In the journey of health care reform, we’ve arrived at a juncture where having access and accessibility remain two distinct things. Nearly 13 million Americans now have access to state or federal insurance exchanges – but we know that having insurance coverage is no guarantee of care when it’s needed.
As outlined in the last post, both health insurers and providers of care have specific responsibilities to embrace if the tale of consumerism is to come true. What we’re seeing is that if these legacy organizations are to become faster, simpler, more responsive, more affordable, more transparent, and so on, we will need both internal cultural transformation and external innovations.
Cultural change will not happen overnight – especially not in healthcare. In the short term, it will be triggered externally through legislative and financial reforms – such as payment for better performance on patient experience measures. Over the mid to longer-term, market forces such as consumer demand and competition from alternate care models (e.g. retail, telehealth) should drive health care providers to button up their patient-facing service operations.
However, waiting for healthcare to change on its own is a losing proposition. The industry needs help from the outside. The zeitgeist of consumer-driven business models from Amazon to Zillow will keep bringing entrepreneurs to the plate to take a swing at improving accessibility, customer service, convenience. Both provider and payer segments will need to enact some of these changes. Fortunately, opportunities have bubbled up for tech startups, entrepreneurs, and other external innovators to get involved.
Waiting for healthcare to change on its own is a losing proposition.
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Payers need better patient-facing provider directories
Imagine if Uber only sent cars to 30 percent of requests. That is where health plans’ provider directories have left consumers today: patients who have signed up for insurance aren’t able to reliably use their coverage to seek care because typically, the list of doctors they are given (and forced to use) is woefully out of date or inaccurate.
The implications of this dysfunction are twofold: clinically, organizations are missing an opportunity to administer screenings, detect issues early, and deliver preventive care for a legion of new patients – creating more precise risk scoring and enabling better long term population health management in the process. Secondly, it’s a missed opportunity to onboard new consumers with a handshake, get them and their families plugged into a new care team, potentially earning loyalty and renewal during the following year’s open enrollment period.
CMS has proposed harsh penalties for Medicare Advantage plans and may follow suit for Medicaid plans; commercial insurers and exchange plans’ requirements vary from state to state but the writing is on the wall. Last year, California fined two blues plans for inaccurate directories. Yet penalties and fines alone will not be enough to magically improve the issue – there is a technology deficit to address. In closed loop environments (e.g., health plan-employer-provider network) vendors like HealthSparq are building directory solutions for their customers.
But beyond the relatively contained employer market, the fragmentation and heterogeneity of the payer provider market mix make things much messier. I asked Kyle Cox, a co-founder of Capsenta, a database solutions startup in this space, about some of the technical and business challenges of building and maintaining accurate directories.
“Information related to health providers can change as much as 25 percent on a yearly basis,” Cox pointed out. “Providers change address, practices and hospitals merge, insurance coverage changes, accreditation is renewed. What we’ve tried to do is enable real-time access to provider practice data, integrate that with the claims data from plans, layer on provider self-reporting data, and integrated all of that with data from the electronic record.”
The standard health IT vendor response to the above goes something like “Oh yeah, we can totally do that.” They may not be wrong, but without customer demand (or federal incentive), we’ve seen how poorly incumbent suppliers push the pace. Grassroots efforts have begun to spring up. Other startups like BetterDoctor, Vericred, and others are actively building solutions in the space. There’s plenty of opportunity (and need) for new entrants here – it’s a huge market and an important piece of the consumerism puzzle.
Without customer demand, we’ve seen how poorly incumbent suppliers push the pace
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For providers: Better front office coordination
Can so-called “CRM for Healthcare” platforms make a dent at improving patient access? As the story goes, health systems operating under a fee-for-value paradigm will have all the right incentives to invest in modern “patient relationship management” (PRM) platforms. These data engines can combine consumer style data (zip codes, demographics) with medical data (Dx, Rx), such that health systems can tailor outreach campaigns.
So, will these snazzy new marketing tools help recruit new patients into a health system? Today, PRM are currently going into larger, hospital-driven systems that can afford them. At today’s fence-straddling crossroads of FFS (fee for service) vs. VBR (value-based reimbursement), there are two major types of use cases: clinical interventions for high risk/high cost patients (rising risk all the way through preventing readmissions), and marketing upsells (attracting pregnant mothers, cutting edge spine surgery, etc.).
Eventually, we’re going to see more sophisticated applications, evidenced by places like Advocate, where data on patient needs and consumer preferences are translated quickly into new support hotlines and after-hours retail care partnerships.
What about the masses of newly insured, who are seeking a long-overdue physical? If and when value-based care models become strong enough to incentivize health systems’ investments in upstream prevention (e.g., nutrition counseling, weight loss, or smoking cessation programs), those systems will only be able to leverage PRM to rein these patients in if they tighten up their outpatient game. When only 30 percent of new primary care appointment requests go through, it’s not about “relationship management” as much as it is about figuring out why you’re single.
In theory – PRM platforms installed in the health system mothership could also intake calls made to every affiliate practice – say via a simple telephone calling tree, and say only in the months after open enrollment. But this seems unlikely — big systems typically buy smaller practices for leverage against insurers, not as new front doors for patients.
This reveals a potential opportunity for entrepreneurs to build smaller, focused systems to help outpatient practices with some basic tools to succeed in a digital era. It seems basic, but we’re talking about low hanging fruit – from search-engine optimization and better websites to easy appointment scheduling and followup. Startup PatientPop calls this a “practice growth engine” – if priced and pitched correctly, this is the sort of tool that big health systems may eventually buy on behalf of their affiliate practices.
Can so-called “CRM for Healthcare” platforms make a dent at improving patient access?
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The time for disruption is now
Health plans’ biggest concern at this stage is attaining consistency and predictability with who will enroll, who will re-enroll, and how much people will cost to care for. This market volatility is what is giving newcomers like Oscar such grief, and driving some insurers out of the exchanges for a few years. On the other side of the fence, providers – particularly big health systems, are still gobbling up as much FFS revenue as possible, while trying to maximize quality bonuses, minimize their exposure to penalties, and dominate their local markets through merger and acquisition, construction, and brand building.
Consumers, whether newly insured, or simply new to the exchanges, represent a huge business opportunity for payers and providers alike over the next several years. Millenial entrepreneurs are much better equipped to grab this opportunity than legacy executives with dinosaur thinking.
Provider directories and patient relationship management platforms are only two examples of what’s needed. For the bet on consumerism to pan out, entrepreneurs can start with some of the basics: appointment scheduling, responsive customer service, up-to-date web sites, and other “web 1.0” amenities can add up to have a noticeable impact on the bottom line – especially when combined properly with things like telemedicine.
Hospital innovation programs like the one at New York Presbyterian are showing they’re willing to play a convening role to scale up these consumer-friendly improvements into standalone programs. Innovation groups like Elevar and Avia are moving innovation from hashtags into workshops and matchmaking programs. And all the while, we’re learning more every day about some of the benefits of expanding coverage – as well as some of the challenges yet to be conquered. In short, health care innovators have a tremendous opportunity to work within their local markets to identify pain points and close some of these gaps.
Putting some “skin in the game” is a standard refrain when it comes to health care consumerism. But in a system as badly broken as ours, changing consumers’ shopping behavior or utilization patterns won’t matter much; health systems are the ones who will feel the pinch if they don’t make some changes.
Health systems are the ones who will feel the pinch if they don’t make some changes
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