What do address books, video cameras, pagers, wristwatches, maps, books, travel games, flashlights, home telephones, cash registers, Walkmen, day timers, alarm clocks, answering machines, The Yellow Pages, wallets, keys, transistor radios, personal digital assistants, dashboard navigation systems, newspapers and magazines, directory assistance, travel and insurance agents, restaurant guides and pocket calculators all have in common?

This question was posed by Paul Nunes and Larry Downes in their recent Forbes article “How Innovations Become Better and Cheaper“.

For today’s quiz, we’ll have 3 levels of scoring– 2 points for a good answer, 5 points for a better answer, and 10 points for the best answer.

The 2 point answer: each of these products or services is in the process of being disrupted by a new technological innovation.

The 5 point answer: each of these products or services  is being supplanted  by what Nunes and Downes refer to as a “Big Bang Disruption”.  Read their Harvard Business Review article for more details on Big Bang Disruption.

The 10 point answer?

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It doesn’t mean that care providers need to hug each other and sing Kumbaya. Ideally, care providers will like each other, but that’s not foundational.

I see 3 critical elements to clinical collaboration:

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The sharing of patient information in the US is out of whack — we lean far too much toward hoarding information vs. sharing it. While care providers have an explicit duty to protect patient confidentiality and privacy, two things are missing:

• the explicit recognition of a corollary duty to share patient information with other providers when doing so is the patient’s interests, and
• a recognition that there is potential tension between the duty to protect patient confidentiality/privacy and the duty to share — with minimal guidance on how to resolve the tension.

In this essay we’ll discuss

1. A recent recognition in the UK

2. The need for an explicit duty to share patient information in the US

3. Implications of an explicit duty to share patient information in the US

1) A recent recognition in the UK

Last week a long-awaited study commissioned by the Department of Health was released. Here are a few key findings from The Information Governance Review Report (Caldicott Review):

…safe and appropriate sharing in the interests of the individual’s direct care should be the rule, not the exception. (more…)

By Gregg A. Masters, MPH; originally posted at ACO Watch

I intended to post updates from Aetna and Cigna next in this series, yet today I received a tweet by Vince Kuraitis, aka @VinceKuraitis, calling attention to Universal American a managed care player I’ve not spent much time on. Yet they present a rather interesting profile and operating footprint some of which I will highlight below. According to their website Universal American (UAM):

...provides health benefits to people with Medicare. We are dedicated to a Healthy Collaboration, working together with healthcare professionals in order to improve the health and well-being of our members.

The JPMorgan Healthcare conference deck is here, and webcast here (you may need to register). Of note is with the recent release of CMS certified ACOs, UAM now operates ’31 ACOs approved for participation in the Shared Savings Program which include more than 2,000 participating physicians covering an estimated 300,000 Original Medicare beneficiaries in 13 states.’ So not only are they a player in Medicare Advantage (the end game for risk bearing ACOs), they have a presence in the gateway market as well. For complete details, click here. Two pieces from their narrative tell the story, 1) the ‘healthcare landscape’: 

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On The Health Care Blog, veteran analyst Vince Kuraitis reviews a report from the consulting firm Oliver Wyman (OW), arguing that the trend toward reconfiguring health systems to deliver more accountable care is more widespread than any of us suspect.

“The healthcare world has only gotten serious about accountable care organizations in the past two years, but it is already clear that they are well positioned to provide a serious competitive threat to traditional fee-for-service medicine. In “The ACO Surprise,” our analysis finds that 25 to 31 million Americans already receive their care through ACOs-and roughly 45 percent of the population live in regions served by at least one ACO.”

OW provides a well-reasoned analysis and conclusions, but I’m skeptical. In discussions with health system executives around the country, I hear some movement toward change, but relatively few organizations are materially turning their operations in a different direction. The specter of policy change is looming, but it is still abstract. As I’ve described before, market forces are intensifying, but they’re mostly still scattered and immature. (more…)

A  recent analysis of the ACO market by Oliver Wyman market suggests we’re well on our way toward being “there”.

My personal take on this report:

Provocative, fresh, thoughtful, well reasoned, expansive — albeit a bit of a stretch

However, I suspect many others will describe it as: 

Speculative, harebrained, unsupported, overly extrapolative, out-to-lunch, wishful to the point of being woo woo

So now that I hopefully have your attention, what’s this report all about? In a nutshell: 

The healthcare world has only gotten serious about accountable care organizations in the past two years, but it is already clear that they are well positioned to provide a serious competitive threat to traditional fee-for-service medicine. In “The ACO Surprise”, our analysis finds that 25 to 31 million Americans already receive their care through ACOs—and roughly 45 percent of the population live in regions served by at least one ACO.

Let’s dig in to the report. In this blog post, I’ll summarize their math, surface their critical assumptions and observations, and comment on their reasoning. I’ve indented direct quotations from the report and have italicized wording that spells out the major assumptions.

While I don’t agree with all of Oliver Wyman’s math and assumptions, I applaud them for the process they have gone through. Please take my commentary as “quibbling at the edges” and that overall I’m on board with their methodology and conclusions. (more…)

This is a case where a picture is worth a thousand words.

Source: Boston Consulting Group, Health Reform Should Focus on Outcomes, Not Costs, October 2012

Are Hospitals Dragging their Feet on Accountable Care?

Commonwealth Fund: “only 13 percent of hospital respondents reported participating in an ACO or planning to participate within a year”

KPMG Survey: “(only) 27 percent of [health system] respondents said current business models were either not very or not at all sustainable over the next five years”

Health Affairs: “Medicare’s New Hospital Value-Based Purchasing Program Is Likely To Have Only A Small Impact On Hospital Payments”

The Bigger Picture

Do hospitals today perceive their current business model on the metaphorical “burning platform” — when the status quo is no longer an alternative? (more…)

Everywhere we turn these days it seems “Big Data” is being touted as a solution for physicians and physician groups who want to participate in Accountable Care Organizations, (ACOs) and/or accountable care-like contracts with payers. We disagree, and think the accumulated experience about what works and what doesn’t work for care management suggests that a “Small Data” approach might be good enough for many medical groups, while being more immediately implementable and a lot less costly. We’re not convinced, in other words, that the problem for ACOs is a scarcity of data or second rate analytics. Rather, the problem is that we are not taking advantage of, and using more intelligently, the data and analytics already in place, or nearly in place.

For those of you who are interested in the concept of Big Data, Steve Lohr recently wrote a good overview in his column in the New York Times, in which he said:

“Big Data is a shorthand label that typically means applying the tools of artificial intelligence, like machine learning, to vast new troves of data beyond that captured in standard databases. The new data sources include Web-browsing data trails, social network communications, sensor data and surveillance data.”

Applied to health care and ACOs, the proponents of Big Data suggest that some version of IBM’s now-famous Watson, teamed up with arrays of sensors and a very large clinical data repository containing virtually every known fact about all of the patients seen by the medical group, is a needed investment. Of course, many of these data are not currently available in structured, that is computable, format. So one of the costly requirements that Big Data may impose on us results from the need to convert large amounts of unstructured or poorly structured data to structured data. But when that is accomplished, so advocates tell us, Big Data is not only good for quality care, but is “absolutely essential” for attaining the cost efficiency needed by doctors and nurses to have a positive and money-making experience with accountable care shared-savings, gain-share, or risk contracts. The promotional literature for Big Data is peppered with jargon and catch phrases — “close to the point of care,” “synthesizing large amounts of information,” “transformational analytics,” and so on — that promise to “de-fragment” the current health care environment and offer predictive insights that the doctors, nurses, and patients do not now possess.

This all may be true. But why wait for Big Data to be put in place, when what we’ll call “Small Data” is already available and can offer information and analytical insights sufficient to get a good start on care management programs capable of improving quality and reducing some unnecessary costs?

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This is the dumbest idea I’ve heard since “I’m going to invest all my money in Facebook’s IPO and get rich!”

Here are six reasons why:

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We are pleased to offer you our updated perspectives on the future of platforms in healthcare.

Click here for a copy of our joint presentation at the 9^th Annual Healthcare Unbound Conference. This is an update from our earlier joint presentation at the eCollaboration Forum as part of HIMSS 12.

What’s different in the marketplace over the past few months? Three key observations:

1) The trend toward platform adoption is accelerating and becoming more clearly understood. The requirements of Stage 2 Meaningful Use are a major catalyst, and in turn platforms are a critical enabler of health information exchange (the verb).

2) We are learning that “data platform” adoption is occurring more rapidly than the adoption of other types of platforms. While there are may elements to platform openness, we have long believed that data portability (separating data from applications) is an essential first step.

Why is there more rapid uptake on data platforms? We’ll speculate on a couple of reasons. First, the Federal promotion of “Government as Platform” generally and specifically CMS’ recent proposals relating to platforms for Knowledge Discovery Infrastructure (see slides 47-61).

Second, application platforms are more likely to involve shared workflow among care providers, not just shared data. Not unexpectedly, we are learning that sharing workflow is much tougher, but we believe in the long run will provide dramatic new levels of value.

3) Expect to see continuing marketplace battles among walled garden (semi-open) and open platforms. As one example, several recent market analyses (e.g., Chilmark, IDC) document more rapid adoption of private, walled garden HIEs (health information exchanges — the noun) than for more open state or regional HIEs.

There are good arguments for both walled garden and more open platforms. More on this topic later.

Again, you can click here for a copy of our presentation.

Early pioneers to Colorado did not have the luxury of waiting for railway or infrastructure to be in place before taming a new frontier. Their vision and determination laid the foundation for the settlers who followed. They used the tools and talents they had to develop an infrastructure and ultimately build viable, productive communities. Had they waited for the perfect conditions, they’d still be back east.

It’s a lesson we’ve applied to health care transformation. At the Colorado Beacon Consortium (CBC), we resisted the temptation to delay good learning opportunities and wait for perfect solutions. We embraced the ONC/HHS’ challenge to demonstrate how costs can be reduced and patient health improved by integrating health information technology (HIT) into a transformed clinical workflow. This pioneering effort requires new competencies with patient and population data, more sophisticated technology, and a supporting workforce. So far, we’ve offered technical assistance to more than 50 primary care practices in western Colorado. We are laying a foundation. (more…)

• Trust of hospitals tends to be high (60–80%)
• Trust of health plans is at the bottom of the heap (10–20%)

Is this written in stone for the future? I don’t think so…and the dynamics for change are in motion.  Please read on.

Here’s the emerging picture I’m seeing:

• Hospitals are dragging their feet in connecting you with your electronic health information.
• Health plans are highly motivated to connect you with your health information. (more…)

One of the biggest concerns about ACOs has been their potential to enable market consolidation— that by uniting health care providers the ACO gains market clout and ability to charge higher prices.

While this is a legitimate concern about ACOs, so far it’s not playing out.

Why?

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Surprised

I had been anticipating this announcement as a defining moment for Medicare’s thrust into accountable care. My expectations had been that we would see either:

Boom — a big splash of new Medicare shared savings ACOs announced, including big name hospitals and medical groups that were starting large scale ACOs, perhaps with hundreds of thousands of patients.

Bust — no one showed up at the party. Providers would have concluded that Medicare ACOs were too risky, bureaucratic, and high effort.

Intrigued

What we got is something in the middle: (more…)

I am hearing that carriers are staying away from ACOs and are not planning on partnering.  What have you heard?

This is one of those blip-on-the-radar-screen comments that jarred my attention — and it raises very important questions about industry dynamics.

First, let me expand on the issue.  As I’ve written before, there are at least two broad categories of “accountable care initiatives”:

1) Formal Accountable Care Organizations (ACOs) by which care providers contract with Medicare

2) Informal Accountable Care-Like (AC-Like) arrangements between care providers and commercial health plans.

The list of accountable care animals in the forest is likely to keep growing. For example, just this week Oregon announced details for CCOs (Coordinated Care Organizations) for Medicaid.

So how are different stakeholders likely to react to the opportunity of a formal ACO contracting with commercial health plans? Let’s look at this from a couple of different angles.

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1. Transaction costs
2. Timing
3. Incrementalism
4. Flexibility
5. Capital cost

There’s an important  6^th  difference worth noting:

Visibility

Formal ACOs will be visible from miles away — think elephants on the Serengeti.

An ACO that wants to contract with Medicare must establish itself as a corporation. The Medicare ACO models have substantial disclosure and reporting requirements. We won’t know everything about formal ACOs, but we will know a lot. ACOs cannot hide.

AC-Like arrangements between care providers and commercial payers could be much more difficult to spot and categorize — think chameleons in the jungle.  

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In 2007, Apple iOS and (Google) Android had a collective market share of 0%.

Today they have a collective market share of 77%.

The health care market is moving toward accountable care. There are at least two broad paths forward:

1) Formal Accountable Care Organizations (ACOs) by which care providers contract with Medicare

2) Informal Accountable Care-Like (AC-Like) arrangements between care providers and commercial health plans

What are the differences between these routes? I see at least 5 factors at play:

• Transaction costs
• Timing
• Incrementalism
• Flexibility
• Capital cost

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That’s inefficient, ineffective, and just plain wrong. 

But we’re seeing light at the end of the tunnel — the proposed Stage 2 Meaningful Use (MU) rules reinforce new, evolving accountable care payment approaches. The rules support moving competition in healthcare to the right bases — sharing and adding value to patient health record data.

Today: Competition Based on Hoarding Patient Data

Health care providers today have incentive to hoard patient health record information. They might phrase it as:

I don’t get paid to share data with other doctors and hospitals — I get paid to do procedures, tests, surgeries, admissions….

HIPAA has severe penalties for sharing data inappropriately. I could spend time in jail for violating privacy/security regs for sharing patient data when I shouldn’t. Better to be safe than sorry.

Why would I want to share data with other doctors or hospitals? They are competitors. Patient data is MY competitive asset. Would I like to have access to their data? Of course…but no way will I share my data.

Would I want to provide other care providers with information to help keep a patient shared care plan current? What’s a shared care plan?

Competition Based on Hoarding: Wrong!

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Implications of a Shifting National HIE Architecture

My colleague Shahid Shah and I are glad to make available to you a copy of the slides from our upcoming presentation “The Future of Platforms in Healthcare.”  This presentation takes place at the eCollaboration Forum as part of HIMSS12 on Thursday, February 23.

You can access the slides here.

While the eCollaboration Forum in Las Vegas is sold out, you can still sign up for the live webinar all day Thursday, February 23: http://eCollab12.eventbrite.com

Here’s a brief summary of our presentation “The Future of Platforms in Healthcare”.

I. NECESSARY: Platforms are a “Must Have”, Not Just A “Nice to Have”

Today’s EMR (electronic medical record) products cannot enable accountable care. Here’s what you would have to believe to think that closed, proprietary products can get us to accountable care:

1. That one company can develop all needed functionality, and
2. That health IT will become a winner-take-all market (either through single-payer or all care providers in a market voluntarily choosing to buy the identical “product”), or
3. That optimal collaboration across products can be achieved by phone, paper, fax

Our conclusion is: interoperable platforms are a “Must Have”.

II. COMPLEX: Many Key Characteristics of Platforms (more…)

The inaugural eCollaboration Forum taking place at HIMSS12 on Thursday, February 23, 2012 in Las Vegas is SOLD OUT!

A webinar is available to those who will not be in Las Vegas: http://eCollab12.eventbrite.com

Theme — Collaborative Platforms and Applications in Health Care

This is the Health IT industry’s first-ever event focusing on collaborative health platforms and applications! We take an expansive view of platforms and will be exploring the required technologies, business ecosystems, and clinical care delivery needed to achieve accountable care.

It is also the first event ever that HIMSS has partnered with an outside organization to produce a “conference-within-a-conference”, as well as the first event of it’s kind focused on collaborative platforms and how they enable new models of care delivery and new business models for health care!

Full agenda:

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A recent article by Andreas Constantinou in Vision Mobile blog provides guidance. The article lists a Dead Platform Graveyard from the past 10 years — you will probably recognize some of the names: Meego (Nokia/Intel), Palm 5/6, Symbian OS (Nokia) WebOS (HP), Windows Mobile (Microsoft). Blackberry RIM is a candidate to make next year’s list.

Software platforms have failed for a combination of reasons:

• Cost of ownership
• Conflicting revenue model
• Lack of network effects
• High adoption barriers

The author also provides great lessons and guidance as to what DOES work:

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Brian Ahier sparked a feud with his Google+ post commenting on a recent JAMIA article entitled Shift in the Architecture of the Nationwide Health Information Network. We’re at 60+ comments and going strong. The discussion has also been picked up on in Modern Healthcare.

The JAMIA article was written by Leslie Lenert and colleagues, and Lenert joins in heartily in the Google+ discussion. From the abstract, here are 3 key points they make:

1) …a significant change in the architecture of the NwHIN is taking place. Prior to 2010, the focus of information exchange in the NwHIN was the Regional Health Information Organization (RHIO). Since 2010, the Office of the National Coordinator (ONC) has been sponsoring policies that promote an internetlike architecture that encourages point to-point information exchange and private health information exchange networks.

2) The net effect of these activities is to undercut the limited business model for RHIOs, decreasing the likelihood of their success…

3) These changes may impact the health of patients and communities. Independent, scientifically focused debate is needed on the wisdom of ONC’s proposed changes in its strategy for the NwHIN.

What does the Family Feud survey audience think of these points?

While I’ll acknowledge that one could draw many inferences from the discussion, here’s my interpretation, synthesis and commentary of the main points in the Lenert, et. al. article.

1) A Shift in NwHIN Architecture is Occurring

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The headline in yesterday’s LA Times declares:

‘App Economy’ credited with creating 446,000 jobs.

What’s the App Economy?

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By 2020, the American health insurance industry will be extinct. Insurance companies will be replaced by accountable care organizations — groups of doctors, hospitals and other health care providers who come together to provide the full range of medical care for patients.

Irresponsible

Provoking and demonizing health plans might have had populist appeal and political value in 2009, but in 2012 it’s an unnecessary attack on a constituency that has potential to be one of the administration’s best allies in advancing accountable care.

Prior to ACA reform legislation, health plans had the wrong economic incentives — the rules of the game were not consistent with good public policy:

• Health plans had incentives to AVOID risk, not manage risk. They were economically incentivized to avoid high risk patients (with preexisting conditions) and to get rid of patients that became sick
• Health plans had minimal incentives to CONTROL systemic costs — they could pass them on in the form of premium increases.

ACA changed incentives and disrupted the payer business model:

•  Health plans will longer be allowed to avoid high risk patients; they must accept all comers
•  Health plans must MANAGE, not avoid costs. Health plans are abandoning their old business models.

What are we seeing in the marketplace? Almost all health plans are embracing the vision of accountable care and need to shift the system from Volume to Value. Health plans could be administration’s biggest friend in revamping the health care delivery non-system.

Naive (more…)

Eric Schmidt, Chairman (and former President) of Google, coined the term “Gang of Four” in referring to the similar platform/application technical architecture and business models of these companies. In the case of Apple iOS and Google Android OS, much of the value is created by the 500K+ applications built on these platforms, not just by the platform themselves.

So four of the largest, most successful companies in the world are built on platforms — what does this imply for health care? Are “platforms” in health care a “Nice to Have” or a “Must Have”?

(more…)

Please consider attending the inaugural eCollaboration Forum taking place at HIMSS12 on Thursday, February 23, 2012 in Las Vegas at the Venetian Sands Expo Center.

Theme — Collaborative Platforms and Applications in Health Care

This is the Health IT industry’s first-ever event focusing on collaborative health platforms and applications! We take an expansive view of platforms and will be exploring the required technologies, business ecosystems, and clinical care delivery needed to achieve accountable care.

Speakers

Sponsored by HIMSS and Collaborative Health Consortium (formerly the Clinical Groupware Collaborative), the inaugural eCollaboration Forum has scheduled the following speakers [updated as of 2/3/12]:

• Farzad Mostashari, MD, ScM – National Coordinator for Health Information Technology
• Esther Dyson – Principal, EDventure Holdings
• John Mattison, MD – Assistant Medical Director and CMIO of Kaiser Permanente, SCAL
• Jinesh Varia, Technology Evangelist, Amazon Web Services
• Mark Blatt, MD, MBA – Worldwide Medical Director, Intel, “Collaborative Care: An Economic Imperative for Care Delivery Systems”
• David Whitlinger – Executive Director, NY eHealth Collaborative “Supporting New Models of Care Through Collaboration with States & Vendors”
• Steve Adams – President and Chairman, Collaborative Health Consortium; EVP Collaborative Care, Alere
• David Kibbe, MD, MBA – The Kibbe Group and American Academy of Family Physicians “Developing Trust in the Health Internet as a Platform”
• Vince Kuraitis – Principal, Better Health Technologies “The Future of Collaborative Health Platforms”
• Shahid N. Shah – CEO, Netspective and Blogger at HealthcareGuy.com “The Future of Collaborative Health Platforms”
• Brian Ahier – Health IT Evangelist, Mid-Columbia Medical Center
• Joshua Newman, MD, MSHS – Director of Product Management and Health Strategy, Salesforce.com
• West Shell III – Chairman and CEO, Healthline
• Scott Rea – Vice President GOV/EDU Relations and Senior PKI Architect, DigiCert
• Joe Miller – Director of eBusiness, AmeriHealth Mercy
• Richard Migliore, MD, EVP Health Services, United Health Group
• Jordan Shlain, MD – CEO, HealthLoop
• Joseph Miller, Director, eBusiness, AmeriHealth Mercy
• Bettina Experton, MD, MPH, President and CEO, Humetrix
• Josh Mandel, MD, Lead Architect, SMART, Harvard Medical School
• Brian Prestwich, MD, Assistant Professor of Family Medicine, Keck School of Medicine USC
• Rushika Fernandopulle, MD, President, Iora Health
• Jonathan Hare, Chairman, Reslient Networks
• Richard Migliori, MD, Executive Vice President, Business Initiatives & Clinical Affairs, Chief Healthcare Officer, UnitedHealth Group Alliances
• Dave DeBronkart, @ePatientDave
• Robert M. Kolodner, MD, Chief Health Informatics Officer, Open Health Tools
• Scott Barclay, Chief Strategy Officer, SureScripts
• Jinesh Varia, Technology Evangelist, Amazon Web Services

For the latest up-to-the-minute list of speakers, click here.

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Yet, for my lifetime, I have been incredibly frustrated by medicine’s cultural and practical lack of acknowledgement of this law.

FINALLY, the American College of Physicians (ACP) got it. Kaiser Health News describes the revelation:

The American College of Physicians hit a nerve when it released an updated ethics manual calling for doctors to provide “parsimonious care” – in other words, “to practice effective and efficient health care and to use health care resources responsibly.”

This recommendation, included in the Jan. 3 Annals of Internal Medicine special supplement, drew immediate reaction – and not just because of its use of the infrequently heard “parsimonious.” It’s been viewed as a definitive statement of medical ethics directed at the organization’s 132,000 members – physicians who practice internal medicine and its related specialties, among them cardiology and oncology, that often involve expensive procedures. And, the guidance comes at a time when health care costs are central to the national policy debate.

My personal reactions to this are very mixed. (more…)

Tracey Moorhead, President and CEO of the Care Continuum Alliance, writes today’s inaugural post. She persuasively notes the increasing importance of the full continuum of population health interventions – wellness, prevention and other approaches to improving health, reducing disease risk and raising productivity.

Bob Laszewski’s essay on today’s THCB resonated with me: 2012: A Year of Huge Uncertainty in Health Care Policy. In my 30 years in health care, I have never seen more uncertain and fluid times.

Yet in times of uncertainty and confusion, it’s important to focus on what IS certain and predictable. The need for population health approaches is one of those certainties. While care providers are recognizing the need to develop and invest in strong care management abilities, health plans are redoubling their efforts to develop these capabilities in-house.

Tracey’s first post includes a link to the CCA’s new white paper: Key Issues in Population Health Management: Key Industry Issues for 2012.  Check it out.

What are acceptable bases of competition in health care?

My sense is that the distinctions here are not well understood and often go undiscussed, so I’ll quickly get to the point:

It’s OK for care providers to compete on the bases of quality, price, patient satisfaction, and many other factors

It’s NOT OK for care providers to compete on the basis of controlling or limiting access to patient health information. It’s just not right.

Today’s US healthcare system embraces market competition. For-profit and non-profit health care systems and care providers compete against one another. While we might or might not like this, all I’m asking you to do here is to recognize it.

Hospital based delivery systems work hard to keep patients within their network (walled garden) of providers. That’s understandable. But we need to probe deeper and examine how they are doing this — again, what are the bases of competition.

In many industries we accept the idea of creating proprietary, non-interoperable technology as a means of competitive differentiation. For example, the Apple iTunes system is not interoperable with MP3 players. This is an explicit and intentional part of Apple’s business strategy. I have no problem with this type of competition in digital entertainment.

Health care is different.

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a unicorn — a fantastic creature that is vested with mythical powers. But no one has actually seen one.

a camel — a horse designed by a committee, one that already has its nose in the tent

With this background, you can begin to appreciate the difficulty of conducting an accurate census of ACO animals in the wilderness.  Yet, this is exactly the task undertaken in the excellent Leavitt Partners report measuring ACO activity in the US.

As I will explain, the Leavitt report has the potential both to overestimate and underestimate ACO and accountable care-like activities. In my judgment, however, it’s far more likely to be understating just how much accountable care activity actually is going on.

Findings in the Leavitt Report

The Leavitt researchers “identified ACOs from news releases, media reports, trade groups, collaborations and interviews through the beginning of September 2011. Also included were entities that either self-identified as being an ACOs or specifically adopted the tenets of accountable care.”

The report counts 164 ACOs — 99 that are primarily sponsored by hospital systems, 38 by physician groups, and 27 by insurers.

Here’s how Leavitt summarized their results: (more…)

My mom would not know what I mean by “Standard Health Data Connectivity Specifications,” so I’ll try to write this in plain English.

Who Are These Guys? The EHR|HIE Interoperability Workgroup

The workgroup consists of HIEs (Health Information Exchanges) representing seven of the largest states, eight EHR vendors, and three HIE software/services vendors. (more…)

A couple tables in particular caught my attention.

(click on the graphic to view a larger version)

Key findings in this table include:

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by Nate DiNiro

HealthCamp Oregon is organizing 2 events during the 3rd week of October in Portland, Oregon. The events will focus on Healthcare, Health IT, the ePatient & Participatory Medicine movement and all-things Healthcare Transformation!

The first event, a panel that will focus on the impact of social media in healthcare, is scheduled for Thursday 10/20. We’re also helping to promote the annual Kaiser Center for Health Research Saward Lecture, scheduled for Friday 10/21. More information on that event can be found below. The second event we’re planning is a HealthCamp unconference, scheduled on Saturday 10/22 and to be held at the offices of Urban Airship. If you’re unfamiliar with either of the previous terms “HealthCamp” or “unconference”, please read on and we’ll fill you in below.

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Here are six quick first impressions:

1. It’s very creative and innovative. CMS has demonstrated out-of-the-box thinking and leaves a lot of room for applicants to propose their own approaches. Expect to have to read the materials 2-3 times to wrap your thinking around it.

Unlike the Medicare Shared Savings ACO rule, the BPCII is flexible.  Anticipate some innovative and non-traditional proposals from diverse applicants. Unlike the Medicare ACO Shared Savings rule, the BPCII invites flexibility in:

• Definition of care bundles
• Proposal of specific financial terms
• Participation by diverse care providers (see below)
• Risk adjustment of beneficiaries

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by Jaan Sidorov MD, MHSA, FACP and Vince Kuraitis JD, MBA

Physicians face great uncertainty. According to a survey conducted by The Physicians Foundation, the great majority of physicians (89%) believe the traditional model of independent private practice is either “on shaky ground” or “is a dinosaur soon to go extinct.”

In the face of this uncertainty, many physicians are jumping to a conclusion that “I have to sell my practice to the hospital.” In this post of our series on The 100 Year Shift, we will examine physician practice.  We’ll show that the economic and clinical environment  is changing rapidly and that selling to the hospital is one option. However, it is not the only option. (more…)

In our introductory posting of this series, we noted that economic incentives previously aligning doctor-hospital interests were changing. This creates the potential for The 100 Year Shift – physicians awakening to possibilities for stronger partnerships with payers than with hospitals.

In this post, we will zero in on the changing economic position of hospitals and the effect this is having on physician-hospital relationships. We will examine the trend of hospital employment of physicians and point out challenges and tensions for the future. [This is a long post...so now might be the time to refill your coffee cup.] (more…)

IMHO, the recent acquisition by Highmark Blue Cross Blue Shield of West Penn Allegheny Health System (WPAHS) for $475 M is unique to local market conditions. It was done as a last resort and should not be taken as a signal that health plans are starting a hospital buying binge.

Why are hospitals unattractive investments for health plans:

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It’s a different issue whether closed or walled garden HIT is an acceptable means toward that end.

Outside of healthcare, we understand and can accept that businesses used closed, proprietary IT as part of their business model. Apple has designed their iPod with an eye toward incompatibility and high hassle factor in not being plug-and-play with other music players and systems.

IMHO, however, healthcare is different. Keep your proprietary business model away from my body and gimme my damn data.

Google+ v. Facebook on Data Portability

We are witnessing an important dynamic begin to play out between FB and Google+. I note a significant difference in mindset and policies toward data portability. (more…)

by Jaan Sidorov MD, MHSA, FACP and Vince Kuraitis JD, MBA

In our introductory posting, we suggested that a huge shift is underway in the health care industry.  Decades of hospital-physician cooperation are not only eroding, we suggest this trend could accelerate.  Instead of a natural clinical and economic affinity with hospitals, we foresee the potential for physicians forming a new dyad with insurer-buyers.

In this post, we will examine what we and many other commentators view as inevitable: the demise of volume-based payment systems and how the drive for greater value will cause physicians and insurers re-examine their normally antagonistic relationship. (more…)

Gazing at the horizon, we foresee the potential for a tectonic realignment among physicians, hospitals and payers. Here’s a quick visual representation:

This essay is the first of a seven part series. In this first post we will capsulize our vision of this potential 100 Year Shift, answer initial FAQs, and lay out the structure for the rest of the series.

The Lynchpin — Changing Economic Incentives

In the past, physicians and hospitals have benefited from mutually supportive economic interests. (more…)

Readers and commenters (on e-CareManagement and The Health Care Blog) quickly grasped that a social networking platform could play a very useful role in coordinating our health care, yet also agreed with the conclusion that Facebook wasn’t  “it”.

So let’s ask the question again: Could Google+ be your platform for care coordination? This post will

• Describe Google+ and Circles
• Discuss how Google+ gets past some of Facebook’s limitations as a care coordination platform
• Comment on Google+ as a care coordination platform (promising, but too early to tell) (more…)

1) Hospital administrators assume that tighter physician-hospital integration (e.g., through employment of physicians) will result in ”captive referrals” by physicians back to the mother-ship hospital.

2) Medicare administrators are assuming that Medicare Shared Savings ACOs will be able to coordinate patient care even without limitations on patients’ choice to go to providers outside of the ACO provider network.

Here’s the data that challenges the validity of BOTH of these assumptions:

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Ironically — at the same time — commercial payers are awakening to ACO opportunities.

Please read further.

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Major U.S. health insurers, including Aetna Inc., Humana Inc. and WellPoint Inc., are retooling to become more than just health plans, in the wake of the federal health-care overhaul that is changing the rules for the industry’s core business.

Diversification plans, touted in meetings with investors this year, include stepped up acquisitions and partnerships that will allow the companies to employ doctors directly, deliver health-information technologies, and participate in new hospital-doctor groups known as accountable-care organizations.

Wall Street Journal; May 12, 2011

Does this make sense? Absolutely!

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Why have hospitals increasingly been buying physician practices?  Are these marriages based on true love or convenience? Will these marriages survive?

To address these questions, let’s take the long view (50–100 years) and revisit 7 assumptions that have driven us to today’s healthcare non-system:

1. Healthcare payment systems have rewarded piecemeal work.
2. Despite uneasiness, hospital-physician relationships have been cooperative.
3. Physicians can function effectively in small/medium size practices.
4. The healthcare mindset: built on control, not collaboration.
5. Barriers to sharing patient info and coordinating care are high.
6. The hospital has been the economic bedrock of the community.
7. Health plans are the bad guys.

For more details and discussion, tune in to tomorrow to BlogTalk Radio. Host and ACO guru Gregg Masters will be interviewing me and we’ll discuss the topic of “Is Hospital-Physician Integration Sustainable?”

The details:

Wednesday May 11th 2011 broadcast, at 11AM Pacific/2PM Eastern

Click here to add a reminder to your calendar or to read more information about our session.

UPDATE: May 11, 2011. A replay or download of the interview is now available by clicking here.

According to the Pew Internet and American Life Project, 88% of American adults with Internet access research health information online and 60% say Internet info influenced a decision about how to manage a health condition. Further, going online no longer is a one-way stream of information from computer to patient, but has launched into the web 2.0 reality of social networking. Patients go online to find meaningful engagements with other patients and now – not so uncommonly – with their providers. Such a trend provides opportunity for providers to distinguish themselves competitively, and more importantly, to improve the patient experience and quite pos­sibly their health outcomes.

The report is a compilation of what key health IT experts from across the United States think are the most important things you need to know about engaging patients in the digital age. There are also four key recommendations for practical action. It discusses how healthcare organizations that provide high quality outcomes for patients will be the ones who prosper under new health reform models, such as Accountable Care Organizations (ACOs) and the Patient-Centered Medical Home (PCMH). This report also explores the concerns that come with patient engagement and the advantages and strategies that should be explored. (more…)

Reprinted courtesy of MCOL.

Perspectives on a Selected Key Topic |     April 2011/May 2011     |   Volume Three Issue Two

Will a material number of hospitals and their core medical staffs, that are relatively independent, evolve into highly integrated delivery systems during this decade, and why?

William J DeMarco MA, CMC

President and CEO, Pendulum HealthCare Development Corporation

The great momentum brought about by government and private payers demand for more accountability is unstoppable. Rapid consolidation of hospitals and consolidation of physicians by physician groups, hospitals and now insurers will shift referral patterns and consumer preference. 1 out of 4 hospitals will fall short of providing value and close or be absorbed within 10 years.

Physicians will be offered higher prices to sell out to insurers and investors who value the short supply of PCPs and will try to control care demand by retooling the care system building ASC and small scale short stay hospital.

True clinical integration will follow for the survivors. The ability to prospectively develop clinical budgets and bundles of services will connect regional tertiary and quaternary care facilities to local hospitals so integration can be regionalized across larger populations and payer segments.

Once these delivery systems realize they need a product recognizable to individual consumers they will seek alliance with select insurers or create their own insurance company thereby achieving the true definition of integration which is to integrate financing and delivery of care.

This offers the shared savings with themselves and stabilizes patient flow and overhead to achieve value to purchasers and users of care.

We think these opportunities will be at a tipping point on a market by market basis over the next 5 years and will be a national definition of success within 8 years. We believe this will happen because already the bond rating companies are looking at physician alignment and payer alignment as factors in establishing credit worthiness of hospitals for expansion and mergers.

Benjamin Isgur

Director, PricewaterhouseCoopers LLP’s Health Research Institute

Integration is certainly on the rise. The notion of independent physicians may be a myth because so-called independent physicians are becoming increasingly financially tethered to hospitals. In fact fifty-six percent of physicians PwC surveyed want to more closely align with a hospital in order to increase their income. The new health reform law focuses on population health and adopts a Medicare compensation model that penalizes poor quality and rewards cost savings and electronic information sharing. Some commercial payers are also pushing this business model. (more…)

Healthcare needs positive role models for innovation…and we have a real-time mentor in Netflix.

If you have a Netflix subscription, you probably identify with the company as providing a convenient DVD rental service — order on the web, the DVD arrives by mail, send it back in the handy pre-paid envelope when you’re done.

Today’s ReadWriteWeb describes Netflix’ latest letter to shareholders and explains how the company is preparing for the demise of DVDs:

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Let’s take a minute to consider the mechanics of how this will occur. You’ve received a prescription, and it directs the pharmacist to tailor the medicine to YOUR genetic profile.

Consider two possible scenarios of how this transaction might happen. You’re on the phone with your pharmacist:

1) “OK, you need my DNA sequence. I keep my genetic profile in my mattress…let me get it and I’ll read it out loud to you.  C, A, T, G, G, A, T… no,  that was actually a G…let me start over.  C, A, T, G, G, A, T… (19 hours later) … T, and G. Can you read that back to me to make sure you got it right?”

2) “You have permission to access my DNA sequence at my health URL (or maybe a health record bank, or perhaps hand her a flash drive, or ??).

Still think you’ll never use a PHR?

In my mind, the issue isn’t WHETHER, but WHEN.

Yes, I know that adoption has lagged and that surveys suggest 7% or less of the U.S. population has used a PHR.

Stay with me on this one for a minute. You’d have to have two underlying beliefs to conclude that PHR systems won’t eventually emerge:

• That health record data will persist in non-electronic formats, i.e., paper
• That people won’t have interest in accessing or using their health record data (more…)

(click on the graphics to link to original sources)

Regular readers know that I find Professor Clay Christensen’s theory of disruptive innovation to be a useful lens to explain industry evolution. Let’s look at two recent health IT initiatives and see why one is working and the other is stalled.

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1. Technical barriers aren’t the limiting factors to Facebook becoming a care coordination platform.
2. Facebook’s company DNA won’t play well in health care.
3. Could Facebook become the care coordination platform of the future? If not Facebook, then what?

1) Technical barriers aren’t the limiting factors to Facebook as a care coordination platform.

Can you imagine Facebook as a care coordination platform? I don’t think it’s much of a stretch. Facebook already has 650 million people on its network with a myriad of tools that allow for one-to-one or group interactions.

What would it take to make Facebook a viable care coordination platform?

• More servers to handle the volume — not a problem
• Specialized applications suited for health care conditions — not a problem
• Privacy settings that made people comfortable — more on this later
• A mechanism to identify and connect the members of YOUR care team — really tough, BUT this is NOT a technological problem, but a health system one

Suppose you are a 55–year-old woman who is a brittle diabetic. Your care team might include a family physician, an endocrinologist, a registered dietitian, a diabetic nurse, a ophthalmologist, a podiatrist, a psychologist, and others. Ideally you’d have one care plan that coordinates the care among members of the team, including you.

What’s the reality of today’s health care non-system?

• There is no formal designation of “your team.”
• There is no mechanism to designate one “plan” that coordinates the plays among your team members.
• It’s possible that multiple quarterbacks are calling the plays for your care.
• It’s possible that members of your team have no knowledge THAT you are being treated by others and HOW you are being treated by others.

Care coordination today is in the stone ages — there is no system for care coordination.

Supplying a modern Facebook-type technology platform doesn’t change this. The major limiting factors in Facebook’s becoming a care coordination platform aren’t technological.

Let’s look a bit deeper.

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1. Administrative Mandates (Compliance HIPAA 5010, ICD-10, etc.).
2. Care Management, Data Analytics, and Informatics.
3. Health Insurance Exchanges and Individual Markets.
4. New Provider Payment & Delivery Systems (ACOs, PCMHs, etc.).
5. Bend the Cost Trend.
6. Medicare and Medicaid.
7. Health Information Exchanges and EMRs.
8. Consumer’s Role in the Modernization of Healthcare.
9. Reform Uncertainties.
10. Payer/Provider Interoperability.

Dear health plan colleagues,

Wake up! The order of this list is totally out of whack.

#2: Care Management, Data Analytics, Informatics. Good…sounds about right.

However,

#2 can’t happen before you address:

#7: HIEs and EMRs

#10: Payer/Provider Interoperability

Health plans can’t analyze the data and assist in care management unless they first have access to it. Payers need access to clinical data, and they are at risk of being cut out of the loop.

P.S.

Please also take a look at priority #1: Administrative Mandates (Compliance HIPAA 5010, ICD-10, etc.). This is completely reactive!

In these times of great change, is this how health plans want to posture themselves in the community?

On March 31, CMS released the long-awaited “Medicare Shared Savings Program: Accountable Care Organizations” document (ACO Rule). Read the details here (strong suggestion: unless you’re working on your PhD in ACOs, start with the fact sheets).

There are many surprises. Here are eight first impressions on this 429 page tome:

1. The bar has been set high…very high.  Tire kickers need not apply.
2. Don’t expect to see many or any small ACOs.
3. Patients will be confused by ACOs.
4. Concerns over maintaining competition and avoiding antitrust are being taken seriously.
5. CMS scores points for coordinating the ACO Rule across Federal agencies.
6. CMS loses points for micromanagement and a controlling mindset.
7. Possible losers — hospitals, ACO vendors.
8. Possible winners — physicians, health plans.

The details follow.

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On Friday April 1st, 2011 (yes, ‘April Fools day’) at 4 PM Eastern and 1 PM Pacific

ACO Watch: A Mid Week Review will host a special roundtable series on the ‘hot of the press’ Notice of Proposed Rules’ pertaining to the implementation of Accountable Care Organizations. For the published rule, click here.

The roundtable team will consist of Mark Browne, MD, PYA, aka @consultdoc, Vince Kuraitis, e-Care Management blog, aka @VinceKuraitis, and David Harlow, the Harlow Group, LLC,  aka @healthblawg, with Gregg Masters, aka @2healthguru, as moderator and host.

To listen live, or via archived replay, click here. During the broadcast you may also listen in via (619) 393-2836, and even participate in the chatroom.

ACO Fact sheet from HHS

Medicare Fact Sheet: What Providers Need to Know

HHS press release

Don Berwick’s article on ACOs in the NEJM

ACO Quality Performance Standards Summary

FTC/DOJ Joint Antitrust Statement on ACOs

TheHill article “Leaked memo reveals Dem strategy for defending healthcare reg”

The leaked memo

Having been a debater in high school and then trained as a lawyer, my default mode of thinking is to be critical:

“Hey, Vince, how ya doin’? Great day isn’t it?”

“Well, …err…maybe, maybe not…actually, here’s 14 reasons why not.”

My wife and friends kindly tell me that this personal quality can be insufferable, and if you’ve ever met a lawyer you know what I’m talking about. My internal defense mechanism against my inner-critical brain is simply to turn it off — just go along for the ride and live in the moment.

To the extent that you can connect with what I’m saying, I suggest that before reading this report that you turn off the critical part of your brain.

If you’re a regular reader, chances are you’ve read individual white papers on these topics:

• PCMH — the Patient Centered Medical Home
• Care Coordination
• Access to care for the un and underinsured
• HIT — health information technology and the HITECH Act
• Payment reform, especially as it’s been discussed around ACOs (accountable care organizations).

“Better to Best” transcends all these topics — it weaves them together, displays the interrelationships, and describes specific components of what a truly integrated health system could look like. (more…)

Health care lobbyists and advocates are bracing for six pages of the health care reform law to explode into more than 1,000 pages of federal regulations when the Department of Health and Human Services releases its long-delayed accountable care organization rules this week. Politico

What should you be looking for as you snuggle by the fireplace this weekend reading the draft ACO regs?

Rob Lazerow writes a helpful article listing 5 Things to Watch in the Medicare Shared Savings Program Proposed Rule. His list of five key design issues includes:

1. How will patients be assigned to ACOs?
2. To what cost benchmark will ACOs be compared?
3. How will bonuses be calculated and paid?
4. For which quality metrics will ACOs be responsible?
5. What is the application process?

I’d like to add a sixth  item — which actually would be #1 on my list.

As I’ve previously written, IMHO the central issue around ACOs is:

Are (hospitals and doctors) viewing ACOs as a way to truly develop patient centric, collaborative care or as a means toward consolidating market power against payers? We really don’t know.

So here’s item #6:

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Click here.

The whitepaper is a great overview of accountable care and ACOs (Accountable Care Organizations). It’s a quick and easily digestible read.

However, there is one key point articulated in the paper that I’d like to emphasize here:

accountable care is not synonymous with ACOs.

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“If banks can exchange funds electronically through the ATM system, why can’t my doctor and hospital exchange information electronically?”

Keith Boone’s concise article “A Doctor is Not a Bank” explains why this conclusion about healthcare interoperability is overly-simplistic.

…and Keith’s article reminded me of an even deeper explanation presented in the National Academies’ Frontiers of Engineering series — Why Health Information Technology Doesn’t Work, by Elmer Bernstam and Todd Johnson. The table below summarizes the differences between health data and banking data.

  (more…)

What struck me about the list is that the state-of-the-art is stand alone applications — I didn’t see any that had any connection to an EHR (electronic health record).  Here’s the top 5 to give you a flavor of what’s on the list:

1. Medscape
2. Micromedex
3. New England Journal of Medicine
4. Epocrates
5. Free Medical Calculators

I expect that this list will begin to look very different in coming years as EHRs continue to open their platforms to outside developers…and applications will increasingly be integrated into direct patient care.

Doctors love iPads…not surprising? But, how might you explain this?

There are at least two different possibilities:

• Coincidence Theory
• Conspiracy Theory

The Coincidence Theory

So doctors want to access EHR software through the iPad…what’s the big deal?

Apple has built a great new hardware platform with the iPad. There’s nothing else like it in the marketplace.  While other companies are building competing tablets, Apple’s has been the only viable option in the market for over a year.

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At that time, the Direct Project was still being incubated and was not widely known or understood. Since then, it’s gone from being an idea to a project in full-speed implementation.

The simplest conceptualization of the Direct Project has been as a secure email alternative to medically-related transactions that today typically occur by fax, e.g., Dr. A faxes a medical record to Dr. B.

The functionality of the Direct Project has been described as “push-only”. Fred notes that

Push-only means that A can send messages to B, but B cannot automatically get data  from A (that would be pulling). Email and Faxes are push models. Web pages are pull models (i.e. sent to you when your browser asks for them).

“Push-only” misses the innovative potential of how the Direct-Project could be used. Let me try to make a simple conceptual leap that hopefully will open your eyes to The Power of Push.

With a little creativity and jury rigging, push transactions can easily become pull transactions.  For example, what if I were to call you on the phone (or send you an email, a fax, a carrier pigeon, a smoke signal) simply asking you to send (push) me some information.

Voila. Push is turned into push and pull.

Fred describes examples of  higher level functionality enabled when you get creative with push:

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Keith Wright and Gregory Drutchas’ incisive article Economic Credentialing: A Prescription To Secure Shared Savings Under Accountable Care provides useful history and context about economic credentialing:

For many years, the use of economic factors by hospitals in making medical staff credentialing decisions has been the subject of much discussion and debate among physicians, groups such as the American Medical Association (AMA), healthcare providers, payors, and attorneys….the implementation of healthcare reform is likely to bring the debate over economic credentialing to the forefront once again.

While economic credentialing has been talked about a lot, it’s rarely been used.

The controversy over economic credentialing arises again with ACO’s…and this time the answer might be different — and opportunistic for primary care.

Economic Credentialing from the Hospital POV— The Big Red Button

From my personal experiences, the threat of a hospital imposing any type of economic credentialing on their medical staff has been a big red button  issue — akin to a hospital declaring war on some physicians, with the risk of alienating nearly all physicians.

Management guru Peter Drucker wrote that the two most difficult organizations to “manage” were hospitals and the military. Most hospitals work hard to integrate physicians in decision making and they share a great deal of information about clinical and business issues. (more…)