Tag Archives: kasich

Healthcare Debate Misses Key Point

As Congress considers another healthcare bill, the conversation continues to be about insurance, even though a form of reinsurance could solve many of the problems we face as a nation. The money for what I call “transparent health reinsurance” is already even in the various bills that Congress has considered; the more than $100 billion that has been designated for stabilizing healthcare insurance in the individual states would simply have to be redirected.

See also: Transparent Reinsurance for Health  

Transparent health reinsurance enables more people to receive better health care at less cost. As I wrote on this site in May 2016, “Transparent reinsurance programs could emerge as significant opportunities for healthcare providers, issuers, reinsurers, technology innovators and regulators to address health insurance.”

Transparent health reinsurance, pioneered by Marketcore, creates robust technologies that enable better, patient-centered health care through predictive analytics.

“Sharing information generates participation and creates cross-network efficiencies to enhance quality, improve delivery and reduce costs,” remarks Constance Erlanger, Marketcore’s CEO. “For healthcare insurers and providers, there are two key value-adds. First, the technologies incorporate any and all specific features a state and insurers in its jurisdiction may or may not include in state healthcare markets. Second, risk lenses clarify quality, delivery, outcome and cost across the 56 states and territories for transparent health insurance and healthcare services. Such robust information symmetry could rationalize healthcare insurance, quality and delivery. Such technologies, created by Marketcore, are already in development for bankers and insurers in multiple markets for complex risk assessments to finance recoveries from large-scale natural disasters.”

Everyone experiences strategic and financial advantage

Transparent health reinsurance supports these innovations by providing incentives that tackle the “widespread lack of transparency about both the costs and the effectiveness of treatments,” as Dr. Brian Holzer calls for in a timely article.

Any state could create a high-claim reinsurance pool managed by a recognized reinsurance operative. With supervision by the Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services (HHS), a state insurance commission or its designee could invite qualified firms to function as a recognized reinsurer. These recognized reinsurers would work with qualified, innovative health service providers that demonstrate abilities to improve health outcomes at reduced expense.

The reinsurers would be part of a matrix solution, where some firms provide health management solutions, while others provide disease- specific solutions and others provide innovations in treatment. A state could, perhaps, elect to focus on the largest drivers of healthcare costs in its jurisdiction, such as chronically ill individuals or those with acute conditions that are difficult to predict.

Due to the technology’s granularity and clarity, a state could just as readily specify participation among all issuers for any plan being offered in its jurisdiction, including every participant in every plan or defining reinsurance participation for individuals with chronic conditions in employee-sponsored or state-managed plans.

Or, states could fund a high-claim reinsurance pool with a payment per covered life, preferably covering everyone in the state, thus lowering the per-life charge.

Pending state decision-making, employers would have the right to move employees into this pool, and would want to do so if it was clear that the innovative approaches reduced costs while improving health outcomes. Clearly, the lowest per-capita contributions would occur with the widest participation.

If a state targets the largest cost drivers, reinsurer and insurers would then work together to assign “high-claim” individuals to reinsurance pools once those individuals cross a defined expense threshold. Each individual would be assigned to one or more innovators under contract to deliver better health outcomes at reduced costs. An innovative tracking mechanism would measure and rank outcomes and savings. Crowd-sourced information would drive confidence scores.

Burgeoning digital applications managing chronic illness would yield voluminous, timely data, and blockchain technologies afford accountability.

Scoring would rank service providers and eliminate failed providers.

A state insurance commission or its designee as reinsurer could manage transparent health reinsurance as states reach management decisions with stabilization funds. A single designated entity could oversee a system that would reward innovative, successful healthcare delivery and quality. To that end, participating firms would be for proposals detailing expected improved health outcomes and costs.

The technology leverages continuing achievement. Some studies indicate 40% cost reductions for some chronic conditions. By adding transparency to these achievements, the technology scales to yield much lower overall healthcare costs, healthier populations and stabilized or lower insurer premiums.

At the end of each year, a new reinsurance pool would be formulated with adjustments based on actual experiences. If the previous pool ended up in surplus, a portion of that surplus would be retained in reserve, and any remaining amount could be returned to individuals, providers or both. If the previous pool ended up in deficit, the reinsurer could choose to fund that, with contributions in the following year meant to provide for recovery.

Several states could decide to form an umbrella reinsurance pool to cover some or all of their high-claim individuals.

All activities focus on improving health outcomes at reduced costs.

No state residents are asked to fend for themselves.

States are encouraged to develop innovative firms.

Overall health of state residents should improve, which would lead to a healthier economy.

Ultimately, state-related healthcare costs would decline.

In the process, transparent health reinsurance would animate highly profitable growth for corporations with domain strengths in mobile data, operating systems, search and social media. These firms could tap data and metadata markets by creating valuable, time-sensitive risk information and metrics. (With such robust technologies, privacy matters, and all platforms are HIPAA-compliant.)

As healthcare reform faltered in the Senate, Govs. John Kasich (R-Iowa) and John Hickenlooper (D-Colorado) called for bipartisan solutions. Technologies and tools are at hand to make those solutions possible.

“If I am for myself alone, who will be for me? If not now, when?” the prophet Hillel remarked centuries ago.

Paging Dr. Evil: The War Over Opioids

Over the past several years, the epidemic of prescription drug abuse under the guise of “pain management” has generated headlines all across the country. The improper use of Schedule II medications in the workers’ compensation system is a part of this public health crisis. Publications by the Workers’ Compensation Research Institute (WCRI), the California Workers’ Compensation Institute (CWCI) and the National Council on Compensation Insurance (NCCI) have underscored not only the costs of such abuse but the tragic consequences to those who, through no fault of their own, have been consigned to a life of addiction and disability. Those tragedies are unnecessary and avoidable.

When it comes to workers’ compensation, the payer community has been at war with the provider community for generations. In some respects, the debate can be reduced to a clash of two business models  — the claims payer wants to reduce workers’ compensation costs while providing mandated medical care, while the care provider must build a business model around a dazzling array of payment (and paperwork) systems to maintain profitability. It is, in part, the economics of healthcare that so confounds payers and so stymies providers who are honest and ethical but who nevertheless still have to keep their offices open and a roof over their heads.

But consigning the issue of opioid abuse to this paradigm is too easy an exercise.

Equally significant, regrettably, are the problems associated with the insular world of workers’ compensation and how regulatory decisions are made within this highly regulated, if not suffocating, environment.

Some states get the process right. Oregon and Washington have transparent and inclusive processes to engage claims payers, worker representatives, providers and regulators on important issues of occupational medicine. The Oregon Medical Advisory Committee has as its charge: “…to advise the director, with a diversity of perspectives, on matters relating to the provision of medical care to injured workers. The ‘director’ is the director of the Department of Consumer and Business Services or the administrator of the Workers’ Compensation Division (WCD).” That’s a lot larger charge than adopting treatment guidelines in a rule-making process.

In Ohio, Gov. Kasich’s Opiate Action Team developed prescribing guidelines in a process that involved all key public and private stakeholders: “The clinical guidelines are intended to supplement — not replace — the prescriber’s clinical judgment. They have been endorsed by numerous organizations, including: Ohio State Medical Association, Ohio Osteopathic Association, Ohio Academy of Family Physicians, Ohio Chapter of the American College of Emergency Physicians, Ohio Pharmacists Association, State Medical Board of Ohio, Ohio Board of Nursing, Ohio State Dental Board, Ohio State Board of Pharmacy, Ohio Hospital Association, Ohio Association of Health Plans and the Ohio Bureau of Workers’ Compensation.” Like Washington, Ohio maintains a monopolistic state fund to provide workers’ compensation benefits. Ohio’s Bureau of Workers’ Compensation uses the same guidelines as every other provider of medical services.

And, of course, there is the large body of work being done by the Agency Medical Directors Group in Washington. That entity coordinates medical treatment among all state agencies providing medical care, including their state-run workers’ compensation program at the Department of Labor and Industries. Professional licensing boards and medical associations are also an integral part of that process.

Why aren’t these collaborative initiatives the template for further prescription drug reforms in states like Arizona or California? The much-lauded Texas closed formulary wasn’t created in a vacuum, and policymakers in that state recognized that open (“legacy”) claims required special treatment. As reported in TexasMedicine, the publication of the Texas Medical Association, “The regulations require physicians and carriers to formally discuss the pharmacological management of these patients. Ideally, the two parties would agree before Sept. 1 (2013) on how to proceed. That agreement could include a weaning schedule, a plan to continue the patient on the N drug or other alternatives.” California didn’t do that when making the transition from a judicial medical dispute resolution process to independent medical review, and Arizona has on the table a review/dispute process that will be equally jarring for open claims

It would be remarkably naïve to suggest that a more transparent approach to the development and application of treatment guidelines and having processes in place that encourage a peer-to-peer dialogue between requesting and reviewing physicians would result in an immediate drop in prescription drug abuse. But it would also be remarkably cynical to proclaim that the approach won’t have an effect.

The current workers’ compensation monologues over Schedule II drugs needs to be replaced with a dialogue that has as its goal not only the delivery of appropriate care to those who will be injured at work in the future but that also addresses the sad legacy of the abuses of past decades and offers help to those who so desperately need it now.