Tuesday, May 28, 2013

Transforming Big Data into Valuable Solutions

By Kameron Gifford, CPC 

Data provides us with the information to answer empirical questions. Every fifth grader in America is familiar with the Scientific Method and its ability to prove or disapprove a hypothesis. But what about Big Data? How do we modify our approach to find tangible value for our consumers?

Ask the Right Questions

Big Data is messy and not precise. Two plus two equals three point nine, and that’s okay. When we have twenty data points in a system, accuracy is essential; but with twenty million sensors, accuracy is not so important.  

We know that predictions based on correlations lie at the heart of Big Data, but to unlock all of its potential we must adjust our expectations.

The entire conversation of Big Data in the healthcare industry must change. Instead of asking “Why” we must first ask “What”.

The “Big Data” Mindset

You can lead a horse to water, but you can’t make him drink. Once we begin to ask the right questions, we must open our minds up to “see” the solutions. This shift towards a “Big Data” mindset will enable us to see things differently and allow us to act on opportunities before others do.

Creating Solutions from Correlations

To extract value from data we must first be able to see the possible. This unique sight is what empowers innovators to create disruptive solutions.

The Medical Star Washington Hospital Center in Washington, D.C. and Microsoft Research recently teamed up in an effort to reduce hospital re-admissions. They wanted to identify “What” correlations existed between patients that were re-admitted to the hospital within 30 days.

With the help of Microsoft’s Amalga software they uncovered all the usual “predictors” but also found something else. One of the top predictors of re-admission within 30 days was highly correlated with mental status upon admission. If a patient’s H&P included a negative mental status with words such as “depression” the patient was more likely to return to the hospital.

With this knowledge the hospital can now create new initiatives to prevent re-admissions; thus adding value to both the consumer and the hospital.

 In Denmark, a study combined 3 million cellphone records with the National Cancer Registry to see if they could find a link between cell phones and cancer. Their study didn’t show any correlation, but the idea of combining multiple data sets to predict points of intervention allow us to view the world around us in a much different way.

The solution to our healthcare crisis is far from simple, but I believe the answer lies somewhere in the masses of data we have captured.

What is your data telling you? Are you acting on the opportunity? If not, why?

One Strategy for Health-Law Costs: Self Insure

UnitedHealth and Humana Will Offer Smaller Businesses Options Typically Left to Big Corporations

As businesses cast about for ways to minimize new costs related to the federal health law, health insurers are stepping up. Among their latest offerings: allowing ever-smaller companies to switch to a riskier form of coverage traditionally favored by big employers.
[image]The Wall Street Journal
UnitedHealth Group Inc. UNH -0.48% andHumana Inc. HUM -1.14% will begin offering smaller employers—including firms with as few as 10 members in UnitedHealth's case—the option of so-called self-insurance in some markets later this year. Self-insured businesses pay their workers' medical costs directly, instead of joining a traditional managed-care plan. Usually, they hire benefits firms or insurance companies just to administer their plans.
Most big companies choose the approach, because it gives them more control over benefits and can lower costs.
For small businesses, being self-insured would let them avoid new requirements under the law that call for traditional small group plans to include richer benefits, such as mental-health and maternity care. Self-insured companies can also avoid changes to pricing rules that could increase costs for groups of healthy workers.
It comes with risks: A car accident or cancer case can leave small businesses on the hook for big medical bills. That is why most large insurers have generally offered such services to companies that have 100 or more workers and can spread the costs around.
Now, the health law is changing the risk-benefit calculation for smaller businesses such as Buckno Lisicky & Co., an 85-person accounting firm in Allentown, Pa. The company switched from a traditional health plan to a self-insured plan run by benefits-manager WellNet Inc. this year, in part because of the law's small-business rules, said Jack Lisicky, a founder.
"The big guys have a lot more flexibility and that's what we're trying to get," Mr. Lisicky said.
The approach is part of a growing playbook of strategies to minimize the effects—and potential costs—of the health law. Insurers are also letting small companies renew their yearlong health-benefit plans early, before the end of 2013. That would delay the impact of health-law provisions that broadly kick in on Jan. 1, but would only affect plans once they renew after that date.
Some regulators worry the tactics, if they catch on widely, could undermine the exchanges—online insurance marketplaces for small businesses and individuals that are a centerpiece of the law. Starting next year, the law will block insurers from setting rates for businesses with fewer than 50 or 100 workers, depending on the state, based on how healthy they are. The exchanges are supposed to help spread around the risk, and cost, of coverage.
But strategies like self-insurance would tend to most benefit employers with younger, healthier workers who have lower costs, such as Serenic Corp., SER.V -16.36% an Alberta, Canada-based maker of nonprofit accounting software. The firm will move its 40 U.S.-based workers to a self-insured plan in June, in part to avoid the health law's risk-spreading provisions that could raise its costs, said CEO Randy Keith.
"It was a good option because we do have a relatively healthy company," Mr. Keith said. Under an existing UnitedHealth plan, the company would have seen a 30% premium increase next year. Serenic's Denver-based broker, Roper Insurance & Financial Services, said UnitedHealth has been closely tracking the business it has lost to self-insured arrangements.
If more healthy companies like Serenic effectively opt out of the exchanges, that leaves their less-healthy counterparts on the exchanges. And that could push up premiums in the marketplaces, regulators say.
"You could have a result where the rest of the market…is left with employees that are older and sicker, and as a consequence, rates would go up," said Dave Jones, California's insurance commissioner.
Officials in several states are seeking to stem the strategy by limiting so-called stop-loss insurance, which covers unexpected, large health-care bills for self-insured companies. Lawmakers in California and Rhode Island are considering bills that would impose new rules on such coverage when offered to small employers, who otherwise would find self-insurance too risky. Some states, including New York, bar stop-loss insurers from covering small groups.
Still, self-insurance by small companies "is growing because of its ability to circumvent some of the" federal health law's provisions, said Tanji Northrup, assistant insurance commissioner in the Utah Insurance Department.
Federal health officials said they haven't seen evidence that these strategies are gaining momentum among small employers. "We think it would be unlikely that there'd be a significant change in the volume of" self-insurance for small firms, said one official with the Department of Health and Human Services.
Regulators "remain very confident that the implementation of the new reforms will create a competitive marketplace that offers choices to [small] groups and individuals that they didn't have before," the official said.
Only about 15% of firms with fewer than 200 workers were self-insured in 2012, compared with 81% of larger firms, according to a Kaiser Family Foundation survey.
But, insurers appear to anticipate that at least some small groups—particularly healthy ones—will want to give the self-insured tactic a test drive, brokers and analysts said.
UnitedHealth, the nation's largest insurer, is lowering the threshold for administering self-funded plans to as few as 10 workers, from 100, in at least some markets, according to emails from UnitedHealth sales executives to an insurance broker.
Humana also plans to offer self-insurance to companies enrolling as few as 26 workers in some markets where it previously restricted such services to larger companies, according to an email from a Humana sales executive to a broker.
The insurers said they were being responsive to their customers. UnitedHealth said it "has always provided our customers with the flexibility to manage the value and affordability of their health plans."
Humana said it is aiming to provide "coverage that is affordable and of high quality" and meets regulatory requirements, and it is "exploring a variety of coverage arrangements in the commercial market for individuals, small employers and large employers."
Cigna Corp. CI -1.02% said it has offered self-funding options to businesses with as few as 25 employees in 26 states and the District of Columbia. "Employers want choices," the company said.
Software Advice Inc., a consulting firm for software buyers that has many male employees in their 20s, is likely to move to self-insurance when the law's effects kick in for employers of its size, currently 60 workers. The company's broker has warned the law could mean a rate hike of 30% to 40%, and "that's not something I want to pay," said Don Fornes, chief executive of Software Advice, based in Austin, Texas. He said his firm is financially solid enough to bear the risk of self-insurance.
—Sarah E. Needleman contributed to this article.
Write to Christopher Weaver at christopher.weaver@wsj.com and Anna Wilde Mathews at anna.mathews@wsj.com

Multimillion-dollar verdict for doctor hailed as victory against insurer tactic

 The California case is one of several recent lawsuits against health plans in which doctors allege poor business practices.

By Alicia Gallegos amednews staff — Posted May 27, 2013

California family physician Jeffrey B. Nordella, MD, said he hopes a jury award against insurer Anthem Blue Cross will encourage more physicians to fight unfair network denials and terminations.
In April, jurors awarded Dr. Nordella $3.8 million in compensatory damages after Anthem shut him out of its network. Dr. Nordella claimed that the insurer was retaliating against him because of his advocacy for patients who were denied Anthem coverage.
“I’m hoping that people will use [my case] as a call to action for other physicians that this has occurred to,” said Dr. Nordella, who practices family and emergency medicine in Northridge, Calif. When insurers “have so much power and authority, they disrupt the patient-physician relationship for financial gain. As in this case, they restricted their provider network for their own personal financial gain, which affects patient’s access, to health care by limiting its network. It’s wrong. The insurance company should not be in the middle of the relationship.”
Dr. Nordella sued Anthem in 2010 after his application to rejoin the network was rejected. He was terminated from the network in 2003. Anthem claimed that Dr. Nordella did not meet the criteria of its credentialing policy because he was not board certified at the time of his application. In addition, the insurer said there were more than 100 family physicians in a 10-mile radius of his practice.
But Dr. Nordella argued that Anthem was misstating its policy. At the time, the insurer had allowed doctors into its network if they were previously board certified and had practiced consecutively in that specialty for the last 10 years, he said. He claimed that Anthem was targeting him because he had repeatedly challenged its interpretation of “medically necessary” treatment and fought for patients who were denied payments.
At trial, attorneys for Dr. Nordella said Anthem violated a California law that requires insurers to have good cause for rejecting network inclusion. During testimony, Anthem could name only a small number of family physicians in the area, according to Dr. Nordella and attorneys familiar with the case.
Jurors ruled in Dr. Nordella’s favor, finding that Anthem had breached his right to a fair application procedure. After the $3.8 million verdict, Anthem and Dr. Nordella reached a settlement regarding punitive damages. Neither Dr. Nordella nor Anthem would discuss terms of the settlement.
In a statement, Anthem said it was disappointed with the verdict and is examining a possible appeal.
“In order to provide high level care for our members, Anthem generally requires board certification for all providers in our network,” said Anthem Blue Cross spokesman Darrel Ng. “Because Dr. Nordella did not have board certification in family medicine, the medical specialty for which he applied to be listed in the network directory, and Anthem had a sufficient number of general practitioners, he was not accepted into our network.”
The verdict is a significant victory for physicians nationwide who experience unfair treatment by insurers, said Rocky Delgadillo, CEO of the Los Angeles County Medical Assn. The Los Angeles County Medical Assn. supported Dr. Nordella and his position, Delgadillo said.
“Doctors at their core are patient advocates, and I think this case is about advocating for your patients even when that might put your career and your livelihood in peril,” he said. “Dr. Nordella’s actions in bringing this case and following it through to the end is an inspiration to other doctors throughout the state and the country to be fierce advocates for their patients, not just in the way they treat them with science, but in the way those patients are treated in the world of public policy.”

Moves by health plan questioned

Dr. Nordella’s case is one of many recent challenges filed by physicians against insurance companies.
In July 2012, the California Medical Assn. and more than 50 physicians sued Aetna for allegedly underpaying out-of-network physicians. CMA said the insurer is refusing to authorize some out-of-network services and illegally terminating the contracts of doctors who make such referrals. Also in 2012, the LA County Medical Assn. sued Health Net, claiming that the plan routinely denies payment for lifesaving health care services.
Several suits filed by insurers against doctors are ongoing, including four legal challenges by Aetna related to overbilling claims. The suits, filed in courts in California, New Jersey, New York and Texas, accuse doctors of drastically overbilling for out-of-network services.
In general, insurance companies are not often held accountable for unfairly denying or terminating physicians from their networks, said Andrew H. Selesnick, a partner at Los Angeles-based Michelman & Robinson LLP and chair of the firm’s health care law department. Frequently, insurers will use their power to “get rid” of physicians who appeal payment decisions or complain about the insurer’s practices, he said.
“For physicians, [Dr. Nordella’s case] is a terrific result, because these cases so rarely go to trial, and this case was a pretty substantial verdict,” he said. “It sends the message to health plans that you can’t retaliate against doctors and you can’t try to trim your rolls for your own economic benefit. You really need to have an excellent reason to exclude a physician from your network.”

'Your Care Matters' - NHS Brings Patient Feedback into the Spotlight

'Your Care Matters' - NHS Brings Patient Feedback into the Spotlight | SYS-CON MEDIA
BIRMINGHAM, EnglandMay 28, 2013 /PRNewswire/ --
A hospital Trust in the South East of England has introduced a new patient experience management programme that is set to take patient feedback to a new level.
Surrey and Sussex Healthcare NHS Trust (SASH) is pioneering a new approach to improving patient care in the NHS by implementing its 'Your Care Matters' programme in East Surrey Hospital in Redhill in partnership with customer experience management specialist Empathica. The programme collects feedback from patients and offers continuous performance feedback to its ward managers, enabling them to implement improvements that make a difference to the service they provide.
New Government regulations mean that from April 2013 all acute NHS Trusts are required to ask both inpatients and Emergency Department patients one standard question known as the Friends and Family Test. The test asks: "How likely are you to recommend our ward/Emergency Department to friends and family if they needed similar care or treatment?" It aims to encourage patient feedback, prove to patients that their views and experiences matter to the NHS and improve patient care.
SASH has worked with Empathica to build on this requirement for patient feedback by following up this one question with a number of key questions which will allow them to drill down to the finer points of the patient experience. The Trust's management team can use the insights from the patient feedback to take action to improve patients' experiences whilst they are in the hospital's care.
Following a three month pilot that ran across 24 inpatient wards at East Surrey Hospital, the Trust also implemented 'Your Care Matters' in its Emergency Department. The programme is now being rolled out to outpatients, day surgery units, endoscopy and chemotherapy services - areas not yet mandated by the Department of Health.
The new programme also aims to motivate and empower staff, by allowing patients to identify where they have received exceptional care. Using Empathica's WOW system, patient feedback is flagged up to the relevant manager, allowing them to commend specific employees for their commitment to outstanding patient care.  The opportunity to receive positive feedback, known as SenSASHional Patient Care Commendations, is extremely popular with staff. With over 500 commendations received from patients so far, it has been instrumental in ensuring everyone supports the programme and actively encourages patients to participate.
CEO of Surrey and Sussex Healthcare NHS Trust, Michael Wilson, commented: "In these days when healthcare experiences are more under the spotlight than ever before, we are leading the way when it comes to actively seeking feedback from our patients. We want our patients to know that we listen to their feedback and action operational changes so that next time we exceed their expectations.
"The thinking behind the new programme came from wanting our patients to feel that East Surrey Hospital is at the heart of their community and that we welcome their ideas to help us improve. We wanted to move past static measures of performance to a more 'caring' solution that gauges our patients' experience and most importantly, enables us to take actions based upon their views."
Gary Topiol, EMEA managing director for Empathica, said: "We're delighted to have the opportunity to bring best practices in customer service from the private sector to the public sector. It's inspiring to see a healthcare organisation taking such a forward thinking approach to service and putting patients at the heart of the care system. The programme we have developed with Surrey and Sussex NHS Trust has the potential to assist employees to improve the standard of healthcare and we hope organisations across the UK will follow their example."
Notes to editors
Surrey and Sussex Healthcare NHS Trust runs East Surrey Hospital in Redhilland provides a range of services at hospitals in CrawleyHorsham, Dorking, Caterham and the Oxted Health Centre. It has growing catchment population of 535,000 residents in east Surrey and northeast West Sussex and is the designated hospital for Gatwick Airport and the M25. The Trust employs about 3,500 staff and has an annual budget of circa £220m delivering vital NHS services. For more information see http://www.surreyandsussex.nhs.uk
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