As the team here in Nashville continues to refine the upcoming release (February 2008) requirements of our enhanced platform, which henceforth shall be referred to as “Project Thunderbolt aka PT” in this post — I took some time to get caught up on the plethora of health2.0 and web2.0 and other feeds clogging my Google Reader pipes (bursting at 188 feeds and 500+ unread articles…sigh, i’m very behind).  Below is a picture of the PT purpose/focus of our new platform name… which the specs were already finalized several weeks ago and coding has already begun:

Ironically, the team (who did not go to the SF conference) came up with the 7 core items independently with little guidance from Rob and me (honestly).

So as i came across the post from Matthew Holt and Marty Tennanbaum… well, read both quoted items and it will help to lay the groundwork of where the MedBillManager a la Project Thunderbolt team is evolving. Maybe not literally, but i suspect that when we unveil our platform in February that Marty will be calling to tell the team (not me) that we’ve “done good!”

Marty Tenenbaum’s vision of accelerated eHealth (as espoused at the San Francisco Health2.0 Conference):

This organization would do for ehealth what CommerceNet did for ecommerce by catalyzing the market. The Blog posting focused on standards. While standards are important, so is evangelism, business development, lobbying, and especially visionary integration projects that demonstrate the potential of Health 2.0 for improving people’s lives.

and per Matthew Holt’s Health 2.0 Blog…

Early CommerceNet members included startups like Netscape, Yahoo, and Amazon as well as established organizations like Visa/Mastercard, FedEx and IBM. The members of CommerceNet collaborated on initiatives like search, catalogs, security, payment, and shipping/fulfillment, leading to complete end-end transactions where one could actually locate a product, buy it, pay for it and get it delivered. Not only was overall market growth accelerated; many business deals resulted, generating a lot of wealth.

The parallels with Health 2.0 are obvious. Like the days of ecommerce, many energetic entrepreneurs are exploring the seemingly limitless opportunities and obstacles of a huge and important market. Each provides useful but highly fragmented data or services (e.g.,PHRs, search, patient and doctor communities). Aggregating data across communities and integrating services into complete solutions (e.g., selecting the best treatment or physician for you) is much more valuable to consumers and essential if we’re actually going to impact healthcare in meaningful ways.

Comments

I certainly think it’s a good idea. The vast majority of medical inflation starts with medical equipment manufacturers and pharmaceutical companies, passed on through docs to patients to diagnose and care for chronic conditions caught too late by overworked, underpaid (and often the least skilled since they are the lowest paid) docs. This is counter-intuitive… the best docs should be in primary care, and the most time should be spent there. …Comment by Ready for change

Comments by “Ready for Change” are proof positive of why we are in this medical/health mess–ignorance and wrong-thinking…Moreover, primary care docs are not the least skilled. By the very nature of their occupation, they need to be a “jack of all trades” when it comes to their knowledge and practice of medicine. Because they are on the “front lines” of medicine they need to know a lot about everything as opposed to a specialist which knows a bit more about a few things…Comment by Rick De La Pena

As an emergency department doc, I can state this with certainty: different PCPs have different capacity to keep their patients out of the ED. The patients of some primaries only come when they are in seriously decompensating. The patients of other primaries are in the ED all the time for trivial issues…Comment by jz-md

JZ has it right — Blanket statements about primary care being “better” are off-base a fair amount of the time. As a specialist, many of my referring primary care docs are excellent — and some are marginal. After you see patients who have been watched with rising PSA for several years, then finally sent to the urologist with late-stage, incurable prostate cancer (as I have quite a few times, unfortunately), you realize that “primary care” and “preventive medicine” are just comfortable phrases which do not guarantee better care. Of course, the late-referring doctors were practicing “cost-effective” care by keeping their patients away from “expensive” specialists, keeping the third-party payors happy, and would have scored well therefore under most current “pay-for-performance” measures…Comment by Dr Bob

the state of primary care is disastrous. with rising costs and malpractice premiums and no increase of fees for service there will not be a primary care physician left who will accept insurance fees and medicare.if you want to see a barefoot practitioner in the future keep the system as is…Comment by rr md

Health Blog : Payers Propose to Boost Primary Care.

Whew! The article announcing the NCQA initiative focused on Primary Care-focused services as a preventive cost measure sure generated some interesting comments.

Tags: wsj, primary+care

For some reason no one seems to be distinguishing between these two very different ideas in health care: ACCESS and CHOICE. All of this talk about socialized medicine creating less choice within our system and long waiting periods for care makes my head hurt. I can’t help but wonder why so many people are focused on choice in health care. Are they simply confused, or do they legitimately have their priorities mixed up?

Here’s a little story. I was speaking to an individual the other day about our current health care system. What was important to this person was that they never had anyone telling them what doctor to see or what services would be covered. So they made the choice to pay a ridiculous premium every month to ensure that their health care “choices” were never restricted.

I know this is an atypical situation. Most individuals at least have to choose an in-network provider for their primary care. But even then, everyone wants the ability to choose that physician.

Another example – benefits enrollment “season”. An employer that offers its employees health care generally gives them options, in terms of which health insurance plan they would like. Sure some plans come with shiny incentives and rewards for healthy behavior, but the choice is always there for the employee to make at their own discretion, regardless of which plans are being more readily promoted.

On October 17th Vidhya Alakeson (in Health Affairs Blog) started my mind on this subject in her article titled US Health Care: International Scholars Experience Our System – What They Would Change. She said:

The design of the policy prioritizes the act of choosing rather than the outcome of the choice. Not enough consideration is given to whether the time and effort required to make a choice are justified by the value created by the choice itself, or whether it is possible to make an informed decision. In our experience, this was the difference between choice for choice’s sake and choice that led to a greater sense of control.

I could not agree more. Especially with healthcare, having a choice in no way implies that you will have control over the situation or outcomes that head your way.

Truthfully, you can never really predict how much healthcare coverage you will need in a year. You can never really predict, even with adequate research, which physician will be the best match for you (that friendly physician with the nice new office may not provide his/her patients with the best care). You can probably never really know whether the health plan you chose will fit your health care needs over the upcoming year.

So here’s my question. What’s really important at the end of the day, that you got to choose your provider or insurance plan, or that you had access to care when you needed it?

I would imagine the latter would be more popular… but then again I’m writing this for a reason.

For what its worth, here’s my opinion:

So many people are scared of universal healthcare or socialized medicine. This is not where our solutions lie… focus your energy elsewhere. I challenge those people to stop criticizing and start suggesting solutions. I challenge those individuals to be smarter healthcare consumers and stop running to the doctor every time they have the sniffles.

I will admit that access is an uphill battle. Once you extend healthcare to those millions of children and older Americans lacking coverage, you still face quality issues, treatment compliance, prescription costs… the list goes on.

However, I still advocate access over choice as deserving more attention.

I know I am guilty of being part of the problem. I paid the $20 co-pay every time I saw the doctor for the sniffles. Never once did I consider how much my office visit really cost or who was footing the other portion of my bill.

Now I am proud to say that I am making an effort to be part of the solution (rather than the problem). I am officially on my way to being an educated and thoughtful healthcare consumer. You all should join me, the air is pretty clear over here.

At the end of the day what’s really important is that I have quality medical care available to me when I need it. At the end of the day what should be a priority for Americans is finding a way to provide quality medical care to all its citizens. Stop being so gluttonous. Take a step back from the medical buffet. Remember that over-consuming is never a good idea.

My advice is to share the wealth… medical care that is. The more you focus on being a better healthcare consumer, the more room you leave at the buffet for those individuals who are truly starving.

For some reason I believe there is plenty of food for everyone. All we have to do is learn to stop going back for seconds… thirds…

No one ever said change was easy.

Had the pleasure of being at the recent Health 2.0 Conference in San Francisco hosted by Matthew Holt with a big assist from Indu Subaiya, John Pluenneke and Sara Sara Walker. GREAT JOB! They really pulled off an incredible conference. My only complaint is that we needed at least one more day – oh, and we should be on the panel next time. But seriously, I think Health 2.0 went in as a movement and just may have come out of it as an industry.

During the course of the event, we got to meet quite a few people – people like us – genuinely interested in seeing our healthcare system improved. That’s a broad statement, and virtually everyone there had their own variation on the theme. One of those I found myself aligned with is that of Fard Johnmar. He triangulates in on his interests by focusing on three points: health literacy, technology, and caring for caregivers. We at change:healthcare find ourselves at the center of that very same triangle.

Another person we particularly enjoyed was Bob Coffield. Yes, he’s an attorney, but man we enjoyed hanging out with him – even though he kept us out until 2AM CST (3AM his time in all fairness). We shared alot of similar interests and no doubt will be looking for ways to work together in the future. Bob does a far better job than I can providing an overview of the H2.0 conference.

Some of the companies represented there were fantastic. PatientsLikeMe was one of the jewels of the show.

Steve Krein or Organized Wisdom was an immense pleasure. He unveiled a significant shift in their approach that was not only unique but aggressive. Krein was very “naughty” as Matthew Holt pointed out for all 550 of us in the room, but having gotten to know Steven a bit more, I think that’s just how he prefers it.

Marty Tenenbaum called for collaboration between those represented there and offered up his Commerce.net venue as a means for facilitating that opportunity. We’re already going down that path to working with some of the folks we’ve met there. Some of those I’ve listed here as well as some others who really impressed us and we’ll mention in future posts. Look for more as we move forward.

As Christopher mentioned, we’ve closed our Series A round this past week.

Never ones to slow down, we’re in San Francisco this week for the upcoming Health 2.0 conference hosted by Matthew Holt. But before we could leave, we had to squeeze in a meeting Monday AM before our flight with some new friends – a major healthcare company with multiple presences across the US.

We came early to SF catch up with a whole host of folks out here on the west coast – people like us who are interested in changing the healthcare industry for the better of the consumer. We’re finally getting to sit down with people face to face, people we’ve only been talking and e-mail with until now. It’s been great already, and the conference isn’t until Thursday!

And we’ve got great things going on while we’re away, too. Way to go Katrina, Matt, Matt, Mark, Prakash, and Jakob!

There are a lot of great people working healthcare from the technology side out here. Nashville (where we are headquartered) is the bricks and mortar of the insustry are. Clinic management companies literally spring up overnight. They are the children, grandchildren and more of HCA and its many spinoffs. Someone has to bring the technology and tangible together to make a change.

Scott Shreeve has been a great sounding board for us as we’ve rolled out MedBillManager, and we’re finally going to get to meet him in person.

We’re also going to catch up with some other people like Ben Heywood and Jeff Cole from PatientsLikeMe (a great site that focuses on helping people living with ALS, PD and MS). Since we have a partnership with MS, we obviously have some common interests.

On top of that Unity Stoakes at Organized Wisdom tells us they have big things brewing over there.

There’s more. So much more. But so little time. Off to another meeting.

OK call me naive. I thought my healthcare provider was working for me. In all fairness, it usually does, but this past incident reminds me that they do not always.

I recently had a provider’s office call me back for a follow up – some photos. Pretty simple really – they had already done it once. Problem is, the insuror said the pictures were not sufficient to determine if they would approve the procedure. So the nurse called and asked me to come back. I asked who would pay for that. The other end of the line went quiet for a moment, the nurse clearly taken off guard by the question, but she quickly understood that it was a customer service issue and said that if the pictures weren’t good enough that they would not charge me to retake them. Satisfied, I went in.

At the front desk, the woman asked for the co-pay. I explained the situation and what the nurse had told me. I had distracted the lemming from its path and now it was left to wander, “I don’t know how to do that.” She looked around as if something on her desk might explain. She made to get up and go ask, then sat down. She looked around the desk again (what the hell was she looking for?). And then she had a spark of an idea. “I know what I’ll do. I’ll make it a follow up visit with no charge.” Worked for me.

Got the photos. Went home.

Then the bill for my co-pay arrived. And an EOB arrived. They charged my insurance $33 and wanted the $20 co-pay from me. I called the provider’s business office (part of a large medical center). They put it in for review.

I got another statement. They wanted $20.

I called my insuror. I explained to the lady on the other end of the line what had happened and that either my provider was a poor photographer or my insuror was unnessecarily driving up my expenses on the matter by asking for uneccesary procedures.

Here was the basic response.

Our contract with the provider is that they bill us, and we pay them. That agreement you made was a private side agreement. We have no control over that. They bill us, and we pay them.

So I asked, “Basically what you’re telling me is that I might get my co-pay back, but you’ve sent them the $33 and they are going to keep it?”

“Yes, sir. They bill us, and we pay them.”

I think I went over her head in my understanding of things with the next part. “So you’ve paid out $33 that was not supposed to be paid out, and I’m going to be underwritten with that as an expense when it comes time to renew and establish my rate for next year?”

“Um. That’s our agreement with them.”

It’s not the amount. It’s the principle of the thing. I got them to write off the co-pay. They kept my $33 paid by my insuror.

They bill us, and we pay them.

Thanks.

How unclear can things possibly get?? Every direction I turn there is a different discussion, different concern, a new point of interest, new topics, new programs, new ideas, new technology, different ways to use your personal health record, different insurance plans, different reimbursement rates… you get the picture. Trying to understand healthcare is exhausting.

So here is my attempt to clear (only a small portion) of this murky mess called “healthcare” and bring a couple things I feel are important to the forefront.

Bottom line: For the 6th year in a row the number of uninsured individuals has increased. We have yet to find a way to decrease this number… not at all… not one bit. Personally, I’m not looking for a solution that wipes this 40 some million uninsured off the map. I’m more interested in making 2007 (or 2008 if need be) the first year that this number decreases.

SCHIP: Unfortunately this program to increase the number of children with health insurance has turned into political party line propaganda. Nina Owcharenko from Health Affairs Blog summarizes the debate quite nicely in SCHIP: It’s Not Just About the Children, “One side in the debate is using SCHIP (State Children’s Health Insurance Program) reauthorization to incrementally expand the role of government in the health care system. The other is trying to minimize the role of government and argues for a more market-based solution to the troubles in the health care system.” I have already given my opinion on SCHIP in another blog Learning to Value America’s Youth if interested.

Democrat or Republican?: Each party’s views can be summed up quite easily (all in my words).
Democrat Party says, “The healthcare crisis is real and needs a real solution. The only way this will happen is if the government gets involved and provides logical answers.”
Katrina says, “Umm ok like what? Universal Healthcare? HA!”

Republican Party says, “The government needs to continue to support programs like Medicare, keeping its role minimal and support private sector, economy fueling solutions.”
Katrina says, “HA! Because that has done Americans so much good in the past (note that I mentioned above that we are on year 6 of the number of uninsured Americans increasing).”

Consumer Driven Health Plans: Due to the increasing cost of healthcare many employers have been forced to minimize coverage for employees or offer more affordable alternatives. Enter the Consumer Driven Health Plan (CDHP), a high deductible (over $500) plan that emphasizes consumer engagement. These plans may or may not be accompanied by an HSA or HRA.

At first glance this alternative seems like a great idea. They save the employer money and have potential to save the employee money as well. However, many companies are forgetting that without the right tools and education a CDHP is like giving a 5-year-old keys to a car and seeing if they crash.

Beside my bad analogy, I think with preparatory education on the CDHP options and the healthcare marketplace – along with the proper tools to help employees gauge healthcare costs and quality – that CDHPs are a great solution, or at least a step in the right direction.
Lastly, I would like to applaud Presidential hopeful Mr. John Edwards for accidentally pointing out good things about his democratic competitor Ms. Hillary Rodham Clinton. He was quoted in Clinton Edwards Tussle Over Lobbyists (AP Monday) “I think the lesson from that [her previous attempt at healthcare reform], my lesson, is not the same as hers,” Edwards said. “Her lesson is give them a seat the table. I think if you give the drug companies, insurance companies and their lobbyists a seat at the table, they’ll eat all the food.” Unfortunately (for him) he continued to say, “There’s a fundamental difference between Senator Clinton and myself about how we bring about the change we need,” Edwards said. “We have to take their power away from them. I don’t believe we can compromise with them.”

I do not know who I will vote for for president in ‘08, but I do know that cooperation and compromise are fundamental abilities of a good leader. So why does this quote from Edwards bring about my applause??

I am praising Clinton for recognizing one fundamental element of America’s healthcare system, that the insurance companies and drug companies have a lot of control. I must disagree with Edwards, if any change is going to be made compromise just must come first. Good luck getting yourself out of a hole with a little help from the men holding the rope and shovel!

I was having a peaceful Tuesday afternoon, happy that it was finally under 100 degrees for the first time in weeks, when my boss sent me and email titled “Fwd: Google Alert – “medical bills”. Well of course I opened it (it’s from my boss), but I had no clue what I was about to read.

The email says: Google News Alert for “medical bill”

And the top headline reads:

“Drowning in medical bills, man kisses ailing wife before throwing …
Ottawa Citizen - Ontario, Canada
Her medical bills ranged from $700 to $800 US a week, and she has no health insurance, according to court records. In April, her husband petitioned the…”

I suggest only daring individuals check this one out. (Now do not be fool by the Ontario Canada publication, the incident took place in Kansas City, Missouri.) Talk about snapping out of the joy of a beautiful day. The man literally did not want to face his wife’s medical bill any longer, so he threw her to her death off their balcony.

If you are interested in the other wonderful headlines Google News Alert had to offer for “medical bills” here you go:

Identity thieves go medical
TheNewsTribune.com (subscription) – Tacoma,WA,USA
Study your medical bills and health insurer’s explanation of benefits. *Report suspicious transactions to your health insurer’s special investigations…

Medical Insurance Refuses To Pay Maternity Bills
KUTV – Salt Lake City,UT,USA
Allstate is now paying for all the covered medical bills for the pregnancy and birth. That is exactly why Brett and Ashlee purchased medical insurance in …

San Diego Hospitals Sue County Over Prisoners’ Medical Bills
KPBS – San Diego,CA,USA
The dispute centers on medical bills run up last year by prisoners of the sheriff’s department. The hospitals say the sheriff’s department has to pay the …

AHHHHH…..What is the world of healthcare coming to? Is this what the crisis is driving people to do?

Let’s hope that the system gets repaired before this kind of story becomes the majority rather than the minority.

For the individuals out there that still think we do not have a problem with our healthcare system, check out some of these stories. Maybe ask yourself… if you were having these kinds of medical problems or expenses “What would healthcare drive you to do?”

Chris Fleming of Health Affairs Blog has highlighted the debate surrounding State Children’s Health Insurance Program (SCHIP) reauthorization, discontinuities, and enrollment in his blog. Undeniably this is such an important topic. I wrote a research paper this spring on uninsured children and the variations across SCHIP. Unfortunately the discussion is warranted (referencing the first article and second article he pointed out in Health Affairs). There are gaps in coverage, low enrollment, and eligibility changes and interruptions.

Though the function of my research paper was not to express my opinion, rather to report information, I certainly developed one by the end of it.

Reading all of these different individuals’ research on the SCHIP debate frustrates me.

• First, they cannot seem provide me with any new information in addition to what I discovered last spring.

• Second, how is everyone missing the point? Really. I want to read an article by an individual that has an opinion on how our policy makers have failed once again and created a patchy program. I do not need to read more statistics. Give me a solution.

Consequently I have decided to share my opinion on the topic…. And I would love to hear anyone else’s opinion or proposed solution.

To me SCHIP is about developing and supporting the youth of our country. We have developed and supported our country’s children for years through public schooling. We give every child the chance to succeed in life through educational opportunities from youth to adolescence. “Knowledge equals power”… right?

Well kind of. In this country it’s more along the lines… “Knowledge and health contribute to wealth and wealth equals power.” For this reason I believe that every child should additionally be afforded the chance to maintain a good bill of health. I cannot see how anyone, especially children, who doesn’t have access to a doctor, or medication, or any other care they need from the health arena (e.g. psychiatry, physical therapy), can truly succeed in school, much less life.

The answer is not about increasing enrollment, making single mothers, fathers and families fill out application forms, standardizing eligibility, or closing gaps in coverage. The answer is providing every child with free education and free healthcare.

If this were the premise of childhood (free education and free healthcare) I might reconsider my opinion on needing a more “universal” healthcare system. Who knows, I might even believe that our government was providing children with an equal (well at least a more honest) chance of succeeding as adults.

At the end of the day I simply wouldn’t feel so bad about turning people loose at 18, expecting them to contribute to society and figure out their own healthcare.

We were all told as children to respect our elders, and obviously our country does that. We provide social security and healthcare (Medicare) to the individuals that have contributed to what our country has become today. This country also needs to learn to value our children, the future contributors, by giving them every opportunity to learn and remain healthy throughout childhood.

We’ve all seen it – the EOB (Explanation of Benefit) with the bold lettering that proudly declares THIS IS NOT A BILL. So what is it? We called around to some insurers to find out about it and to see if they had a guide for the high math that they so often employ.

“It’s pretty easy.”

That’s what the customer service guy on the other end of the line had the audacity to say. Must be the kid from calculus class that always worked every problem at the end of the chapter. I asked him if they had a guide on how to read their EOB. They didn’t. But to his credit, he was willing to talk me through it. He started out, “It has THIS IS NOT A BILL written on it in big letters.” Thanks.

Another customer service rep said, “A guide? No we don’t have one, but you know, that’s a really good idea. We should do something like that.” His must not be so easy to read as Mr. Calculus’ or maybe he was sitting in the back of the class with me.

But there are a few insurers who put out a guide. There is even one – Humana – that publishes a guide to reading their EOB and [GASP] they have it available for download. The Humana EOB is one of the best I have seen for ease of understanding, and still it’s four pages long (And the first guy thinks people don’t need a guide? Yeah, and we didn’t need the teacher to work another problem on the board because we all got it – hah!).

Why was I doing this? Well we wanted to see how many different layouts and subtlties of semantics existed in the EOB world. So we had a small competition – see who can collect the most EOB forms from different insurors. Loser buys the coffee (Chistopher and Katrina, how do you take your java? Starbucks or Bongo Java?).

So now, in an effort to redeem myself, I am throwing it out there.

IF YOU ARE WILLING TO SHARE YOUR EOB WITH ME, POST A COMMENT.

DO NOT post your e-mail address in your comment. You have to enter it to post a comment, but it is not publicly available – it is only available to me. I’ll e-mail you with my direct e-mail address and/or fax.

You can strip off the personal data.

I don’t need to know who you are, your addess, your subscriber ID or Group ID or employer or any of your family member names. I don’t need the claim number, who you saw, what they did, the service date, how much they billed, how much your insuror discounted it, how much the insuror paid, how much was your responsibility, how much went to your deductible (OK, if you have a guide that might be helpful).

Yep. Send me your EOBs. I’m a glutton for punishment. It’s time for me to learn that high math that I thought I would never need in the real world.