David Toomey is a senior healthcare executive with 30 years of extensive healthcare expertise in addressing the fragmentation within the healthcare system. He spent 25 years with two national insurance companies, before he spent close to 5 years in an early stage healthcare company. His experience includes revenue/P&L management and business development, with products ranging from transparency, wellness, performance networks, medical cost management, and clinical management programs.
As physicians and hospitals compete for the “under 65” patient — whose payments are generally 150%-plus higher than for a Medicare patient — they have to determine their pricing model. The traditional choice is to offer a low price per service based on a higher volume, or a high price per service based on a lower […]
During the ‘90s, a new medical plan, called consumer-directed healthcare, was introduced. It was based on the premise that through a high deductible coupled with a funded account, employees would have incentives to become better consumers of healthcare. To maximize the account dollars, employees received access to a transparency portal, either through their carrier or […]
The healthcare industry is changing – same old headline. Since we’ve been in the industry, the “unsustainable” cost increases have been the talk every year, yet somehow we have not reached a tipping point. So what’s different now? How has ACA affected the healthcare industry, and more specifically the insurance companies? The drafters of ACA […]
In a previous article, we mentioned the Centers for Medicare and Medicaid Services’ (CMS’s) new provider reimbursement model, Medicare Access and CHIP Reauthorization (MACRA), which replaces the current reimbursement formula. MACRA will include an incentive component that will replace those in plans today; performance criteria will roll out in 2019. From the providers’ lens, they […]
The New England Journal of Medicine carried an excellent article by David Casarette, MD, on the topic of healthcare illusions and medical appropriateness. Click here to read the full article. Casarette observes that humans have a tendency to see success in what they do, even if there is none. Casarette writes, “Psychologists call this phenomenon, […]
Claims data captures the services provided to a patient. This information can be grouped into different cohorts—those getting preventive exams, those seeing specific physicians or hospitals for conditions, etc. The data can be grouped by diagnosis. However, all claims data is just a collection of medical bills. Medical bills do not contain a complete look […]
In most healthcare discussions today, “the exchange” is usually described as a solution to address employers’ health and cost challenges. The exchange model is now being offered by carriers, by consulting firms and by independent companies. Accenture says the enrollment in private exchanges exceeded 6 million in 2015, and it’s projected to be 40 million […]
Readers of Cracking Health Costs know that healthcare is both complex and consuming, and an ever-greater share of GDP in the U.S., while our health outcomes are falling behind our peer countries. According to the 2015 Health Care Services Acquisition Report, the deal volume for businesses in the healthcare services sector rose 18%, with 752 […]
The first three articles in this series by David Toomey and me are here, here and here. Over the last few years, the buzz in the healthcare industry has been about accountable care organizations (ACOs), and the next wave will be the promotion of “value-based contracting.” These are similar approaches, different words. Generally, an ACO […]
In Part 1 and Part 2 of this series, David Toomey and I described a wildly successful collaboration with Virginia Mason Medical Center (VM) and a few Seattle employers. During the the time of the VM collaboration, we invited major physician groups to meet with the employers. One of the most memorable meetings was with the CEO and chief medical […]
This is the second of a two-part series, by David Toomey and me, on why healthcare cost growth has historically been much higher that general inflation. In the last blog post, we outlined the complexity of the network negotiation process and the challenging dynamics among the insurance companies, the providers and the employers. The majority […]
