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free clinic

What New Delhi’s Free Clinics Can Teach U.S.

Rupandeep Kaur, 20 weeks pregnant, arrived at a medical clinic looking fatigued and ready to collapse. After being asked her name and address, she was taken to see a physician who reviewed her medical history, asked several questions and ordered a series of tests, including blood and urine. These tests revealed that her fetus was healthy but that Kaur had dangerously low hemoglobin and blood pressure levels. The physician, Alka Choudhry, ordered an ambulance to take her to a nearby hospital.

All of this, including the medical tests, happened in 15 minutes at the Peeragarhi Relief Camp in New Delhi, India. The entire process was automated — from check-in, to retrieval of medical records, to testing and analysis and ambulance dispatch. The hospital also received Kaur’s medical records electronically. There was no paperwork filled out, no bills sent to the patient or insurance company, no delay of any kind. Yes, it was all free.

The hospital treated Kaur for mineral and protein deficiencies and released her the same day. Had she not received timely treatment, she may have had a miscarriage or lost her life.

This process was more efficient and advanced than any clinic I have seen in the West. And Kaur wasn’t the only patient; there were at least a dozen other people who received free medical care and prescriptions in the one hour that I spent at Peeragrahi in early March.

The facility, called the “mohalla” (or people’s) clinic, was opened in July 2015 by Delhi’s chief minister, Arvind Kejriwal.  This is the first of 1,000 clinics that he announced would be opened in India’s capital for the millions of people in need. Delhi’s health minister, Satyendar Jain, who came up with the idea for the clinics, told me he believes that not only will they reduce suffering but also overall costs — because people will get timely care and not be a burden on hospital emergency rooms.

The technology that made the instant diagnosis possible at Peeragarhi was a medical device called the Swasthya Slate. This $600 device, the size of a cake tin, performs 33 common medical tests including blood pressure, blood sugar, heart rate, blood haemoglobin, urine protein and glucose. And it tests for diseases such as malaria, dengue, hepatitis, HIV and typhoid. Each test only takes a minute or two, and the device uploads its data to a cloud-based medical-record management system that can be accessed by the patient.

The Swasthya Slate was developed by Kanav Kahol, who was a biomedical engineer and researcher at Arizona State University’s department of biomedical informatics until he became frustrated at the lack of interest by the medical establishment in reducing the cost of diagnostic testing. He worried that billions of people were getting no medical care or substandard care because of the medical industry’s motivation in keeping prices high. In 2011, he returned home to New Delhi to develop a solution.

Swasthya Slate is a mobile kit that empowers front-line health workers with usable technology for prevention diagnosis care and referral of diseases. The Swasthya Slate kit was launched in the state of Jammu and Kashmir by the Ministry of Health in 2014. (Swasthya Slate)

 

Kahol had noted that, despite the similarities between medical devices in their computer displays and circuits, their packaging made them unduly complex and difficult for anyone but highly skilled practitioners to use. They were also incredibly expensive — usually costing tens of thousands of dollars each. He believed he could take the same sensors and microfluidics technologies that the expensive medical devices used and integrate them into an open medical platform. And with off-the-shelf computer tablets, cloud computing and artificial intelligence software, he could simplify the data analysis in a way that minimally trained front-line workers could understand.

By January 2013, Kahol had built the Swasthya Slate and persuaded the state of Jammu and Kashmir, in Northern India, to allow its use in six underserved districts with a population of 2.1 million people. The device is now in use at 498 clinics there. Focusing on reproductive maternal and child health, the system has been used to provide prenatal care to more than 22,000 mothers. Of these, 277 mothers were diagnosed as high-risk and provided timely care. Mothers are getting care in their villages now instead of having to travel to clinics in cities.

A newer version of the Slate, called HealthCube, was tested last month by nine teams of physicians and technology, operations and marketing experts at Peru’s leading hospital, Clinica Internacional. They tested its accuracy against the Western equipment that they use, its durability in emergency room and clinical settings, the ability of minimally trained clinicians to use it in rural settings and its acceptability to patients. Clinica’s general manager, Alvaro Chavez Tori, told me in an email that the tests were highly successful, and “acceptance of the technology was amazingly high.” He sees this technology as a way of helping the millions of people in Peru and the rest of Latin America who lack access to quality diagnostics.

The opportunity is bigger than Latin America, however. When it comes to healthcare, the U.S. has many of the same problems as the developing world. Despite the Affordable Care Act, 33 million Americans ,or 10% of the U.S. population, still lacks health insurance. These people are disproportionately poor, black or Hispanic, and 4.5 million are children. They receive less preventive care and suffer from more serious illness — which are extremely costly to treat. Emergency rooms of hospitals are overwhelmed by uninsured patients seeking basic medical care. And even when they have insurance, families are often bankrupted by medical costs.

It may well be time for America to build mohalla clinics in its cities.

Driver Safety Ratings Add Sophistication

According to patent applications recently filed with the U.S. Patent and Trademark Office, Allstate is planning a driver safety scoring system that will take into account speed laws, road signs, traffic signals, weather and possibly even biometric data such as your heart rate. These driver safety ratings would then be used to determine what kind of car insurance you can buy and how much you’ll pay.

Allstate’s plans are part of a wider effort in the industry to gather telematics data from today’s advanced vehicles, smartphones and other devices. Many insurers already offer “usage-based insurance” programs that set rates based on actual driving behavior, such as Allstate’s Drivewise, Progressive’s Snapshot and State Farm’s Drive Safe. If you tailgate, speed, drive through high-crime neighborhoods or even drive at night, insurance companies might be able to justify charging higher rates, regardless of whether you get a ticket or cause an accident. You’ll probably find yourself getting a driving score for each trip, even paying different insurance amounts each time you go out.

Filing a patent application doesn’t guarantee that a plan will ever be used, but, within five years, it might be hard to find an auto insurance company that doesn’t have a plan to score your driving and use that score for setting your rate, says David Lukens, director of telematics at data analytics company LexisNexis.

If insurers don’t want to develop their own scoring system, they can buy one. LexisNexis, which has tracked and analyzed more than a billion miles of driving behavior based on data from insurers that have telematics customers, has developed its own system for scoring driving behavior and offers it to insurers.

Allstate declined to comment on details of its patent but said it “is committed to shaping the future of insurance to add more value and best serve customers’ changing needs.” The company’s statement to NerdWallet added that “Allstate treats this information confidentially, enabling customer control over the distribution of their personal information.”

Allstate’s system wouldn’t necessarily operate silently while you speed and blow through stop signs. The patent application describes incorporating real-time feedback such as warnings that you’re driving over the speed limit or approaching a stop sign—much like a spouse who yells “Watch out!” from the passenger seat.

This is similar to a system being developed by State Farm (first described by NerdWallet) that would measure driver emotions and respond with in-vehicle stimuli such as music and even fragrances to improve driving.

Allstate’s proposed system for rating drivers could incorporate more than just data from the car. For example, the insurer is considering monitoring and evaluating your heart rate, electrocardiograph signals and blood pressure through sensors embedded in the steering wheel.

According to another patent filed in 2014, Allstate is also working on a game-like system where groups of drivers would encourage each another to drive better to improve the overall driving score of the group. Allstate calls it “geotribing.” Allstate imagines this as a kind of high school scenario where the baseball team is competing with the basketball team to see which group can capture the better score to earn rewards.

Real-time driving scores could be monitored remotely by all members of the group. Allstate’s hope is that this “creates a self-policing atmosphere.” The sense of always being watched should make drivers “more conscious of practicing safe driving habits,” according to the patent.

Lukens says such group encouragement can make a big impact on driving habits—if done the right way. “It gets iffy when it comes [down] to allowing people to comment on other people’s behavior,” he says. “You can’t control the way people talk to each other.” Encouragement could devolve into bullying.

Many consumers seem interested in getting driver scores and improving their own driving. In March 2015, LexisNexis asked slightly more than 2,000 consumers whether they would be interested in a smartphone app that measures their driving score and offers ways to drive better, without any insurance discount. Fifty-nine percent said it would be nice to know their score, and 50% liked the idea of improving their score. But only 28% said they were interested in comparing their scores to others.

Although you might not be forced into a scoring program, Lukens says you should expect to pay higher rates in the future if you opt out. Allstate says, in one of its patent applications, that drivers who decline to participate might be signaling concern “that the information would demonstrate less-than-ideal [driving] behavior.”

Allstate is also considering how to leverage all this data for additional business opportunities. For example, it says a person who has a specific spending and credit profile—and who refuses to share her driving data—“may be particularly receptive to an ad campaign for luxury sports cars or certain vacation travel.” Similarly, NerdWallet has previously reported that State Farm has made plans to collect customer data for targeted advertising.

Driving scores aren’t on the horizon; they’re already here. Insurance companies are, right now, internally testing them. In fact, Lukens says, if you are a customer of a usage-based insurance program, you already have a score, even if your insurer hasn’t told you about it.

End the Dysfunction in Functional Exams

Functional capacity exams (FCEs) are in dire need of quality standards. Employers who want better workers’ compensation claim results must take the lead.

The FCE is intended to objectively test a patient’s thresholds of pain, strength and movement. An FCE should play a major role in things like qualifying a claimant to return to work, ascribing reasonable permanency awards, calculating objective settlement valuations, indicating malingerers, providing defense evidence and essentially helping you close cases.

As I see it, the FCE has been under a quality assault because of fee-squeezing managed care schemes. Managed care means only steering work to those “in-network,” which emphasizes use of the lowest-fee providers. The overriding value premise of “managed care” is fee reduction, not quality assurance.

As such, the peripheral specialty of functional exams has gone unchecked. They have become a perfunctory step in a chain of litigation activities, conveniently extending an adjuster’s diary with the appearance of action. When was the last time your WC case turned on FCE results? When was the last time your defense counsel’s essential witness or deposition list included the FCE provider? The answer may escape you, just as has the missed opportunity to leverage and move churning cases.

Quick Tip: Demand Quality FCE Standards and Expect Actionable FCE Results

Institute FCE standards in your claim account service instructions. Craft them from the checklist to follow. Require that you or your WC coordinator pre-approve FCE referrals to ensure quality in the application and outcome expectations. Along with selecting a quality provider, you need to provide adequate medical history and other background while asking specific questions.

When it comes to provider selection, apply this quality-question checklist:

Who is performing the test and what is her certification? Demand licensed physical therapists, optimally with enhanced related certifications. Do not accept PT assistants, sports trainers, vocational counselors or others who are less qualified.

Is modern computerized instrumentation used for validity? Do not accept manual systems, which involve subjectivity and simple gauge reading. For example: A manual hand-squeeze test shows pounds of squeeze strength, while modern testing measures isometric contraction and provides an actual “force curve” indicating effort, true point of muscle fatigue and pain. Simply stated, modern computerized systems can indicate real physical capacity while pointing out faking subjects.

Will raw data be fed into appropriate computer applications for reliable objective results? Functional exams need to process individual body-part tests and things like coefficient of variance formulas to ascertain whole-body determinations such as “lifting capacity” or other job-specific activities. Calculating these aspects by hand, based on assumptions, is not reliable, and the results may crumble under legal cross-examination.

Will heart rate and blood pressure be monitored during testing? This is essential to establishing consistency and overall patient effort.

Will the process measure distracted testing? This is a specific technique whereby one test is cross-checked by the appearance of a separate test. For example, back-bending angles are first tested; later, a “straight leg raise” test is performed, which actually re-creates the back bending angles and can be compared with the thresholds of prior back-angle results. This is a critical part of establishing patient credibility.

Will the results be admissible as strong evidence? Adherence to aforementioned aspects combined with early communication and input from defense counsel will strengthen evidence.

In conclusion, employers must confront a status-quo claims service process to demand FCE standards. Agree to pay for higher-priced FCE providers if you can establish the appropriate quality level. Pick your cases wisely and use detailed oversight. The power of a good FCE will help you move cases.