Post-HIMSS Interview with NaviNet

2014 NAVINET EXPERT INTERVIEW SERIES

Laura McCaughey’s Interview with Janice McCallum on 2014 Outlook for Health Insurance Exchanges, Health Start-ups, and Need for Price Transparency Tools

Janice McCallum, Managing Director of Health Content Advisors, is a leading blogger and contributor to healthcare IT conversations on social media. Last night, Janice graciously spent time with us after Hillary Clinton’s HIMSS14 keynote address to discuss what surprised her in 2013, her thoughts about the progress of health insurances exchanges (HIX) to date, the most interesting start-ups she’s seen in the past few months, and what applications she expects to have the biggest influence on healthcare in 2014.

(1) What event/nonevent or trend surprised you the most last year?
I’ve lived through several periods of rapid change where digital technology radically improved access to information and transformed how we purchase goods and services. So, it’s not easy to surprise me; I’ve seen a lot!

But, to answer your question, I’d have to single out the problems with the Massachusetts Health Connector as it transitioned to an ACA-compliant health exchange last fall as the biggest surprise. The HealthCare.gov problems didn’t surprise me as much, since I had an inkling of how complex the set of data extraction and matching algorithms had to be. However, within Massachusetts (my home state), where we had ample experience with an existing insurance marketplace that we call the “Connector,” it took me by surprise that the transition to the ACA HIX was—and still is—such a disaster. Perhaps it was due to overconfidence, or more likely, it was due to the fact that Mass chose the same IT contractor as the federal government used for the launch of Healthcare.gov: CGI Federal. I don’t place the entire blame for early problems with the Healthcare.gov site on CGI’s shoulders, but it does appear that they had insufficient resources to complete either job on time. Overall, I’d say there’s plenty of blame to go around, but for now the focus has to be on moving forward and fixing the problems.

(2) Uncertainty and painful reality around health insurance exchanges (HIX) are keeping payers, providers, and patients up at night—and demanding a lot of problem-solving during the day. What advice would you give to health plan CIOs as they strategize to leverage technology to insulate their companies from the reality of HIX versus the model?
I can only offer high-level strategic advice, since I’m not an expert in the technology underpinnings of the exchanges. My advice is to learn from the successes and failures on HealthCare.gov and the state exchanges, adopt best practices from the successes, and avoid duplicating the mistakes made by others.

(3) You are quite active in the world of innovation. What are some of the most interesting start-ups you’ve seen in your travels over the past few months?
I see a lot of well-intentioned start-ups that aim to help patients/consumers manage their health—whether their audience consists of consumers managing chronic diseases, trying to maintain wellness, or fitness enthusiasts who want to analyze data to gain a competitive edge – or just a better understanding of the effects of exercise. However, I think it will be a couple of years before these consumer apps really take off, because it will require more connectivity between consumers, researchers, providers, and payers. More important, business models that offer benefits to consumers are needed. I’m concerned that the business model that is gaining momentum involves sending data to providers and payers who will use the data to dictate to patients/consumers what they must do to stay compliant with their health plan. Personally, I want to see a more inclusive model where motivated patients have full access to the data and their observations and analyses are taken seriously by payers and providers. At present, we don’t have an evidence base that is solid enough to jump to a model where health plans make decisions based on device data without involving the consumers, whose observations about the data could reveal insights about interactions or other factors that affect the interpretation of data.

Apart from devices and sensor data start-ups, I’d point to investments by Google Ventures for early-stage companies that merit watching. Their investments include One Medical Group, Foundation Medicine (which recently went public), InformedDNA, and About.me. On February 20, 2014, Google Ventures announced investments in two enterprise/mobile security companies—Ionic Security and ThreatStream. These applications certainly play a big role in healthcare enterprises. Also, I think Rock Health does a very good job of tracking and categorizing healthcare start-ups.

(4) What application do you expect to have the biggest influence on healthcare in 2014?
Apps that help consumers track healthcare expenses and aid in price transparency will be in demand in 2014 as high-deductible and health savings account (HSA) plans expand. Castlight Health is a player in the price transparency space and is a darling of the investment community, but it is targeted to the employer, not consumer, segment. I am more interested in tools that help consumers understand what an encounter with a provider or an episode of healthcare will cost. To really make an impact, apps will have to provide information to consumers before they make a decision to visit their general practitioner, urgent care center, a specialist, or choose some other path.

Apple’s planned Healthbook platform may be a game-changer in this space if they can go beyond consolidating data from apps and patient health records (PHRs) and connect that data with information from a consumer’s health plan. I think Intuit had planned to focus on the financial tracking aspect when they acquired Medfusion in 2010 to grow the Quicken Health Expense Tracker. But, that goal was short-lived when Intuit’s corporate strategy shifted away from the consumer market, and they sold Medfusion back to its founder.

To succeed in achieving the price transparency and out-of-pocket expense tracking objectives, these consumer application developers—Apple, HealthVault, and others—will have to collaborate with health plans in order to have access to the cost-sharing structures of each health plan. Policymakers and health plan executives keep emphasizing how important it is for consumers to make wise healthcare decisions. In 2014, I’d really like to see significant movement toward giving consumers access to information that helps them make better decisions about their health and their utilization of healthcare services.

This interview was originally published at http://www.navinet.net/blog/2014-navinet-expert-interview-series-janice-mccallum on February 27, 2014.

Look to Payers for Innovation in Health Information

So much attention has been focused on the adoption of EHRs by provider organizations—largely because of ARRA HITECH funding—that one could be led to believe that most health IT advances are occurring on the clinical side of healthcare.  In reality, the business side has been quicker to adopt IT systems that add efficiency to the workflow of the participants. Practice management software and revenue cycle management solutions are two examples.

However, the exchange of data between stakeholder groups remains the stumbling block in improving the efficiency of our healthcare system.  On the provider side, it has been evident from the start that one of the most “meaningful” uses of a patient’s electronic record is the ability to make the information available where, when and to whom it is needed.  But, the pathway to meaningful health information exchange (HIE) is a bumpy one—not just because of technical issues, rather because of the regional nature of healthcare laws and regulations that has led to a very fragmented healthcare market.  I overheard someone from a hospital system in Florida at HIMSS say that a Florida-wide exchange may be a good thing, but it doesn’t solve his real problem of the snowbirds who come to Florida in winter but whose primary healthcare providers are in the Northeast. 

But once again, payers are leading the way in “meaningful” exchange of patient data between providers and payers.  The infrastructure created for revenue cycle management applications—eligibility checks, claims submissions, etc.—already exists, so why not build upon it?

In March, I attended the grand opening of NaviNet’s new headquarters in Boston.  I knew that NaviNet provided a communications platform for payers to exchange information with providers and that they were actively expanding their portfolio of services, so I wanted to know more about them.  I left that evening thinking that NaviNet’s existing platform that already connects 470,000 physicians in 128,000 offices to a growing number of large health care plans could be leveraged for exchanging clinical data. 

This week I had a follow-on conversation with Kimberly Labow, Chief Marketing Officer at NaviNet.  Kim confirmed that NaviNet recognizes the opportunity to leverage their existing network to become a single point of contact for business and clinical communications. 

At this point, NaviNet has already expanded to offer practice management and EMR applications to provider clients and has recently launched a mobile eprescribing application in Florida in conjunction with Aetna.  It’s interesting to note that Availity is also part of this strategic partnership because they were working with Aetna and Prematics prior to NaviNet’s involvement.  NaviNet subsequently acquired Prematics, which led to this multi-factorial “coopetition”.  [Note: Aetna has recently acquired Medicity, a health information exchange vendor, which makes the level of coopetition even more multi-dimensional.] However, this level of cooperation is not an anomaly; I see it is a sign of things to come as our healthcare system undergoes periods of consolidation within and across stakeholder groups. 

Given the existing structure of our healthcare system, the payer segment— unlike the providers—has clear incentives to use information to increase efficiency in business and clinical areas.  Payers recognize the benefits of working with patients to encourage more healthful behavior and are taking an active role in creating care plans and follow-on communication with patients.   At the recent Patient-Centered Computing and eHealth: Transforming Healthcare Quality course, Blackford Middleton suggested that in an alternate future, if providers don’t respond to the challenges of adopting health IT and learning how to use and analyze data, they will be disrupted and the insurers will become our healthcare coaches. 

I doubt that many patients, physicians or hospital groups want health insurance plans to become the primary source of health advice and care management.  However, we are moving toward a more integrated payer-provider model with ACOs and we have witnessed the success of integrated delivery networks like Kaiser Permanente. Convergence is occurring from all directions: providers are merging with physician groups, providers are consolidating, payers are consolidating, and payers are also diversifying into healthcare delivery.  A recent Wall St. Journal article described the payer diversification efforts as including: “acquisitions and partnerships that will allow the [health insurers] to employ doctors directly, delivery health information technologies, and participate in new hospital-doctor groups known and accountable-care organizations”. 

With alliances and acquisitions occurring within and across stakeholder lines, it is becoming a challenge to coordinate standards efforts and for analysts like me to try to diagram an industry that’s in flux.

NaviNet is trying to make a contribution toward coordinating efforts with the Unified Patient Information Management (UPIM) platform they are supporting. For my part, I rely on variations of the convergence diagram below that I created some time ago, which attempts to illustrate the clinical information market in an EHR-centric world. The initial version had payers outside of the inner circle. After writing this post, I think it’s time for another updated illustration that more closely aligns providers and payers!

 

Clinical Information Flows in an EHR-Centric World