Healthcare Transformation

Digital Transformation

The Canadian healthcare system is undergoing a similar digital transformation as the US.

Even though the healthcare systems are different in how they are financed, the triple aim of the transformation is for the most part the same.

The triple aim:

1/ Enhance the patient experience

2/ Reduce the cost of care

3/ Increase population health

A couple of differences to note:

1/ Patient vs. Consumer experience: The US has been trying to engage patients in consumer type behavior to help lower the cost of care. The jury is out on whether it’s having the intended effect or not. However, the word consumer resonates even less in a Canadian healthcare context even though many also have private insurance and pay some healthcare costs out-of-pocket.

2/ Clinical experience and productivity: The 4th aim in Canada whether official or not, is about making things easier for clinicians in order to utilize their time effectively and to reduce the risk of errors. Given the number of reported issues with EHRs and physician burnout, most US physicians would likely sign on to that aim.

Regardless of country, it’s hard to manage risk in large scale transformations without stifling innovation. There are differences in how the risk is being mitigated and managed. I’ll touch on that next.

Now – Near – Far

Now – Near – Far is a strategic framework that some executives of legacy healthcare systems are using now.

The framework was developed by James Hackett, CEO of Ford to assemble and align the resources needed to deal with disruptive market forces.

1. Now – Assembling and aligning resources for the Far.

2. Near – Executing on the strategic plan in a way that continuously meets the expectations and needs of patients.

3. Far – Imagining who your patients are, what they will need, what they will expect and how you can serve them.

The problem for some executives is that they are not thinking about the Far and may in fact be brushing it off as something they have seen before. However, the consolidation and emerging technology will eventually result in disruption to the status quo.

The threat for the legacy healthcare systems is the vertical consolidation of outpatient providers and insurers. The resources of the combined entity and the lucrative services provided will make them hard to beat.

Uber didn’t start with Pool. Uber started with a resource some people already used and made it easier to use. Then they offered cheaper options to capture more marketshare.

If something sounds too crazy to work. Don’t brush it off. Think about the possibility.

Health + Healthcare

Is health a personal choice or is there a role for physicians?

A friend recently said to me that the best thing a General Practitioner [GP] could do is write a referral to a specialist. He’s not in healthcare so I had to ask whether he thought GPs should help keep people healthy. He said no. Health is a personal choice.

Are GPs limited in what they can/should do for us by our limited expectations of them? Has the healthcare system trained people to have limited expectations? Or are GPs truly limited in their scope of work?

This conversation relates to another recent conversation with a dialysis nurse as well as our post on complimentary care providers. The dialysis nurse uses a GP that works as a complimentary care provider similar to a naturopathic doctor that helps assess among other things hormones and vitamin deficiencies that affect sleep, weight, mood etc.

The work of a complimentary care providers extend our ability to live healthy lives but few people know about them or know what they can do. Why?

The problem is that complimentary care providers are typically not integrated into the healthcare system and coverage is limited.

Apparently when they are integrated, GPs get the benefit of seeing what’s done and why. They get the full scope of the patient’s care. Patients get comprehensive care that helps them live healthier.

Limited vs. Premium

Forget “Medicare for All”.

The easiest way to think about fixing the healthcare system is to use the framework for reconstructive vs. cosmetic coverage.

Three words are used to evaluate whether something is covered or not: Bad – Good – Better. Here’s how it works:

1/ Reconstructive Services: [Bad to Good]

Reconstructive services focuses on health improvement from bad to good. [ie: reconstruction following mastectomy vs. breast augmentation.] The idea is that the service restores the body to “expected” function or appearance. The same concept can and is applied in coverage decisions for any body part or core function now in government programs. It’s limited coverage to keep people in good health.

2/ Cosmetic Services: [Good to Better]

Cosmetic services which focus on improving appearance or more broadly, services that improve quality of life aren’t covered. Anything that extends “expected function” isn’t necessary to sustain life. However, those services tend to enhance the quality of life. A good example is fertility services that are now an option for some commercial plans.

Of course, there would still need to be safeguards because some in the industry have a misguided understanding of capitalism.

Limited vs. Premium

It’s an easy concept for Americans to grasp limited vs premium coverage. And according to the Koch Brothers, there is more than enough money in the system now to provide limited coverage for all. While also giving Americans the option to purchase richer premium benefits.

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.