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This week in healthcare news: Warren Buffett, CVS, Aetna all talking about lowering costs—who will succeed?

Healthcare

February 27, 2018

Warren Buffett Shares Details on His Healthcare Alliance with Amazon, JPMorgan

Warren Buffett made some bold statements for CNBC on Monday about Berkshire Hathaway’s healthcare alliance with Amazon and JPMorgan. Buffett stated, “I love the idea of tackling what I regard as the major problem in our economy,” referring to the rapidly increasing proportion Americans are paying for healthcare. He goes on to explain that in 1960, healthcare was 5% of GDP ($170 per person), and this spending has increased to today’s rate of 18% of GDP (over $10,000 per person). For Warren Buffett, this is a competitive disadvantage for America. 

Speaking of the goals of Berkshire Hathaway’s alliance with Amazon and JPMorgan he states, “It would be very easy to shave off 3-4% just by negotiating power…we’re looking to do something much bigger than that.” They want to halt healthcare’s increasing share of U.S. GDP by finding a way to deliver better care at a better cost. See the 5-minute interview here: Buffett Shares Details on Healthcare Alliance.

Today: CVS and Aetna’s General Counsels Testify Before Legislators in Washington

Amid investigations in numerous states of accusations of unfair claim denials and unfriendly patient practices, Aetna has been getting its fair share of negative press in the last month. But on Tuesday, February 27th Aetna’s and CVS’s General Counsels testify before the House Subcommittee on Regulatory Reform, Commercial and Antitrust Law on CVS’s planned acquisition of Aetna. Their goal? To convince this subcommittee that CVS and Aetna’s combined forces are good for healthcare and good for consumers. The testimonies, both published in full on sec.gov, paint a very different picture of Aetna’s future goals from what’s currently volleying through the media.

The testimony of Thomas Sabatino, General Counsel for Aetna, starts by acknowledging that the U.S. healthcare system is inherently flawed; he explains it was formed in the mid-20th century for the benefit of hospitals, employers and insurance companies—not for the benefit of patients. He acknowledges that the U.S. is “the most expensive system in the world,” yet half of American adults are affected by chronic conditions such as diabetes, heart disease and obesity. With rapidly rising health costs and deteriorating health, he says that Aetna recognizes that “the status quo is not sustainable.” But he goes on to assert that now, with increasing consumer demands and rapidly advancing technology, that it’s time to focus on the consumer.   And, as his testimony states, CVS and Aetna are the players that will make that possible. With compelling figures that 70% of Americans live within 3 miles of a CVS store and 5 million people visit a CVS every single day, he lays out how the retail chain is poised to be a community-based health center to address the areas of the World Health Organization’s holistic view of health (“a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”) He states, “the key to our strategy is more regular, individualized, and effective engagement with health care consumers not just when they are sick, but as they take steps to maintain and improve health.”

Same Goal, Two Very Different Strategies

Buffett’s healthcare alliance and CVS’s Aetna acquisition are two completely different strategies to tackle rising healthcare costs, but at the helm of these initiatives is a goal to accomplish the same thing—to provide better care for Americans at a lower cost. It’s an exciting time for healthcare with big changes on the horizon. Stay tuned to see if these initiatives live up to their hype.

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BetaXAnalytics is a healthcare data consulting firm that helps employers to cut their healthcare spending through proven strategies to contain costs. For more insights on using data to drive healthcare, pharmacy and wellbeing decisions, follow BetaXAnalytics on Twitter @betaxanalytics, Facebook @bxanalytics and LinkedIn at BetaXAnalytics.

Will Amazon’s Joint Healthcare Venture Make You Smile?

Healthcare

Amazon has revolutionized so many aspects of our lives, and now the big question is: will they revolutionize healthcare? It seemed that way, given their joint announcement on January 30th with Berkshire Hathaway and JPMorgan Chase, claiming they were teaming up to form a healthcare company “free from profit-making incentives and constraints.” While the intended goal of this joint venture is “to improve U.S. employee satisfaction while reducing overall costs,” Jamie Dimon of JPMorgan Chase explained, “the three of our companies have extraordinary resources, and our goal is to create solutions that benefit our U.S. employees, their families and, potentially, all Americans.” This announcement sent shockwaves throughout the market, as the stocks for major insurers and healthcare companies went tumbling. Market analysts began waging their predictions for what this new company would look like—Alexa for employee benefits? Diagnostic wearable technology? What could it be? To calm the fears of JPMorgan Chase’s clients, company representatives tempered the message, explaining that the initiative can be compared to a group purchasing organization, similar to the type of setup used by hospitals to buy supplies, so the 3 companies could leverage better deals for their employees.

Whoa, Nellie.

OK, maybe we all got a bit ahead of ourselves. Warren Buffet, who compared healthcare’s skyrocketing costs to a “hungry tapeworm on the American economy” admitted that the three companies do “not come to this problem with answers.” But he resolutely stated that they did not need to accept the current state of healthcare. Bezos went on to say, “hard as it might be, reducing health care’s burden on the economy while improving outcomes for employees and their families would be worth the effort.” These companies bring serious purchasing power to the healthcare market.  Amazon, JPMorgan Chase and Berkshire Hathaway have a combined market cap of $1.62 trillion, and between all 3 companies there are 1.2 million employees. Last year, JPMorgan alone spent $1.25 billion on medical benefits for U.S. employees where the medical plan covers almost 300,000 individuals, including employees and their family members.

What will this healthcare partnership most likely look like?

While we can’t predict what this solution will evolve to become over time, JPMorgan disclosed a crucial piece of information following the joint venture announcement—that the initiative can be compared to “a group purchasing organization.” The overall goal of this initiative is to cut healthcare costs and to improve employee satisfaction. So the best way we can understand what this joint venture solution will be is to look at the current state of employee healthcare for these companies.

Hint: follow the money

Taking a look at who is currently making a profit off of Amazon, Berkshire Hathaway and JPMorgan Chase’s healthcare benefits is a good place to start when we’re asking ourselves what this new healthcare company will look like. 

A 30-second tutorial on health benefits

But it’s useful to take a 30 second detour for anyone unfamiliar with the employer healthcare market to understand where these companies are coming from. These days, most employers with over 1000 employees “self insure” for their healthcare benefits, meaning they pay health claims for their associates from dollar 1. For large employers, and especially for jumbo employers like Amazon, Berkshire Hathaway and JPMorgan Chase, it’s simply more cost-effective to pay for healthcare in this manner—they tend to not need to pay a health insurance company to take on the financial risk of their “sickest,” most costly employees (i.e. people who require major surgeries or treatments, those requiring costly medications or people with multiple chronic illnesses). Employers like this work with a health insurance company (for instance, United Healthcare, Aetna, Blue Cross) to perform the administrative functions of paying providers and settling claims. Either the health insurance company or a pharmacy benefits manager will handle the pharmacy side of employee healthcare claims.

Large employers such as these 3 have been using innovative tactics to control healthcare costs for years. From using healthcare analytics to strategically manage wasteful spending to moving health clinics right into their corporate offices, large employers historically have been ahead of the game with managing healthcare spending. After all, it’s Warren Buffet who notoriously said, “GM is a health and benefits company with an auto company attached,” understanding that because healthcare is the first or second highest company expense, that portion of the “business” must be managed as strategically as any other business unit.

Mission critical: cut out middleman expenses, cut down on employee healthcare headaches

So back to the original question of, “who profits from Amazon, Berkshire Hathaway and JPMorgan Chase’s healthcare spending today?” Here’s a sampling of the likely suspects who are middlemen in the game of keeping employees and their families healthy:

1.      Health insurer(s) (United Healthcare, Aetna), who charge an administrative fee for settling medical claims

2.      Clinical condition managers (often employed by the health insurer) who help to coordinate care for employees with chronic conditions such as diabetes, cancer, heart conditions

3.      Wellness service companies such as Limeaid or Virgin Pulse, who administer health-related educational programming, employee health screenings, incentive programs to encourage employees to see their doctor and stay active, and fitness challenges to encourage physical activity and healthy behaviors

4.      Pharmacy benefits managers or related pharmacy services, such as Optum or CVS who take care of prescription drug claims and/or cost-management

5.      Surgery cost-bundling vendors who negotiate with medical providers to receive more competitive, bundled rates on surgeries and costly medical tests

6.      Health analytics companies such as Truven (IBM) or Medeanalytics who use health and pharmacy data from employee claims to help with strategic healthcare cost management

7.      Telemedicine vendors who offer the availability of doctors via phone for employees who need to discuss a health concern, but cannot see a doctor in person (or cannot wait for an appointment)

8.      Health advocates and/or health “concierges” that exist to help employees navigate the confusion of the health system to better understand services that are in and out of network, applicable deductibles and coinsurance

9.      Employee benefits platforms that exist so employees can understand the specifics of all benefits available to them, including health insurance and pharmacy coverage, and employee health savings accounts

10.  Benefits brokers and consultants who help to manage the coordination of all these programs and manage vendors

Understanding that the goal is to cut healthcare costs, it’s this list of middlemen who may be on the chopping block, as their services may potentially be replaced by this new joint venture. For instance, these 3 companies may form a non-profit company to handle settling their employee claims (the job which is currently done by the health plan). Similar to many health insurance companies, managing chronic diseases, managing pharmacy claims and offering wellness services could be companion services offered by this new venture. Only these services would likely be more effective than those of a health insurer because the company would solely exist to keep employees healthy—not to make money. And since profit would not be the motive, access to healthcare analytics to enable strategic management of costs and population health would be more transparent, truly existing for the benefit of Amazon, JPMorgan and Berkshire Hathaway. There are many possible solutions that will save healthcare dollars and improve employee satisfaction for these companies, but the most likely solution will incorporate some form of replacement of some or all of these 10 services that employers use to provide healthcare coverage, to manage healthcare costs, or to help employees to better leverage healthcare services for better health outcomes.

So will this forward-thinking trifecta hack healthcare to solve the problem of rising costs for the rest of the country? Perhaps in time. But the more significant message in this bold move is that Amazon, JPMorgan and Berkshire Hathaway have taken a public stand to say that they will not accept the status quo of healthcare in the United States. The rising costs, the confusion of employees trying to navigate the tangled healthcare maze, and the overall lack of improvement in employee health can no longer be accepted as the norm. And as this solution begins to take shape, it will send ripples through the healthcare space, as a new expectation takes priority in employer-sponsored healthcare—getting healthcare shouldn’t be so difficult, it shouldn’t cost so much, and healthcare should be making people healthier. Now there’s a change that will bring a smile. 

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BetaXAnalytics is a healthcare data consulting firm that helps employers to cut their healthcare spending through proven strategies to contain costs. For more insights on using data to drive healthcare, pharmacy and wellbeing decisions, follow BetaXAnalytics on Twitter @betaxanalytics, Facebook @bxanalytics and LinkedIn at BetaXAnalytics.

Correcting Patient Coding Can Save Millions

Healthcare

Physician burnout is a real thing. Between seeing increasing numbers of patients, documenting visits and reviewing health records, more tasks are expected of healthcare providers. According to a Mayo Clinic Study, 54% of physicians reported at least one symptom of burnout. While there are many new technologies to assist with patient care, using new technology does not always integrate well with the face-to-face, personal nature of providing medical care. Some physicians perceive that technology slows them down, as they do not have the time between patients to update codes and clinical details in documentation. But the reality is that taking the time to ensure proper coding reduces the likelihood of redundant tests, the risk of medical errors, and can significantly impact value-based contract reimbursements. So in this sense, taking the time to input patient information, document and code patient conditions is critical.

From a financial standpoint, healthcare CFOs understand the benefits of accurate patient coding. The transition to value-based payment models in healthcare is accelerating under the Medicare Access and CHIP Reauthorization Act (MACRA). The intent is to provide financial motivation for providers to manage more patients under risk-bearing or coordinated care contracts. The two methods of managing physician reimbursement under MACRA—Advanced Alternative Payment Models (APMs) and Merit-Base Incentive Payment Systems (MIPS)—both hinge on correct clinical documentation to assign accurate risk adjustment scores.

From a provider’s standpoint, risk adjustment scores such as the Hierarchical Condition Category (HCC), impact physician documentation practices and requirements. This means that all chronic conditions need to be reported on an annual basis for all patients, regardless of the care setting, in order to correctly estimate the risk score for a provider’s patients. Annually, this information is reported to the Centers for Medicare and Medicaid Services (CMS) in a Risk Adjustment Processing System (RAPS) submission. In many cases, this submission is compiled from claims data; but while claims data carries a great deal of information on a patient’s medical history, it often understates the true “risk” of the patient population. In financial terms, this means that providers who understate their patient risk receive a lower reimbursement from CMS. In other words, because of inadequate patient coding, healthcare providers are leaving money on the table.

How can healthcare organizations solve the problem of underreported patient risk? We ventured to take on this problem, and sought to find a solution that any provider group, large or small, could use. Understanding that not everyone has the budget for an expensive platform or a team of auditors to check through exhaustive patient records, we wanted to see what technology could do to ensure patient risk is accurately coded and reported—without putting an additional burden on physicians. 

We used machine learning and natural language processing of unstructured data, encompassing millions of files, including doctor’s notes and faxes. Within the many silos of data were notes captured of patient conditions that were not always reflected in the claims coding in the patient’s electronic health record. This technology enabled us to shortcut the work that would normally be undertaken by an entire auditing team manually reviewing patient files. To give an idea of the efficacy of a process like this, in this case we were able to discover $1.3 million in under-represented risk reimbursements for the provider group. 

For healthcare CFOs who are looking to make sure patient coding is accurately reflecting population risk adjustment for CMS reporting, there 2 options to ensure your organization isn’t leaving money on the table. 1) Invest in hiring additional people to educate, input, and audit correct patient EHR codes or 2) invest in a technological solution to ensure you’re not losing out on reimbursements due to under-reported patient risk. Healthcare organizations who form a strategy to ensure correct risk adjustment reporting can see millions in additional deserved reimbursements on their bottom line. 

For a free demo, contact us.

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BetaXAnalytics is a healthcare data consulting firm that helps payers and providers to maximize their CMS reimbursements and helps employers to reduce their healthcare spending through proven strategies to contain costs. For more insights on using data to drive healthcare, pharmacy and wellbeing decisions, follow BetaXAnalytics on Twitter @betaxanalytics, Facebook @bxanalytics and LinkedIn at BetaXAnalytics.

How To Make Data-Driven Decisions When You Don’t Have Data

Data

In 1934, T.S. Eliot famously lamented the empty soul of modern work life. Though he wrote “Choruses from the Rock” over 80 years ago, he hits a nerve in our present-day struggles by asking, “Where is the wisdom we have lost in knowledge? Where is the knowledge we lost in information?” In current times, we have so much data at our fingertips, but does that mean we are making better decisions? Today, the core of data analytics is simply using information to make well-informed decisions. The only difference today from 80 years ago is that we simply have more information available to make decisions and more sophisticated methods to use this information. 

A question that I get time and time again from managers is “How do I make data-driven decisions when I don’t have any data?” As a decision maker, it’s incredibly frustrating to feel hampered by a lack of data.  Despite wide availability of information, companies might not put data into the hands of decision makers for a couple reasons. Maybe the organization does not have an effective way of capturing data—this happens in companies that have older technology in key areas of the business. Or maybe the data they have is too messy—for instance, perhaps they can track customer quotes online, but they have no way of cleaning up the 30 different customer quotes that actually were generated by the same person. In other cases, data is kept sectioned off in certain parts of a company, but it is not shared widely with people whose decisions depend on the information. For whatever the reason that managers feel like they do not have access to information to make an informed decisions, there are a few guidelines you can follow to ensure that you are making the right decisions.

The key is not to get more data – it’s to get the right data.

It’s important to keep in mind you can have all the data in the world and still not have the information you need. The key is not to get more data – it’s to get the right data. In research from the book Stop Spending, Start Managingexecutives reported wasting an average of $7,731 per day—or $2.8 million per year—on wasteful “analytics.” The first step to making sound decisions is to recognize what that “right” data is for your business. Once you identify this, you can cut your time looking at reports significantly because now you have a strategy. You know exactly what you need to see to make a decision, and you can see through the noise of mountains of data that don’t add value to your decisions. 

Executives reported wasting an average of $7,731 per day—or $2.8 million per year—on wasteful “analytics.”

If you don’t have access to the data you need at work, here are some steps you can take:

1.      Identify your business goals.  Here’s your opportunity to start at square one and holistically rethink how your decisions are made. This entails taking a 50,000 foot view of your business to make sure that you’re asking the right questions. We often get in the habit of process, and we repeat process patterns of looking at old reports that don’t tell us what we really need to know. If your business unit always looked at a set group of metrics, it’s easy to get tunnel vision and to see it as a bad decision to stop looking at a certain report. But I recommend taking a step back to ensure you’re asking the following questions before even looking at any data:

·        What are the business objectives for which we are responsible? (In other words,what are our goals?)

·        What are the crucial areas of the business that we need to be tracking?

2.      Identify which data you need to track progress on your goals. What data do you need to see to be able to track progress on these goals and to make sound decisions? In most cases, every business goal you cite has one or multiple metrics that will help you to gauge progress against that goal.

3.      Examine your data access. Identify which of these must-have pieces of data you have access to. For the data you don’t currently have access to, identify how you can get access. This can be as easy as requesting access from another department, or as hard as implementing a way to capture new data.

4.      If needed in the short term, identify proxy data for the information to which you don’t have access. When you can’t access crucial data, is there a proxy measure that would tell you the same thing? For instance, if you have no way today of tracking the number of customers who are calling with a particular complaint, can you poll your front line customer service representatives to identify trends in complaint themes? Finding a short-term proxy for needed data will provide you with some useful information. The proxy is not a perfect solution, but in the short term it’s better than using no information at all.

5.      Start the process of gaining access to the data that you need. As simple as this sounds, if you’re in a situation where you don’t have access to crucial data, the goal is to exit this reality as soon as possible. Whether this means insourcing or outsourcing to gain access to data you need, there’s simply no business case for continuing to manage without the right information.

The guiding principle of how to manage your data is to identify what data aligns with your goals—if you don’t have access to this data today, the best place to be is somewhere on the track to gaining access to this data. Identifying proxy data is a bridge to dealing with an undesirable situation, and moving towards one that puts you on the right path. But it is important to not accept a lack of data within your company simply because it’s “the way it’s always been done.” If you find yourself clamoring for meaningful metrics, creating a process to get this data involves some work–but there are huge rewards for your business in the end.Y

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BetaXAnalytics is a healthcare data consulting firm that helps payers and providers to maximize their CMS reimbursements and helps employers to reduce their healthcare spending through proven strategies to contain costs. For more insights on using data to drive healthcare, pharmacy and wellbeing decisions, follow BetaXAnalytics on Twitter @betaxanalytics, Facebook @bxanalytics and LinkedIn at BetaXAnalytics.

The Future of Healthcare is 3 Letters: CVS

Healthcare

There’s a lot of speculation surrounding CVS’s acquisition of Aetna that’s planned for 2018. But one thing we know for certain is that CVS’s direction in 2018 will make an enormous imprint on healthcare in the U.S. as we know it. 

On December 3, CVS announced their agreement to acquire Aetna, the nation’s 3rd largest insurer, for $69 billion. To put the sheer magnitude of a deal like this into perspective, this deal would be the largest in the history of health insurance. CVS is currently a Fortune #7 company with an annual revenue of $177.5B; Aetna is #43 on Fortune’s list with an annual revenue of $63B. According to the current Fortune 500 list, the merged CVS/Aetna would have the 2nd highest annual revenue, second only to Wal-Mart. 

CVS has expressed the desire for this acquisition to improve the integration of patient care, and to provide higher quality care at a lower cost in “communities, homes and through the use of digital tools to support health.” CVS’s President and CEO Larry Merlo communicated the desire to put customers “at the center of health care delivery.” The intent would be to leverage CVS’s 9,700+ retail stores and 1,100 Minute Clinics to create community-based centers that include resources for wellness, medical, pharmacy, vision, hearing and nutrition services. And the touted benefit of acquiring Aetna is that integrated care and higher negotiation power for pharmaceutical drugs is the key to lowering costs. 

This deal is projected to happen in the second half of 2018. At this point, it is unknown whether the acquisition will face anti-trust opposition. While vertical mergers (which combine 2 companies which are not direct competitors) don’t traditionally get blamed for stifling competition, CVS’s announcement comes on the heels of the Justice Department’s block of AT&T’s takeover of Time Warner, citing the acquisition would create “too powerful of a content company.” And with 2 recent horizontal healthcare deals halted for antitrust reasons (Aetna/Humana and Anthem/Cigna), CVS’s Aetna deal will need to pass through close scrutiny in Washington before the deal can be finalized.  In October, Trump declared  “My administration will…continue to focus on promoting competition in healthcare markets and limiting excessive consolidation throughout the healthcare system,” though many are betting that this vertical deal will go through with only the requirement of some concessions by CVS and Aetna. 

My predictions for 2018? One of two things will happen.

Possibility #1: Regulators block CVS’s Aetna acquisition

What is to stop regulators from saying that this deal will create “too powerful of a healthcare company?” This is indeed a possibility, albeit one that many think is unlikely. But in this past year alone, the Federal Trade Commission blocked Walgreens’ purchase of Rite Aid, while the Justice Department intervened to prevent Aetna’s acquisition of Humana and the Anthem/Cigna merger. While these were considered horizontal deals among competitors, the Department of Justice blocked these deals because they would drastically restrict competition and “fundamentally reshape the insurance industry.” Would the CVS/Aetna deal not also do the same thing?

If this acquisition is blocked, it signifies that the regulatory tide could be changing with respect to how the largest players in healthcare can evolve. With the “big five” insurers, which cover approximately 90% of all commercially insured Americans, unable to strategically gain market share through jumbo mergers and acquisitions, this opens up the door for new entrants into healthcare markets who are better at solving healthcare’s problems than their behemoth counterparts. It also encourages existing competitors to home-grow solutions in their organizations rather than joining forces with outside partners.

Possibility #2: CVS’s Aetna acquisition moves forward in 2018

Let’s imagine for a moment that the deal does go through as planned.  The likely next step is that Express Scripts, the only other big PBM not owned by an insurer, will merge with a health insurer like Humana, and may even buy its own pharmacy chain such as Walgreens. This trend would change the landscape of healthcare, giving all power to a few vertically integrated giants, and putting any smaller PBMs or insurance companies at a crippling competitive disadvantage.  

CVS’s vision of transforming local retail stores into community health centers where people can not only pick up prescriptions, but also see a doctor, talk to a nutritionist, or receive vision care is a compelling evolution of the way we seek self-care. This type of model could be the answer to the convenience that people want with telemedicine, but it breaks down the barriers to full adoption by putting a community-based centralization on the care they receive.

As we consider these two possibilities, we should ask some big questions. 

  1. Do companies become more innovative when they get bigger?
  2. Do competitive moves like this help to fight the steadily rising costs of healthcare?
  3. Will this improve the quality of care that people receive?

Whether 2018 is the year that the CVS/Aetna merger moves forward, or whether 2018 is the year that the CVS/Aetna deal is blocked, either way will lead to a crossroad that will signify the next evolution for healthcare in America. The promise of the benefits to consumers—transforming retail stores into hubs for health services and potentially better prices as a trickle-down benefit from improved negotiation power with pharmaceutical manufacturers—paint a compelling picture for what the future of American healthcare could be. Only time will tell whether consumers will be the winner in this deal, whether the winner will be the shareholders, or whether we’ll never get to find out.

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BetaXAnalytics is a healthcare data consulting firm that helps payers and providers to maximize their CMS reimbursements and helps employers to reduce their healthcare spending through proven strategies to contain costs. For more insights on using data to drive healthcare, pharmacy and wellbeing decisions, follow BetaXAnalytics on Twitter @betaxanalytics, Facebook @bxanalytics and LinkedIn at BetaXAnalytics.

My Top 4 Strategies for Saving Money on Employer-Sponsored Healthcare

Healthcare

If you think understanding your own hospital bill is confusing, imagine scrutinizing a bill for 18,000 people. How do companies know if they’re being overcharged for healthcare services? Are people receiving care that is actually effective? Why are some medications so expensive? As an employer, this is a challenge that is all too real. 

Many companies want to offer competitive benefits, but the high cost of healthcare adds real challenge (and cost) to this goal. A great quote from Warren Buffett wraps up the employer/healthcare conundrum in a bow:

GM is a health and benefits company with an auto company attached.  -Warren Buffett

Employers who purchase health insurance for their employees are paying one of the most significant portions of our total healthcare “bill” in the U.S.–$640 billion each year to be specific. It’s unfortunate that we’re in this place where the cost of healthcare has risen so sharply over the past decade that healthcare is now often an employer’s 2nd highest expense, right after salaries. Shouldn’t this expense be managed with the same rigor as any other part of the business? 

If you ask a traditional broker how to manage costs as an employer, you may get a list of strategies that don’t actually lower healthcare spending, but rather they change who is paying for it. Here’s an example of exactly what this looks like. The 2016 Society of Human Resource Management (SHRM) Survey  lists the following strategies as the most successful in controlling health care costs:

  • Offering consumer-directed health plans (e.g., health reimbursement arrangements, health savings accounts).
  • Creating an organizational culture that promotes health and wellness.
  • Offering a variety of preferred provider organization (PPO) plans, including those with high and low deductibles and co-pays.
  • Increasing the employee share contributed to the total costs of health care.
  • Offering a health maintenance organization (HMO) health plan.
  • Providing incentives or rewards related to health and wellness.
  • Placing limits on, or increasing cost-sharing for, spousal health care coverage.
  • Increasing the employee share contributed to the cost of brand name prescription drugs. 

These strategies absolutely hit the goal of impacting an employer’s bottom line, but this often happens at the expense of employees. Noticeably missing from these strategies is anything that actually gets at the high source cost of services. But what actually lowers the underlying cost of healthcare?

Instead of these mainstream strategies that are often-cited as the go-to methods for employers to “save money,” here are just some of my top high-value strategies that target cost-management without putting more financial burden on employees:

1.      Explore new funding models. Small and mid-sized employers who are fully-insured pay higher operational costs since the health plan takes on more financial risk. However, hybrid plans of self-insurance provide lower costs while incorporating stop-loss coverage and predictable, level payments so that even small and mid-sized employers can self-insure.

2.      Change the healthcare delivery model. Employers can use high performance networks that have a limited number of quality health care providers. Because the cost of health services can vary wildly between different providers and these price differences are not correlated to the quality of care, using narrow networks helps to ensure that you’re getting the best value for your money—great care at a fair price. The benefit of exploring new healthcare delivery models is lower premiums, lower out of pocket costs, or a combination of both.

3.      Use new payment models. This solution includes care that is pay-for-performance such as partnering with Accountable Care Organizations (ACOs). The advantage of moving away from traditional payment models is that we move away from “fee-for-service” (the doctor gets paid more for seeing you more often) and towards outcomes-based payments (providers get paid for curing you, regardless of how many times they see you). The National Business Group on Health’s 2018 Health Care Strategy and Plan Design Surveyindicated that 21% of employers plan to promote ACOs in 2018 but that number could double by 2020 as another 26% are considering offering them. Other payment models include using “centers of excellence” for high-cost procedures. This enables the employer to ensure that associates are receiving the best care and the best price under payment agreements that are bundled into one comprehensive cost. 

4.      Proactively manage pharmacy costs. Partnering with an organization to keep pharmaceutical drug costs in check can hold a great deal of value for an employer’s bottom line. A big part of the management of pharmaceutical costs involves developing a strategy around specialty medications. This includes looking at specialty drug spending trends among members, how drugs are being used, cost differences in where they’re administered (hospital vs. provider), coordinating benefits between the medical and prescription plans, and implementing step therapy to ensure that options for less-expensive similar medications are used before jumping to the most expensive prescription. In addition, reviewing and revising formularies can make a large impact on costs with very minimal impact on members.

Are you cost-saving, or cost-shuffling?

Just how any other business unit in a company manages to their budget, managing health spending and strategy is a necessary part of ensuring that the high cost of health services are kept in check. This can be done by shuffling who is paying for healthcare, or it can be done by going after the source of what’s driving the costs. If I can share one takeaway here, it’s that employers have options with respect to saving health dollars. In the coming years we will see more and more employers moving away from simple “cost-shuffling” of health dollars and getting strategic about managing healthcare’s underlying high cost.

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BetaXAnalytics partners with employers to use the power of their health data “for good” to improve the cost and quality of their health care. By combining PhD-level expertise with the latest technology, they help employers to become savvy health consumers, to save health dollars and to better target health interventions to keep employees well. For more insights on using data to drive healthcare, pharmacy and wellbeing decisions, follow BetaXAnalytics on Twitter @betaxanalytics, Facebook @bxanalytics and LinkedIn at BetaXAnalytics.

The 3 Top Reasons Why Your Hospital Bill Is So Confusing

Healthcare

It’s no secret that we have a pricing issue in healthcare. The U.S. healthcare spending was $2.7 trillion in 2011 and is expected to reach 20% of our GDP by 2020 if this trend continues. We spend twice as much per capita on healthcare in this country, but ironically our health ranks among the worst in the world. For us, the baffling reality is that the high cost of healthcare in no way means that we are healthy.

When we break down our cost and quality issues in healthcare, we find that the experience for patients trying to navigate the maze of the health system is a micro version of the macro problem. It’s confusing, and it seems that there is no relationship of the cost of services and their quality.

Why? Our best intentions say that the average consumer has the tools they need to gain some visibility into pricing of healthcare services, but unfortunately there are some big obstacles that make this difficult.

1.      Different patients and payers are charged different prices for the same services. Each hospital assigns a price to each service in what’s known as a “chargemaster.” This is a price list for each and every service and supply a hospital provides. The chargemaster is something very few people inside a hospital have visibility into, let alone consumers trying to navigate the health system. Oh, and we should mention that a chargemaster could contain 20,000 services and supplies; scrutinizing price lists is not easy for the average person. Insurance companies negotiate these list rates down for their “in network” providers. These discounts are usually related to how much buying power the payer has, and these discounts tend to be buried in private contracts. A patient who is uninsured or out of-network does not get the same negotiated discount on services that would be afforded to a patient who is insured and in-network. 

2.      Prices for the same services can vary significantly from hospital to hospital. Can you imagine 2 car dealerships each selling a Honda Civic, where the price at one dealership is $18k, yet the price at the other dealership is $100k? Well, this is exactly what happens in healthcare right now. The difference between prices for the same procedure can be upwards of 800%, and the price difference is in no way indicative of a higher-quality surgery. 

Consider a few real examples:

  • report from the Healthcare Financial Management Association cited estimates between $33,000 and $101,000 for a knee replacement when several dozen health providers were asked by the US Government Accountability Office.
  • The cost for a hip replacement can range between $11,100 and $125,798.
  • An appendectomy can cost anywhere between $1,529 and $186,990.
  • A basic health care plan available under the ACA can cover most, but not all health expenses. According to George Washington University, an appendectomy could mean anywhere between $458 and $56,000 in patient out-of-pocket expenses.
  • Cotton swabs or x-rays can be marked up by 400%.

3.      Even if you shop around, you can still get a surprise bill. If you have ever needed a trip to the emergency room, chances are your wallet may have taken a hit. A recent Yale study found that 1 in 4 emergency room visits to an in-network hospital resulted in surprise billing to consumers for an out-of-network doctor. That’s right—your in-network hospital can bill you for out-of-network doctors. This could be for an anesthesiologist, a radiologist, or a doctor who is helping your in-network surgeon, and involvement of any of these individuals on your care team could end up on a surprise bill once you’re discharged.

The reality: price transparency in healthcare is murky at best. The Catalyst for Payment Reform gave 43 states an “F” grade for price transparency in health care. You can see how your state stacks up here: Report Card on State Transparency Laws 

Health Transparency Grade, By State

Source: 2016 Report Card on State Transparency Laws 

How employers can help. Employers are footing $640 billion of the healthcare bill in the U.S.; we have the buying power and leverage to have a say as to where this money is going. The lack of healthcare price transparency makes it a challenge for people trying to navigate the healthcare system, but employers can use strategies to control the source of healthcare costs. Stay tuned for my part II of this post, where we will explore these strategies in detail.

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BetaXAnalytics partners with employers to use the power of their health data “for good” to improve the cost and quality of their health care. By combining PhD-level expertise with the latest technology, they help employers to become savvy health consumers, to save health dollars and to better target health interventions to keep employees well. For more insights on using data to drive healthcare, pharmacy and wellbeing decisions, follow BetaXAnalytics on Twitter @betaxanalytics, Facebook @bxanalytics and LinkedIn at BetaXAnalytics.

Blockchain is Like the Internet of 1992

blockchain

If you’re in the banking or healthcare industry, you’ve likely heard the term “blockchain.” On the surface, this technology behind the exchange of bitcoin may not be taken seriously because some think that bitcoin, now valued at $41 billion, is a passing fad. But as the framework that makes bitcoin exchange possible, blockchain provides an innovative level of security that allows anonymous people who do not know each other to exchange money, without the traditional safety net (or fees) of a bank acting as a middle-man to authenticate funds transfers. And since this solution has opened up so many possibilities within the financial sector, many other industries are preparing for how blockchain can fundamentally change the way we all do business.

Imagine it’s 1992. Think back to what the internet was to you at that time. During this year, the first readily-accessible browser of the “World Wide Web” was launched. At the time, how would you have explained to people what the internet was?

In 1992, the internet was described as “a wide-area hypermedia information retrieval initiative aiming to give universal access to a large universe of documents.”

HUH? Sure, this description is technically true, but in 1992 this didn’t even begin to scratch the surface of how the internet would fundamentally change daily life for us all in 2017. In the ‘90s while we would wait 15 minutes to dial-up to the World Wide Web or wait 10 minutes for a picture to download, it would have been hard to imagine a day when we would do most of our banking, shopping, reading and communicating online.

Today is not so different from 1992, because we still have the same difficulties describing new technology and envisioning how it can change our lives as we know it. In the context of bitcoin exchange, blockchain creates an encrypted peer-to-peer network where every single bitcoin transaction is recorded and validated throughout the entire network. This is different from our traditional model of transferring money from one account to another, where we rely on a bank (a central location) to verify that originating funds are available, to guarantee the safety of the funds while they are in transit, and to ensure that these funds reach the destination account as intended. Today, banks act as intermediaries for financial transactions, which allows us to trust in the safety and security of our money as we transfer funds.

Blockchain is a solution that also allows us to trust in the exchange of money, only the process works differently. The blockchain is referred to as a “ledger,” a series of records of validated monetary transactions, where the identical updated ledger resides throughout the peer network, not in one central location as under the traditional banking model. The system of blockchain is characterized by a few unique attributes that make this solution uniquely secure and positioned to transform many types of traditional business transactions:

  • Distributed: This describes the fact that the ledger exists throughout the blockchain network, and is not maintained in one central location.
  • Smart Contracts: We can think of this as an automated execution of a legal contract that governs the rules of each financial transaction.
  • Consensus: In order for each transaction in blockchain to take place, “consensus” prevents fraudulent transactions by ensuring the validity of each transaction and agreement between parties of the transaction.
  • Immutability: The record of a transaction in blockchain lives forever and it cannot be erased. The benefit of the inability to erase a transaction is that one single asset can be tracked throughout its entire life. In this sense, if a bitcoin were a dollar bill, the blockchain would track where and when the dollar was printed, who the first owner of that dollar was, and it would record every single date and exchange of hands along the blockchain, and none of these transactions could ever be erased.

Today, blockchain is a solution looking for problems to solve. The healthcare industry has high hopes for blockchain technology since interoperability, or the ability to securely share medical records across providers and patients, is the driving force behind many technology investments within healthcare. It’s widely believed that blockchain will be the technology that will form the basis of securely creating and sharing medical records that will solve many of healthcare’s current issues of siloed stores of data that lead to the delays and administrative burden of sharing health information. Designing an overlay of blockchain throughout the healthcare system reimagines a world without duplicate paperwork, inefficient payment systems, and delays in sending health records from provider to hospital, and these improved processes could all take place with a superior level of security.

Just as the internet was to 1992, so is blockchain to 2017.  We’re just getting started, and we can barely describe what is to come. This technology is indeed already transforming some industries, but in relation to identifying new ways it can enhance transaction security, prevent fraud, remove “middle man” fees, automate legal agreements, and increase the speed of information-sharing, we have yet to scratch the surface.

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If you are interested in exploring what blockchain means to the future of healthcare, banking, government and cyber-security, join us on November 29th at Salve Regina University in Newport, Rhode Island for Blockchain, Bitcoin and Crypto-Currencies – Is Your Organization Ready? organized by the Rhode Island Israel Collaborative.

Also for more information on blockchain and bitcoin, we recommend this succinct explainer video: Bitcoin Made Simple

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BetaXAnalytics is a healthcare consulting firm that helps payers and providers to maximize their CMS reimbursements and helps employers to reduce their healthcare spending through proven strategies to contain costs. For more insights on using data to drive healthcare, pharmacy and wellbeing decisions, follow BetaXAnalytics on Twitter @betaxanalytics, Facebook @bxanalytics and LinkedIn at BetaXAnalytics.

If you want to learn more about solving healthcare’s challenges, you may also like:

My Talk for TEDxProvidence

Dear Employer: High Deductible Health Plans Are Making People Sick

2 Reasons Why Your Data Is Lying To You

Dear Employer: High Deductible Health Plans are Making People Sick

Healthcare

We get it. Healthcare is expensive and costs are going up every year.  Medication costs are skyrocketing. For some chronic conditions, a year of treatment with a specialty drug can exceed $100,000. American companies are shouldering the burden of a healthcare system where ½ of what we spend in healthcare is considered “wasteful”. Healthcare is now the 2nd highest business expense for most companies, second only to salaries. And because most employers pay their health claims at dollar 1, regardless of what their business does, by default all companies end up in the business of healthcare. And something’s gotta give.

Why do employers bear the burden of the inefficiency of the US healthcare system? In US healthcare we spend twice as much per capita with health outcomes that rank among the worst in the world. So the growing trend for employers to deal with crippling health care costs is to find others to share in this cost. Why not hold employees more accountable? After all, employees’ personal health choices and behavior make up37% of health costs. Employers tell their employees “let’s solve this together. We will support you.”

So very well-meaning companies offer “high deductible health plans” to employees. On the surface, it’s a win-win. The thought behind these plans is that if employees have to contribute more to their healthcare costs, they will take more responsibility for their health. In theory, employees will take better care of themselves so they can stay healthy. They will avoid unnecessary medical procedures, since they are responsible for paying for costs under their deductible. Employees will start to compare costs of medications and procedures to make sure they’re keeping their health expenses as low as possible. And so with average out-of-pocket costs for individual employees at $5,248, the rationale is that overall health costs for both the employer and the employee will go down since employees start to understand the value of their health, and they become smarter consumers of health care.

From an employer perspective, this sounds like a brilliant plan to control costs. But does this idea to transform Americans into savvy health consumers actually happen once a company starts expecting employees to pay a higher share of health costs?

Nope. 

As we track the results, there is evidence that raising employees’ out-of-pocket costs for healthcare does NOT increase consumerism, and it also has led to people not taking necessary medications and delaying care for chronic conditions, which leads to more serious health events (and costs) later on down the road.

Employers save money in the short term…but at what cost?

Researchers from UC Berkeley and Harvard studied the results of a large employer’s choice to offer a high deductible plan over 2 years. But instead of finding evidence to support the theory that high-deductible plans make people take more charge of their health spending, they found some surprising trends. Yes, employees spent 12% less on their healthcare, so in the short term these plans achieved their goal of lowering health costs. But these “savings” were from avoiding care of EVERY type. There was no evidence to show that employees were comparing costs or cutting unnecessary services once they had a high healthcare deductible. They went to the same doctors. And they cut low-value health services at the same rate as they were cutting important medical services, causing the employer to question whether members were making the right choices for their long term health.

Yes, But What if Preventative Services are Free?

The common response from employers with high deductible plans is to make sure necessary and preventative health services come at little to no cost to employees. But a recent study from California found that despite these efforts, 1 in 5 people still avoided preventative care citing cost as the reason. In fact, most high deductible health plan members surveyed did not know that their preventative screenings and important care was available with little or no out-of-pocket payments.  Additional studies show that high deductible health plans have the most adverse impact on those with chronic conditions, people with mental health disorders, and low-income individuals and families.  The danger of high deductible health plans is that their members with the highest health risks have shown that they avoid necessary care and medications. And this trend is one of many symptoms of the crippling cost of healthcare in America. 

Employers: we know you did not ask for the job of footing $640 billion of our healthcare bill in the U.S. It’s ridiculous, we know. But we just want to make sure you know high deductible health plans are a band-aid—not a solution. 

Signed, Hardworking Americans

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If you’re an employer who feels there’s got to be a better way to control health care costs, you’re on to something. And we can help. BetaXAnalytics partners with employers to use the power of their health data “for good” to improve the cost and quality of their health care. By combining PhD-level expertise with the latest technology, they help employers to become savvy health consumers, to save health dollars and to better target health interventions to keep employees well. For more insights on using data to drive healthcare, pharmacy and wellbeing decisions, follow BetaXAnalytics on Twitter @betaxanalytics, Facebook @bxanalytics and LinkedIn at BetaXAnalytics.

@SRShallcross on Twitter

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