Category Archives: Irony

Getting Real: Can Health 2.0 Stay Relevant?

Relevant (rĕl’ə-vənt)

1. Having to do with the matter at hand; to the point

I read with amusement Susanna Fox’s redux review about the relevance of Health 2.0 in general and in changing patient’s behavior specifically.  Here questions reveals her bias in a very limited definition of Health 2.0 that I attempted to abolish originally in some of my bantering with Matthew Holt. I always saw Health 2.0 as a “movement” that would not be defined so much by its technology but rather enabled by it. As an “enabler”, the technology can help people do new things in new ways but I never believed technology in and of itself  had the power to truly change health, health behaviors, or health care delivery in and of itself.

That is why my definition of health 2.0 was always more expansive and contemplated an entire “movement” to the next generation health care “system”. This new system must include new delivery models, new financing mechanism, and the new tools and technology that bring all of this together in a simple, efficient, and affordable way.  Clearly this next generation of care would include technology, the new tools, but until we had a new delivery system that is financed in a new way we are going to continue to have the same behaviors across the patient, physician, provider, and payor continuum.

So Susanna, I don’t think your version of Health 2.0 (Tools and Technology) do much to get us to the behavior change you seek. In fact, getting to the root of behavior change requires almost a religious experience. Interestingly enough, the health care industry provides plenty of “religious” experiences including passing close to death, unbelievably poor customer experiences that invoke deep passions (ie, the birth of ePatient Dave), and promise of a far better world than we currently enjoy. So while the tools and technology show us what is possible, health care delivery and health finance are the catechismal doctrines we must reform first that actually incent the behavioral change we all seek.

So is Health 2.0 Relevant?  I think it depends on your definition!



Filed under Health 2.0, Innovation, Irony

CLEAR! Shocking Google Health Back to Life

* This is the second part of my commentary on the June HealthVault Connected Care Conference in Seattle. I hope to use this post to motivate my good friends at Google Health into taking a much more public, visible, and proactive role in the health conversation. More importantly, it is a call to Google HQ to wake up to the opportunity within health care to leverage their current tools and technology to create a platform that others can use to enable the creation of a next generation health system.

The scene was familiar, but it didn’t take away the tragedy. A young motor vehicle accident victim was involved in a head on collision with a drunk driver. The blunt trauma to the chest had created a literal mish-mash of complex internal injuries. The ambulance crew had attempted multiple times enroute to obtain a pulse and the monitors were all flatlined from the field. They intubated the patient in the field, performed CPR enroute, and initiated a ATLS protocol which included shocking the patient en route. In the face of asystole (lack of heart movement) after blunt trauma to the chest, the indication is to literally crack the chest open (called a anterolateral thoracotomy), a serious medieval last ditch rescue effort to save a life.

My perception is that the Mack truck called Microsoft HealthVault has just run over a young upstart, Google Health, who had such a promising future. The blunt trauma has put the patient in a precarious fight for survival, and the only way out that this ER doctor can see is to crack the chest open.

I really like Missy, Roni, and crew and believe they are smart, capable, and well connected individuals who have really done some great work to get the product launched. However, I cannot for the life of me understand why Google as an organization cannot get serious about the Health care vertical. A couple of stats:

My most recent assessment of the Google Health vs. Microsoft Health Here is my most recent assessment of the Microsoft Health vs. Google Health

It is not like Google couldn’t do some amazing things very fast. I am not just talking about Google Wave style innovation, I mean just their current assets themselves could be reassembled in short order to produce a very useful health care communication platform. They already have gmail, calendering, photos, search, documents, video, chat, and a framework from which to store/retrieve their health information. I think you could build out a mashup in no time that is immediately competitive and would be the leading “groupware” tool available. They also have all their current relationships and the interest of any health care CEO in the country.

Ironically, the reference to iGoogle (platform w/ widgets of functionality) was mentioned more than once at the Microsoft HealthVault conference. I don’t remember hearing about this at the Google conference – oh, oops – Google doesn’t have a conference.

I guess my point is that I love the innovation machine that is Google. I am just profoundly disappointed at what appears to be a lack of commitment by the organization to truly invest and innovate in the health care space. Is it a strategy question? An opportunity cost situation? Why the paralysis?

Google! The patient is dying on the table. The only thing I can see doing at this point is getting out the rib cutters.


Filed under Conferences, Innovation, Irony

CPT Codes-Why physicians always get screwed, thanks AMA

CPT Codes

  1. Set of health care procedure codes based on the American Medical Association’s Current Procedural Terminology
  2. Established in 1978 to provide a standardized coding system for describing specific items and services provided in delivering health care.

Daniel Palestrant comes right back from his opening salvo of last week to continue his crusade against the AMA. In another hard hitting email blast sent out to his 100,000 physician community he lays out the case of how the CPT system, maintained and propagated by the AMA, actually holds physicians hostage to the insurance cycle of care. He also lays the groundwork for the new retail health care economy where CASH will be king, relationship with the provider will be DIRECT, and physicians and patients will once again re-establish a relationship built on trust, advocacy, and professionalism.

This should be put in context with the recent announcement that Qliance just received $4M, Hello Health continues on an unprecendented media tear, and groups like Current Health and Crossover Health can emerge in this reality for American medicine. Whether or not we actually end up with health reform this year, you can be assured that Americans will want a separate system of “off the grid” providers.

July 8, 2009

Dear Dr. Shreeve,

In the healthcare debate it is rare that we find a single issue that all parties can agree is a big part of the problem.  Too much paperwork and complexity in the billing process is one of those few things.  Lately, EMRs have been lavished much of the attention and money; however, medical records are not the problem.  CPT codes are.

For most physicians, Current Procedure Terminology or CPT codes have become a defining aspect of how we must practice medicine.  They have become the “currency” of healthcare, mandating all manner of payments to physicians from the most complex surgical procedures to routine office visits.  In the process, the CPT coding system has turned into an incredibly complex system of codes, modifiers, and exceptions.  Add to that the RVU formulas, and it is no wonder that most physicians are drowning in paperwork.

Physicians feel the impact of this system in their day-to-day practice, especially on cash flow.  Not only do we have to maintain an extraordinary overhead of staff to submit, resubmit and document around CPT codes, the system robs the physician of any leverage we have with payors.  Once we have rendered care for our patients, we must submit (and often resubmit) forms to outside parties to get paid. Make no mistake, the more complex the system, the greater the opportunity payors have to delay and/or refuse payment to physicians, not to mention manipulate those reimbursements to their own advantage, as we have seen in the recent case led by the New York Attorney General against insurance companies.  Their profits grow at the expense of your cash flow.

The negative impact on physicians might be even greater when considering how handicapped physicians are in negotiating reimbursements for a given CPT code.  The current system allows payors to aggregate physician payment statistics, carefully playing one physician off another to negotiate down physician payments, while it is an anti-trust violation for physicians to compare data with one another, much less unionize.  It helps explain why physician compensation goes down every year while demand for those same services continues to explode .

As the national healthcare debate rages on, it is important to recognize that physicians are not the only victims of the CPT codes, the general public is too.  Beyond the massive administrative overhead (it is estimated that 20-50 cents of every healthcare dollar goes to administration), there is something worse, much worse.  The CPT system is privately owned.  Its use is strictly limited so that licensing fees can be obtained.  This has the unfortunate side effect of keeping the general public from doing easy comparisons of healthcare goods and services, also benefitting the insurance companies (who do not want those side by side comparisons because they promote competition and transparency).  There have been many attempts to break the CPT monopoly, most notably by Senator Lott in August of 2001.  Somehow they have always managed to remain in control.  Of course it’s a reliable revenue source.

Beyond offering a tremendous opportunity for improving our healthcare system, one has to wonder why this issue hasn’t been a topic of more focus.  With so much consensus around the excessive complexity and overhead in the billing process, this is completely baffling.  Dentists, lawyers, plumbers pretty much every professional in this country has avoided the fate physicians now face, allowing the market forces of supply and demand to create balance.  Only physicians have seen third parties come between them and their patients.

So who do CPT codes benefit? Well for starters, the AMA receives approximately $70 million in “licensing fees” from anyone who needs to use those codes.  Add to that insurance companies (who pay the AMA many of those millions) who can use the CPT coding system to further their own gains at the expense of the physicians, and it starts to make you realize why CPT codes have been so conveniently left out of the current debate.

So what’s the alternative?  Pretty simple.  Physicians have a service and people are willing to pay for it.  We are the single most critical part of the healthcare system.  We need to start acting like it.  We are at the dawn of a new era in the medical profession.  There is a New Business of Medicine upon us.  Sermo’s data shows that there is a trend towards alternative practice styles (fee for service being among the most prevalent) that is quickly turning mainstream.   To quote another Sermo member, “the new CPT: Cash Please, Thanks.”.  Leave the old CPT to the insurance companies.

The current CPT coding system represents a collusion of convenience between the business side of the AMA and the insurance companies…. at the expense of physicians and patients.  Perhaps most galling, thousands of physicians work on the CPT codes, for which they receive no compensation, while the AMA generates millions of dollars in revenue.  Clearly this presents a massive conflict of interest as the AMA is supposed to be advocating for physicians, yet it receives the majority of its revenues from the very same insurance companies that the rest of the physicians increasingly find themselves facing off against in the deepening healthcare debate.

As overwhelmed as we are with the offers from this community for financial contributions and your willingness to volunteer on behalf of this effort, for now we’d ask that you help us in mobilizing our colleagues in this effort. Remember:

Focus on the things that unite us, ignore the things that divide us. Concentrate on large numbers. Take a stand. Tie a knot.

Daniel Palestrant, MD
Founder & CEO
Sermo, Inc.


Filed under Direct Practice, Innovation, Irony, Medical Home, Value

Ferrari Medicine: We don’t need more horsepower

Horsepower (hôrs’pouər) n.

    1. A unit of power in the U.S. Customary System, equal to 745.7 watts or 33,000 foot-pounds per minute.
    2. The power exerted by a horse in pulling

    I had the opportunit to present to the Managed Care Executive Group yesterday in Chandler, AZ. In a beautiful desert setting, this group of executive IT folks from regional health plans gather to share ideas that will propel them forward in the year ahead. I was the final keynote of three densely packed sessions. The other key noters did a wonderful job describing in thorough detail with graphs, charts, and well documented trends the challenges in our health care system. Given their depth of coverage, all that was left for me was to highlight as succinctly as I could was my perception of the problem with our current health care system:

    Ferrari Medicine - Overcapacity leads to Worse Outcomes

    Ferrari Medicine - Overcapacity leads to Worse Outcomes

    I call it Ferrari Medicine.  The United States is culturally geared to bigger, faster, stronger mentality that is under-girded by a pervasive me-me-me affluenza that demands the very best (as long as someone else is paying for it!) at all times regardless of the cost. The above Ferrari is an amazing machine – one of the most advanced in the world. It has incredible horsepower, finely tuned instrumentation, plush interior with the finest woods and leathers, and exquisite styling and exterior. Unfortunately, given its expense and care requirements, it is not very useful for the 98% of times that you just need to transport yourself from point A to point B. It would be unthinkable, in fact utterly absurd, to use such a masterpiece as this as a pizza deliver vehicle.

    However, for alot of what we do in health care, we just push on the gas pedal. We build in more horsepower, more features, more functionality, more procedures, more capacity, and more of everything. However, despite all the appeal of the latest and greatest, the evidence shows that all the capacity within are system actually make the care and outcomes worse! More is definitely not better, and in fact, it is often worse. This has given rise to the concept called Slow Medicine, being advanced by the wonderful folks at Dartmouth. We can often do better with less, being more thoughtful, including the patient in the decision making, and doing the simple things that allow each patient to move from point A to point B in the way and manner in which is appropriate and desired by them.

    We should begin to educate patients about the perils of too much horsepower, and instead reserve Ferrari Medicine for the health care equivalent of the Autobahn.


    Filed under Healthcare, Irony, Quality

    “An Unnecessary Effort”: Wuesthoff Health Pays for EOB’s

    Unnecessary (ŭn-nĕs’ĭ-sĕrē) adj.

    1. Not necessary; needless.
    2. Serving no useful purpose or function

    You have got to love it, huh? Did you see the most recent series of lawsuits just announced by the AMA. They must just be loving the opportunity to pile on their arch nemesis insurance companies at a time when their very future is in question.  It looks like the “price of opacity” is going to get a lot higher (will blog on that later).

    Apparently, there is also a “price of transparency” being offered up in the market as well. In a very interesting article (a take off of my Million EOB March post?) from Wuesthoff Health System revealed that they are actually paying consumers to have access to the EOB’s from other hospitals for specific prices of procedures. Wuesthoff is obviously interested in this information for a variety of reasons, including general business intelligence, competitively pricing their own health services, and to optimize their business operations. Paying consumers $100/EOB to get this information is revealing in that this is what is required to obtain market information in health care – we have to resort to these types of tactics (which I applaud!).

    Couple comments:

    • Social Networking tools as Collective Intelligence engines – I am an obvious big fan of Health 2.0 technology not for the buzz but rather for the bang when they are actually applied to meaningful problems. Utilizing collaborative pricing tools like Change:Healthcare that allow consumers to contribute to the overall knowledge of something (by sharing information) can be powerful. I believe incenting them to do so might be a great investment by not only gathering the information but ultimately breaking down the entire opaque pricing schemes of the insurance industry
    • Competing on Networks vs. Competing on Value – For too long insurance companies have competed on their ability to aggregate the broadest swath of physicians for the cheapest prices. The hold down costs by paying way less than market rates. Physicians respond by jacking up their retail prices to make up for lost revenue from insurance and the end result is everybody loses. The siren song of “increased volume” seduced many physicians, but those same physicians are now rejecting the “hamster wheel” medicine that it created. Instead of competing on the prices they can coerce in the physicians into taking, they should instead by competing on teh value they can create for their members. They should be offering tools, technology, alerts, and reminders that actually help their members stay healthy, that add to their ability to care for themselves, and to optimize their own health. If Insurance companies can’t do this, then they SHOULD be reduced to claims transactions shops that get commoditized.
    • “Completely Unnecessary effort, just pick up the phone and call us” – this was the money quote of the entire article from a competing health care organization, Health First, public relations team. Come on! Really – I can just pick up the phone and your going to tell me any of the prices I would like to know? If that is the case, why don’t you just publish your prices – both the retail as well as what you have agreed to pay to accept from health insurance companies. We all know that retail prices are IRRELEVANT, so only the contracted prices (as contained in EOBs actually matter). And because I seriously doubt organizations will provide contracted rates, I’m guessing we are left to aggregating EOB’s to get some real pricing information. And now, because of social collaboration tools, the information available in EOB’s has the very real potential to be aggregated and available to all.

    Be kind, save your neighbors some gas money, and REALLY make all this “petty” price gather efforts UNNECESSARY by posting your prices.

    A $100 gas card says you won’t do it . . .

    UPDATE: I received a call back from the Health First Public Relations person mentioned in the article. He was straightforward in informating me that this “Pay for EOB” concept was less about transparency and mostly about an anti-trust lawsuit that Wuesthoff and Health First are engaged in. Apparently, the pricing issues are an essential part of the lawsuit and instead of using typical legal discovery tools, Wuesthoff has appealed to the public to gather this information as well as pick up some additional publicity in the process. While this little wrinkle puts somewhat of a damper on the motivations behind doing this, the concept of increasing pricing transparency remains an important element in helping people obtain the best health care value.

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    Filed under Consumerism, Insurance, Irony, Transparency, Value

    Mary Jerome: The Rosa Parks of Transparency

    Scheme (skēm) n.

    1. A systematic plan of action
    2. A secret or devious plan
    3. An orderly combination of related parts

    “Usual and customary” just became “Transparency and consistency”

    The United Health Group, in what will become a sweeping decision (interesting interview with author here) within the Health Insurance industry, was just levied a $50M wrist slap by New York Attorney General Andrew Cuomo for their participation in “a scheme to defraud consumers by systematically underpaying the nation’s patients by hundreds of millions of dollars over the last decade.” While United denied any wrong doing and continues to stand by the database their subsidiary Ingenix developed to determine what appropriate reimbursement rates should be, they appear to be on the wrong side of both history and reality.

    So what was the nature of the scheme?

    Essentially, members of health plans who go “out of network” (to physicians who are not on the approved panel of the insurer) to receive care agree to pay a higher rate for this freedom of choosing their own provider. This typically shows up in the form of higher co-pays as well as having the consumer pay the out of network provider cash for the service during the visit and then seek reimbursement from the insurer later. The insurers would then use the Ingenix database to determine what the reasonable and customary charge for that particular geography should be. Therein lies the rub. Insurers were relying on a data” base, owned and maintained by another insurer, to tell them the “usually and customary” (UNC) price for that service in that area. The formula to determine the UNC was not known, was not shared, and apparently was a little too low for AG Cuomo. As a result, insurers who relied on this database systematically “under reimbursed” patients for years.

    This would be like if you were an employee seeking reimbursement from your employer for travel mileage. You would submit the appropriate documentation and they would reimburse you 25 cents per mile. You never really knew how or why they arrived at 25 cents but you just took it for years. Later on, one fellow traveler complained about this and after some investigation you found out that they were supposed to be reimbursing you 50 cents per mile all along and they knew it. Now that would be bad.

    That fellow traveler is Mary Jerome, (great video!) a professor at Columbia who was diagnosed with Ovarian cancer at age 46. She was met with crushing medical bills for “out of network” services that should have been reimbursed at higher rates. As her personal finances began to bleed out, she was smart enough to make contacts with the sharks at the AG office who went right into attack mode (“I am having fish tonight“). They were able to determine that indeed both the idea and the input of Ingenix database was both suspect and potentially criminal. Instead of dragging this out in court, United wisely chose to settle.

    But what of the settlement? It seems that it only solved one of the two major problems behind the case. The first issue of the conflict of interest of United owning Ingenix that owns this data was clearly a conflict of interest. The second issue, how prices by physicians are set and what insurance companies are obligated to pay remains completely unsolved. The $50M that United is required to pay could go a long way toward removing the opacity.

    In fact, I have an idea . . . why not use $1M (~2%) of the settlement) to build a simple consumer portal for NY State to accept real consumer EOB’s? Consumers would be paid 50 cents for each valid EOB submitted and the organizer of the site would receive the other 50 cents to design, build, analyze, report, and maintain the transparency information gathered. As momentum and publicity build around the project, self insured companies could begin to contribute their claims data (which contain infinitely quantity and quality of information), and soon you would be well on your way to “surfacing” the actual prices that are paid. I am serious and will be providing information on how to do this shortly.

    All of this, interesting enough, could be obviated if insurance companies just made the information transparency to begin with and competed on value as opposed to the proprietary pricing schemes by which they have lived on the spread for decades. But no longer, consumers are not going going to go to the back of the bus anymore.

    Thanks Mary. May you continue to “do good. be well. enjoy life


    Filed under Change Agents, Consumerism, Innovation, Insurance, Irony, Transparency

    Sales Objection #2: MUMPS is Dead (No, its actually EPIC)

    Epic (ĕp‘ĭk) n.

    1. An extended narrative poem in elevated or dignified language, celebrating the feats of a legendary or traditional hero.
    2. A series of events considered appropriate to an epic

    Epic is a beautiful surfing slang word to describe a day, a swell, or a ride that is totally out of the ordinary, transcending into a state of pure awesomeness. It is also an appropriate term to use to describe an interesting statistic I saw recently.

    I have not written about VistA for a while, but there appears to be a resurgent interest in the media regarding it to which I will contribute. In my last post I describe the “platform issue” as a significant barrier to commercial adoption. Another major hurdle is the unique MUMPS programming language and database from which it is constructed. We ended up producing several media pieces in order to help quelch the fears of CIO’s who were considering how to overcome this development hurdle.

    We typically countered with what do you care? Or more appropriately, what does it matter to you what the backend is written in? Its fast, reliable, and powers the largest health care system in the United States for the past 25 years with minimal interruptions. Furthermore, nearly all the leading software vendors in the acute care (Hospital) based information technology space use MUMPS to power their solutions.

    Yeah, uhuh! Let me count the ways . . .

    Phamous / IDX / GE trilogy, Meditech, QuadraMed, Partners homegrown HIS, and my personal all time favorite health information technology platform vendor – EPIC. Someone, somewhere has most likely done some study to show how many current lives are powered by MUMPS powered software. I bet the number would be EPIC:

    This is about as brash as EPIC gets in their marketing.

    This is about as brash as EPIC gets in their marketing.

    EPIC systems has quitely pounded the acute care hospital IT market into absolute submission. Eclipsys, Cerner, GE – not even competitive in terms of features and functionality. Everyone knows that EPIC is the premium car in the lot (Tick Tock that Neal). In fact, nearly every brand name health system in the United States of any reputation has selected EPIC. Let me just rip off the names to get a feel: Cleveland Clinic, Geisinger, Sutter Health System, Stanford University, Memorial System in SoCal, and the grand daddy of them all – Kaiser Permanente (in what will be a $10B deal).  Judge Judy (EPIC Founder and CEO), for all her eccentricities (including not giving media interviews although I physically saw her once at a HIMSS show), knows how to run a pretty tight ship.

    What this also means, of course, is that MUMPS is going to be around for a very, very long time. The sheer number of MUMPS-based EHR implementations is only going to increase which guarantees that MUMPS is NOT dead . . .its future is EPIC!


    Filed under Irony, VistA