Healthcare Transformation

Post: Rules

Not all rules are made to be broken.

The healthcare industry has always struggled with patient compliance. Many patients stop taking a prescription or adhering to a care plan as soon as they starting feeling better.

It’s a huge problem for physicians trying to adopt value based care models because non-compliant behavior often results in the need for more healthcare. Under value based care that additional care is provided at the physician’s expense. No wonder physicians are not keen on the new risk models.

Ideally every American should understand how they respond to rules.  However, it’s likely another thing that physicians need to address with patients to increase compliance.

There are 4 responses to rules:

1. Upholders: Uphold all rules both outer and inner.

2. Questioners: Questions all rules and uphold only the rules that make sense to them.

3. Rebels: As the name implies, they resist all rules.

4. Obligators: They are motivated by outer rules but not inner rules.

EMR companies should consider updating Patient Registration screens to capture patient’s rule behavior and to identify the Questioners and Rebels who are less likely to comply with meds and care plans. Rule behavior should also be factored into reporting and payment to avoid penalizing physicians.

 

Post: Balance Billing

More regulations or should we fix the payment system?

Years ago, I attended a ABA conference and asked “why don’t we just fix the payment system” rather than add more regulation. I am reminded of that event this morning in reading the KHN proposed options for addressing balance billing.

The proposed solutions are a bunch of new federal and state laws addressing charges and billing practices. Regulation is an important part of protecting individual Americans against corporate wrong doing. However when regulation is used as a bandaid, regulations become part of the problem.

In the case of healthcare, additional cost. High cost is one of the big issues that the industry needs to address in order to make healthcare more affordable.

The problems that need to be addressed are:

1/ Fragmentation: Makes it difficult for patients to navigate and costly to administer.

2/ Network: Not all providers participate in commercial networks which means some patients are exposed to balance billing.

3/ Transparency: Insurers and healthcare providers don’t want their contracted rates shared to enable the consumer.

4/ Current Billing Regs: Healthcare services and products are marked up because everyone needs to be charged the same and there is variability in the contracted rates.

The problems require a more fundamental change.

Universal healthcare

Is it the end of employer-sponsored healthcare or the beginning of employer-driven healthcare?

When I posed this question to my Linked In network, many people viewed the post, some followed up for links to sources but no one commented even though healthcare is top of mind right now for many Americans.

Healthcare is an emotional topic. It’s something that everyone wants and needs but most Americans are struggling to pay for it. The healthcare jobs boom is still going strong which means the total cost of healthcare is continuing to increase. While there doesn’t seem to be a rolling average cost of healthcare per GDP publicly available to see the impact, the math is pretty simple  – more jobs means there is more healthcare being delivered which means more cost.

The total cost of healthcare will not decrease until we curb demand. 

Consumer Driven Healthcare initiatives failed.

Consumer driven healthcare initiatives such as high deductible health plans curbed demand in the short run but resulted in more costly healthcare outcomes. Americans simply couldn’t afford to pay their premiums and the patient portion of healthcare services under those plans. Consequently, they didn’t seek treatment until their health issue became a big problem. In simple terms, big problems cost more to treat. Other consumer initiatives such as pricing transparency never really saw the light of day.

Employer-Driven Healthcare

Employer-Driven healthcare is a new theory and consistent with the Republican trickle down economic policies. The assumption is that if the Republicans can tweak policies enough to get the economy to full employment, every American or at least nearly all Americans will get a job with healthcare benefits. In theory, all employers will offer benefits that are rich enough to ensure timely access to healthcare services.

Some employers are taking initiative to implement on-site and near site clinics, lower deductibles and implement wellness initiatives even though there is a perception that wellness doesn’t work.

There are ways to make wellness programs work better but the key words for an employer-driven healthcare system to work is ALL and SOME. If only some employers offer rich benefits, many Americans will continue to be underinsured or uninsured.

Medicare for All

The idea of “Medicare for All” was endorsed this weekend by former President Barak Obama. The initiative is gaining traction due to the economics and financial condition of Americans.

1/ Healthcare is becoming a bigger portion of the take home pay of low and middle income Americans which means they have less money to spend on housing, food, clothing and other life essentials that affect their health and wellbeing.

2/ The middle class is eroding to the point that it needs to be supported with social wealth-fare spending. Reportedly, $1 in every $7 is now spent to subsidize the middle class.

3/ Republicans are working to privatize Medicare. More health plans are getting into the Medicare and Medicaid business. According to the press release for Oscar Health, it is a more “lucrative” segment. Oscar [co-founded by Jared Kushner’s brother, Joshua] historically sold individual and family plans on the exchanges. Many of the people purchasing policies on the exchanges were sicker and needed more healthcare than expected.

4/ New Medicare Advantage plans are now addressing social determinants and covering many basic living costs. Bankruptcy filings are increasing in the senior population.

5/ Koch brother sponsored study reports “Medicare for All” saves $2 Trillion.

What does this mean for healthcare?

If we just look at the economic condition of many Americans and how the financial strain is impacting their health, it’s clear that we need a new universal healthcare system.

If we consider the changes underway to Medicare and the momentum of the “Medicare for All” movement, it looks like Medicare will be the underpinning of the new universal system. It’s a good thing for you because all or nearly all healthcare providers participate in Medicare, it has well established coverage standards for medical care along with a fee schedule and excludes bad actors from participation.

If we factor in everyone’s deep seated emotions about healthcare, we need a system that offers choice.

What we end up with is a two tiered system offering basic coverage for all Americans and enhanced benefits for those who choose and can afford to purchase additional coverage.

Simplicity wins:

There are plenty of models in other first world countries that can serve as a framework. The key is choosing a framework that simplifies the healthcare system for all to navigate and understand. Not only will it make it easier for all Americans to access care when they need it rather than when they can afford it. It will also reduce the cost. The administrative burden of the current system alone is estimated at 30% of the total healthcare burden in America.

Learn the three Ds

Use the three Ds from the process of “Get Stuff Done” to make good decisions and be more successful at work and in life.

The three Ds are Discussion, Debate and Decision from the process of “Get Stuff Done” described in Radical Candor. I happen to be reading the book this week and used the three Ds as a framework for explaining my process for flushing out the problems, generating ideas and developing the right course of action from a project.

My application of the framework isn’t an exact textbook example. However, it has served as a good way to frame the complexity of the project and balance the complexity with the drive to get the project done.

Discussion:

According to the book, discussion is supposed to take place in 1:1 meetings. Meetings between managers and direct reports are supposed to provide a safe and constructive environment for discussing new ideas, challenges and other issues.

The discussion phase for me happens with a small group of subject matter expertise. It’s a low key discussion to flush out the details of the problem and constraints so that we can generate new ideas for how best to address the need. We basically spend the time thinking about what’s possible. Afterwards I send out a recap of our discussion and capture any additional thoughts on the matter. The recap ensures that we all left the discussion with the same understanding.

Debate:

Debates are bigger meetings to present the ideas so that others can raise their questions and concerns before a decision is reached. Keeping people in debate rather than decision mode is tricky when you have debaters and deciders in the room. Debate can be almost painful for those who already know what they want and/or want a quick decision. If you have ever felt like you got shut down too early during a debate meeting it’s a clear indication that you have debaters and deciders in the room.

The best thing you can do based on my own experience is to communicate your expectation for the meeting and what you want to get from it. If the ideas aren’t flowing, directly challenge the group on a specific problem or idea to spur further debate. The book has some techniques for making sure everyone is in the mind space for a debate meeting and for making it a fun process.

Decide:

People who have a strong grasp of the facts need to make the decisions. Those people are usually closest to the work. That’s why leading edge companies have a process for decision making and why many use the process for Getting Things Done. All of the meetings to discuss, clarify and debate the issues facilitate the decision making process.

The three Ds also help me respect the boundaries of my role as a consultant which is to help flush out the problem, generate ideas and facilitate the decision making process – and not make decisions no matter how tempting.

Application in life

You could apply the three Ds to other relationships as well. Think about the 1:1 meeting framework. When friends and family have problems, they often just want to someone to listen and to ask questions that help them clarify their issues and ideas. They don’t want to be told what to do and definitely don’t want to be judged.

Debate is necessary when decisions affect others. It gives everyone an opportunity to ask questions and raise their concerns so that they can be addressed before a decision is made. Debate often ends too early in the process and unfortunately, the relationships suffer. So keep the debate going until you can make a good decision.

About the Author: Shannon Smith is a healthcare strategist with over fifteen years of experience helping companies achieve greater success. She is also the founder and CEO of Hello Workout.

TrumpCare?

Success of TrumpCare depends largely on whether or not Americans have sufficient disposable income to purchase enough insurance and needed healthcare.

As many of you know, the healthcare industry is going through more changes. Americans like the parts of ObamaCare that gave them more protections for pre-existing conditions and extended coverage for their adult children. What they didn’t like was the cost of comprehensive coverage. Some Americans paid more for richer benefits that they may or may not have needed, while others benefitted from subsidized insurance that enabled them to get needed healthcare. Unfortunately, repealing ObamaCare also means repealing the subsidies that were largely funded with new tax dollars [3.8% investment tax] levied on wealthy Americans.

Going forward cost and coverage are the two variables that you need to keep in mind when choosing health insurance. More insurance options that trade off coverage for a lower cost are likely under TrumpCare. Less healthcare coverage is not bad but Americans will need to read the fine print closely to understand what they are buying. In choosing a policy, everyone will need to consider their savings, disposable income and health status.

If you’ve never had health issues, it might be hard to imagine scenarios when you would need healthcare insurance. It’s like purchasing a new car. You don’t expect repair bills beyond scheduled maintenance unless you have an accident. Unfortunately, accidents do happen. Imagine catching your pointy toe shoe in your pant leg and doing a high diving off the curb onto the street. Speaking from experience, there is a good chance that you’ll crack and/or break a bone or two. One accident like that can get you well on your way to meeting your Out-of-Pocket Maximum for the year. As you would expect, the repair bills for your car become more frequent and get bigger each year – same with your healthcare costs. Brand [genetics], mileage [lifestyle] and adherence to scheduled maintenance [check ups] affect the total cost of the annual repair bills.

You will also likely be paying more out-of-pocket for healthcare. To help you pay for health insurance, TrumpCare will likely provide tax credits for health insurance purchased rather than subsidies and help you save for qualified medical expenses by increasing the annual saving limit for healthcare savings accounts [HSA] so that you can save more tax free. To help Americans spend wisely, the cost of healthcare services are becoming more transparent and the billing easier for the average consumer to understand.

Some Americans value paying more for the peace of mind of having richer benefits or what some think of as “prepaid healthcare” while others skimp on coverage choosing a high deductible or catastrophic policy and pay more out of pocket. Whatever you choose to buy is fine as long as it gives you enough insurance coverage. Just don’t buy the cheapest insurance policy and expect it to cover everything. If you do, you might want to sharpen your “Go Fund Me” campaign skills.

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About the Author: Shannon Smith is a healthcare strategist with over fifteen years of experience helping companies achieve greater success. She is also the founder and CEO of Hello Workout.

Join us on Hello Workout for help covering the weekly minimum requirements for good health, advice from professionals and other tips to help you achieve more success in work and life.

Power of Habits

Your habits are the key to your success in business and life.

A habit is something you do when triggered by something that only you know when you crave the reward.

The Anatomy of a Habit:

A habit has four (4) parts. Once you understand the parts, you can change any habits that is limiting your success.

Cue: The cue is the trigger which can be a feeling, time of day, specific event or anything else that makes you start a specific routine.

Routine: The routine is the action or series of actions you take when triggered. The routine is specific to the trigger and is almost an automatic response.

Reward: The reward is something you get at the end of the routine such as a sense of calm, satisfaction, connection, belonging, completeness, control or whatever you feel from completing the routine.

Craving: The craving is your need for the reward.

 

The Problem:

The routine is the problem. It’s the action or series of actions that you take when you crave the reward that is limiting your ability to achieve your goal. To change the routine and your outcome, you have to identify the cue and the reward so that you can replace the routine with something equally rewarding.

We all have some habits that may not be serving our wellbeing or limiting our success. I have been referring to my need for innovation as a “nasty innovation habit” for the last several years. Like other bad habits, my innovation habit affects my wellbeing in a number of ways and it’s hard for me to break the cycle because it’s so automatic. Let me explain why…

Cue: What drives me to innovate?

It all starts with a problem or at least something that seems harder than it needs to be [cue]. I crave the challenge of adventuring into something new, something that challenges my thinking and the status quo. I’m not as satisfied by the nuance of refining one skill over the lifetime of a career as many others do.

Routine: Develop a solution to solve the problem

I ventured into e-learning during the dot com boom because it seemed like the best way to make a big impact on the industry. I didn’t know anything about the technology or methodologies for developing courses at the time. However, I hired consultants to collaborate with me.

At the time we launched, Health South missed their numbers by more than $2 billion which materially misstated their financials and caused the dissolution of the company. Unlike the other CFOs who had unintentionally misstated their numbers, Health South executives intended to deceive investors and succeeded for a long time. Several of them ended up in jail.

The contractual write-offs are still a big problem for most healthcare companies because the system is fragmented, the contract terms for payment vary from payer to payer, systems lack the needed sophistication to administer the payment permutations and the people doing the day-to-day work and reporting the numbers rarely get the needed training.

Outsourcing only solves part of the problem. Every step of the process and very transaction posted into the billing system makes a difference to the accuracy of the numbers. Rather than fixing the problem, the industry added more solutions to address the consequences and shift the blame. The revenue cycle industry generates more than $52 billion annually and is still not satisfying any of the stakeholders – especially patients.

My first solution addressed the training deficit of the people doing the work and reporting the numbers. I thought it would be kind of like writing a book in that it takes an upfront investment of time and effort but then pays off over time. Like Starbucks, our courses provided professional credits that could be used for college courses. With a 10% initial pass rate, I worked harder than I ever imagined. It wasn’t like a book at all because clients transferred performance expectation to me. I tried to be really inspirational during virtual meetings and relatable in our marketing collateral. Our messaging was on the right track but we missed the need for teaching basic life skills.

Starbucks’ program reportedly teaches skills such as “how to live, how to focus, how to get to work on time and how to master emotions”. My sister who is a psychologist identified that her clients at the time were similar to my students. She was just trying to get them through life whereas I was trying to turn them into star performers. I connected the dots, but still couldn’t close the gap.

It was a missed opportunity because we’ve created more problems since then. Offering people a way forward in life empowers them with keystone habits that makes it easier to change other habits to improve their lifestyle and live their best life. In short, education has the power to change lives.

Reward: What do I get for solving the problem?

I often joke with people that I got the whole employment equation all wrong. When you innovate with your own money it often requires significant sacrifice and for some, it seems like unnecessary hardship.

The reward while on the journey are all the “small wins” that reinforce the belief that the goal is achievable. I can actually feel the pleasure center of my brain light up with a win. Another entrepreneur who I met early in my career used to talk to me about progress. The concept of progress stuck but I didn’t fully appreciate the value of it then.

It took experience for the value of progress to really resonate. As with any big goal it takes months or even years to achieve and there are many setbacks that make you question whether you can get through another week or month. I have a sticky note on my monitor with the words “Do whatever it takes”. I move it to eye level on those days when I need a constant reminder to get out of my comfort zone. Of course there are some ethical limits to the “whatever” but I have had to do things and have had conversations that were way beyond my comfort zone. It’s something that needed to be done. Everyone has the power to bust through their self imposed limits.

Carving: What makes me keep going?

My friends and family wonder what drives me to keep innovating. I do well as a consultant and consulting without personal projects provides for a more balanced life. Truth be told, there are times when I crave more balance. Some days I can even hear my subconscious saying “I want my old life back” as though a pouting child. However, the craving to feel the “rush” of solving a bigger problem is more compelling. So I just keep going.

Goals: What are your goals?

I have always wanted to have a “positive impact” on healthcare. Those words alone have served as a guiding force for the type of work that I do as a consultant, the way that I conduct myself within the industry and the types of problems that I tackle on my own. It’s kind of like Google’s “do no evil” mantra.

When Paul O’Neil became CEO of Alcoa, he focused the company on safety. When he spoke about safety at his first annual meeting, investors thought he had lost the typical Republican plot of “synergy, rightsizing and co-opetition”. However, what the investors didn’t understand was that by focusing on safety he united the company around a common goal. As safety improved, productivity and profit improved.

We need a common goal to unit the healthcare industry. The triple aim lacks identity and is hard to remember. I like Patient Wellbeing because it encompasses safety, outcomes, experience, cost and wellness. I’d love to hear your thoughts.

Power of Habit

If you haven’t read the Power of Habit by Charles Duhigg yet, I encourage you to do so. It was enlightening for me on many levels and provided food for thought about how I want to approach my work and life going forward.

If you’re struggling to loose a few pounds, I’ll leave you with the two most important things from the book that you can do everyday:

Eat Breakfast — It will help to keep you full throughout the day and eat less.

Weigh yourself Everyday — It will help inform you which foods make you gain weight and which foods make you loose weight.

Of course, if I was to add a third it would be exercise.

About the Author: Shannon Smith is a healthcare strategist with over fifteen years of experience helping companies achieve greater success. She is also the founder and CEO of Hello Workout.

Join us on Hello Workout for help covering the weekly minimum requirements for good health, advice from professionals and other tips to help you achieve more success in work and life.

Lean In for Healthcare

We need to “Lean In together” to solve the biggest challenge facing healthcare now.

One of my sisters asked me when Lean In was first published if I had read the book. Even though it was getting great reviews, I had no desire to read about another women’s struggles in business and life — no matter who wrote it. However, I checked the book out of the library last week when none of the other books on my list were immediately available.

Lean In made me laugh out loud and cry because it validated so much of what I had felt and experienced over the course of my professional career and life. Some of Sheryl’s personal stories are funny but the book is also filled with some good information and stats for those struggling with the idea or the reality of balancing their careers with family life. It is a book that both men and women should read to inform their perspective and behavior towards one another.

Ironically, I was at home reading Lean In while millions of others all over the world were marching for equal rights. I didn’t join the Women’s March in San Francisco mainly because large crowds make me anxious. To some degree, I regret it now. Opportunities to make our voices heard matter even if they are deflected by those who need to hear them. They will eventually have to listen.

It will come as no surprise to those who know me well that I was also a little mentally preoccupied. I was thinking about the expected changes in healthcare, my HBA mentoring group and recent conversation with others in the industry.

Healthcare:

When I was working for one of the California based payers years ago, I said to the then VP of Strategy that everyone involved in healthcare needed a voice at the table to solve the problems. It wasn’t anything that I had read or heard, but rather what I really felt after working on both sides of the industry for about five years. When the ACA was drafted, everyone involved in healthcare had a voice at the table.

Like any other strategy, the plan for the ACA was hatched with the best information available at the time. Parts of it worked as expected and as with any other strategy, other parts need to be adjusted now that we have more information. It should come as no surprise to any of us especially those involved in healthcare. Repeal and replace sounds more dramatic but “the replacement” is likely to have many of the same elements as the ACA.

The biggest issue that remains is the rising cost of healthcare. There may be some fat left to be squeezed from insurers and prescription drugs. However, healthcare providers seem to be tapped out. For me it’s evident by the level of tension between physicians and administrations.

I don’t believe that we can financially engineer our way out of the rising cost of healthcare because the medical risk for the country is too high. Like the banking industry leading up to the financial crisis, the medical risk is spread across the industry with some verticals better capitalized than others to absorb it. As the screws get tightened, parts of the system will be squeezed to the breaking point. Unfortunately, it’s likely to be the parts serving the most vulnerable Americans.

Mentoring Group:

I participated in the inaugural HBA mentoring group around the time of the financial crisis. It was a great opportunity to meet other women in the industry and gain the perspective of those working in different fields. What’s more interesting to me now having read Lean In are the limiting beliefs that are holding some of the women back.

We did an exercise to help one another prepare for their next job. As part of the exercise, we reviewed the description for a desired job and resume for each person in the group. One of the women in the group is a highly trained scientist working in quality assurance for a biotech company. When she reviewed my resume and the job that I had selected, she told me that she didn’t see the exact qualifications for the job on my resume. She was looking for an exact match. When I selected the job, I was looking at it with a skills and competency lens. I didn’t need to have the exact experience to know that I could do the job as described. I chalked up her feedback as that of a scientist. However, now I understand that her perspective is how most women think which can be limiting to not only her but others including me. Reportedly, men don’t look for an exact match when they select and apply for jobs. My guess is that they may not hire that way either.

Communication was another problem raised by the group. The quality scientist was upset that her manager was always late to meetings. The group concocted this very elaborate plan for her to address the issue. I suggested to her that she just tell her manager “your tardiness isn’t working for me”. No one in the group believed that it could be that simple and dismissed my suggestion. However, Sheryl relays a story about Mark Zuckerberg joining a group at the office to learn Mandarin. When one of the women in the group was talking in Mandarin about one of their managers, Mark kept asking her to simplify so that he could understand what she was saying. Finally, she blurted out “my manager sucks.” Now that is something simple enough that everyone can understand and work to fix.

Mentors and mentoring groups are good because they open us up to different perspectives and challenge the beliefs that are holding us back. We need to get out of our comfort zones and if we are going to rise to the challenges ahead.

Recent Conversations:

Last week, I was able to meet with other executives working in different verticals of the industry. We discovered some shared experiences and mutual interests but what I appreciated most was being able to say “what do you think?” No one person has all the answers and it serves us all to do a reality check on your own perspective and role. Some of us are carpenters fixing problems within the existing system as we go and others are disrupters looking to turn healthcare upside down. We need both to solve the biggest challenges facing healthcare.

With that said, I initiated a new circle for healthcare professionals on the Lean In web-site so that we can meet, share, learn and challenge one another. I don’t have specific goals for the circle other than to give everyone a seat at the “table” who wants one.

About the Author: Shannon Smith is a healthcare strategist with over fifteen years of experience helping companies achieve greater success. She is also the founder and CEO of Hello Workout.

Join us on Hello Workout for help covering the weekly minimum requirements for good health, advice from professionals and other tips to help you achieve more success in work and life.

The Benefit Gap

Purchasing health insurance is kind of like purchasing a specialty light bulb. There are more bulb options than you can ever imagine. Standing in front of the wall of bulbs once you’re at the store, you’ve probably realized that it’s next to impossible to pick the right bulb without knowing the model and wattage needed.

If you’ve used an exchange or picked your insurance from a bunch of policy summarizes, you probably felt that same overwhelming feeling as standing in front of the wall of bulb options and likely thought there has to be a better way.

Exchange and Brokers:
Exchanges and brokers narrow the options so that you only have to look at part of the wall. The problem is that the criteria used to narrow the options basically tell you which policies you can afford but not necessarily which plans are best for you.

Income, age and location are the primary criteria being used to filter the options on the exchanges. Age is a risk adjustment to help insurers price the policies, income addresses your ability to pay for health insurance and location provides all of insurance policies offered in your city. In other words, it’s like seeing only the bulbs that you can afford to buy but they may or may not fit your light.

Healthcare Jargon:
Model numbers and wattage don’t help if you don’t the model and wattage needed. Similarly, the use of healthcare acronyms don’t help you pick a policy when you don’t understand what the acronyms mean.

Exchanges and policy summarizes are littered with healthcare acronyms such as HSA, PPO, HMO and EPA. Some of the acronyms have been around for a while but how they are being used is changing and evolving within the healthcare industry and those newly covered probably don’t have a clue what they mean. The problem is that all of the acronyms affect the cost of healthcare and impact the consumer experience.

Comparable Plans: 
How do you pick a bulb when you don’t know the model and wattage? Chances are you guess. You pick the new bulb from your memory of the old bulb and take it home to try it out. That’s kind of what people do when picking health insurance. They use past experience to find a policy like their old one or a better one if the last one didn’t meet their needs. 

However, the only thing comparable about the plans now are the names and the benefit terms included. Some benefit terms specify a copay or rate of coinsurance and others set a maximum benefit. Consequently, there is no mathematical way to know which term provides the better benefit.

Few people are able to figure out which benefit is better because it takes a lot of work just to get the information needed to do it. So most people guess and hope for the best. Needless to say, emotions flare when they figure out their guess was not so great because unlike a light bulb, they’re stuck with the policy for an entire year.

To provide the math at time of purchase, more information is needed about each insurer’s network. Most insurers have to contract with healthcare providers (physicians, hospitals and others) for services needed by their members. The contracted rates are negotiated and may be different from provider to provider.  For healthcare providers not included in the network, the provider’s charges are needed to calculate the benefit.

The Point:
Healthcare consumerism starts with the selection and purchase of the insurance policy not healthcare services. If consumers don’t purchase the right policy for them, there is friction every time they use their benefits.  

With healthcare costs becoming a bigger part of the consumer budget, we need to make it easy for healthcare consumers to understand what they are purchasing and make better recommendations of policies to serve their needs.

About the Author: Shannon Smith is a healthcare strategist with over fifteen years of experience helping companies achieve greater success.

Let’s Change the Game

Medical risk is like the hot potato that keeps getting passed around between the government, employers, insurers and providers.  Similar to the hot potato game, whoever ends up holding the medical risk usually looses the game.

The responsibility for managing medical risk includes the responsibility for managing a big pot of money to administer claims. Medical billing and collections, as described by Jonathan Bush, founder and CEO of Athena Health, is one of the stinkiest parts of healthcare that few providers do well. So basically by transferring risk to providers they end up with more of the stinky stuff that they haven’t been able to manage well. That alone give me heartburn because the stinky part is critical for monitoring the overall health of the risk pool and their organization.  However, there is even more to the story.

Risk + Money = the Risk Pool:

Healthcare trends like the aging population and the number of obese and overweight people are the risks that suggest a need for a very large pot of money to pay for healthcare. Unfortunately for providers, all the other players in the hot potato game are basically saying they’re tapped out. So healthcare providers somehow have to figure out a way to do more with less. In other words, they are getting less money than they need to pay all the expected claims. 

Do More with Less:

Many providers are accepting the challenge to do more with less even though it’s never been their strong game. Most have been focused on delivering the care patients want regardless of cost because historically, they have been able to make enough from some patients to cover all the bills for everyone. So at this point no one really knows how to do more with less successfully.

Building regulations, staffing regulations and lack of pricing transparency for medical supplies make it challenging to cut costs that companies in other industries routinely cut. Some savings will be realized if providers share records and reduce the amount of duplicate tests but the bigger savings come from not delivering care at all. Providers have yet to figure out how to say “No” to patients who want medically unnecessary care without getting a bad review and how to get people covered by their risk pool to live healthier lives.

Medically Unnecessary Care:

People who are really sick rarely think care is unnecessary even if a treatment has a very slim chance of working. Who doesn’t like to think they will be the exception to the rule? Isn’t that part of positive thinking? That’s what makes coming up with care guidelines so difficult and hard for providers to adhere to. Saying No or No unless you pay for it upfront is hard for all the players. Insurers did a better job of playing the bad cop because they didn’t have to face their member and tell them the bad news or work with them day-to-day.

What healthcare consumers need to understand is that healthcare insurance doesn’t mean covered for everything and anything. Few healthcare consumers read the fine print of their policies before they need to access the benefits – and unfortunately, that’s when the frustration begins for everyone.

Live Healthier:

There are a lot of people in this country carrying too much fat. Providers tippy toe around the issue by telling patients they are at risk for disease and/or by letting them know their BMI measurement is beyond the healthy range. You can only imagine that some patients don’t really see the problem with a point or two beyond normal and why some patients are not connecting the dots or getting the right message about fat. Fat causes a lot of health problem that are costly to treat and makes it hard for providers to do more with less.

Wearables may help connect the dots for some healthcare consumers. The latest technologies measuring our motivation, movement, sleep and food consumption can help us develop awareness, establish a baseline and monitor metrics during periods of physical change.

The problem with wearables now is that they are not sticky enough without a financial incentive to motivate the healthcare consumers who needs to loose weight and they are addictive for people who are already extremely active. Both groups are problems for healthcare providers trying to do more with less.

The Point:

There are a lot of questions left to be answered about how to make it all work so that providers can do more with less and patients get the care they need and want. It’s going to take some more honest conversations and fresher thinking to change the game.

The one thing we know now is that everyone can help by eating a healthy diet, exercising and living an active life.

About the Author: Shannon Smith is a healthcare strategist with over fifteen years of experience helping companies achieve greater success.

Workplace Wellness

Leading edge companies are coaxing their employees into the last frontier of the culture change underway in the healthcare industry – wellness.

For many the thought of employers accessing their health information seems invasive and worrisome because the use of their information may seem like more of a motive or agenda to rid the company of people with negative health habits.  Most people know that the obesity rate is on the rise, smoking causes some serious health issues and the stress of balancing the demands of life is growing as more people become caregivers for children and/or aging parents. 

The problem is that the majority of people cannot see their own health risks.  People often rely on friends and family to help them with other decisions and see issues in their life, but relying on friends and family to help with their health issues is not working.  Let’s face it – talking with friends and family about how you feel about your body or life invites comments and judgements that can be destructive to the relationship.  No one wants to hurt the feelings of someone they love or care about which is why it is so difficult.  So the question then is who should provide and/or hold the mirror to help us see our issues?  

Employers are stepping into the role to provide the mirror and in some cases, are holding it for us.   Why the employers?  We all have a relationship with our employer and there is a mutual benefit if we are healthy and happy on the job and in our individual lives. Several companies on the leading edge of wellness recently spoke at the Silicon Valley Leadership Forum Wellness Summit about their journey into wellness and the success of their programs.

Progress is being made but there is still a long way to go to ignite the wellness revolution in America.  So let’s revisit the culture change framework to get a better understanding of where things are now and what still needs to be done.

Getting Started

Change starts with establishing new behaviors.  The way we work, what we eat and how we live has changed since employers started providing healthcare insurance.  The system that served us well way back then is not working for many people now or the companies competing in the global market.  

To get a competitive advantage or to just level the playing field, some companies are shifting more of the financial burden onto employees to help reduce their labor costs.  However, the leading edge companies are showing us that there are better ways to go about it.  They are providing the mirror in the form of biometric screenings so that employees learn their numbers and know where they stand on health.  Many are starting to change workplace policies, implement benefits to promote healthy living and model healthy behavior in the workplace.  How you ask?  

The programs are as different from company to company as the people they serve.  There is no “silver bullet”.  However, there are some common elements such as discounts on programs such as Weight Watchers to promote diet modification, company gyms or discounts to clubs and gyms to promote regular exercise, standing and treadmill desks to promote movement throughout the day, the use of yoga and meditation practices to promote mindfulness and stress reduction and individual support whether in the form of concierge services, health coaching or on demand solutions.  

If there is one “silver bullet” common to all programs, it is the use of financial incentives to gain participation and engagement.  The promise of better health is simply not enough at this point.

Making Progress

Progress makes people happy. There are glimmers of happiness with the wellness programs in place now.  The leading companies have figured out the right elements of the program needed and have the leadership and financial support to fully implement the initiatives for a successful program.  Other companies are struggling to develop a meaningful program because the Return On Investment (ROI) is not clear to the leadership and is generally not immediate or certain over the long term.

A study was done of the Johnson and Johnson wellness program in  2010 that showed a 3.7% lower average annual growth in medical costs and a return of $1.88 – $3.92 for every dollar spent on wellness.  The Johnson and Johnson program is notable because it has been in place the longest of any program and is routinely evaluated and modified to meet the changing needs of their employees.  Other studies done by Johnson & Johnson since the 1980’s report improved employee health, reduced inpatient healthcare spending and decreased employee absenteeism – all indications of happier employees.

Health is part of the DNA of Johnson and Johnson.  The company’s Credo from 1943 reflects their commitment to healthcare providers and the health, wellness and safety of their employees.

Earning Support

When you tell people your goal and they can see your commitment you will get the support needed to achieve it. Getting people to tell employers their issues and goals can be a little tricky even though there is a mutual benefit. 

Employers can do a lot with the the relationship that exists with employees but like with any relationship there are limits as to how far the relationship can go.  Depression is a bigger issue than diabetes and an issue that often goes unreported because of the stigma around mental health.  

Google reported a rate of 6% but suspects that depression is more prevalent in their workforce.  There was discussion at the summit around ideas and initiatives to support people with depression but most panelists acknowledged the challenge of getting help to the right people at the right time.  So who’s in the best position to help with this kind of issue?

Who is the question that remains to be answered.  It may be the employer, it may be friends and family as health and wellness initiates make it into the home, it may be healthcare providers or it may take the entire village to pitch in, help out and provided the needed support.

Progress is being made to promote health and wellness but conversations are just starting about work life balance and/or work life integration in terms of what makes people happy and more productive.  

About the Author: Shannon Smith is a strategist with over fifteen years of experience helping companies achieve greater success.