Dr. Watson Will See You Now

I recently attended the annual Health IT Insight conference, which was very useful knowledge by the way, and one of the most interesting presentations was presented by IBM and how Watson can be applied within the Clinical Decision Support process.

You've probably all heard about Watson, the IBM computer that defeated two of the greatest champions on the game show Jeopardy! Jeopardy showed off the power and sophistication of Watson.  Watson is able to understand spoken natural language, decipher it and research highly probable answers.  Watson can process 200 Million pages of data (I actually think it can handle much more than that now) in three seconds.  So how can this technology be applied to healthcare?

IBM has a range of ideas but I think the most immediate application is as a decision support tool for clinicians where it can, in real-time, recommend treatment options or provide a second opinion for clinicians to consider as part of diagnosis and treatment planning.

Personally, I would love to see Watson applied to a high-tech minute clinic.  Minute clinics are those drop-in clinics popping up at your local drug store to treat simple problems (sore throats, rashes).  I know we're probably still centuries away from a high-tech unmanned minute clinic, but imagine if a patient can identify themselves using a portable health record on a smart card to a health kiosk running with Watson's intelligence.  After a minute of discussion, a vending machine dispenses a prescription drug for treatment.  It sounds cool!

Senator Scott Brown Visits Venture Café!

On June 10, 2011, Senator Scott Brown stopped by at Venture Café and Cambridge Innovation Center (CIC)!  There was a lot of excitement in the air for his arrival.

Senator Scott Brown encourages entrepreneurs.

All smiles around for Brian Wang, Venture Café Operations Manager; Senator Scott Brown; Renee Lin, Venture Café Acting Community Manager.

Senator Brown gave a talk to CIC clients about jobs, innovation and Massachusetts.  Afterwards, he stayed and mingled to hear about projects that CIC clients are working on.  Thanks to Senator Brown for the visit and inspiration!

How to Replace Health Plan Core Administration Systems

Health Plans spanning the entire United States from Rhode Island to Hawaii will at one point face the challenge of replacing their core administration systems.  These systems are the backbone of these health plans and manage key processes like Member Enrollment, Premium Billing and Claims Processing.  The reason why health plans look to replace these systems is because they no longer can easily support the continuous changing rules of the business, such as changes in plan design.  As Federal Healthcare Reform continues on and Payment Reform continues to evolve, these administration systems must be able to support payment changes too, like bundled payments.  Health plans in their search for a new solution, consider solutions not limited to TriZetto QXNT, TriZetto Facets, Perot Diamond and DST AMISYS.

The initiative to replace a core administration system is no easy task.  It takes a lot of brainpower, years and money.  It is such a hard task in fact, that many health plans have even scrapped the initiative after spending years on the project.

As health plans continue with replacing their core administration systems, here are some key points to consider:

Appoint Exceptional Leadership.  It really does matter who is leading the initiative.  The project team will become so large, that it’s important to make sure that the overall project leader and the leaders below can understand how the whole project ties together and what objectives their teams must meet to make the overall solution work.  All leaders must understand how to implement a replacement system, understand the importance of their team’s contribution to the solution and be able to direct the team to stay focused on the business goal.  It is important for the leaders to be able to recognize when the project has gone off course and to redirect efforts.  An exceptional leader that really understands both systems and business process is essential.

Put your Best Team on it.  The core system replacement will no doubt be one of the health plan’s most difficult tasks ever.  It will take the brightest and most committed team to give it the best chance for success.  There will be many challenges along the way that will require only the best problem solvers.  Commitment is also important because the project will go on for a long time.  There will be up’s and down’s and the team must be able to brave the storm. 

Break it up into Phases.  This means not to try to do everything all at once.  The Health plan is replacing the core systems that cover almost every process; it seems impossible to do it all at once.  Instead, break it up into phases either by grouping the customer accounts into phases or by separating business functions into phases.

Pick the Right Solution.  Make sure to understand what the business and technical requirements are for an ideal core administration system replacement before choosing the solution.  Remember to consider future needs too.  Take time to research which solution meets the needs of your requirements. 

Learn the Product.  Even after choosing a solution, take time to learn in-depth how the product works before configuring it.  An understanding of how the product works will allow you to visualize how to configure it best to work in the business environment.  After visualizing the overall configuration strategy, the detailed configurations can be filled in.

Health “Data Liberacion” – What do we do now?

This month, Todd Park CTO of Health and Human Services and co-founder of athenahealth spoke about what he calls “Data Liberacion”.  I attended this talk organized by Xconomy and witnessed his passion and enthusiasm for this initiative.

Pictured left to right: Chris Herot, CEO of SBR Health; Todd Park, CTO of Health and Human Services; Renee Lin, the “Health Plan Geek”

“Data Liberacion” makes tremendous amounts of health data metrics available to the Public and anyone that wants it, for the purposes of creating new and useful health applications.  Todd recommended reading “The Hot Spotters” in the New Yorker, as a related example of how data can be applied in valuable ways.  “The Hot Spotters” details one Physician who analyzed health data to map out the highest utilization and highest cost geographic points in his nearby city.  The Physician then focused his energy on these high utilization areas with the challenge to increase patient health and lower utilization.  This Physician’s story is admirable, useful and an example of how health data can be applied to add value to everyone in healthcare.

With all this data now available and more soon to be available, what should healthcare organizations do now?  I would suggest a couple of actions: implementing the use of some of the data now, exploring what is available in the data sets (listed below) and then monitoring what kind of applications spawn from it.  One example of something that Health Plans are doing now is to integrate data with their Provider Search tools, such as the Patient Hospital Survey (HCAHPS) and Hospital Compare data sets from Medicare which will help consumers choose a Hospital or Physician by reviews/quality.  Healthcare organizations should also explore what is available in the data sets and brainstorm how the data can add value to existing services already offered.  Also, it would be wise to monitor the applications that come to market as a result of this data availability and make available the helpful applications to consumers.  As we take a look at the data, we may see that some of it still needs some refinement.  Just as an example of the state of some of the data: when I searched for teenage births “Births to Mothers Under 18” on the Health Indicators Warehouse, I received back the metrics for non-teenage females “aged 15-54 years; Female”.  The data could still use some cleaning up, however, as the industry starts to use the data, we should see refinements in the data.

Here are some of the public health data sets to start (re)exploring:

• Consumer Assessment of Healthcare Providers and Systems
• Healthdata.gov
• Health Indicators Warehouse 
• HHS Open Data Sets
• Medicare Data Sets
• NPI Data 

10 Career Opportunities in Health Insurance

Two weeks ago, I wrote here on my blog about some implications of the potential merger of two local health insurance companies, Harvard Pilgrim and Tufts Health Plan.  In response to that post, I received some questions about layoffs due to a merger.  In an increasingly complex industry, the company faces the challenge to remain an attractive product while also doing "the right thing" for members and employees.  So can there be layoffs?  Sure.  Will there also be new career opportunities?  Sure.  I see the need to move employees into new roles to help the company succeed.  As we face a new horizon for what a new valuable Health Plan really can be, new roles must be considered to propel the Health Plan and make it efficient, competitive and grow.  So here is my forecast of ten upcoming career opportunities within any health plan that wants to be efficient, competitive and grow.

1)Re-engineering Process and Systems

As health consumers demand lower costs in healthcare, everyone must do a part to decrease the administrative cost wherever we can.  Now is the time to take a look at current processes and brainstorm how they can be made more efficient.  The optimized process will also identify new system solutions that will enable the new efficiencies.  If the re-engineering is done well, I believe it will be the key driver in lowering cost and create a dominant market appeal.  Employees with knowledge of current business process, current systems and who are forward thinking will be needed to achieve these efficiencies by defining the new processes and implementing the new systems.

2)Vendor Management

With the re-engineering effort, many new service vendors will be in consideration.  Employees will be needed to take a look at existing contracts, re-negotiate contracts and draft new contracts with existing/new vendors.

3)Growth Strategy

How aggressive does the company want to be in signing on new employer groups and members?  What is the best way to compete with competitors?  What will be the strategy?  Employees will be needed to help the company achieve membership goals through building the winning growth strategy.  In the case of Harvard Pilgrim and Tufts Health Plan, they together will be offering insurance in: Massachusetts, Maine, New Hampshire, Rhode Island and must strategize on membership growth starting in these four states.

4)Actuarial

Actuarial is a good role to get into within the industry because there always seems to be a shortage in Actuarial professionals that understand the risk factors in health insurance.  Due to many federal and state regulations now and in the future, Actuaries are needed to analyze the increasing number of new business scenarios, such as New Product Designs (for example, upcoming MA Division of Insurance select/tiered provider network product designs) and new provider reimbursement methods.

5)Healthcare Informatics
Healthcare Informatics is hot now and will continue to be for some time.  Employees will be needed to slice and dice the data to find ways to lower cost, measure results of new programs, monitor provider quality and segment members to offer personalized care.

6)Regulatory Projects

Now until 2016, there will be a focus on Regulatory Projects, such as ICD-10, Federal Health Reform and additional Federal and State Mandates.  Employees that understand the health insurance business and systems will be needed to make policy, process and system changes.

7)Social Media Management

Social Media Management is about protecting and extending the company brand.  Social Media Managers monitor what is being said about the company online, such as reviewing web posts, Twitter comments and Facebook comments.  If faced with a poor review/comment, the Social Media Manager performs damage control by offering to help and hear the situation (sometimes taking the follow-on conversations offline due to privacy).  The Social Media Manager will also perform some marketing and public relations activities to promote the company brand.  Social Media Management is a fairly new career opportunity in the health insurance industry.  Don’t forget that Social Media should be managed in the Member and Provider online mediums.

8)Multi-Lingual Services

In an increasingly diverse country, it is important to provide Multi-Lingual services via written and spoken mediums.  There is a push from consumer advocate groups to better engage, educate and support non-English speaking consumers to promote public health and better access to care.  Healthcare organizations have created units in order to better service the non-English speaking population.  Employees with capability to speak/write a foreign language, perform English translations and who possess good customer service skills are needed to fill these roles.

9)Leadership Development Program

With a growing number of health plan employees approaching and taking retirement, health plans must make investments to ensure that the health plan is able to carry forward a strong business into the future.  A Leadership Development Program can be a rotational, mentorship program to train promising staff to become the next leaders.  Participants in the Leadership Development Program must be offered incentives to stay with the company after the Program is over, otherwise, they may take their talent to other companies.  The desired skill set for candidate selection into a Leadership Development Program, should be: vision, social responsibility and integrity.

10)New Business Ventures

As the health plan recognizes that their core competency is offering insurance, they may begin to diversify into different States and other insurance products, like comprehensive dental insurance, stop loss insurance or worker's compensation.  Any of these would be a huge effort and would require experienced human resources with different skill sets in order to make this possible.

Ten Technologies to Engage Members in Healthy Behavior [Posted in Healthcare IT News]

As the availability of technical consumer healthcare applications continue to grow and with increasing complexity, members can realize the health benefits of technology.  There is also a mutual benefit for healthcare organizations where healthier members lead to higher value care with lower cost.  In order to support members in this process, healthcare organizations can support making these healthy tools available to members.  Here is a look at ten technologies to engage members in healthy behavior.

1)Real-Time Video Communication

Real-time video communication enables a patient to be “seen” by a medical provider from a computer, without actually being geographically together.  Follow-up and consultation can be done one-on-one with medical providers in the comfort of the patient’s home.  Consumer monitoring devices attach to a home computer to allow a medical provider on the other end to see how recovery is progressing, such as a magnified look of a recovering surface wound.  Checking on the patient at-home can ensure that the treatment plan is working.  SBR Health makes these visits possible through their video technology.

2)Mobile Health (mHealth) Apps

Mobile health apps allow members to self-manage and track their health and conditions everywhere they go, using their smartphone or tablet.  The health data collected can also be electronically shared with a medical provider to monitor care.  There are mobile health apps available for every major condition, which makes it possible for relevant content and services to be delivered to the member.  One example is Ubiqi Health’s Migraine app which allows members suffering from migraines to track triggers, record treatments and see patterns.

3)Electronic Personal Health Record (PHR)

The electronic Personal Health Record is a patient-owned digital copy of their health records, including patient data like drug reactions, medications, illnesses, etc.  Since the patient maintains their Personal Health Record, they can quickly share it with any healthcare provider that they choose.  In a medical emergency, the quick availability of this information can help a new physician to determine the best course for treatment.

4)Text Messaging

Text Message is a message that is delivered to an individual’s cell phone.  Healthcare organizations can use this medium to send personalized messages to members, to remind them of appointments, medications, treatment or general motivational messages.  Companies, such as Silverlink, churn through the member analytics to create personalized messages to individuals, which makes communication meaningful to the individual.  Another company, Text4Baby has a popular application for expectant mothers, which sends healthy text messages each week, timed to their baby’s due date.

5)Feature-Rich Member Web Portal

A traditional member web portal offers tools like personal health information and health content.  This traditional offering, enhanced with an online social community makes the member portal more personal and increasingly valuable.  The social elements of the portal would enable members to share and research information to improve community health such as Provider Ratings and Treatment Reviews (within HIPAA Privacy limits).  Myregence.com is an example of a healthcare social community with features such as rewards, ratings, decision support tools and content.

6)Facebook Business Page 

A Healthcare organization can create a Facebook Business Page to extend their communication with members.  Members add this Business Page to their Favorites on Facebook and this lets them see public messages, photos, videos, comments and participate in public discussions, promotions and contests from the organization.  Health organizations can promote health using Facebook’s reach to encourage healthy behaviors and engage in public health conversations.  MayoClinic’s Facebook Page has a large following.

7)Twitter

Twitter works well to offer short, frequent public health tips to members and advertise health events.  Members choose to follow others on Twitter and members see a list of messages (newest to oldest) of everyone that they follow.  MayoClinic uses Twitter well to communicate health tips and promote their open talk-to-a-doctor telephone conference forums.

8)YouTube

YouTube is an online video community.  Healthcare organizations create accounts on YouTube to share videos with the public.  Members can choose to subscribe (free) to the healthcare organization to follow the videos posted by the organizations.  Videos appeal well to visual learners.  MayoClinic uses YouTube to share information about their health facilities and MayoClinic physicians share information about wellness and specialty care.

9)Email
Email is on this list because it is a key tool to engage members, one-on-one, who do not have a smartphone.  Email sent one-on-one between a member and medical professional can make the care more personal and connected.

10)Podcasts
Podcast is a digital talk series that members can automatically have downloaded to their computer; members then listen to downloaded Podcast.  This tool is an additional medium that can be used to push health information to members.  MayoClinic also offers Podcasts.

Save Healthcare Now!

I urge us all to do everything we can to Save Healthcare Now!  I attended the Health Care Quality and Cost Council (HCQCC) - Full Council meeting last week on Wednesday to hear the latest on quality and cost.  This Council in Massachusetts is trying hard to solve the problems around rising healthcare costs in the Commonwealth.  Every time I attend a talk around this topic, I always leave the meeting a bit sad about the healthcare cost crisis that we are in and this time was no different.  In addition, I think about the fact that I had started following this issue about three years ago with my first exposure to this problem at the Massachusetts Medical Society Annual Conference in May 2008.  It is a disappointment that almost three years later, we don't seem to be much better off.

At the HCQCC Full Council Meeting last week, we were reminded of high-level ideas that are in the works to better the quality and cost of care, like ACO's, insurer/provider increase caps, tiering providers/select networks, cost transparency, global payments and risk sharing.  However, the highlight of the meeting for me was two repeated blaring alarms coming from the Inspector General, Gregory Sullivan who pressed that we have to do something NOW.  At the end of last year, there was a public forum for payment reform where public comments received used words like "cautiously" or "slowly" in talking about reform.  The Inspector General illustrated that a common family insurance plan that has a price tag of $21,000 is the equivalent of paying $10/hour from a paycheck!  And with the continued annual increase in healthcare premiums, healthcare affordability is getting farther out of reach and out of control.  While it would be nice to be "cautious" and "slow", we also have to consider that we have to do something NOW if we want to be able to control this crisis.

To me, this problem is so big that it needs EVERYONE to solve it; especially since we are all consumers in this problem.  We should all do a part as patients/consumers, employers, insurers, providers, government and service vendors.

What can we all do now to help lower the cost of healthcare for everyone?  Let's all be mindful of cost in our decisions.  In addition:

Patients/Consumers - Eat and be healthy.  Consider cost too when choosing a Provider.  Consolidate multiple appointments into fewer appointments, if possible.  Be prepared with a full list of what you want to talk about with the Provider.  Share publicly ideas to lower cost.

Employers - Incent employees to be healthy.  Consider selecting plan designs that encourages employees to consider cost when seeking care.

Insurers - Streamline processes (be lean) as much as possible to further lower admin cost.  Keep innovating with new quality plan designs.  Collaborate with other Insurers and Providers to do non-competitive tasks together.

Providers - Streamline processes (be lean).  Keep being thoughtful of cost in recommending and ordering care.  Collaborate with other Insurers and Providers to do non-competitive tasks together.

Government - Encourage, engage and support discussion in the healthcare ecosystem to identify ideas to lower cost.  Be ready to move on good ideas.

Service Vendors - Be innovative and create solutions/systems to lower cost.  Find ways to lower the cost of services billed to clients.

What other high-quality ideas can you think of to save on healthcare?

City of Boston - Ideas to Save on Healthcare

On January 11, 2011, Boston Mayor Menino spoke about the City and mentioned two ways the City of Boston can save on the increasing costs of healthcare. His address titled the "State of the City 2011" was well attended by many government leaders, including Governor Patrick and Senator Brown.

During his speech, Mayor Menino highlighted two different measures to curb the cost of healthcare. The first is an initiative called Neighbor Care. He says, "Neighbor Care will increase the use of community health centers - providing more hours and more services in the neighborhoods." This initiative would also save healthcare dollars through channelling patients to the less expensive community health centers, as opposed to the higher cost big name hospitals. The idea is that common conditions can and should be treated at community health centers/hospitals, while the very specialized conditions would be referred out to the specialty hospitals.

Mayor Menino also spoke about the potential offering of health insurance to City employees that is modeled after the Group Insurance Commission (GIC) which is the self-insured health insurance plan available to State employees. He says "If Boston had the same plan design (as the State), we could save one million dollars a month." The GIC also has an innovative plan design which is comprised of three tiers of physicians. Physicians and facilities that have the highest quality and lowest cost measures are in the "top tier", which have the lowest copay to the patient. The low copay provides an incentive to a patient to goto the "top tier" high quality, low cost physician. The offering of a product like GIC is still in the works and not yet approved.

With the costs of healthcare soaring, many are continuing to find ways to curb the cost. What ideas have you come across?

HIPAA 5010 Checkup: Ten Things to Consider

We are just four months away from CMS' Level 1 compliance date for implementation of the updated X12N transactions to version 5010 for HIPAA.  You've come to see the 5010 doctor.  Run your implementation through my "5010 Checkup" below to see how you're doing:

1. Perform a Gap Analysis between 4010 and 5010 to determine the changes for your organization.  CMS has provided an easy-to-read side-by-side comparison of the differences between 4010 and 5010.  This will identify the detailed list of changes needed for your 5010 implementation.
2. Decide what is in scope for your 5010 project versus ICD-10 project.  The changes in 5010 support the increase in field length to support ICD-10.  How much ICD-10 related tasks do you want to include in your 5010 implementation?  What happens if a Physician sends an ICD-10 code to a Payer before the ICD-10 mandate date of October 2013?
3. Decide the transaction to use for sending/receiving acknowledgements in 997 versus 999.  WEDI has a recommendation that says 999 is a must to acknowledge 5010 transactions and not the 997.  I recommend that everyone follow suit and adopt the 999.
4. Consider the impacts on vendors and internal processes.  Some external and internal systems have a solution architecture that employs the X12N transactions as an interface between systems.  Such as payers that have a partnership where they use the 4010 834 to exchange respective member information or an internal system that turns a paper claim into a 4010 837.  Though these are not mandated to transact in 5010, make a list of what these interfaces are and make a decision if it will remain on 4010 or be upgraded to 5010.  This will make sure you have covered all the bases.
5. Give 837 the highest priority as the first one out the gate.  By far the largest amount of coordination and testing in the industry will involve the 5010 837I and 837P.  Given that some entities still have much to do, I suggest getting the 837 out there first so Providers, Clearinghouses and Payers can start testing sooner.  ICD10Watch poll finds that 60 percent of health org's uncertain about meeting HIPAA 5010 Level 1 deadline.
6. Coordinate with your covered entities to determine when to Test.  Make a list of all the Providers, Clearinghouses, Vendors and Payers in which you transact HIPAA transactions and reach out to determine their readiness for 5010 and when you can start testing with them.
7. For Physician offices, contact your software vendors and determine their readiness for 5010.  Your software vendor is probably deep in getting the software ready for 5010.  Just make sure you confirm that this is the case.
8. Determine how you will read the 277CA.  The 277CA is the claims acknowledgement where you can find out claim numbers and any errors coming from the Payer for claims that you submitted.  The 277CA isn't new, however, CMS Fee-for-Service will be using it for the first time, eliminating their human readable reports.  Make sure you have a means to read this; the solution will probably come through the software solution from your software vendor.
9. Determine if you will support Employer Groups to stay on 834 version 4010 and 820 version 4010.  Or will you support 4010 and 5010 for the 834 and 820?  By the way, Health Care Reform in 2016 will necessitate changes again to these transactions...  Employer Groups are not covered entities and therefore, (though I am not a lawyer) I believe they can choose to stay on 4010.
10. Review X12N Errata's.  In the last two weeks, the X12N transactions have been modified via Errata's.  Most are minor changes, with the biggest one impacting the 835, where it now must send back the Patient Name corresponding to what was sent on the 837.  In the past, Payers may have been sending the Patient Name on record from their Membership application, so this may be a good size change for some. 

CMS also has provided two checklists worth reviewing: Checklist for Level I Testing Activities and Provider Action Checklist for a Smooth Transition.

Remember that the intent of the updates made in X12N version 5010 is to make the transactions better based on what we've collectively learned since we started using 4010 a couple years ago.  Therefore, a majority of the changes are layout and consistency across transactions and the complexity of this implementation isn't as high as when we instituted 4010.  I think this 5010 implementation can be pretty straightforward; the simple secret to success is to be a Task Master and make a list of the tasks that must be completed and track them to make sure they are done.

Most Popular Healthcare Twitter #Hashtags

Twitter is a great place to stay up to speed on Healthcare news and opinions.  This post identifies the most widely used healthcare #hashtags and a definition of their use.  Please send along healthcare #hashtags that you don't see on this list! 

#icd10
#billing - medical billing
#ehealth - electronic health
#ehr - electronic health record
#emr - electronic medical record
#healthcare
#healthit - healthcare information technology
#healthcompanies
#healthdiscount
#healthplan
#hcmktg - healthcare marketing
#hcsm - healthcare social media
#hipaa - hipaa
#hitpol - health information technology policy
#HITsm - Health IT social media
#meaningfuluse
#medicare
#mhealth - mobile health
#onc - the office of the national coordinator for health information technology
#ppaca - patient protection and affordable care act
#physician

The Future Health Insurance Ecosystem

The Patient Protection and Affordable Care Act (PPACA) signed into law this year will change the environment that we know of today where we buy and sell Health Insurance.  In the long-term, the buying and selling of Health Insurance will evolve from a Health Plan centric-model to a Health Insurance Exchange centric-model beyond the implementation of Health Care Reform.  This means that over time Health Insurance Exchanges will be the interface where most people will buy insurance and Health Plans will underwrite the insurance.

I put this diagram together to show the current ecosystem (black lines) and future ecosystem (green lines).

The drivers that will shift the future ecosystem (maybe 20 years from now) from a Health Plan centric-model to a Health Insurance Exchange centric-mode, is due in large part to the following factors:

1.  PPACA puts into law an "Individual Mandate" where every citizen must have Health Insurance.  Therefore, Individuals without the option to purchase affordable health insurance through their Employer will now come through the Exchange to purchase their insurance.  In addition, Members of Congress and Congressional Staff must also elect their insurance through the Exchange.

2.  PPACA creates "Small Business Health Options (SHOP) Exchanges" where small businesses can go to offer Health Insurance products to their employees.  In the Commonwealth of Massachusetts, where an Exchange is already established, the Individual and Small Business functions operate together in one Exchange, called the Health Connector.  Most, if not all, States will probably follow this same model to consolidate both functions into one Exchange for simplification.  Small businesses currently find it confusing to compare and choose health insurance plans and welcome the new SHOP Exchanges.

3.  This next one I call the "White Castle Effect".  White Castle recently said that the Health Reform would be very costly on their business, eating into much of their profit.  Health Reform says that employees must not have to spend more than 9.5 percent of their income on Health Insurance and anything in excess is just not "affordable".  However, due to the income level of the employees at the hamburger chain this percentage would be hard to meet for White Castle to still generate a reasonable profit.  It would be more cost effective for White Castle to take the penalty of not offering insurance than to comply with Health Reform.  We can see that other Employers will follow suit on this approach.  This will drive their employees (and employees of other employers like this) to the Exchange.

4.  "Medical Loss Ratio (MLR)" requires that Health Insurers spend at least 80-85% of premium dollars on medical cost.  This is a huge concern for Health Insurers right now because there are services that go into keeping patients healthly that are not categorized today in the "medical cost" umbrella.  It may be hard to keep in-line with the MLR target, depending on what is classified under medical cost and MLR.  An effect of this is that Insurers have already started to scale back the commissions that it pays to Brokers for bringing Individuals and Employer Groups to buy Insurance.  With lower commissions, Broker may exit the market and the Individuals and Employer Groups will move to the Exchange.

5. This last one is purely my speculation.  As Health Insurance Exchanges settle into the marketplace as a stable working option, Individuals will gravitate to the model.  Employers will see this as a win-win opportunity to ask the government to allow simplification of providing the group health insurance benefit.  Employers may find it easier to provide employees with an allowance to go directly to the Exchange to buy insurance and stay out of the enrollment, contract and health insurance management process.

This opinion assumes that PPACA will go into effect with no major changes.  However, how much of PPACA will be made into reality remains to be seen as things get ironed out.  20 States have filed a complaint with the State of Florida against health reform.  And today, the State of Virgina's lawsuit against the new health care reform law cleared its first legal hurdle to continue further hearings regarding the "constitutional issues" of the new law.  Also, the public-option that allows for a plan created by government and offered through the Exchange is back on the table with the proposal of H.R. 5808.

"Cool" Changes under CMS Fee-for-Service's 5010 Implementation

CMS Fee-for-Service (FFS) is the government agency that is responsible for Claims under Medicare Part A and Part B.  They are currently making some really "cool" changes under the 5010 Project that Providers will be glad to hear about.  Something for Health Plans to consider, as they also implement 5010 by the mandated date of January 1, 2012.

1.  CMS FFS will replace their proprietary claims acknowledgement reports with the widely-used 277CA X12N standard format.  The 277CA is already used by most Health Plans to acknowledge the initial receipt of Claims and to communicate any initial status (such as errors).  This is good for Providers because it means they will receive the same format going forward from Health Plans and CMS FFS which makes claims acknowledgement management easier because it can now follow the same process.

2.  CMS FFS will generate their Claim Numbers up front when the Claim is received.  This is great news for Providers because it means they will be given the assigned Claim Numbers up front so that they can immediately use the number to inquire about the status of their Claim.

3.  CMS FFS will be able to receive paper attachments to electronic Claims.  A Provider can fill out a coversheet and fax the attachments to CMS.  CMS will systematically link the electronic claim to the attachment.  This eases the burden on CMS FFS and Providers because it means no extra time is spent looking for paper or proving that an attachment was mailed or faxed.

4. CMS FFS is going to be ready for 5010 by Jan 1, 2011!  That gives Providers and Secondary Payers ONE year to test with CMS FFS before the mandated compliance date.

How is Medicare Part B Fees calculated?

CMS updated it's fee schedule recently for the reimbursement rates it pay for Part B procedures.  The Factsheet that they put together is very informative.  It describes how CMS determines the reimbursement rate for a claim, in case you ever wanted to know!

Rates are frequently adjusted, usually annually.  With recent regulation, reimbursement rates had gone down which has Providers and Health Insurance Plans concerned.  The update this month increased the reimbursement by 2.2%.

What does Health Care Reform mean to me?

With the health care reform bill newly signed at the beginning of this year, many people are wondering how the federal health care reform bill will impact them.  I've heard stories that when Medicare was instituted that college students were hired to go door-to-door to communicate the message of what the program was all about.  Communication this time around will be equally as important as a lot of people are really confused about the reform.

Very simply, the new health care reform bill means that if you have happy with your insurance through your employer, you can keep it.  However, if don't have the opportunity to buy through an employer or want to purchase independently, you can goto a Health Insurance Exchange to purchase your insurance.  The Health Insurance Exchange will be available starting in 2014 or sooner, depending on the State in which you reside.  The benefit of the reform is that insurance will be more affordable to those where it is out of reach today due to age or health status; everyone is pooled together so the rates can be more affordable for an Individual.  The benefit of the Exchange is that it will provide consumers many product options where it is easy to compare and choose a health plan.  To see how an Exchange might evolve, take a look at healthcare.gov which is the federal version of what a State might offer to compare plans.  The health reform also has an Individual Mandate, where everyone must now carry health insurance or take a penalty; this is a highly debated topic within the reform.

The details of the regulation are still being ironed out.  Also, 20 States have joined the State of Florida to appeal some of the reform.  Therefore, the final landscape will shake out over time.  Some States have already started their paths to meeting the reform and the Exchange requirements.

text4baby - Mobile Health App

Today is a repeat of yesterday where I stumbled upon another very "cool" mobile health app.  This application is text4baby.  Simple tool where expecting and new mothers can sign up to receive weekly text message tips on their cell phone around the health of mother and baby.  Being a recently new mommy of two, I would have loved this application.  Those without this app would probably do what I did... Every week I would confusingly re-calculate how many weeks along I was and hunt through the motherhood book to find the section regarding my number of weeks.  text4baby is a great idea!

(Though I think the concept is cool, I have to be fair and say that I haven't tried it!)

GE Healthcare Morsel - Mobile App

Stumbled upon a "cool" healthly mobile application today.  It came up as an Ad link in my Google Email (gmail).  GE Healthcare has newly created a mobile app called Morsel.  Their tagline is "your daily step toward better health."  The purpose is to suggest small things that everyday people can easily do to improve their health.  For example, today's entry is "Try rice or almond milk instead of regular milk".  It gives the user the ability to say that they tried it, so you can see how many other people have done this; great motivator to try it when you know others are doing it.  It is still in it's infancy so not much functionality yet; the other cool feature is that you can suggest a "morsel".  In the recent past, I had mentioned to someone that I think it's hard to get healthy people to adopt to healthcare mobile technologies, but actually, I think I may be turning the corner on this.  I would use this app!

Prescription Safety

We found out from the doctor that my infant has an ear infection again. She seems to always get them so this is our third trip to the pharmacy in the last couple months. The doctor called in the prescription in the morning and I went to pick it up in the evening after work. My infant and I were there together, I was holding her on my hip because she's not walking yet. When we arrived the line was probably ten people deep, something that I've experienced before at this pharmacy. It was about fifteen minutes until we got to the front of the line for pick-up. I think someone should create a vending machine for frequently prescribed low-risk drugs and leave the personal interaction to the more complicated situations.

At the front of the line, I told the cashier my daughter's name and she couldn't find her prescription so then I had to wait for the ONE Pharmacist on duty. Another half an hour later, we find out that her prescription was flagged earlier by the prior Pharmacist on duty because the dosage prescribed by the doctor was double what is recommended. For someone like me who is curious about healthcare process and systems, this was interesting to me. I had not experienced this type of feedback before. The Pharmacist said it would probably be another half hour while she checks with my daughter's doctor. At this point, it was 45 minutes since we arrived to the pharmacy and my daughter was getting impatient so we left and I would come back later.

When I went back later to pick up the prescription, of course I had so many questions. How did the Pharmacist know it was double the dosage? Did the computer tell her that? I did ask the questions and the answer was, they have a manual process where they check the appropriateness for all prescription for children under one years old. They do have a system that checks the appropriateness of some prescriptions, but this did not fall into that category. The Pharmacist did get ahold of the doctor and confirmed the original dosage was incorrect and modified it. I was so happy that they identified this conflict since it wasn't safe for my baby. I was so happy and the Pharmacist too seemed beaming that she could help.

Bringing this post back to Technology. I was surprised that this wasn't caught by any system either at the Physician's end when writing the prescription or at the Pharmacy. Patient safety is critical and risky for health businesses if prescriptions are not appropriate for the patient. I am extremely grateful that through human review this error was found. However, this is a scenario that I think needs to be more protective to patients by the use of technology. We should be integrating tools like prescription screeners to improve patient safety.

21 Days; 7 Seconds

21 Days = The number of days in which if an activity is repeated it will become adopted by the person.
7 Seconds = The amount of time it takes for someone to form a first impression.

Though I haven't validated these to be the common school of thought, it is what an instructor had told us today.

So how does this relate to healthcare?  Well, I recently blogged about lack of user adoption for healthcare applications delivered on web and mobile technology.  So maybe we can try something here.  Let's get in the face of the users for 21 days to remind them about the benefits of these applications and also incent them to use the product for it's intention for 21 days and see if that helps with adoption.  And let's remember in the design of these applications that we have 7 seconds to catch the users' attention where they will decide if they will buy or fly.  So make sure the entry point to the application is one that quickly wow's the users to stick around.

Healthcare Mobile Technology

I went to a conference recently where one of the sessions discussed Healthcare Mobile Technology.  The panel spoke about their visions and excitement of what Mobile Technology can offer to patients and how their healthcare companies have been involved in this space.  The excitement is that we can involve patients in more around their health management and keep them healthy using a device that is already integrated into their daily life, smart cell phones.  One of these companies is Ubiqi Health which is focusing Mobile Technology for the management of migraines. 

I've personally seen Health Insurers spend Millions on putting tools on the Web for patients.  However, what we have seen is that people are not adopting to the Web and the Return of Investment is not realized.  With that said, I apply this too to Mobile Technology.  I believe that people are not totally adopting to using healthcare applications on the Web and Mobile Phones.  I think we need to spend time to fix adoption before spending too much more money on healthcare tools in these platforms.

A couple of mobile and web 2.0 healthcare sites that I want to point out:
http://ubiqihealth.com/
http://www.healthrageous.com/
http://www.patientslikeme.com/

Also, http://health2con.com/ is a great group for following health 2.0.

Healthcare Human Resources Shortage - Right Around the Corner

With Health Care Reform coming down the pike, it makes me think of the magnitude of work that we in the Healthcare Industry are working through right now and the huge amount of work that awaits us.  In addition to keeping our Health Insurance Plans current by slowly updating some of our internal system to realize some efficiencies that new technology provides, we are also faced with many government mandates.  For example, we are looking at 5010 by 2012, ICD-10 by 2013, Health Care Reform varied dates through 2016 and in Massachusetts we are working through Small Business Rate Regulation.  All these efforts are gigantic and the number of human resources alone to get this all done will be many.  There will be an issue in the next couple of years of being able to obtain and secure people to work on all these initiatives.  In the Healthcare industry, when we hire for Healthcare resources, we require prior experience in Healthcare.  We all have a start in healthcare and for me, I had to buy a car, drive 60 miles one way each day and get underpaid in order to get into Healthcare.  I tell people that it's like when we hire a Janitor, we even prefer the one that has worked in Healthcare before.  Though sarcastic, there is some part of truth to this.  So with all the initatives that we must implement in the next couple of years, we will have a hard time in the Healthcare Industry to retain good Human Resources.  My suggestion to solve this issue is that we need to start to look outside of Healthcare and hire talented skills and pair these people up with workers already in Healthcare that can direct, so that we can increase the volume of workers in the Healthcare workforce.