David Williams: This is David E. Williams, co-Founder of MedPharma Partners and author of the Health Business Blog. I’m speaking today with David St. Clair, Founder and CEO of MEDecision. David, thanks for your time today.
David St. Clair: You’re very welcome. I’m looking forward to it.
Williams: Tell me about MEDecision. What is the company and what is it that you offer?
St. Clair: MEDecision is a 21 year old company that provides health care management solutions used primarily by private insurers and government plans to manage care for about 50 million people in this country. We have a couple of main product categories. One is called Alineo, which you can think of as an electronic medical records system with full clinical decision support. It’s used by the clinicians who actually work for the health insurance company doing quality assurance and case management and disease management. Then we have a product called Nexalign, which is a multi payer connectivity solution. Think of it as an electronic health exchange product. It essentially helps automate a number of the processes that health plans have used for years, but I think more importantly going forward it also is a full blown health information exchange that allows us to share the same clinical history on an individual with that individual themselves, with their doctors, and with their care managers.
We have a set of solutions that we talk about as being ‘simple, smart, and state-of-the-art.’ That matters because a number of those attributes are very important for consumers and for health plans. On the simplicity side, we help consumers navigate what can sometimes be an overwhelmingly complex health care system. We’re able to deliver summary information to a patient’s doctor or to the patients themselves. It’s a good summary of the data that’s available on that particular individual so we try to make that very easy to use.
The ‘smart’ side is really about knowledge flow. We’re trying to help information move around the health care system, always centered on the patient and their best interest. That knowledge is ultimately much more important than the underlying data. We have an instance where we’re looking at an individual patient with 61 pages worth of paid claims data. That volume of information will be essentially inaccessible by anyone who is trying to make a decision about that patient. It’s just too much of it.
The ‘state-of-the-art’ part speaks to the technology we’re using to help our systems be integrated into the broader health care ecosystem. It also addresses the clinical content that we provide to our customers, doctors and others in that we always have to stay abreast of evidence based medicine to make sure that the information we’re providing is appropriate for this individual.
MEDecision, after 20 years of independence and a brief history as a public company, was acquired last year by the fourth largest health plan in the country; Health Care Services Corporation. They are the largest non-investor owned health plan and own Blue Cross Blue Shield of Illinois, Texas, New Mexico, and Oklahoma. Their strategy is about simplicity, affordability, and accessibility.
Our technologies are used to provide the science. The clinicians provide the art to make health care systems simpler. Ultimately by improving the quality of care, we’ve improved the affordability of that care. The accessibility side is about the technologies we use to try to engage consumers in their own health care. We are not a believer in single portals, but rather in trying to create ways to deliver the same information to individuals whether they’re physicians or other providers or patients themselves, where they want to meet us. We don’t try to force them. We don’t try to coerce them into one particular way of acting. We give them a broad variety of choices.
Williams: How do you think about this patient that you referred to with 60 plus pages of claims data? How do you expect that patient to interact with the system? What is their role and what can you do for them beyond simplifying things so that they can get some grasp on it?
St. Clair: I think one of the challenges in discussing health care these days is getting people to think about the right sorts of individuals benefiting from this. So if you look at someone who has 61 pages worth of paid claims (by the way in a two year period) that person has, if I remember correctly, something like nine different medical conditions and was taking something like 18 different medications, was seeing nine different physicians over the course of the last year or so. This is somebody who is a huge consumer.
They are in the sickest half a percent or one percent, which consumes 15% to 20% of the health care costs. It’s a huge drain. Those individuals quite don’t care a whole lot about their health record. They need it to survive. They’re essentially so overwhelmed by trying to take care of themselves that we don’t expect them to interact highly with our systems. We do however need to make sure we can reach out and give them information and give them reminders, but we don’t expect them to be spending a whole lot of time on the computer trying to figure things out because they are simply too ill to be doing that.
But if you look at the next 19%, I think there are lots of opportunities where consumers can get more engaged. The challenge is how one does that because typically the people who are not at all ill don’t have any interest in thinking about health care or their health care record. It really is only those folks who have an active illness of one sort or another. Many of us are accustomed to essentially relinquishing control to our physicians. There is a big cultural change that we have to go through and that’s one of the reasons that we believe very strongly that we have to take every opportunity we can if a consumer indicates an interest in engaging in their own health care in some sort of a system or PDA or something of that nature. We ought to be trying to respond to that, to encourage that use in the future. I think there is going to be a significant change over the next five to ten years in terms of who gets involved with what kinds of interactions around their health.
Williams: You use a lot of claims information from health plans. If I think about claims that I’ve seen and try to even imagine somebody with 61 pages of paid claims over a two year period, there’s got to be a lot errors in there. There are probably some misdiagnoses that have been included and other sorts of errors. Are you able to really make sense of it and determine what’s accurate? Is that an issue and if so how do you overcome it?
St. Clair That’s a very accurate representation of the sources of data that are available today on individuals, and it’s not just claims data. If you look at data in electronic medical records systems, which are available on a very small percentage of the population, there are lots of errors in that as well.
Some of that is due to misdiagnoses on the part of doctors, others are coding mistakes and things of that nature. So for the most part, the data around electronic health history for individuals is, in many cases, quite flawed, whether it’s claims data or not. That’s where the knowledge component comes in. We’ve invested a great deal of time and money and effort to figure out ways we can use a multiplicity of sources about an individual to try to cross-validate information. So if I find an instance where a patient is diabetic I’m going to be looking for other sources of information or a repeated use of that particular diagnosis in order to really verify that that patient is a diabetic.
There are instances where the health plans will only pay for foot exams if the patient is diabetic– and all of the sudden all of podiastrists’ patients become diabetics. So we have to make sure that we look at other providers’ claims, look at medications the patients are taking to try to validate that. We never pretended that even with all of that knowledge our records today are absolutely accurate or absolutely complete because we know that they’re not. It just happens to be the very best summary of information about those individuals that’s available.
The question is: do you want really good information on somebody who is seeing nine different docs knowing that it’s not perfect or do you essentially want none? I think most people say that the biggest issue is the non-use of information rather than the misuse of information.
There is a transition going on on the physician side as well. If you think about the physician population as a normal bell curve you’re always going to have the folks who are at the leading edge of that bell curve who realize that something has to change. With the number of medical errors, with the expense that we’re put into trying to fix things that have gone wrong with the treatment of individuals with some real complexity, they realize that they’ve got to try something. And those folks are quite ready to try innovative ideas like our patient clinical summaries and things of that nature. The emergency room is another place we see very rapid adoption.
What we need to do is to make sure we’re doing the best job we can with those early adopters and then use their experience to get other physicians to adopt it and to get them accustomed to exchanging data in order to improve the quality and affordability of care. There is today and there will continue to be (I would argue forever) people on that trailing edge of those bell curves –payers, providers and consumers– who want absolutely nothing to do with it, who say this is ridiculous, if it’s not absolutely perfect I’m not going to use it all. Those are the folks that we can’t spend a whole lot of time trying to convince at this point. We won’t be able to so it’s a waste of time and breath to try do that. What we have to do over time is have their peers convince them that they really ought to look at things a bit differently.September 24, 2009