Download

A New Dimension in Population Health

Attempts to improve population health typically rely on four categories for assessing risk. A fifth needs to be added.

sixthings
With the healthcare landscape changing from fee-for-service to fee-for-value models, healthcare provider systems (hospitals, clinics, independent physician associations, etc.) are now, more than ever, under pressure to effectively manage the health and cost outcomes of their given populations. Under such models, providers are not only providing healthcare service to the patients, but they are also sharing in the financial risk and reward of patient costs. To effectively become a value-based organization, providers today are adopting a process broadly termed "population health." The "population health" process usually starts with identifying key segments of a population that face certain risks of adverse health outcomes and thereby high cost — a step known as "risk stratification." Once risk is stratified, appropriate patient intervention programs are employed to improve: access to health, targeted encounters with providers and continuous monitoring of patient risk. This leads to lower emergency room visits, better clinical outcomes (such as properly managed blood glucose levels for diabetics) and lower financial cost. There are many proven methods of risk-stratification to assign patients to low-, medium- or high-risk groups. For example, the adjusted clinical groups method examines patient diagnoses, and the elder risk assessment method assigns risk based on patient demographics. In today’s market, we observe many proprietary methods of risk stratification developed by various provider systems. The variables used in risk stratification can be classified into the following categories:
  1. Clinical: Data from electronic medical records (EMRs), patient vitals, laboratory data, etc.
  2. Administrative: Usually patient claims that track diagnosis and procedures already conducted
  3. Socio-Economic: Patients’ social situations, family and friend support systems, language preference, community involvement, the degree of influence that out-of-pocket expenses could have on the patient’s well-being, etc.
  4. Lifestyle: Health and activity tracking devices such as Fitbit, Apple Watch, etc., which carry critical daily lifestyle data about a patient
While the above categories play a large role in risk stratification, a new dimension known as "spatial access" can significantly lend leverage to the provider systems in affecting patient outcomes. For some patients, the overall risk may increase significantly because of their spatial, geographical and transportation access to medical and wellness resources. Spatial access refers to patients’ geographic proximity and ease of mobility to resources such as hospitals, primary care physician offices, primary and specialty care clinics and nurses. The geographic arrangement of patient and provider resources can play a significant role in healthcare utilization. For example, patients living in areas with fewer healthcare resources — regions often termed "doctor deserts" — have been linked with higher rates of preventable ER visits that are notorious for raising healthcare costs without necessarily improving healthcare outcomes. Using geographical and spatial analysis to supplement existing risk stratification techniques can help providers with an untapped method of assessing risk and generating better ROI in the long run. To incorporate spatial access analysis into risk stratification, providers must:
  1. Gather patients’ social network geographic information Most EMR systems already contain patient address information, but they often lack information about the patients’ social network. The following types of data should be collected and refreshed on an annual basis:
    • Distance to closest primary care clinic, both straight-line and network-distance;
    • Distance to closest primary care provider, both straight-line and network-distance;
    • Spatial density of medical resources in a given area, especially primary care services;
    • Access to vehicle transportation, either on the patient's own or through a family member; and
    • Proximity to public transportation.
  2. Conduct “spatial access” risk stratification Using a geographic information system (GIS), assign relative risk to each patient based on each of the components listed above, then create a composite risk based on all of the attributes.
  3. Represent population risk stratification visually via mapping Examine which areas of a provider’s service areas are prone to having individuals with high risk; look for clusters of high- or low-risk patients in doctor deserts. Viewing individual or aggregate risk through mapping would offer analysts and decision makers a comprehensive view of what types of risk are occurring in their service area.
  4. Strategize how to implement interventions based on locations of high-risk patients If clusters of high-risk patients exist in a certain area, begin to strategize about what kinds of interventions may alleviate the problem. Interventions may include the placement of new primary or specialty care clinics. Because creating clinics can be challenging, increased use of mobile provider teams can be an alternate solution. Lastly, a combination of telemedicine and mobile medicine should be assessed for the right mix of care for doctor deserts and lack of physical clinics.
Understanding the spatial context of patient demand vs. provider supply of healthcare service is an important component for accountable care organizations to conduct accurate risk stratification. Moreover, incorporating GIS into healthcare service analyses improves decision-making capabilities for evaluating, planning and implementing strategic initiatives. By taking advantage of the analytic capabilities of GIS and spatial access risk stratification, healthcare service providers are better equipped to more comprehensively understand their patient population and to thrive in this new value-based world.

Munzoor Shaikh

Profile picture for user MunzoorShaikh

Munzoor Shaikh

Munzoor Shaikh is a director in West Monroe Partners' healthcare practice, with a primary focus on managed care, health insurance, population health and wellness. Munzoor has more than 15 years of experience in management and technology consulting.

How Colleges Can Work With Insurers

Unfortunately, the passion that leaders have for a college's vision and its future does not always translate into the insurance process.

sixthings
If you sit down with just about any college administrators and ask about the vision of their university, you may witness a dramatic change as their voices fill with passion, reserve disappears and the entire tone of the conversation shifts away from being transactional. As an insurance broker specializing in higher education, I have witnessed this transformative moment many times. Unfortunately, the passion for the institution, its vision and its future does not always translate into the insurance submission and renewal process. Many people, including some insurance brokers, view buying and selling insurance as a passionless transaction. Information about the college—such as financial statements, property values and loss experience—is gathered, tabulated into Excel spreadsheets and forwarded on to the underwriting arm of seemingly interchangeable insurance carriers. Underwriters review volumes of data about the college to decide whether the insurance company can comfortably provide a college with a certain level of insurance coverage in exchange for a fixed annual premium. See Also: A Practical Tool to Connect Customers The information provided to an underwriter creates a story about the college. Depending on how the information is received and presented, the story can be positive or negative. To the underwriter, sometimes the insurance submission can be as horror-filled as a Stephen King epic or as romantic as a Nicholas Sparks novel. Of course, the insurance submission is not a work of fiction. One of the first things that statistics students learn is that the same information (data set) can be used to draw multiple and sometimes competing conclusions. Where one person may see positive potential, another may see an organization in decline. The conclusions drawn from the data set by different insurers and underwriters reviewing the same information may vary significantly. Why? Though the information contained in a submission or application may be objective—meaning the information has not been altered or manipulated—the conclusions drawn from the information are less so. The underwriting process involves both subjective and objective analysis. And how the data is interpreted may have a significant impact on the underwriting decision and, ultimately, on the total premium an organization pays. Using Data According to a Harvard Business Review article, data can be used as a visual mechanism to direct the narrative surrounding a particular situation. The key is to:
  1. Identify the narrative or the core message the audience should walk away with;
  2. Identify your target audience and figure out what they are interested in—is the presentation to an underwriter, claims adjuster, insurance company executive, etc.?;
  3. Remain objective and offer a balanced viewpoint—your credibility will suffer if what is being said cannot be supported by the facts;
  4. Not censor the data—do not exclude unfavorable information, and this is especially important in an insurance setting as failure to disclose information can constitute insurance fraud; and
  5. Take the time to edit—not the data itself, but how the information is presented.
There are many different methods for presenting the narrative of an institution in the most positive light possible while still providing objective information. The first step to understand both the positive and negative elements. This allows the institution to showcase itself in the best light possible. A failure to fully engage in this process may leave the narrative open to misinterpretation, create questions about unexamined negatives and result in overlooking one or more positive elements. Communicating the story of an institution involves a deep understanding of the goals and vision of the institution, and there is no one better to communicate that story than a passionate college administrator. However, understanding what drives your institution is not enough—and that is where administrators need to leverage key professional relationships. Selecting the right broker is a key step in driving the narrative forward. A professional partner brings market knowledge and the ability to help transform the narrative from numbers into a story that honors the vision of the administration. Developing Key Relationships The majority of colleges and universities work with one or more insurance brokers to engage with the insurance marketplace. At minimum, a broker working with an institutional client assists in (1) identifying insurable exposures, (2) preparing recommendations for coverage types and limits, (3) identifying potential insurers to approach, (4) developing the insurance submission, (5) negotiating pricing and coverage terms and conditions with the markets and (6) presenting the carrier quotes to the institution. Institutions at every level can rely quite heavily on the services and recommendations of their insurance brokers. The broker can play a critical role between having a well-structured insurance program and having a potential mess of overlapping coverage, gaps in coverage, inconsistent coverage terms, out-of-balance limits and potential claims issues. The broker can also act as a key resource in communicating the organizational narrative to the underwriters. There are four key elements a broker adds to narrative development:
  1. Market Knowledge: Insurance brokers keep abreast of developments in the marketplace, including insurer appetites: Like any company, insurers have target or preferred customers. Being in an insurer’s target class can provide premium discounts and coverage enhancements. Insurers typically understand the risk exposures associated with their target customers and are comfortable underwriting these risks and adjusting claims. For the insurance client, this means (1) access to expertise from an insurer that understands your institutional risk and (2) comfort in knowing the insurer has an understanding of institutional risk and will be unlikely to cancel or withdraw coverage in the event of a claim. Ultimately, it does not make sense to send an application to an insurer that does not understand or have a comfort level with higher education risks. Insurance brokers also keep abreast of market conditions. For the past few years, insureds have enjoyed relatively stable insurance rates and coverage offerings. It is currently the norm to see flat program renewals and even rate decreases in several key insurance coverage lines. However, it is unlikely that this trend will continue long -term, and it may be significantly affected by: 1) Mergers: The insurance market is changing as insurers look to increase market share and underwriting profit while minimizing exposure to catastrophic losses and unprofitable lines of business. 2) New Market Entrants: There has been an influx of third-party capital into both the insurance and reinsurance markets, resulting in lower insurance prices in the short term. The question is whether these new entrants are here to stay and whether capital levels have peaked.
  2. Underwriting Guidelines/Expectations: Understanding how underwriters use information is a key element of the narrative development. Different insurance carriers use underwriting information differently. Customizing the insurance submission to highlight critical (or essential) information that will be viewed favorably by the underwriters make a big difference.
  3. Risk Analytics: Analytical services provide a more complete picture of organizational risks, claims trends and opportunities for improvement. These services may include claims dashboards, benchmarking analytics, property valuation and catastrophic loss exposure analysis. This is really where brokers can distinguish themselves. Effective use of analytics allows the institution to home in on key risk and loss drivers and develop a risk management plan to address problem areas early. Early identification processes and plans can be communicated to underwriters as part of the application process. This can be critical for institutions with past losses, as it demonstrates steps to control future loss and an awareness of university exposures.
  4. Alternative Program Structures/Alternative Risk Transfer Options: Not every risk can be transferred, and not all risks are adequately covered by buying off-the-shelf insurance products and services. Taking control of the insurance conversation may require a needs-based assessment of academic, administrative and financial processes to determine optimal (1) coverage types/limits and deductibles/retentions, (2) feasibility of self-insured or captive programs, (3) needed coverage enhancements and (4) key contributors to loss/potential losses.
Tips for constructing and delivering your narrative Start early. Waiting until a couple of months before program renewal does not provide a great deal of time to develop a cohesive narrative or to allow underwriters the time needed to develop a real understanding of the institution. In fact, it can be beneficial to begin the conversation with a prospective insurer years before moving coverage from a current insurer. This is important even if there is a comfort level with the current program structure and insurance providers. Organizational risks are not static, and insurance programs change over time. Engaging in regular dialogue with underwriters at different insurance companies allows multiple carriers to develop an understanding of the college/university’s operations and risks. Developing alternative carrier relationships provides a backup plan. See Also: Are Customers Like Berliners? Know and understand your institutional risks and objectives. This includes both the positive and negative aspects. It can be easy to focus on the positives, but, as with an ostrich hiding its head in the sand, that may result in overlooking key dangers to the continuity of the college itself. You should:
  1. Create an internal risk review team made up of a diverse group of institutional stakeholders, such as human resources staff, facilities/housekeeping, faculty, administrative staff, board of trustees, alumni and students.
  2. Engage an objective third party, such as a risk consulting firm, or use the institution’s insurance broker’s analytical team.
  3. Participate in peer-review activities by engaging with administrative and risk management personnel at other institutions. Participating in risk management round-tables and discussions such as those provided by United Educators, URMIA and other educational insurers/associations can assist in planning for common areas of concern.
Use the data as a guide. As much as insurance brokers may wish otherwise, underwriters are pretty savvy people and will usually catch on to most omissions. It is very hard to recover from a situation where the underwriter feels misled about the organization—there is a loss of trust, respect and partnership that is impossible to get back. Be open and objective about the current position of the college/university. But do not allow the negative information to be all the underwriter sees—provide mitigating information such as steps the college is taking to: (1) improve loss experience, (2) attract higher enrollments or (3) renovate aging infrastructures. Underwriters want to write business, and most of them are looking for a reason to say “yes.” Do not rely solely on the insurance application. The application gathers the minimum amount of information that an insurance company needs to underwrite a risk. If the institution is working with an insurance broker (as most do), it is important to collaborate with the broker rather than just cede the submission development process entirely to the broker. A broker (regardless of how good she is) is never going to be as passionate about your institution as you are. Get to know your underwriters—go to lunch, meet them at conferences, attend a carrier networking event or even schedule periodic conference calls. If all your organization is to an underwriter is a few sheets of paper submitted 90, 60 or even 30 days prior to a renewal, you will not get the underwriter’s full attention or consideration. Engage your underwriters.

Mya Almassalha

Profile picture for user MyaAlmassalha

Mya Almassalha

Mya Almassalha joined the Encampus team in early 2016; she brings with her more than a decade of general insurance and risk management expertise, with a strong focus on higher education and organizational risk management.

Language and Mental Health

Terms like "successful suicide" are common, but they create the wrong climate for addressing mental health.

sixthings
“Commit suicide,” “successful suicide,” “the mentally ill,” “suffering from a mental illness” —These phrases rattle off the tongue, yet we, as social justice advocates, find they rattle our souls as people continue to use them in well-meaning workplace education programs and community discussions. Let us explain… In 1984, George Orwell said, “If thought corrupts language, language can also corrupt thought.” The above phrases are commonly used inside and outside the mental health sector and, because of this common usage, they are accepted. We suggest that they corrupt the thinking of those who speak them and those who hear them. We would like to change this. What if being more mindful of our language could release new ways of thinking that eventually open up new opportunities for creative ideas, thoughtful approaches and ultimately true social inclusion? What if we make a conscious effort to find words that more accurately reflect the experience of mental health conditions and suicide — would we be better able to have empathy, support and inclusion in our workplaces and communities through the use of more skillful language? We argue: Yes. Neurolinguistics tells us the words we use as we speak inform the way our brains store and process information about whatever it is we are talking about. Words carry current meanings and history of meaning. Many words are associated with inaccurate and unfair messages that serve to perpetuate misunderstanding and prejudice. The labels applied by clinicians to people who have mental health challenges create assumptions, expectations and interpretations that can set misperceived limits on how much growth and performance is possible, while also creating the means for social exclusion. We believe this process is often unconscious and has an insidious effect on our collective thoughts and feelings, especially regarding marginalized groups, such as people who live with suicidal experiences and mental health conditions. See Also: Breaking the Silence on Mental Health We are hard-wired to remember problems, especially when we perceive these problems to be dangerous. So, using language that is negative, connotes difference and insinuates a threat tends to be very “sticky.” To undo this, we need to spend extra effort to build a vocabulary that is life-affirming, dignified and inclusive. Paying attention to our language as we talk about mental health and suicide, while constantly working toward improving our language, will help create a workplace culture of compassion, vitality and engagement. Stigma reduction campaigns and workplace mental health trainings that do not pay careful attention to language are limiting their impact and may be the reason why, even after many years, we are not much further ahead in terms of reducing stigma in the workplace. Language is the most powerful tool in understanding each other. In any social movement, language must be addressed. How we speak about people informs us about them, so when we speak unconsciously, without attention to bias and misperception, we are perpetuating social prejudice and damage. By changing our language, we alter our perceptions and attitudes; this is social justice. In a sequel to this blogpost, we will explore the history, impact and alternatives of specific words that are often used when talking about suicide and mental health.

Donna Hardaker

Profile picture for user DonnaHardaker

Donna Hardaker

Donna Hardaker is the director of Wellness Works, a groundbreaking workplace mental health training program of Mental Health America of California. Hardaker is a workplace mental health specialist and has been developing and delivering training and consulting services to organizations since 2003.


Sally Spencer-Thomas

Profile picture for user SallySpencerThomas

Sally Spencer-Thomas

Sally Spencer-Thomas is a clinical psychologist, inspirational international speaker and impact entrepreneur. Dr. Spencer-Thomas was moved to work in suicide prevention after her younger brother, a Denver entrepreneur, died of suicide after a battle with bipolar condition.

Microinsurance Model in Non-Standard Auto?

Can we learn from microinsurance programs and make auto insurance accessible to foreign-born, non-licensed residents in the U.S.?

sixthings
In the spring session of the Texas Legislature, I listened to testimony about the impending House Bill 335, which would have prohibited the sale of Named Driver auto policies in Texas. So what does this have to do with microinsurance? A recent development, microinsurance has primarily been considered to offer solutions in life insurance, credit insurance and agricultural insurance and is being marketed primarily outside the U.S. to low-income individuals and families. See the recent article by the CPCU Society in its Insights publication as an excellent primer on the relatively recent development and use of microinsurance in these foreign markets. The question is: Can we learn from foreign microinsurance programs to help solve an insurance dilemma closer to home--how to make automobile insurance accessible and affordable to foreign-born, non-licensed residents in the U.S. Evaluating the Need During the testimony on proposed Texas HB 335, insurers and other interested parties repeatedly argued that the Named Driver product was needed to provide an option for “low-income households” in Texas--the very argument made on behalf of microinsurance in foreign countries (where, of course, the definition of poverty may be quite different than in the U.S.). Only we don’t have to go to a foreign country to find potential customers. An estimated 3% of the current U.S. population is individuals who have immigrated, not only from Mexico but from Central America, South America, Europe and Asia. Isn’t this population ideal for microinsurance? Foreign-born potential customers have behavior patterns and attitudes toward personal risk management and poverty that have followed them to the U.S. This group needs to assimilate and follow U.S. laws of financial responsibility. But as far as any evidence of prior insurance, any credit history, the availability of driver history and the ability to pay, this market differs from the typical U.S. consumer. Striking Parallels I find striking parallels between what is being attempted in Texas with the non-standard market and the goals and concepts espoused in microinsurance. Based on my experience in the non- standard market, my assessment is that the industry has attempted to capitalize on the burgeoning market, but the question is --has it done so in a manner that is consistent with the principles of effective microinsurance?
I would submit that we have not yet matured in our approach to providing auto insurance to the low- income, non-licensed immigrant population. Perhaps now is the time to take a step back and focus on both goals of effective microinsurance: 1) to help the poor and 2) to make a profit. Explosive growth in the non-standard market indicates that insurers have seized the opportunity. But couple this positive impact with the confusion and outrage over issues like the Named Driver policy debate, and the 2014 legislation that forced insurers to more clearly inform a consumer that he is purchasing a policy that has strict limitations of coverage in Texas. We may have a long way to go. As an industry full of collaboration, expertise and innovation, why should we draw the attention of the state legislature? Surely, we can come up with better solutions. We have an obligation to look “beyond the profit” and consider the societal implications of the programs we implement. It may be helpful to illustrate some examples of exactly how the non-standard auto market meets, or falls short of achieving, the goals of microinsurance. This might lead us to actions that could improve access, affordability and quality of auto insurance to the foreign-born, low-income, non-licensed resident in the U.S. This might also shed some light on the challenges ahead. SUAVE Accepting the challenge of Chmielewski and others, let’s view the non-standard auto market through the lens of microinsurance. Because the concept of microinsurance only arose in the 1990s, it may be helpful to restate the definition according to the Microinsurance Center: “Microinsurance is risk-pooling products that are designed to be appropriate for the low-income market in relation to cost, terms, coverage, and delivery mechanisms.” We can employ the framework suggested by Chmielewski that effective microinsurance should have the following characteristics: It should be Simple, Understood, Accessible, Valuable and Efficient, or SUAVE. Is the Non-Standard Auto Product Simple? Most of us grew up on the standard ISO Personal Auto Policy. Even so, we are continually challenged to correctly analyze and interpret coverage terms, insuring agreements, exclusions and conditions. Even today, articles are being published educating us about whether our personal auto policies cover rental cars! Insurance contracts are complex. If we are challenged with our years of experience, how then might we expect a non-English speaker to understand non-standard policy language in insuring agreements, exclusions and endorsements? Imagine how the foreign-born consumer must struggle to understand the coverage restrictions and limitations that vary from one non-standard policy to another. An example of this complexity in coverage terms can be seen in some non-standard auto coverage offered under Part D Damage to Your Covered Auto. Agents and purchasers of non-standard Physical Damage Coverage may approach this coverage according to traditional assumptions. That is, that Part D is first-party coverage being purchased for the insured’s financial protection against loss to the insured’s property itself as a result of a collision or a comprehensive-type loss, like theft or vandalism. However, although a premium is paid, non-standard policies may not provide Physical Damage coverage under certain circumstances—such as when the person driving the vehicle is not named on the policy. The vehicle may not be covered for theft if the person who last had custody of the vehicle is not a listed driver. Permission to drive the vehicle is not a relevant factor. This Part D coverage is often restricted by endorsement, and the interpretation of the endorsement itself is often the subject of discussion and disagreement by those selling the endorsement. And yet we expect the non-English speaker with most likely limited education to fully understand that if he allows his resident brother who is not listed on the policy to drive his vehicle, and the car is totaled, that he may have NO collision coverage? In addition, the lienholder is often surprised that there may be no coverage for the lienholder either in this scenario. While insurers understandably insist on narrowing down the known risk and declare that a premium reduction justifies this treatment of Physical Damage coverage, others may offer that this is form freedom gone awry. No, non-standard auto coverage is not simple. It fails the test of simplicity. Chmielewski may argue that trying to sell this traditional product to this market is not effective. Is the Non-Standard Auto Product Understood? When I meet people who, like me, have spent most of their careers in the standard market and I mention Unlicensed Driver Auto Policies, eyes glaze over as if these policies are a figment of my imagination. (As a point of clarification, these are not policies sold to individuals who have had their licenses revoked or suspended or have a poor driver history. Rather, a foreign-born individual is considered an unlicensed driver because he cannot obtain a driver’s license in some states.) Not only is the non-standard product not simple, the product is also difficult for judges, law enforcement officers, lawyers, claimants and, yes, even underwriters and other insurance professionals to understand. Exactly how does an individual who does not qualify for a driver’s license qualify for a valid auto insurance policy? Given the complexity of the product, the uninformed consumer and market reaction, has the industry provided information or training regarding this non-standard product to improve understanding? Does the industry provide adequate training to the agents who are on the front-line selling this product? My experience says: no. Consumer complaints in Texas forced legislation in 2014 to require insurers selling the Named Driver policy to issue both a written and oral contemporaneous warning to policy applicants at time of sale that the policy has restrictions on coverage for drivers. This law was a significant blow to Texas non-standard insurers. Some have appealed for more lenient requirements, and some left the market. Why were these drastic measures needed? Because the consumer did not understand the coverage. Is the Non-Standard Auto Product Accessible? The change in underwriting eligibility for some non-standard policies has spawned the “No License? No Problem!” business model we see advertised on agency storefronts along Texas highways in neighborhoods where immigrants tend to cluster. The existence of this type of marketing does appear to make the product accessible. The close-knit characteristic of foreign immigrants and sense of family unit responsibility allows for very effective word-of-mouth marketing. Local agents are accessible for initial personal assistance with applications, payments or policy maintenance. Neighborhood shopping creates a captive customer pool, and there are literally thousands of agents in Texas alone. The product is also accessible because it is sold with 30-, 60- or 90-day policy terms in addition to a six-month option. One insurer testified at the Texas legislative hearing that, at some point in the year, a significant number of customers experience gaps in coverage due to inability to pay a premium. Offering shorter terms appeals to the buyer. However, what is often overlooked is that this convenience and accessibility come at a cost, in Texas anyway. While the advertisements for “Liability Insurance for $29.00 a Month!” sound appealing, when a policy lapses, and must be reinstated, Texas allows agents to charge fees that are not regulated. While insurers are quick to say that they do not charge the customer a reinstatement fee, they turn a blind eye to this practice by the agents selling the policies. Selling these shorter-term policies raises ethical issues because agents have the option of collecting new-policy fees more often. Although the customized payment terms seem to be consistent with effective microinsurance and appear to meet the customer’s need for low premiums, the reality is that a $29 monthly premium does not include policy fees and other surcharges such as substantial one for not having a valid U.S. driver’s license. Is it time to re-evaluate the distribution channel? Can larger economies of scale reduce the need for policy fees and make total payments more affordable, to the point that applicants might list all drivers? Does the Non-Standard Auto Product Offer Value? We can agree that auto insurance should offer peace of mind and protection from financial loss. Even with all its restrictions, a basic level of coverage offered by non-standard forms may benefit the individuals named on the policy. Maybe we could also agree that, if a foreign-born driver living in the U.S. cannot obtain a driver’s license because state law does not allow it, it may still be advantageous for that driver to have auto insurance. A lienholder would require insurance to protect its interest in the vehicle. The question of whether the non-standard product is valuable to policyholders might lie in the insurer’s response to claims. Legislators questioned Texas insurers about the seemingly high number of claims denied. However, the data was difficult to interpret, and, because the details are proprietary information, no definitive conclusions can be drawn. But Chmielewski asks only if the product meets the needs of, or has value to, the low-income customer. Of equal importance is whether the product meets the needs of the public at large in the U.S.. How well the non-standard auto product achieves this goal is up for debate. Enter the uninsured motorist dilemma... Unlike the standard form, under the non-standard Named Driver policy no coverage may be afforded for anyone living in the household who may be driving the insured vehicle who is not listed on the policy, and members of an extended family might be living in the same household. This is not only a problem for the driver himself, who may have no coverage if he is not the Named Driver, but a problem for an injured claimant struck by one of these members of the extended family. Just ask the family of Walter Sullivan, who was struck and fatally injured on a Sunday morning. Even though there was a policy in effect on the vehicle, the insurer denied coverage to the driver. The Sullivan family was left to its own financial resources to fill the void created by the wrongful death. Screen Shot 2016-03-16 at 1.34.31 PM So the question of value is two-pronged. Is it enough that the policy has value to the policyholder? Should our model of microinsurance as it pertains to U.S. non-standard auto not also assess if the product has value to the driving public? A dilemma is presented when current non-standard insurers argue that the sale of their policies is the panacea for the uninsured motorist problem. They state that, without these affordable policies, the uninsured motorist rate will surely increase. I would argue that it depends upon how the rate is derived. Statistics from, say, Texas Sure, report only insured vehicles. But there is no way to track the “functionally insured” -- those drivers who are driving a vehicle that is insured, while the driver is not. Another issue is the restriction on business use contained in some non-standard policies. Standard personal auto policies allow some business, but some non-standard policies exclude all business use. This treatment of business use raises the question: Are we overlooking the issue of “Who is the customer?” The customer may be the landscaper, construction worker or tradesman who uses his vehicle to carry his tools and drive from one site to another. Often, only after an accident, does the policyholder learn that he has no coverage because the insurer sees a placard on the driver’s door and denies coverage because of "business use" of the vehicle. This scenario runs counter to the principles of effective microinsurance; the policies restrict coverage so severely that they may have little value to the customer. Is the Non-Standard Auto Product Efficient? Efficiency is an area where significant progress has been made in the auto market in general. And the non-standard market has enjoyed these efficiencies. Where premiums are purportedly lower, administrative costs have to be low. Automation means applications can be generated and signed in the agent’s office on a signature pad, premiums can be collected and credited to the policy instantly to bind the coverage, vehicle photos can be uploaded to the underwriting file, polices can be sent automatically without effort by the agent, and notices such as renewals are automatically generated. Automation also allows for policy self-service via online or by phone, which is encouraged to keep costs down. Efficiency occurs when insurers encourage agents to sell the policies and leave the customer service— telephone payments or policy changes--to the insurer’s customer service department. Not tying up the agent maximizes cash flow. The Challenge Without getting too deep into the political mire: Progress is likely to be hindered by the lack of an immigration policy and inconsistency from state to state on immigration issues. For example, state legislatures decide whether to grant driver's licenses to immigrants, and the question often evokes emotional responses. From a business standpoint, licensing drivers would help capture driving history. Traditional underwriting criteria are not useful when there is no DMV record for an applicant or resources for reasonable evaluation of the risk. Driver’s licenses give insurers access to driver information, which allows for each driver to be rated on his driving history, not his nationality. Neither from a business opportunity standpoint, nor from a social responsibility standpoint, should we ignore the potential of the foreign-born U.S. resident. Some insurers have grown exponentially in this market under the existing policies, terms and lack of underwriting information. But is the kind of growth the industry desires—after reflecting on some of this issues raised in this article? Consider that these policyholders may eventually rise above the need for minimum-limit, restricted coverage policies. Most of these individuals are here to stay, grow their families and possibly build their own businesses. If properly serviced, a company could develop a pipeline of ready applicants for more standard products, including renters or homeowners insurance and commercial insurance. These customers of tomorrow promise to be untapped potential worth further investigation. While he was not referring to domestic use of microinsurance, Chmiewlewski ‘s thought-provoking introduction to the topic begs to be given consideration in the non-standard auto market, especially as it relates to foreign-born unlicensed drivers in the U.S. In “Microinsurance 101,” he lays out the challenge: “Microinsurance products have proven helpful when the product and delivery are tailored to the specific needs of the policyholder, and when the policyholder is educated to understand the value and limitations of the specific policy.” With no easy answers, this is perhaps a place to start.

Libby Evans

Profile picture for user LibbyEvans

Libby Evans

Libby Evans is a highly motivated insurance professional. She is a strategic thinker with strong organizational skills and a proven ability to manage high-impact projects effectively and efficiently.

Competing in an Age of Data Symmetry: Part 2

How can insurers compete when everyone has the same data? Here are three potential differentiators.

|
In 1983, Microsoft Word was introduced. It wasn’t the first word processor, and it isn’t the only word processor, but it quickly became a standard — a “given.” From a productivity standpoint, the first adopters of word processing certainly had advantages over the alternatives (typewriters and ball point pens). Today, however, we all use Word and Excel and Outlook. Your only advantage may be in how quickly you can type or speak into your device. This is not unlike what is happening in the world of data. Data availability has become ubiquitous. Not only has data become freely available, but data analysis through tools, consolidators and rating companies has become freely available, as well. When everyone has access to the same information at the same time, that’s data symmetry. In Part 1 of our data symmetry blog, we followed the quickly shifting trends from asymmetrical data availability to a market filled with data symmetry. We illustrated how data symmetry is rapidly changing the idea of competitive advantage. If everyone has access to the same data and if digital technologies are increasing the number of data sources, an organization’s proprietary data will lose the ability to keep the company ahead. Data symmetry will then throw established insurers into a mid-life crisis, with everyone from marketing to underwriting to claims asking, “What makes our insurance actually different?” Once insurers are operating from the same data, and the prediction of symmetrically available data has become a full-blown reality, then data will no longer be a differentiator, and something else will be.  But what? The good news is that there will always be a way to create advantage if insurers remain active in fostering their uniqueness. From a data standpoint, here are three differentiators for your organization to consider: Moving from individual histories to virtualized views The data that is contained in today’s individual history will pale in comparison with tomorrow’s virtual record. In the very near future, everyone will take advantage of virtualized views of complete individuals or commercial accounts. These will includ/.e every facet of someone’s lifestyle, health history, safety records, common travel patterns, activity levels and even purchase histories. Virtual individuals will be known and understood in ways that real individuals may not even know themselves. We already see this happening in online sales of music, books, movies, coffee, auto parts and tennis shoes. Where there is a purchase, there is a preference. Purchase patterns are allowing digital retailers to accurately predict which marketing messages will work with hyper-targeted methods. Modern insurers will use these same automations and data analysis to improve timing, not only for marketing but also for claims prevention. As virtual individual data interacts with external sources, such as geographic and weather data, the insurers who have been practicing their data science will become predictive pros. Predictive analytics will still allow some competitive asymmetry to exist. Think of data streams as colors in a box of paints — the more colors one finds in the box, the clearer the picture that an insurer will be able to be paint. Data analytics experience will be the art classes that will make some insurers capable of predictive masterpieces. The old colors will still be in the box. Claims histories and proprietary risk models will still be available, but they will sustain their value when they are supplemented with fresh colors and new data perspectives. Innovating around products and services Predicting results and preventing claims will support business in the current realm of insurance. Both are still subject, however, to data symmetry. Data symmetry will, in turn, push insurers to innovate. What will be striking to see is how often these front-end innovations of all types will enhance back-end data capabilities. Early in 2016, for example, Liberty Mutual and Subaru announced a partnership that will bring usage-based insurance into Subaru’s connected car platform. Usage-based insurance is one of the clearest examples of innovative products, fueled by data that will also improve data analytics. This involves a new measure of innovation — how quickly data can move from collection to analysis. The quicker an insurer can transfer data gathering into meaningful action, the more valuable the innovation. Companies will be asking what levels of automation can be employed to turn prediction into prevention. They will also be looking for formulas that make innovative products or services attractive to consumers. Data innovations aren’t instantly palatable to people. In-car telematics devices are a great example. The initial innovation was somewhat offset by the expense of installation and the perception that an installed device invaded consumer privacy. Most efforts at product innovation will make consumer incentives part of the formula. As insurers turn “free data” into better ratios between pricing and risk, both the insurer and the consumer will need to see the clear benefits. Residential insurance is an example of an area ripe for innovation. Home insurance premiums are most often paid within the house payment. Most homeowners would be thrilled to have their house payment go down $100 to $200 per month. Property insurers that can take advantage of home sensor data and Internet of Things data could make that happen. In exchange for the savings, many homeowners would sign off on the idea that their insurer now has monitoring capability. Property insurers would then be adding home data to their available data streams. This could give carriers a competitive difference. Lender/insurer partnerships (additional product innovation) may also arise with greater frequency if lenders can find corollary trends between home monitor data and clients with the fewest incidents. This same data/pricing correlation will apply to commercial insurance. If the use of drones, security system monitoring and environmental system monitoring will result in lower insurance costs, most companies will see the value in an insurer that is looking out for their bottom line. Insurers will find some of their differentiation in data-driven, value-added services. Anywhere that data can point to a better practice, an insurer will want to promote that to customers. Whether that means suggesting alternative travel routes for trucking companies or promoting add-on products for specialized risk, the influence of data symmetry can be overcome with creativity and innovative thinking. Focusing on the stars When we discuss data, our mindset traditionally envisions incoming data. Customer experience data, however, is much more of a two-way data street. Consumers are painting a new world of service with their ratings and stars. These outside views are also subject to data symmetry. Prospects are now able to efficiently compare insurers with real service data, including both sources that are verifiable and those that contain unstructured, conjectural data. In Competing in an Age of Data Symmetry, Part 3, we’ll look at what an insurer should be doing to prepare itself for greater customer scrutiny and how reputation analysis will validate or invalidate an organization’s brand promises.

John Johansen

Profile picture for user JohnJohansen

John Johansen

John Johansen is a senior vice president at Majesco. He leads the company's data strategy and business intelligence consulting practice areas. Johansen consults to the insurance industry on the effective use of advanced analytics, data warehousing, business intelligence and strategic application architectures.

IRS Is Stepping Up Anti-Fraud Measures

But attempts at fraud are on the rise: The IRS reported a 400% increase in phishing and malware attacks related to the 2016 tax season.

sixthings
The Internal Revenue Service is taking as long as 21 days to review tax returns, according to research from fraud prevention vendor iovation, a clear sign that Uncle Sam has stepped up anti-fraud measures. Even so, tax return scams that pivot off stolen identity data continue to rise for the third consecutive tax season. The latest twist: Tax scammers are increasingly targeting vulnerable populations—low-income, children, seniors and homeless—as well as prisoners, overseas military personnel and the deceased, according to an FBI alert. Complimentary webinar: How identity theft protection has become a must-have employee benefit And criminals have gotten very creative about conducting phishing campaigns to fool individual consumers—and key employees at targeted companies—into handing over personal tax-related information, useful for filing fake returns. Tax software vulnerable The FBI also says criminals often use online tax software to commit the fraud. That’s particularly troubling, considering what the Online Trust Alliance found in a recent audit of free e-filing services approved by the IRS. Of the 13 services audited, about half failed somewhat basic security protocols, such as email authentication and SSL configurations. craig Craig Spiezle, Online Trust Alliance executive director Craig Spiezle, executive director of Online Trust Alliance, says some of the vulnerabilities, such as unsecure sites, are obvious to the casual person, let alone criminals. “These sites are such high targets, you’d expect 100% of these to be like Fort Knox,” he says. “There’s no perfect security, but you would expect not to see (simple) vulnerabilities.” Some e-filing sites, for example, had simple server misconfigurations or didn’t have current secure protocols; one provider failed to adopt an extended validation (EV) SSL certificate, leaving it open to spoofing. Although not everyone is eligible for the free e-filing services that OTA audited, Spiezle says many of the paid e-filing services are run by some of the same parent companies, and thus use much of the same lightly protected infrastructure. He says it would be fair to assume that many of the paid e-filing sites would have the same 46% failure rate as the free e-filing services audited by OTA. Personal information trades on black market Even if cyber criminals don’t use stolen tax-related data for filing fraudulent returns, that information is highly valuable on the black market. Spiezle points out that it’s the only place where this type of rich information—such as income, employer, number of dependents, Social Security numbers and even bank accounts—is available all in one swoop. “All that data that’s amassed is a treasure chest,” he says. “If you want to create a persona of someone’s identity, you have all the data in one place.” The IRS expects that, this year, 80% of the estimated 150 million individual tax returns will be prepared with tax software and e-filed—and that’s music to fraudsters’ ears. One typical avenue for cyber thieves is to file returns as early as possible, claiming refunds as large as $1,000 to $4,000 on untraceable prepaid debit cards. They can fly under the radar by filing very generic returns, and those multiple refunds turn into a lucrative operation. “They have immediate access to that cash, as opposed to credit card fraud where the value is not as high and the delivery is through a retailer, so they have to figure out what to do with those goods,” says Scott Olson, vice president of product at iovation, a provider of device authentication and mobile security solutions. Phishing, malware skyrocket According to the Government Accountability Office, the IRS prevented $24 billion in fraudulent tax refunds related to identity theft in 2013, while paying out $5.8 billion in fraudulent refunds that it didn’t discover until a year later. And the number of fraud attempts is on the rise: As of March 25, the IRS reported a 400% increase in phishing and malware incidents related to the 2016 tax season. Email phishing campaigns include links to web pages requesting personal information, useful for filing fake returns. These fake pages often imitate an official-looking website, such as IRS.gov or an e-filing service, and also may carry malware, which can turn over control of the victim’s computer to the attacker. This January alone, the IRS counted 1,026 email-related fraud incidents, compared with 254 a year earlier. Phishing scams also are targeting employers—because criminals know that’s where they can find large caches of income-related information. One growing trend is the so-called business email compromise (also known as “CEO fraud”), a variation of spear phishing. The phisher does deep research on a targeted company, then impersonates a senior executive to get a subordinate to do something. vidur
Vidur Apparao, chief technology officer at Agari, which offers an email security platform, says malicious attachments and URLs compromised the bulk of spear phishing emails in the past. But what his company is seeing now is phishing ruses aimed at specific employees that leverage trust to get the recipient to take a specific action. Such attacks do not carry any viral attachments or bad URLs that can be detected. Yet they have proven to be very effective at duping the recipient into forwarding files containing employees’ W2 forms. “Criminals are leveraging the cloud at three separate points, in ways they couldn’t before: developing social engineering content, sending out spear phishing attacks and getting back a response,” he says. Basic security helps According to the OTA, 92% of the publicly reported breaches in 2015 could have been prevented. Take email authentication. It’s almost a basic security tool that prevents emails from being spoofed. Those OTA-audited e-filing services that didn’t use it are contributing to the breaches. “The lack of email authentication or the slow adoption in some cases has led to the prevalence of this easy type of attack,” Apparao says. Spiezle says people need to be aware that emails and other tactics are becoming more sophisticated, and protect themselves accordingly. “The problem is that we are all moving so fast, and we have all these devices and desktops—we are multitasking,” he says. “And the criminals play off that, and they’re getting more precise.” This article was written by Third Certainty's Rodika Tollefsen.

Byron Acohido

Profile picture for user byronacohido

Byron Acohido

Byron Acohido is a business journalist who has been writing about cybersecurity and privacy since 2004, and currently blogs at LastWatchdog.com.

Do Healthcare Costs Shift to Work Comp?

Yes. Higher reimbursement rates for treatment under workers' comp encourage doctors to classify injuries as work-related.

sixthings
A new study―Do Higher Fee Schedules Increase the Number of Workers’ Compensation Cases?―from the Workers Compensation Research Institute (WCRI) explores to what extent workers’ compensation reimbursement rates influence the decision by the medical provider on whether to classify an injury as work-related. According to previously published WCRI research, in many states, workers’ compensation pays higher prices for treatment than group health does. For example, one study found that workers’ compensation prices were two to four times higher than group health prices in some states. And, in most states, workers’ compensation systems rely heavily on the treating physician to determine whether a patient’s injury is work-related. ”Physicians may call an injury work-related in order to receive a higher reimbursement for care he or she provides to the patient,” said Dr. Olesya Fomenko, the author of the report and an economist at WCRI. See Also: Are Your Health Cost Savings an Illusion? The study found, among other things:
  • If the cause of injury is not straightforward (e.g., soft tissue conditions), case-shifting is more common in the states with higher workers’ compensation reimbursement rates. In particular, the study estimated that a 20% increase in workers’ compensation payments for physician services provided during an office visit increases the number of soft tissue injuries being called work-related by 6%.
  • There was no evidence of case-shifting from group health to workers’ compensation for patients with conditions for which causation is more certain (e.g., fractures, lacerations, and contusions).
This analysis relies principally on workers’ compensation and group health medical data coming from a large commercial database. This database is based on a large national sample of patients where the data were provided by health insurers and self-insured employers. It includes individuals employed by mostly large employers and insured or administered by one of approximately 100 group health plans. The database is unique in that, for a given employee, it shows whether a given medical encounter (visit) was paid for by group health or workers’ compensation. For more information about this study, visit here.

Ramona Tanabe

Profile picture for user RamonaTanabe

Ramona Tanabe

Ramona Tanabe is executive vice president and counsel at the Workers Compensation Research Institute in Cambridge, MA. Tanabe oversees the data collection and analysis efforts for numerous research projects, including the CompScope Multistate Benchmarks.

Does College Matter Any More?

Yes, more than ever. But many in Silicon Valley are arguing otherwise -- and I fear that I am losing the debate.

sixthings
In the technology future we are headed into, the half-life of a career will be about five years because entire industries will rapidly be reinvented. Education counts more than ever. A bachelor’s degree is now the equivalent of high school, and technology skills are as fundamental as reading and writing. Given this, my greatest frustration is that Silicon Valley is regressing by encouraging children to skip college and play the start-up lottery. That approach glorifies college dropouts who start companies—even though the vast majority will fail and permanently wreck their careers. Billionaire Peter Thiel, who cofounded PayPayl and Palantir, goes as far as giving elite students $100,000 to drop out of college. Sadly, I am on the losing side of this debate. My first defeat was in a globally telecast Intelligence Squared debate on whether too many kids go to college. With Northwestern University President Emeritus Henry Bienen by my side, I debated Peter Thiel and conservative icon Charles Murray. We lost, with 40% of the well-educated Chicago audience voting against the need to college and 39% agreeing with us. Needless to say, I was shocked. I lost again over the weekend, on a segment on CBS Sunday Morning, which is the most watched morning news show in the U.S. CBS hyped the college dropouts without showcasing the dozens of failures and lives that have been ruined. CBS took the Thiel Foundation at its word that its fellows have started world-changing companies, created 1,000 jobs and raised $330 million in venture capital. These are gross exaggerations; even the  start-ups that CBS featured are all more of the same silly apps—and there are literally thousands more like these. Here is what I said on the show: "It breaks my heart when some of the most promising students don't fulfill their potential because they're chasing rainbows. "It's like what happens in Hollywood: You have tens of thousands of young people flocking to Hollywood thinking that they're gonna become a Brad Pitt or an Angelina Jolie; they don't. "They don't become billionaires. There haven't been many Mark Zuckerbergs after Mark Zuckerberg achieved success." I added that there is little evidence the Thiel dropouts are doing much that isn't already being done in Silicon Valley. "Everyone does the same thing: It's social media, it's photo-sharing apps. Today it's sharing economy. It's 'Me, too,' 'More of the same.'" You can see the full article published by CBS here, and you can view the segment here.

Vivek Wadhwa

Profile picture for user VivekWadhwa

Vivek Wadhwa

Vivek Wadhwa is a fellow at Arthur and Toni Rembe Rock Center for Corporate Governance, Stanford University; director of research at the Center for Entrepreneurship and Research Commercialization at the Pratt School of Engineering, Duke University; and distinguished fellow at Singularity University.

A Word With Shefi: At Telematic

Insurers must understand that "telematics is a play toward a one-to-one relationship with their customers, rather than an extra tool to price risk."

sixthings
This is part of a series of interviews by Shefi Ben Hutta with insurance practitioners who bring an interesting perspective to their work and to the industry as a whole. Here, she speaks with Marti Ryan and Tom Yates at Telematic. To see more of the “A Word With Shefi” series, visit her thought leader profile. To subscribe to her free newsletter, Insurance Entertainment, click here. Describe Telematic in 50 words or less: Telematic is a SaaS platform that creates personalized pricing models based on driving behavior, mobile phone usage and lifestyle behaviors. It offers insurance companies a way to more accurately price risk, yet more importantly it's a new marketing channel for a more personalized insurance experience. Why Telematic? [Marti] Because usage-based insurance (UBI) makes sense; it’s where insurance is moving; and it’s a good problem for us to solve as a team. Tom was working for a top carrier and saw how difficult it was to execute a dongle-based telematics program and realized that mobile would most likely replace the dongle/hardware solution, so he went home and built it for a year. [Tom] Marti has over 10 years of market research experience making cities sticky for the next generation. Together, we can make insurance sticky. Describe your typical client: We are in the B2B space targeting small to mid-sized, forward-thinking carriers that are looking to explore UBI and are willing to do something different and stand out. Biggest challenge: Convincing insurance companies that telematics is a play toward a one-to-one relationship with their customers, rather than an extra tool to price risk. The space is crowded with several companies focused on actuarial, B2C and fleets, but then again that's an indication of the role this technology has in the currently evolving insurance value chain. Our solution brings in a different approach to the space, one that creates a new marketing channel using 17 years of combined insurance experience to leverage mobile in an engaging way for the next generation. Who has been supportive of your cause? Co-Manager at Wisconsin Investment Partners Bob Wood has been a champion, Brian Worden CEO of TeamSoft, Liz Eversol from SOLOMO Technology, Tera Johnson of the UW-Extension Small Business Development Center programming in Madison and, of course, our families. Why did you decide to take part in the Global Insurance Accelerator? [Marti] The timing of our start-up lent itself well to an accelerator program that took place in the spring. I’m new to the accelerator scene but understand the huge value it can offer when the right circumstances align to the right program. We had applied to a Madison-based program, and in doing so we broadened our application to the Midwest market. GIA proved to be the perfect fit for us given its insurance focus and our goals; we've made connections and built relationships within the GIA network that will help us get Telematic to where it needs to be. If not for Telematic, what would you be doing? [Marti] Most likely doing three to four other things; working with the B-Corp group to help B-Corps tell their story via B The Change Media and continuing to provide business planing and consulting for the food industry, including a non-profit, kitchen incubator (FEED Kitchens) and a local restaurant kitchen buildout to allow scaling a meal preparation and delivery business using organic, local and gluten-free ingredients. [Tom] Working as a software engineer for another SaaS startup. Best life lesson: Never give up and keep asking the right questions to the right people. What are you most excited about with respect to Telematic? The opportunities that are in front of us are outstanding. We’re certain we’ve got a shot at being a partner for our target market, and, because we’re in the GIA, we’re well positioned to support Midwest-based carriers.

Shefi Ben Hutta

Profile picture for user ShefiBenHutta

Shefi Ben Hutta

Shefi Ben Hutta is the founder of InsuranceEntertainment.com, a refreshing blog offering insurance news and media that Millennials can relate to. Originally from Israel, she entered the U.S. insurance space in 2007 and since then has gained experience in online rating models.

Are Your Health Cost Savings an Illusion?

“Physicians overestimate the benefits of everything from interventions for back pain to cancer chemotherapy.”

sixthings
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, which is based on our tendency to infer causality where none exists, the ‘illusion of control.'” This illusion applies in all walks of life, especially in politics and parenting, and it includes medical care. In medical care, the phenomenon has been referred to as “therapeutic illusion,“ and it affects both doctors and patients. Undoubtedly, therapeutic illusion is why placebos can be so effective. In one clinical study, faux surgery worked as well or better than an actual surgery for the treatment of specific conditions. If patients perceive they need surgery, e.g. for knee pain, even though it may not be medically appropriate some will search for a surgeon who can validate the need and perform the surgery. Casarette writes, “Physicians also overestimate the benefits of everything from interventions for back pain to cancer chemotherapy.” Casarette’s article is most interesting to us. Why? We’ve often felt that doctors who perform unnecessary surgeries have ethical problems. The reality may be a little more complicated. The surgery decisions may have a subconscious influence. Toomey had an interesting conversation with the chief medical officer (CMO) of a major health system. The CMO relayed that his wife was having pain in her hand, so they scheduled an appointment with one of their system’s highly recommended specialists. The specialist looked at the wife’s hand and, after a few minutes, stated that she needed surgery. The specialist did not know he was taking to a physician, and the CMO questioned how the specialist could arrive at a diagnosis from just looking at a hand. The response was, “years of experience.” The CMO and his wife got a second opinion and opted for the recommended therapy rather than surgery, and the therapy solved her issue. The attention today is on value-based contracting and data analysis. A group of 20 national employers have come together to share data, so they can assess the healthcare supply chain. But, as noted in our last blog post, analyzing the data is complex, especially because claims data are just a collection of medical bills. How are employers assessing medical appropriateness? What reports can be generated to assess a need for care? In 2014, one state's Medicare costs were $6,631 per capita while another's were $10,610. A big driver was the variation in the volume of procedures, and cognitive biases among doctors can help drive those volumes. Healthcare involves people – patients, physicians, and other providers -- and the human element makes it even more complex. So how do those involved in healthcare address the variation in medical care that is driving up costs? We are biased – we believe the employers are the catalyst to drive change for increased consistency by working collaboratively with suppliers (think Six Sigma). In any case, it’s time for change.

Tom Emerick

Profile picture for user TomEmerick

Tom Emerick

Tom Emerick is president of Emerick Consulting and cofounder of EdisonHealth and Thera Advisors.  Emerick’s years with Wal-Mart Stores, Burger King, British Petroleum and American Fidelity Assurance have provided him with an excellent blend of experience and contacts.