Health for life

Check out the three page article on "U.S. Health Cares Future" in the Marketplace section of the December 12 Wall Street Journal. Using personal stories of a doc, hospital CEO, insurance executive, human resources manager and a patient, the news piece portrays the blurring business lines between insurers, buyers and providers.  Mainstream readers of the Journal are likely to think the topic is both timely and novel.  Regular readers of the Disease Management Care Blog learned about his months ago.

Who are these five canaries in the health care coal mine, these bellwethers of the insurance business, these oracles of management and what are they telling us?

1. Dr. McCullough, a salaried physician with 28% of his income contingent on quality and satisfaction.  Some measures were imposed by the local Blues plan, which was passed through to the him by his employer.

Message: Purchaser and buyer control of physician reimbursement is already big and its growing.

2. Jim Taylor, a hospital CEO who cannot buy an electronic record system unless he merges with two other hospital systems.  If the merger is approved, the hospital will also be able to take on "warranty-style" payments from insurers.

Message: "Bigger is better" for capital-constrained hospitals.

3. Chris Day, an Aetna executive who got an Arizona health system to share insurance risk.  The main sticking point was the two-way mutual sharing of internal cost and contracting data.

Message: If insurers are willing to share internal pricing data, they must really mean it and think its an important success factor.

4.Robert Jacobs, the HR person, who linked about $10 per week of employees health insurance premiums to healthy behaviors (like tobacco) and quality test results (like blood cholesterol levels).

Message:  "Dont just stand there," say the employers, "do something."

5. Louis Kandor, an 86 year old man with advanced diabetes, who is being visited by a nurse who, in turn, is employed by a care management service provider under contract by his Medicare Advantage insurer.

Message: One key to mitigating risk for every insurer (except fee-for-service Medicare) is to use nurse-led care management.

While the Journal article doesnt spell it out, the DMCB believes the anecdotes can be distilled down into three useful insights:

1. Stakeholders are scrambling to demonstrate measurable outcomes to an increasingly educated and  skeptical public.  Thats the basis for physician pay-for-performance and premium surcharges.

2) Sharing proprietary insurance data is important.  Is information the secret ingredient that was lacking during the similar - and mostly unsuccessful - insurer-provider collaborations back in the 1990s?  Well see. 

3) For those hospitals that cannot or will not take risk, the next best answer is to merge.  That will mean economies of scale, access to capital and negotiating leverage.

Baron Von Munchhausen

Despite host Peter Segals occasionally highbrow insider cleverness, The Disease Management Care Blog remains a loyal fan of NPRs "Wait Wait... Dont Tell Me" radio show.  While the DMCB has its suspicions about the ratio of truly spontaneous wit to pre-planned ripostes, that wont stop it from turning to a part of the show called Bluff the Listener for bloggy inspiration.

BtL has guests try to guess which of three funny stories is based on a real true news report. The DMCB thinks health care is so wacky that itd be more challenging to guess which of the four stories below is false.

Unfortunately, if you win, getting the DMCB to put its voice on your home answering machine is unlikely to impress anyone. However, if you can pick out which story is a complete Munchhausenesque fabrication, you will deserve the respect of your friends and co-workers.

Ready to try to get some bragging rights?


Even doltish man-trolls know better than to try to organize an all-male blogging conference. Unable to reach out to that demographic, HHS Secretary Kathleen Sebelius did whats best: appeared before the annual "BlogHer" Conference in an appeal to women bloggers to tout the benefits of Obamacare. Her outreach supplements plans to rely on celebrities to help with a nationwide drive to increase enrollment through the insurance exchanges. Next up will be effort to recruit motor scooter owners to sport pro-Obamacare ads on the back of their helmets.  Then its on to asking members of the European Beret Society to host recruitment drives at their monthly chardonnay tastings.

Answer here.


Al Lewis and Vik Khanna condemned the wellness industry in a Wall Street Journal editorial when they proclaimed that "workplace programs dont work." They went on to say that they are "ineffective at reducing costs, lack support in the medical literature, are unpopular enough to require incentives and are occasionally even harmful." Yet, the Khanna On Health Blogs “workplace wellness consulting” page suggests the authors’ unique consulting insights can help potential customers “do wellness right.” Did the DMCB mention that both individuals are lawyers?

Answer here.


Writing in a separate issue of the Wall Street Journal, former Vermont Governor and Democratic National Committee Chair Howard Dean actually attacked Obamacare by criticizing its Independent Payment Advisory Board as a rate setting enterprise that is doomed to failure. Brazenly using Tea Party terms such as "bureaucrats" and "health rationing," Dr. Deans liberal-progressive apostasy prompted ACA architect Peter Orszag to curiously opine in a separate article in Bloomberg that the argument favoring IPAB is that it will be a much better rate setting body than Congress. If this keeps up, even labor unions will start criticizing Obamacare.

Answer here.


While partisan blood continues to spill over Obamacare in Washington DC, there is much good news outside the beltway.  Its been announced that the IRS will not only rely on self-reporting of income levels in setting premium subsidies. Even better, individuals who qualify for tax credits while buying their health insurance with the on-line exchanges will get a two-fer: 1) the option of applying the rebates to reduce their monthly premiums, and 2) confidence that there wont be any tax liability "claw backs" should their final income be higher than anticipated. Interest and penalties will be optional.

Answer here

Only the Disease Management Care Blog can find population health management lessons from yesterdays Superbowl.

With only 57 seconds left in the game and the Giants in possession of the ball at the six yard line, elite running back Ahmad Bradshaw got the hand-off.  He was only a few steps into the play when he simultaneously realized that the Patriots were purposely not tackling him and that his quarterback, Eli Manning, was shouting at him to not enter the end zone. Thats because Mr. Manning knew that a quick touchdown would turn possession of the ball back to the Patriots and give their star quarterback Tom Brady plenty of time to stage a comeback.

It was the difference between running out the clock and getting points on the board.

Against every instinct, Mr. Bradshaw slowed, turned and tried to sit down, only to end up squatting his way butt-first into Super Bowl history.  Fortunately for the Giants, while the Patriots did get possession of the ball, Mr. Bradys passing game was stymied and the Giants won.

The Actuaries:

The DMCB thinks of Eli Mannings cunning as a demonstration of the actuarial sciences, where the past experience of Tom Bradys passing magic was projected into a future of time-outs plus clock-stopping sideline plays that were calibrated with situational awareness and educated guesswork.  Such is the business of health insurance where the beneficiary population, the mix of services and the cost per service are used to make huge bets on a premium.  No wonder Eli had a some "eye of the tiger" about him when he was standing on the sidelines.

The Providers

The DMCB thinks of Ahmad Bradshaw as an archetype of those elite docs who live to make the diagnosis (with end zone ahead and ball in hand) and cure it (i.e. a touchdown).  Asking a provider to not commit all possible resources for patients ends up like Mr. Bradshaws ungainly scoring: not only isnt it pretty, it seems to happen anyway.  Such is culture of U.S. health care where the latest technology is combined with professional judgement to drive revenue. Last but not least, Mr. Bradshaw was ironically credited with the game-winning touchdown.

As providers transition into assuming more risk with a variety of bundled payment, gainsharing and global budget arrangements, they would be well advised to think about the logic of running out the clock and saving as much on utilization as they can.  If they dont, they may gain plenty of revenue points but will end up losing when the books close on the final seconds of the fiscal year game.

Futures so bright, gotta wear shades!

Optimism.  Enthusiasm.  Bullishness.  Who can blame the Care Continuum Alliance for describing the future as "bright" in a ebullient 2012 population health management "Industry Outlook" white paper?  Based on a survey of unnamed "industry leaders,  the CCA found that practically every high visibility health policy initiative out there is relying on the principles of care management.

Theyre right.  Given growing recognition that "health care as usual" cannot continue, companies, vendors and organizations (and blogs) that offer new approaches will thrive.  Have a good idea on reducing chronic illness and improving health and the value proposition will follow.  Have a value proposition and the business model will follow.   Have the business model and an early comfortable retirement will follow. 

The report can be downloaded here.  No company or individual resource knowledge library is complete without it.  The Disease Management Care Blog also thinks that forwarding the report to colleagues, co-workers, bosses, underlings, friends and enemies will demonstrate two key traits:

1) your situational market business awareness is second to none
2) reading the DMCB is a competitive advantage

A DMCB summary review is below

ACOs and Shared Savings: the industry has a host of necessary  risk assessment, predictive modeling, information technology, analytics, patient engagement and condition management tools that can be built and tailored. Provider organizations that seek to make money from "upside gainsharing" ignore these resources at their peril.

Electronic and Mobile Health: remote physiologic monitoring, app based coaching and "pull" style  social media engagement are all reaching a tipping point.  Or rather, are all eReaching an eTipping ePoint. The Disease Management Care Blog, sharing in the eEnthusiasm, has initiated a remote "eSpouse" offering. More on the ePerils of that eBusiness model in a future ePost.

Reducing Readmissions: Come Oct. 1 2012, outlier hospitals with more than their fair share of heart failure, heart attack and pneumonia readmissions can look forward to a painful revenue cut.  "Pay us now or pay later," says the industry, with too numerous-to-count proven care management strategies that have been described at the Care Continuums annual meetings for years.

Medicare Advantage Bonus: Thats right, MA plans will be eligible for bonuses from CMS based on HEDIS inspired commercial insurance outcomes that have been the bread and butter of the care management service providers since the beginning of time.

Dual Eligibles:  This highly vulnerable population has been trapped in a twilight zone of overlapping and uncoordinated benefit plans thanks to a well-meaning but typical Washington-style mishmash of Medicare and Medicaid.  The good news is that the Feds have finally woken up to this and are interested in funding many of the coordination strategies that the population health industry stands ready to offer.

Prevention and Wellness: The Feds have money to put into this and employers are increasingly willing to invest in it.  Medicare covers annual wellness visits and covers obesity counseling.  The controversial ham-fisted involvement of HHS in calculating the MLR has thankfully correctly slotted the cost of wellness programs.  Wellness and prevention are one of the ten essential benefits.  The industry is poised and ready to go.

And what about "build" versus "buy" and the notion that providers already know how to do all this stuff?   The DMCB points to the sine wave of on-again off-again in and outsourcing that has been the norm for the commercial insurer-disease management vendor relationship for years.  The DMCB suspects the same will occur for providers, hospitals, delivery systems and ACOs that have to operationalize complex programs that achieve measurable accountability.  The difference is that, up until now, they havent had to do that at all.  Based on a mix of in-house competencies, interest, speed to market needs and cost comparisons, many will buy. 

The population health industrys outlook is very bright indeed.

Image from Wikipedia