Category: Health plans

Getting a handle on health insurance data: Podcast with Vericred CEO Mike Levin

January 3rd, 2018 by
Michael_Levin_Vericred_CEO
Mike Levin, Vericred Founder and CEO

A huge ecosystem of technology companies has sprung up with tools to shop for health insurance, search drug coverage, administer HR and benefit plans, make physician appointments and more. They all need accurate, accessible, and detailed data on topics such as health plan design and rates, provider network participation and drug formularies in order to succeed. It’s remarkably difficult and expensive to obtain and maintain the data, and this has created an opportunity for a specialized company —Vericred— to perform the function as a utility for the whole industry.

I’m excited by the opportunity and recently joined the board of Vericred to help guide the company’s growth. In this podcast, I interview founder and CEO Mike Levin about the market and how Vericred is addressing it.

Overview:

  • (0:15) What are some of the key data challenges in the health insurance market?
  • (1:53) Why are these problems so tough? Don’t other industries have similar issues?
  • (6:23) So what’s the problem? With consumerization you have all these new players springing up and health plans just need to work with them, right?
  • (7:40) What are the typical approaches to addressing these problems? Are the problems being solved?
  • (9:16) You talk about “liberating” the data. Doesn’t that scare health plans?
  • (11:11) What does Vericred do to address these issues? Are you gaining traction?
  • (15:03) Who are your customers?
  • (17:10) Are there analogs in other industries or this is a unique beast for healthcare?
  • (18:13) What changed with the passage of Obamacare and emergence of the marketplaces? And what is the impact of recent actions to undermine Obamacare?
  • (20:23) How did you get involved with founding the company? How did it go from concept to implementation?
  • (22:44) What changes do you expect in 2018? How is the company evolving to keep pace?

By healthcare business consultant David E. Williams, president of Health Business Group.

CHIPping away at the social contract

December 20th, 2017 by
And then there were none

Long before the arrival of the Obama Administration with its explicit goal of expanding health insurance coverage to everyone, the country had achieved consensus on the need to insure all children. The Children’s Health Insurance Program (CHIP), first enacted in 1997, enables relatively low income families who don’t qualify for Medicaid to get low cost, high quality insurance for their kids.

Congress let funding for the program expire at the end of September. CMS and the states have been scrambling to shift other funds around to keep the program going. But time is now running out.

Alabama looks to be the first state that will have to close its CHIP program, according to Kaiser Health News. Seven thousand kids will be tossed off on January 1 (Happy New Year!) and tens of thousands more would exit a month later. Within a few months, all 9 million CHIP-covered kids across the US will be gone.

CHIP has had a dramatic effect in lower income states like Alabama, where the childhood uninsured rate dropped from 20 percent in 1997 to under 3 percent in 2015. Prior political fighting over CHIP funding back in 2004 led to long-lasting damage to the program, and we can expect the same or worse this time.

I cheered the election of Doug Jones in Alabama, and find it notable that his first pronouncement was a plea to Congress to fund CHIP even before he is seated. If everyone looked out for their constituents the way Doug does, this wouldn’t be an issue at all.

CVS + Aetna. Are we sure this adds up?

December 5th, 2017 by
CVS and Aetna. Love at second sight?

Many of the stories I’m reading about CVS’s acquisition of Aetna suggests the deal is a bold move to expand CVS’s retail clinic business.  See for example, CVS-Aetna deal has major implications for retail health, primary care practices in FierceHealthcare.

If the merger goes through, CVS plans to expand health services at its retail pharmacies, according to CVS and Aetna officials. Although it will take several years to accomplish, CVS will increase its number of clinics and add staff and equipment for a wider variety of treatments.

This seems like silly reasoning. If the idea is to get health insurers to offer plans that favor retail clinics, why not just contract with those plans? Aetna is a big company but as a national plan its market share in many geographies is relatively modest. Often –like here in Massachusetts– the local Blue Cross has the biggest market share. If CVS is big and powerful enough to actually buy Aetna, surely it can get that company and others to come to terms on retail clinics.

If there’s strategic logic behind the deal it’s more likely to be in the pharmacy management side of the business, where, for example, the combined CVS/Aetna will be the biggest player –but not a dominant one– in Medicare Part D pharmacy plans. That’s not so compelling.

Possibly, the two companies just wanted to do a big deal that wouldn’t get blocked by the Justice Department. Aetna already got slapped down for its attempt to merge with Humana, and CVS doesn’t have a lot of options for horizontal takeovers of other drug chains or pharmacy benefit managers.

There is some kinship between the companies. Both are New England based and CVS’s Chief Medical Officer, Troy Brennan previously held the same role at Aetna.

It seems just as likely that CVS will offer Aetna “products” through its stores. As @WilliamGerber points out on Twitter, CVS could sell Part D plans at retail. I’m thinking maybe CVS will eventually offer consumer friendly health plans from Aetna that go beyond pharmacy.

Certainly, the shadow of Amazon is hanging over the deal. CVS is extremely nervous about Amazon coming in and eating its lunch in a way that Walgreens never could. So it’s doing something Amazon won’t –getting more into third-party reimbursement.

Stay tuned. I look forward to seeing how this one plays out.

Ambulance bill rip-off: There’s always a public option

December 1st, 2017 by

A Kaiser Health News story on sky-high ambulance bills caught my attention; I have a long-standing interest in out-of-network billing and a more recent experience of taking a pricey ambulance trip myself.

Taken for a ride? Ambulances stick patients with surprise bills, is not a new story. To sum it up: it’s not unusual for a patient to get a bill for thousands of dollars and then to be stuck with a big part of the charge, even if that patient is insured. That’s because many ambulance companies can make more money by being out-of-network. Unlike physicians and hospitals, ambulance companies don’t lose patients by being out of network and refusing to offer discounts. After all, if you need an ambulance you wouldn’t have time to shop around, and it doesn’t affect repeat business either.

The article cites an example of a Fallon ambulance in Chestnut Hill, MA, one town away from where I live. A patient was transported to Brigham and Women’s hospital four miles away and charged $3,660, which the article points out is $915 per mile. The insurer paid about half and half was the responsibility of the patient.

In my own case I was crossing the street in a crosswalk and was struck by a car making a left turn. My bill from Fallon was $3,427.50 for a one-mile ride, so at least on a per mile basis it was much higher than the Chestnut Hill example.

But to be fair, the bill comprises a base fee of $3,350 for an advanced life support ambulance plus $77.50 per mile. That works out to exactly the same rate as what the suburbanite paid ($3,350+4x$77.50=$3,660) and demonstrates that Fallon is not mainly charging for mileage, it’s charging for the equipment and personnel being ready to show up on a moment’s notice.

Much of the ire is directed at the ambulance company for price gouging and the insurance company for leaving patients hanging. There are calls to regulate prices and otherwise tighten the rules, and I’m sympathetic.

But notice this point a little further down:

” If the injury had happened just a mile away inside Boston city limits, he could have ridden a city ambulance, which would have charged $1,490, according to Boston EMS, a sum that his insurer probably would have covered in full.”

When you call 911 to report a fire or a crime in Chestnut Hill and anywhere else near Boston, fire fighters and police officers are dispatched at no charge. It doesn’t matter what insurance you have –or whether you have insurance– it’s a service provided by the local government as part of its budget. Police and fire fighters responded to my crash, too, but they aren’t sending a bill.

Cities and towns could do the same with ambulances if they want. Some, like Boston, do. Public ambulances can still bill insurance and individual patients, but they’re less likely to antagonize patients and insurers with outrageous bills.

So while we think of policy solutions for ambulance bill rip-offs, let’s not forget that there are public options and lots of hybrid solutions, too.


By healthcare business consultant David E. Williams, president of Health Business Group.

Advances in care management: podcast interview with AxisPoint CEO Dr. Ron Geraty

August 10th, 2017 by
Ron Geraty
Dr. Ron Geraty, CEO of AxisPoint Health

AxisPoint Health is part of the new breed of care management companies, leveraging new data sources and digital techniques that go beyond the traditional paradigm of nurse call centers focused on a handful of common chronic conditions. Industry veteran, Dr. Ron Geraty (former CEO of Alere) took the reins of the company a couple years back.

In this podcast interview, Ron and I discuss the evolution of care management, the role of digital, and what the future will bring.

  1. (0:11) What’s the current state of care management in the US?
  2. (2:27) How is care management being done differently across populations: commercial, Medicare, Medicaid, dual eligibles?
  3. (5:36) Care management traditionally focuses on 5 common chronic conditions. Has it made a significant difference in those areas?
  4. (8:26) What attracted you to AxisPoint? How is it different from other population health management companies?
  5. (13:08) Who are the customers? Who is drawn to your approach and why?
  6. (15:26) You work with the most vulnerable populations. Do you attempt to influence the social and behavioral determinants of health?
  7. (19:18) What’s at stake for AxisPoint in the debate about healthcare in Washington, DC, especially since you are serving populations that have been a major focus of the ACA?
  8. (22:33) How will digital tools be leveraged for vulnerable populations? Will you still have feet on the street?

By healthcare business consultant David E. Williams, president of Health Business Group.