Wednesday, November 18, 2015

Smartphone Apps: Architecture Trumps Content

According to this The Wall Street Journal article, the prospect that "your doctor may soon prescribe you a smartphone app," has put us on the cusp of a new age of m-healthiness. 
Regular Population Health Blog readers are not surprised. They have an "over-the-horizon" awareness of health information technology and know that the health app ecosystem has been flourishing for quite some time
What is surprising, however, is how the news article from a prestigious news organization conflated architecture and content
The PHB explains.
The WSJ article describes how intrepid e-researchers from marquee academic institutions are documenting the impact of apps on medication compliance, symptom management, risk reduction and provider-patient communication. Once users open these apps, there's not only an eHealth technology platform but an accompanying library of tailored e-prompts, e-reminders, e-pop-ups, e-recommendations, e-messaging, e-images and e-videos.  Mix one app with one patient and quality goes up and costs go down.
Unfortunately, what the article failed to mention is that much of that content made up of information that is freely available in the public domain, and that these app developers have reconfigured and adapted it according to the interests, expertise and culture of their sponsoring institutions.
While policymakers and researchers would like to believe that on-line and public domain health information is a commodity, the fact is that buyer, purchaser and provider organizations have been accessing and downloading it for years.  They've take special pride of ownership in the wording, editing, formatting, presentation of that content.  That's what makes it "theirs" for both their providers and their patients.  After all, all healthcare is local.
This has important implications for the smartphone app indsutry.  While the academic e-researchers and business e-developers dream of having their apps adopted by delivery systems everywhere, the problem is that their apps are often tethered to their own organizations' content
In other words, you can have any breast cancer, heart failure or post-hospital discharge smartphone-based solution that you want, just so long as you also import their prompts, reminders, pop-ups, recommendations, messages, images and videos. 
The Population Health Blog believes the secret sauce for competitive success for app developers is accordingly three-fold:
1) Architecture Trumps Content: Smart app developers understand that the value proposition of the underlying technology architecture is separate from the value proposition of the content.  The app itself needs to be independently stable, secure and snappy with minimal branching logic, an easy-to-use interface and freedom from annoying bugs, whether it's heart failure in for a hundred patients in Halifax or a dozen persons with diabetes in Des Moines. 
2) Architecture Supports Content: Very smart app developers also understand that the architecture should be able to accommodate any content that is preferred by their customers. If ABC Regional Health System wants their in-house policies, procedures, pamphlets, web-pages, in-house guidelines and electronic record prompts to be reflected in a smartphone app, then the app's framework should be able to import it.  Think plug and play.
3) Architecture Has Content: That being said, not every buyer, purchaser or provider will have all the content needed to manage a target population. That means app developers will need to have generic content ready to go to fill in the gaps
The business case for apps may be similar to selling a house.  First off, make sure the foundation is solid and the roof is intact.  Be prepared to move walls and windows, if that's what the buyer wants.  And, if the house needs to be furnished with some furniture, do it; if the buyer wants some or all of their furniture to furnish the house, do it.

Saturday, November 14, 2015

Tuesday, November 10, 2015

Service Guarantees in Healthcare: Not So Easy

From time to time, the bad behavior of airlines will prompt the awarding of frequent-flyer mile credits or partial refunds to aggrieved customers.  Given that that industry has been used to portray everything that's wrong with U.S. healthcare, why hasn't this virtuous example of customer service been used by hospitals and other medical providers?

According to this news article, it will be.  As the PHB understands it, once patients have completed their treatment, they will be able to access an app to register their displeasure and access a "money-back guarantee" in the form of a partial refund.

PHB readers know that there is always more to stories like this. Despite its familiarity with the population health service industry's many years of money-back guarantees, the PHB decided to help its readers stay ahead of the competition with a quick look at the topic of provider guarantees.

It's not a slam dunk.

For starters, "service guarantees" can be divided into two categories: specific and unconditional.  The former is tied to one or more measurable elements of the service, such as the on-time delivery of a pizza or the HCG + implantation of a fertilized embryo. The unconditional category is typically tied to a global assessment of the consumer, who can access the guarantee for any reason, such as the disappointing frothiness of a cappuccino or the unfriendly persona of a nightshift nurse. 

The service guarantee described above appears to be unconditional.  

Service guarantees have long-known upsides and downsides.  In the healthcare industry, the upsides include motivating patient-centric behaviors, minimizing the use of the dreaded complaint line and undermining the competition. The downsides are that they can be used by many more patients than anticipated, once unleashed it's hard to pull it back and refunds could be driven less by satisfaction than by economic self-interest.  The PHB also worries that it's one more step toward the commoditization of healthcare and that a refund for an otherwise unavoidably bad outcome could be misinterpreted as agreement that the physician is at fault.

Service guarantees are not unheard-of in healthcare settings.  A quick Google search will reveal that they're common in in-vitro fertilization (IVF) and LASIK clinics. That's because these services are typically not covered by insurance and the fees are paid directly by the consumer.

Which raises the role of health insurance.  The PHB is no expert in this field, but it suspects that the historical absence of guarantees for services covered by insurance has to do with two broad principles:

1) if the insurer is ultimately bearing the cost of the service, the insurer should benefit from a refund.  The consumer arguably paid a premium to transfer the cost of the service to the insurer. Like it or not, the insurer, and not the patient, "owns" the cost, which is why we have insurance in the first place.

2) since the consumer is often responsible for out-of-pocket expenses "before" the insurance "kicks in," it could be argued that the aggrieved patient owns some of that service risk/cost and that the patient should also benefit from a service guarantee.  Good point, but there are decades of thorny anti-kickback laws that are designed to prevent service providers from using rebates of any kind to secure referrals or market share. Partially "waiving" or "refunding" co-pays or co-insurance as been a big regulatory no-no, and unconditional service guarantees are perilously close to crossing the line.

Bottom line:

Whether this latest foray into healthcare service guarantees remains a sideshow, or is the start of a trend remains to be seen. Much will depend on how any refunds are legally "immunized" against the insurance issues. 

Image from Wikipedia

Monday, November 9, 2015

Five Reasons to be Bullish About Theranos

Pushing back
When the Population Health Blog watched Theranos CEO Elizabeth Holmes push back during a CNBC broadcast against a Wall Street Journal report about her diagnostics testing company, it began to pay attention.
As the PHB understands it, Theranos is a privately held and fabulously priced biotech company built on two value propositions:
1) proprietary technology that enables parallel testing to be done on a weenie blood sample obtained from a single finger-prick.  
2) direct-to-consumer availability of blood testing outside of the dreary hassle of doctor ordering, laboratory queuing, expert interpreting and insurance reimbursing. Instead, customers can stop by their corner pharmacy, scan the menu, select some tests, use VISA or Mastercard and use the results as they see fit.
According to the Journal, Theranos' technology isn't necessarily ready for prime time.  It appears that while the company obtained the Food and Drug Administration approval for its proprietary technology, it's limited to testing for herpes. There are allegations that for all the other bloodwork, the results can be inaccurate and that the company is relying on the standard vein-puncture blood draws to service its consumers. 
The FDA is asking for more information, Walgreens has paused and super-litigator David Boies has joined the company's board.  Connect the dots and this Silicon Valley start-up is starting to look a bit tarnished.
Rather than join in the schadenfreude, the Population Health Blog has five reasons to be contrarily optimistic about Theranos:
1. All medical advances follow the Hype Curve of innovation, euphoria, disillusionment and equilibrium:

Thernos' travails in the trough are not only part of the natural life cycle of a health tech company, it's also a good reminder to only go public after the disillusionment has passed.  A plateau of cash flow productivity lies ahead.
2. The second value proposition still stands. While the notion of letting an unsophisticated lay-person interpret the meaning of an (for example) elevated adrenocorticotropin hormone level, Ms. Holmes seems to be unwittingly arguing that this another step toward "actionable" shared decision making. While the market sorts that out, a) there is considerable consumer interest and b) educational consumer-friendly resources are becoming increasingly available. While self-testing can complicate the doctor-patient relationship, it can also help it.  And if it drives consumers to Walgreen's Healthcare Clinics, so much the better
3. Speaking of the second value proposition, consider an unpalatable alternative: Regional health system monopolies, where consumers can get any test they want, just so long as it's through their doctors, at their labs - and done the old fashioned way.   
4. In looking at its ten best practices for the boards of health care companies, the PHB is going to give these heavy-hitters the benefit of the doubt. It figures that in their interactions with the C-suite and especially with their interactions with the FDA, the directors have all the resources they need to bring skepticism, rely on dual data reporting, know about human research, perform audits and access research expertise. They should know about maintaining the right tone at the top and understand how incentives can help and hinder corporate integrity. Assuming business reporters can drop the nattering negativity (like this) and instead confirm that those key governance principles  are in place, Theranos should do OK.
5. And one of the Theranos board members is a physician.  While time away from hands-on practice may have blunted Dr. Frist's clinical acumen, the PHB has heard him talk in conferences: he still knows of what he speaks.  As noted by the PHB here, physicians bring a unique perspective to the boardroom, including understanding patient-centric outcomes, helping the CEO navigate the clinical side of the industry, bringing a diverse viewpoint, giving insight to the competition's strengths and weakness and helping fellow board members further their healthcare education.
The PHB's assessment of Theranos:

Thursday, October 29, 2015

Why Become a Doctor?

Talk about good timing.

This just-broadcast NPR Morning Edition segment spoke to the importance of "STEM" (i.e., Science, Technology, Engineering and Math) high school education. When the network's framing began (Mr. Obama's "stargazing" vs. "hard-line" House Republicans), the otherwise agreeable Population Health Blog began to tune out.

Its attention snapped back when it heard this....

.... combination of budget cuts and policy decisions has left many local, state and federal bodies short on funds to robustly back science education. To help fill the gaps, a national patchwork of corporations, non-profits, foundations, and volunteers have stepped in to help. Volunteer and corporate-backed STEM networks "can help schools bridge those gaps and make those connections".....


The PHB spent the prior day - October 27 - participating in a Junior Achievement-sponsored "STEM Summit" at a local Harrisburg PA high school. Groups of 9th graders rotated through a number of stations (fun experiments in physics, food science, electrical engineering and math) and panels (presentations about careers in geology, food science, finance and health care). 

The loquacious PHB was naturally assigned to a panel, and its job was to prompt the rotating groups of participants to think about becoming doctors:

After you graduate from high school, go to college, and continue your studies in science. But remember the goal is a broad education that will help you become a better and informed global citizen. Then you go to medical school.  That involves four years of both lectures and exposure to real patients across a range of disciplines.  By the time that is over, you have a doctor degree, but you're not ready for independent medical practice. For that, you have to pick a specialty career path with an additional 3 to 5 years (or more) in an apprenticeship called a internship/residency.

Medical school can result in more than $100,000 in debt. That sounds like a lot, and it is. But during your residency, an income of more than $50,000 is likely. Once you are in independent practice, your income can exceed $200,0000 a year. 

Your debt will be serviceable.  Being a doctor is in your reach.

Remember that 1 out of very 5 dollars (the PHB held up a $5 bill) in the U.S. will be going to healthcare - 20% of your and everybody's income will be going to people like me.  This is a growth area in the U.S. economy.  As a doctor, you will always have a job and be able to put a roof over your head and put food on your table.

If you like science and people, medicine is a good place to be, and we need talented people like you in there.

Thursday, October 22, 2015

Value Creation for Healthcare Apps - or - Avoiding the Mistakes of "Meaningful Use"

Meaningful Use is debated
Any health care provider who hasn't been sealed in a Faraday cage for the last five years is likely aware of "Meaningful Use 3" or "MU3." Briefly, thanks to the American Recovery and Reinvestment Act (ARRA) of 2009, CMS can impose incentive payments to promote the adoption and "meaningful use" of electronic health records (EHRs).  Meaningful Use or MU has since become its own government program.  MU1 and MU2 are well underway, and CMS is preparing for the third phase, or MU3.
But a phunny thing happened on the way to this phase phorum. While insiders have saluted the good intentions behind the latest requirements, there's a lot of bad and even more ugly. It's telling when even the prestigious New England Journal publishes a highly critical perspective like this. It seems that skepticism over the fit of MU with the realities of clinical practices is being misinterpreted in some quarters as technophobic non-cooperation.

And so it goes.

Fortunately, for the Population Health Blog, its psychological EHR scars have long healed.  It, like a lot of other colleagues, has moved to a market of (for example) electronic care solutions that are not local and PC-based,  but are mobile and cloud-based.  And the good news is that - so far - there is no ARRA statute intended to enable a well-intentioned lawyer from uttering those Nine Most Terrifying Words just when the health app ecosystem is reaching critical mass.

But that doesn't mean that we can't learn from the EHR-MU Wars.  To wit:
1) Learn from mistakes; for example, better, not more, information technology begets more patient safety.

2) It's ultimately all about user value creation: for example, resist linking the technology to billings/revenue and link it to care/satisfaction.

3) Design with the end-user in mind: for example, release no product unless the intended user has shown that it can fit in their (provider) work flows or their (patient) home setting

4) Align the time frames: keep in mind that the short-term time technology horizon of 2-3 years to may not align with the 5 or more years it takes to "bend the curve" for a insurance risk-bearing organization

5) Resist the allure of government help: while incumbent companies may believe federal legislation may turbocharge their business models, the MU suggests that the downsides are considerable.

Tuesday, October 13, 2015

Of Rising Risk and ACO Success in the Medicare Shared Savings Program: Community Health Network and Pharos Innovations

To each according to their need, from each according to their ability.

While that famous (and paraphrased) adage was originally used to attack capitalism, it's also not a bad way to think about effective care management programs.  Ill persons have varying needs, and care providers have varying resources.  In a resource-constrained environment, the health system that matches the right needs with the right resources will win.

A case in point may be one of the few Medicare Shared Savings Program (MSSP) ACOs that met CMS' savings threshold.

"Community Health Network" is a joint venture between HealthEast Care System and Entira Family Clinics that serves Medicare beneficiaries in Minnesota's Twin Cities.  According to this Pharos Innovations case study (which can be found here), the organization analyzed their population's past utilization and future risk and realized that a relatively small group of beneficiaries were high need.

High need was defined as those individuals with "rising risk" or what the Population Health Blog has termed the "sweet middle." These are individuals who are not only burdened by chronic medical conditions (such as heart failure), but have a constellation of issues (such as a recent discharge from a hospital) that also can be mitigated or impacted.

Once these patients were identified, Pharos Innovations provided the "transition coaches" and "engagement specialists" for the high need/rising risk/sweet middle patients who were most likely to have an admission and/or readmission.

By pinpointing state-of-the-art heart failure treatment protocols, care management, self-care coaching and discharge-care interventions, avoidable admissions and avoidable readmissions - compared to a control group of patients - dropped in significant manner. That was enough to skew the ACO's overall admission and readmission costs downward and reach CMS' savings threshold.

Population Health Blog lessons:

1) If a healthcare organization is willing to take on the financial consequences of health insurance risk, it will have to array its covered population's risks from high to low, and deploy interventions that can address the needs of patients at high - yet modifiable - risk.

In other words, within any high risk subpopulation are sub-populations with specific health care needs that can be addressed with smart population-based care management interventions. 

2) The PHB looks forward to these data appearing in the peer-reviewed literature.  In the meantime, kudos to Pharos Innovations for achieving credible outcomes based on a comparison to a valid control group.

3) Patients who don't have to go into a hospital are better off for it.  Despite Karl Marx's antipathy, aligned economic incentives can be win-win for everyone.  Community Health Network deserves to be financially rewarded by CMS.

4) There is a good reason to believe that Community Health was destined to do well versus the other MSSP participants. As pointed out here, physician leadership may be one ingredient to the MSSP ACO secret sauce. According to the case study linked above, Community Health Network expended considerable resources to convince their physicians that this approach was a good idea.  What's more, their board is majority physician controlled.  In addition, Pharos Innovations was started by a doc and they have additional physician representation on their board.

Friday, October 9, 2015

The PHA Forum 2015. the Premier Population Health Meeting

If you have any interest in medical costs, outcomes and consumerism, you really should think about attending the Population Health Alliance Forum November 2-4 in Washington DC.


The PHA is an advocacy and education association dedicated to advancing population health as a component of health reform.  The Population Health Blog likes the PHA because its membership is made up of a wide range of experts who have worked to translate the theoretical and fiduciary interests of insurers, payers, government and other stakeholders into real-world and sustainable programs. 

After rubbing elbows with these guys in meetings, hallways and over beverages, the PHB always walks away a little bit smarter.  If you go, you will too.


Great keynotes that connect policy, theory and reality;

A debate between wellness skeptic Al Lewis and widely published Ron Goetzel.

Instructive case studies that you won't hear about anywhere else;

Insights about monitoring and communication technologies;

Continuing education credits;

You'll get to meet PHA CEO Fred Goldstein and the other outstanding PHA team members;

The PHB will be there!

Registration information here.

The Latest Health Wonk Review Is Up!

Revolving doors at the FDA, anti-Obamacare lawsuits, meaningful use, shared savings, alleged corporate malfeasance, health insurer interest in your Fitbit data and the prognosis of private practice.

Where else can you find linked insights on these topics and more, but at the latest Health Wonk Review hosted by the brainy Joe Paduda


Monday, October 5, 2015

Physician Owned Private Practice Is Still Alive and Well: Here's Why

A death greatly exaggerated...
The Population Health Blog recently broke bread with a Director at the Tucker Advisory Group.  TAG provides professional services to a host of health care entities, including physician-owned provider groups.

The PHB has been skeptical about the death of private practice, and the breakfast did little to change its mind.

What it learned is that there is no shortage of business for outfits like TAG.  A typical private practice client is a group of ten or more physicians with multiple clinics in a multi-county area serving thousands of patients.  These groups range from primary care to pain management to women's service to cardiology.  While their revenues and expenses cannot be taken for granted and payer hassles abound, it's not impossible for a nimble and hard-working group of private practice docs to serve their patient population and still end the year in the black.

In addition, it hasn't been that unusual for individual physicians who are in salaried positions in large hospital-dominated provider organizations to contact TAG to explore the options for going into "private practice."

Anecdotal you say?

Despite the narrative that the death of private practice is "unstoppable," there are plenty of reasons to be contrarian:

1) The latest good information (like this) on physician employment that supports the narrative that private practice is dead is from the AMA's 2012 data base.  While newer data from 2014 indicate that independent primary care practice is dwindling, there are pockets of specialty physician private practice that are remaining strong. In other words, one reason for the growth of salaried physicians is their flight from continuing struggles of primary care, not toward the advantages of employment.

2) Whether they're in a salaried position or in private practice, today's physicians are still demanding autonomy, adequate resources, input and to be rewarded.  Given reports like this and this on getting docs to do what they're told cooperate, is it any wonder that physician entrepreneurship is still alive?

3) And speaking of being rewarded, physician compensation in ACOs don't appear to provide any particular advantages.

4) What about the patients, you ask?  Good question, and you can be sure that the docs are asking it too.

The point?  Large hospital-provider systems relying on salaried physicians are an important option in health care reform.  The PHB suggests that reports of the death of private practice have been exaggerated and it will also remain an important option. 

Stay tuned!