen and try to even imagine somebody with 61 pages of paid claims over a two year period, there’s got to be a lot errors in there.  There are probably some misdiagnoses that have been included and other sorts of errors.  Are you able to really make sense of it and determine what’s accurate? Is that an issue and if so how do you overcome it?

St. Clair That’s a very accurate representation of the sources of data that are available today on individuals, and it’s not just claims data.  If you look at data in electronic medical records systems, which are available on a very small percentage of the population, there are lots of errors in that as well.

Some of that is due to misdiagnoses on the part of doctors, others are coding mistakes and things of that nature.  So for the most part, the data around electronic health history for individuals is, in many cases, quite flawed, whether it’s claims data or not. That’s where the knowledge component comes in.  We’ve invested a great deal of time and money and effort to figure out ways we can use a multiplicity of sources about an individual to try to cross-validate information.  So if I find an instance where a patient is diabetic I’m going to be looking for other sources of information or a repeated use of that particular diagnosis in order to really verify that that patient is a diabetic.

There are instances where the health plans will only pay for foot exams if the patient is diabetic–  and all of the sudden all of podiastrists’ patients become diabetics.  So we have to make sure that we look at other providers’ claims, look at medications the patients are taking to try to validate that.  We never pretended that even with all of that knowledge our records today are absolutely accurate or absolutely complete because we know that they’re not.  It just happens to be the very best summary of information about those individuals that’s available.

The question is: do you want really good information on somebody who is seeing nine different docs knowing that it’s not perfect or do you essentially want none?  I think most people say that the biggest issue is the non-use of information rather than the misuse of information.

There is a transition going on on the physician side as well.  If you think about the physician population as a normal bell curve you’re always going to have the folks who are at the leading edge of that bell curve who realize that something has to change.  With the number of medical errors, with the expense that we’re put into trying to fix things that have gone wrong with the treatment of individuals with some real complexity, they realize that they’ve got to try something.  And those folks are quite ready to try innovative ideas like our patient clinical summaries and things of that nature.  The emergency room is another place we see very rapid adoption.

What we need to do is to make sure we’re doing the best job we can with those early adopters and then use their experience to get other physicians to adopt it and to get them accustomed to exchanging data in order to improve the quality and affordability of care.  There is today and there will continue to be (I would argue forever) people on that trailing edge of those bell curves –payers, providers and consumers– who want absolutely nothing to do with it, who say this is ridiculous, if it’s not absolutely perfect I’m not going to use it all.  Those are the folks that we can’t spend a whole lot of time trying to convince at this point. We won’t be able to so it’s a waste of time and breath to try do that.  What we have to do over time is have their peers convince them that they really ought to look at things a bit differently.

Continue to Part II

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MEDecision offers “smart, simple, state-of-the-art” solutions to health plans to enable them to collaborate on patient care. At the heart of MEDecision’s offerings is Alineo, which lets payers identify high-risk (i.e., costly) patients, apply clinical knowledge and automate the administration of health care programs. The company also offers Nexalign, a health information exchange service.

I spoke today with MEDecision’s CEO and founder, David St. Clair about the company’s offerings, its customer base, the role of private health plans, and the fate of the disease management industry.

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David Williams interviews David St. Clair of MEDecision Play Now | Play in Popup | Download

Looks like the FDA will soon be taking up the issue of how drug and device companies can use social media like blogs, Twitter, and Facebook. According to the NPR Health Blog, key issues to be considered include:

1) What online messages and chatter are regulated companies responsible for? And what’s not their problem?

2) How do companies comply with existing regulations, requiring such things as fair balance in ads, within the confines of, say, a 140-character tweet?

3) When does a company have to correct misinformation posted by third parties? Hello, Wikipedia! Some companies, the FDA said, haven’t taken action on known problems, fearing they’d then be responsible for correcting everything anywhere online.

4) To link, or not to link? is the FDA’s question. Specifically, FDA wants to know what sorts of linking is appropriate and when users find it misleading.

5) The bogeyman in the social media closet has long been chatter about side effects and other problems with products. When do companies have to report these bad experiences as recounted on the Web to FDA?

Pharma companies tend to have slick websites, but I’ve been less impressed with their forays into other areas such as blogs. Even their DTC advertising doesn’t strike me as that sophisticated or effective. And as I’ve written pharma companies have been pathetic at using Twitter. Sure the rules are unclear about what they can do, but why aren’t they at least sitting on their corporate and brand names rather than letting random people grab them up?

I think any attempt by FDA to issue guidelines in this area will be problematic. The new media themselves are evolving rapidly, and it’s unclear exactly how things will shake out over the next several years. The best we can hope for are a set of principles.

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Grand Rounds is six years old and a birthday edition is posted at Residency Notes.

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In A Tax on Cadillac Health Plans May Also Hit the Chevys, the New York Times examines the Baucus plan’s proposal to levy an excise tax on the most expensive health insurance policies. (I chuckled to see the term “Cadillac” tossed around by the Times and President Obama in this context –how quaint! Reminded me of the good old days of Cadillac Dog Food.) Anyway the article points out a couple of uncomfortable facts:

• A tax on high-end benefits will quickly encompass the mainstream market, because health insurance premiums rise so quickly
• A blanket tax will be inequitable, because some people have higher insurance costs for others

Considering that the provision is expected to raise ~$200 billion of the $800 billion price tag for the Baucus plan, why are people surprised that it will have a broad impact?

In the lower part of the article, Dartmouth business professor Robert G. Hansen is quoted saying,

It’s the worst kind of economic engineering… You end up with something that looks like the I.R.S. code.

I haven’t seen that name for a while but I recognize it as the same Dr. Bob that I used to work with at LEK more than 20 years ago, when he had a desk in the same “pod.” The LEK founder, Jim Lawrence liked having a brainy, academic guy around to keep the MBA types under control, and Dr. Bob fit the bill. He was particularly useful in making sure I was expressing the outputs of my conjoint analyses in a statistically valid manner.

Anyway, I think health insurance should be taxed just like other forms of income. It’s a modest but important cost control measure and ultimately will be more equitable. The challenge is managing the transition period, because it is indeed true that the tax will fall unevenly. Personally I would back load the impact, setting a higher initial bar so that fewer people are caught in the trap in the early years.

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Nobel laureate Paul Krugman thinks the health care reform plan emerging from Max Baucus’s Senate Finance Committee is too weak. If it’s strengthened he could envision supporting it, otherwise it seems he’d scrap it. Krugman compares the health reform bill to the stimulus package; in his view both have been watered down too much in an attempt to get Republican votes, which probably won’t come anyway.

Krugman has three main problems with the Baucus plan:

1. It “bungles” the employer mandate by tying employers’ fees to the subsidies its employees receive. Krugman doesn’t like that because employers would avoid hiring people from low income families and it would create a “bureaucratic nightmare”
2. Subsidies for those who can’t afford insurance are too “stingy”
3. It does not promote sufficient competition among health insurers

I agree with Krugman that the Baucus plan is flawed. Of course it is. To me the main objective in this stage should be to get everyone into coverage, which will then force the country to tackle the problem of health care costs sooner rather than later.

The Massachusetts experience has shown that relatively modest penalties are sufficient to encourage employers to offer coverage. Whether that would be true nationally remains to be seen, but it’s worth a try. Therefore I’d agree with Krugman on his first point but would probably set the penalty level lower than what he has in mind.

On the second point it’s probably unaffordable to offer sufficient subsidies to everyone to purchase comprehensive insurance. That’s true in Massachusetts –a rich state with a low rate of uninsured– and would be even more true on a national basis. The way to deal with this is to allow policies that are relatively bare bones or to have overt (rather than covert) rationing.

On the third point I don’t think competition among health insurers is going to make much difference. I’d rather see more encouragement of competition among providers.

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