Category Archives: Patients

PicnicHealth tries to make medical records work better for patients

PicnicHealth CEO Noga Leviner

PicnicHealth CEO Noga Leviner

Patients confronting complex medical situations often learn the hard way that no one is assigned to assemble and coordinate their records. PicnicHealth CEO Noga Leviner gained firsthand experience with this problem when she was diagnosed with Crohn’s Disease. Now she’s doing something for people in the same boat.

In this podcast interview Noga addresses the following:

  • (0:10) What’s the concept behind PicnicHealth?
  • (0:46) What motivated you to launch the company?
  • (2:20) I love the concept of a single online record, but what’s the process you follow to bring the record together and maintain it?
  • (5:13) Who are your typical users? What value do they get from using the system?
  • (7:28) You recently announced a partnership with uBiome. Tell me about that.
  • (9:28) What is the business model? Who pays?
  • (11:32) Can you provide the data needed for health plans to run pay-for-performance programs for drugs?

By healthcare business consultant David E. Williams, president of Health Business Group.

Sorry Captain, there’s no transparency in medical pricing

Just what the doctor ordered

Just what the doctor ordered

In the 1990s I used to go to a decent family seafood restaurant in the Coolidge Corner area of Brookline: Captain’s Wharf. The restaurant was pretty successful and underwent a nice renovation. Soon after it closed, which was a surprise, but the building was soon put to a better and higher use:  Coolidge Corner Imaging — an outpatient MRI/CT center.

I thought of Captain’s Wharf recently when I read a Kaiser Health News story about a consumer who did his darndest to find a good deal on a CT scan, finally settling on the $475.53 price at Coolidge Corner Imaging.

But the bill he got later was for $1,273.02 — more than twice as much — from a hospital he had no idea was connected to the imaging center.

“I was shocked,” said White, a doctor of physical therapy who thought he knew his way around the medical system. “If I get tripped up, the average consumer doesn’t have the slightest chance of effectively managing their health expenses.”

The patient wasted tons of time and effort trying to get the problem cleared up. He cared since he had a high deductible plan.

In my view, high deductible plans are a pretty crude instrument to encourage cost consciousness and price transparency. I switched to a high-deductible plan recently because the premium was so much lower –as a business owner I pay the whole premium in any case. It has no real impact on the way our family uses the insurance. The main impact is that I struggle more to understand the medical bills and EOBs that arrive. In particular, once one dependent met his deductible I kept getting confused by new bills that arrived asking for the out-of-pocket payment.

Were these expenses not subject to the deductible? Was the date of service before the deductible was met? It was hard to know and I’m still unclear. What is clear is that my administrative cost is higher from trying to deal with the nonsense.

Meanwhile, on the lower end of the income spectrum are people with high deductible plans who are afraid to use their benefits for fear of the deductible. That’s an indirect subsidy to folks like me, because when people hold back on running up a bill it holds down overall expenses.

High deductible plans are pretty lame. Transparency isn’t here yet and even then it will only be part of the answer. Can’t we do better?

Image courtesy of stockimages at

By healthcare business consultant David E. Williams, president of Health Business Group.


Call to action: America’s Health Rankings Senior Report


Dr. Reed Tuckson

Dr. Reed Tuckson

Rankings reports are a great way to spur the public and policymakers to pay attention to important issues. The 2015 America’s Health Rankings Senior Report from the United Health Foundation, released today, is a case in point. It combines a holistic approach to the definition of health with detailed information for each state.

I had an opportunity to interview Dr. Reed Tuckson, senior medical advisor to the Foundation, about the report.

  1. (0:12) What is the purpose of this report?
  2. (1:28) What should we learn from the high-ranking states and the low-ranking ones? What are some success stories?
  3. (3:28) The report includes a “call to action” from Dr. Jewel Mullen, based on a national prevention strategy. Who is Dr. Mullen and what is the strategy?
  4. (4:55) The report mentions Alzheimer’s and dementia. There is rising prevalence, no cure, and not a lot of effective treatments. How should we be addressing Alzheimer’s?
  5. (7:52) It’s clear from your comments that this report is not meant to sit on the shelf. What impact do you think the report will have?
  6. (10:18) What else would you like to highlight?

By healthcare business consultant David E. Williams, president of Health Business Group.

Do it yourself death panel

How are you feelin' today, mom?

How you feelin’ today, mom?

Federal law allows states to recover Medicaid costs from heirs. This little known provision is getting more attention as part of the debate over Medicaid expansion. The Wall Street Journal (New Wrinkle for Health Law) wrote a balanced article about it, highlighting consumer fears about having to sell assets while also sharing the government perspective that “estate recovery helps shore up the program for others who need it.”

The online comments and letter to the editor generally support the view that recipients’ estates should have to pay back the government. The letter (First, Estates Should Repay the Taxpayersis characteristic of the righteous indignation provided by the commenters.

Where is it written that a person is entitled at death to leave assets to children, particularly after someone else, in this case the taxpayers who fund Medicaid, has paid the health-care bills? Where is it written that children are entitled to inherit assets from a parent who has unpaid bills for services received during his or her lifetime?

Maybe if the issue were framed differently the commenters would rethink. Two points in particular:

  • If we seek to reclaim Medicaid payments we need to reclaim Medicare payments as well. Although recipients pay into the system, Medicare is far from self-sustaining. More than 40 percent of Medicare spending is financed from general revenues.
  • If the government starts going after estates for medical expenses more broadly, dying patients will worry that heirs will ration care to preserve their own inheritances. And with so much at stake, it’s not a paranoid thought

So here’s my question for the commenters and letter writers: Are you willing to expand this logic to Medicare and provide your own heirs with an incentive to form a death panel for you?

Image courtesy of artur84 at

By healthcare business consultant David E. Williams, president of Health Business Group.


Meaningless Use: Pediatric portal example

I love my family’s pediatrician. He’s an old school guy who keeps up with the literature, is a great diagnostician, has an informative and comforting manner, and uses the hospital system’s medical records and phone calls to track the progress of his sicker patients as they deal with specialists. He’s available for a call-in hour every morning.

The practice’s patient portal from eClinicalWorks is another matter. The “PHR-View” has tabs for Allergies, Vitals and Immunizations. The information appears to be complete, which is nice, but where is the standard form that I need for school, camp, etc? It’s nowhere to be found and I have confirmed with the practice that it isn’t available. The practice doesn’t like to use the secure message system, which anyway doesn’t allow attachments.

Bottom line? I obtain the forms the same way I did close to 20 years ago: Call the practice and ask them to fax the form. They are always happy to do it, but it seems a little silly. Surely we can expect more from patient and family portals in 2015.

By healthcare business consultant David E. Williams, president of Health Business Group.

Hospitals say: Show me the money! (I’m quoted)

Hospitals and other healthcare providers are struggling to collect out-of-pocket costs from patients. This has always been the case to some degree but with the growth of high-deductible plans and other forms of cost-sharing, patient payments have become a much more significant share of the pie.

This state of affairs can lead to some ugly publicity. Hospitals are more likely to collect if they do so upfront, but it can also strike patients as rude and even unethical.

The Pittsburgh Tribune-Review covered this topic, leading with an example of a breast cancer patient who was told her surgery would be canceled if she didn’t bring along her $900 co-pay.

I’m quoted in the story:

David E. Williams, a health care consultant in Boston, said patients are leery of hospital bills because they don’t understand the complexities of health insurance. He encouraged people to become more familiar with the plans.

“If hospitals wait to bill later, the patient, in addition to being generally less likely to pay, may not believe that they actually owe it because they’re not sure how the insurance works,” said Williams, co-founder of the Health Business Group.

With high-deductible plans, a patient who once was responsible for $50 might be on the hook for thousands of dollars, Williams said. Owing money for a health-related procedure is different from owing money for a car, he said.

“If you don’t make your (car) payment, somebody can repossess it. They are not going to undo your surgery or take your knee replacement,” he said.

By healthcare business consultant David E. Williams, president of Health Business Group.

Sovaldi: a near-perfect example of price discrimination

The controversy over the pricing of Gilead’s Sovaldi for Hepatitis C is a textbook example of price discrimination in action. I hope that my quick review of some of the principles involved will help explain what’s going on.

Gilead sells Sovaldi for high prices in the US: up to $85,000 or so for a course of treatment. The price is a little lower in Europe, substantially lower still in middle income countries and less than  $1000, or 1 percent of the US price in poor countries such as India. Such stark differentials set up major financial incentives for people in richer countries to obtain the product in poorer countries. With more than $80,000 per patient at stake, grey marketers could easily make millions of dollars and even an individual patient from a rich or middle income country would find it financially worthwhile to go to a low income country to procure the medicine.

This isn’t just theoretical. I was approached by a consultant representing large US employers who were exploring pharmacy tourism that would send patients abroad for their drugs.

Gilead has responded by taking steps to limit diversion of product. Patients must present IDs showing they are residents of the country to be eligible for the low-income country price. Patients can only get one bottle of medication at a time. Naturally some folks, including Doctors Without Borders, are complaining about the burden on patients and caregivers, and accusing Gilead of being greedy and maximizing profits.

Although the anti-Gilead people have a valid perspective, my sympathy is mainly with Gilead. The concept of price discrimination: charging different prices to different customers based on willingness or ability to pay, maximizes a monopolist’s profits but it also maximizes societal benefit. As the simplified chart below illustrates, Gilead makes the most money if it can sell the medication at different prices in different countries. That also leads it to sell the highest quantity of product, meaning more people can be treated.


Price discrim

If Gilead were required to charge the same price everywhere in the world –as shown below– it would result in a windfall for consumers in high income countries (“consumer surplus”) and lack of affordability in poorer countries (“deadweight loss”), because patients in poorer countries could not afford to be treated. Even assuming Gilead wanted to maximize its profits in that scenario fewer people would get the treatment.

No discrim


Because of the opportunity for price discrimination, Gilead was willing to introduce Sovaldi in rich and poor countries at the same time –something that doesn’t usually happen.

For price discrimination to work, the following conditions must hold:

  1. The firm (Gilead) must have some monopoly power. In this case the monopoly is based on patent rights. Gilead critics can try to undermine this power by encouraging governments to ignore patents.
  2. Markets must be able to be segmented and kept separate. Here that means segmentation by country, but theoretically it could be done down to the individual level so that rich people in poor countries pay the same or more than poor people in rich countries. (In rich countries there are other mechanisms to do this, such as patient assistance programs, but let’s not make this even more complex.)
  3. There can not be leakage between markets, otherwise the price is eroded in the expensive market. That’s why Gilead needs to confirm residency and why pharmacy tourism undermines societal benefit.

Price discrimination maximizes profits and maximizes societal benefits by increasing the number of people who can afford treatment, while rewarding the monopolist for bringing a valuable innovation to market. It’s not necessarily true that patients are harmed when Gilead maximizes its profit.

Allowing and even encouraging price discrimination is good global health policy. It encourages innovation and lessens global disparities.

By healthcare business consultant David E. Williams, president of Health Business Group.