Category Archives: e-health

How 23andMe got in trouble

Open sesame?

Open sesame?

Lukas Hartmann shares a great, detailed story (My deadly genetic disease was just a bug) of what happens when a self-described nerd is “confronted with a life threatening situation,” in this case a message about him from 23andMe that read:

“Has two mutations linked to limb-girdle muscular dystrophy. A person with two of these mutations typically has limb-girdle muscular dystrophy.”

Turns out this was the result of an error by 23andMe’s computer system. Now I’m all for patients having control over their lab results and getting away from the paternalistic idea that all results have to be filtered through a doctor. I support the new rule that gives patients direct access to their lab data. Still, this report on 23andMe is troubling and demonstrates what can go wrong when lab results are misinterpreted –either by patients, or, in this case, by a computer program.

Since I am stuck at the Cartoon Guide to Genetics level, I asked a scientist friend for his interpretation. Here’s what he told me:

The errors made by 23andMe are pretty basic:

1.  Lumping all forms of limb girdle muscular dystrophy into one entity and calling a biallelic mutation based on monoallelic mutations in two different diseases

2.  Even calling a compound heterozygote based on two different mutations in the same gene is sloppy because they could both be in the same copy of the gene, leaving the other copy functional.

Reporting such stuff directly to the patient when their output leaves much to be sorted out is a setup for false positives.  And using single nucleotide polymorphisms in the first place is less than reliable in diagnosing disease.  The results can be correct, but they can also be the genetic version of racial profiling.

23andMe is an expression of the approach that fancy software is more important than careful medicine.

There are definitely great opportunities to leverage knowledge and patient data to assist in diagnosis, treatment and clinical research. Companies like iCardiac, SimulConsult and Brain Resource are doing just that. But the technology has to be based on hard science and careful programming, and we still need expert physicians and scientists to interpret the results.

photo credit: widdowquinn via photopin cc

By David E. Williams of the Health Business Group.

When using a free health care website, consider the business model

Is a free lunch worth the price?

Is a free lunch worth the price?

When Google first came along I assumed that their business plan was to get users addicted to search and then start charging for searches. But it turns out they were a lot savvier than that. Instead of thinking of Google as a service to help users search out content, they thought of it as a service to help advertisers target customers. Users revealed their interests through their search habits, and Google delivered relevant customers to advertisers. Brilliant!

For a long time now Internet users have expected useful sites to be free. That’s true of consumer sites and it’s also true of professional sites. But before getting too involved with these sites it’s worth stopping for a moment to ponder their business models. That’s especially important for medical sites, where privacy is often a concern.

iMedicalApps  reveals the business model behind popular websites used by physicians:

Many free apps aren’t really free, though. We talked about the hidden price of free medical apps about two years ago, an issue that was later highlighted in the New York Times as well. In essence, the price of these apps is that we share enough personal information to enable targeted advertising, surveys, and so on.

What may come as a surprise to many healthcare professionals is that many apps they frequently use like Medscape and Epocrates share users’ names, NPI numbers, and other identifying information with pharmaceutical advertisers. As it turns out, Facebook and Twitter have stricter privacy policies than some of your favorite free medical apps.

The comments section is interesting. Most of those posting profess not to care if their information is shared. Maybe that’s reasonable, but at least it’s worth knowing that it’s occurring.

If you stop to think about it, it’s kind of obvious that “free” apps are leveraging user data to make money from other parties. Even so, many people are surprised when they learn about these business models. But even when the user pays there’s no guarantee that their data will be protected. Marketers are eager for information on doctors and others regardless of whether the user is getting a freebie. If anything, marketers are more interested in obtaining information about users with a demonstrated willingness to pay. And the purveyors of the information see no real reason not to double dip.

Edward Snowden’s revelations about NSA spying are having an interesting effect on the market. Snowden has raised awareness that information is often improperly used. Theoretically that might make people wary of signing up for sites that disclose their information. On the other hand, some may reasonably conclude that since the government is looking at their information anyway there’s no reason to try to protect it.

photo credit: webted via photopin cc
By David E. Williams of the Health Business Group.

Health insurance exchange for employers: Interview with ConnectedHealth (transcript)

This is the transcript of my recent podcast interview with Joe Donlan, co-founder and president of ConnectedHealth.

Joe Donlan, co-founder and president of ConnectedHealth

Joe Donlan, co-founder and president of ConnectedHealth


David E. Williams: This is David Williams, president of the Health Business Group. I’m speaking today with Joe Donlan. He is president and co-founder of ConnectedHealth. Joe, thanks for joining me.

Joe Donlan: Glad to be here. Thanks, David.

Williams: Joe, what is ConnectedHealth? What’s the idea behind it?

Donlan: ConnectedHealth is a private health insurance exchange. We’re focused on helping employers grow their business by offering a compelling and competitive benefits package to help acquire and retain key talent. The idea is that by offering this type of defined contribution solution, we can get employees thinking about their health and financial security, thinking much more holistically about how they spend and allocate their benefit dollars across benefit options. We know that if an employee is healthy and financially secure, they tend to be more productive in the workplace and can focus on growing the business.

Williams: Joe, there are a number of private health insurance exchanges around. Some focus on specific areas. For example, some work more with retired employees, those that are Medicare-eligible. Does ConnectedHealth have a particular focus?

Donlan: Absolutely. Most of our focus has been on the commercial, under 65 market. We offer capabilities on a group basis as well as offering capabilities for individuals, while always going through the employer. We can help solve employer problems and provide competitive benefits packages both in an individual and group world to those employees.

A good example of what we’re seeing in the marketplace is employers that have both group-eligible populations as well as a lot of 1099 or part-time employees that might not be eligible for those group benefits but could benefit by having easy access to individual health insurance plans.

Our approach has been going to those employers and being able to solve for each and every single one of their employees, given their diverse employee population.

Williams: It’s interesting what you’re describing. From a health care policy perspective and with all the noise regarding the Affordable Care Act, you hear a lot about the employer mandate being a problem for employers. You’re coming at in the other way, which is to say an employer might want to offer benefits even to employees who wouldn’t typically be eligible, in order enhance their attractiveness as an employer.

Donlan: That’s exactly correct. The ACA and health reform really has accelerated much of our business. Our business was never predicated on health reform at all. It was predicated on the fact that employers still need competitive benefit solutions and given their size and challenges, those needs may vary. So, an employer that has fewer than 50 employees might have a different benefit strategy and approach than an employer that has 500 or 1000 employees. We try to solve for those different situations by leveraging our e-commerce shopping platform and oftentimes using a defined contribution approach in the process.

Williams: The idea of a shopping or a customer-oriented approach to selecting health insurance is a new one. It’s getting a lot of attention now because of the Affordable Care Act. But can you describe what the experience would be like for a user? And is it more like what they would do in a typical kind of insurance purchase or is it more similar to Amazon or some other kind of consumer e-commerce website?

Donlan: It’s a great question; Amazon often comes up in this type of discussion. And really, it’s pretty different from Amazon. When you go to Amazon, you tend to know what you want. You know what products you’re looking for and you’ve already done some research, and you go there and you type in that particular product and you buy it and take advantage of Prime and all the other great services that Amazon offers.

Our approach is that people in benefits don’t necessarily know what they want. I’ve been part of organizations that have been developing consumer-oriented health care decision support tools for the past 13 years. And so there have been a lot of lessons learned in terms of what works and what doesn’t work when presenting very difficult information or, said differently, providing solutions or answers to complicated health care questions. So we spend a lot of time thinking about behavioral economics and spend a lot of time thinking about how you establish frameworks and put decisions in context to make the decisions easier for the end user and consumer. We always start with the consumer in mind, and then work backwards in understanding the key factors that influence those decisions.

Health insurance and other related benefits are very complicated and can be very confusing. And when we start talking about an exchange or a marketplace environment, oftentimes we’re talking about creating more choice. But choice doesn’t necessarily ensure satisfaction. The approach we’ve taken is looking at the key factors and the influences: What are the attitudes? What are the behaviors that we can ask someone in order to provide a smart and intelligent recommendation about a particular product? And so, we ask things such as, what is your risk tolerance?

Certainly we don’t literally ask ‘What is your tolerance?’ We ask it in a way that helps people understand how they would balance their dollars so that they realize that if they pay less in premium they could end up spending a heck of a lot more money when they need care.

And that is a concept that, with the way we address the question and the graphics we use, makes it very intuitive for someone to understand. We also ask them how they typically use health care over the course of the year for themselves and their family members. We ask how many times they typically see a doctor and how many times they typically take prescriptions, et cetera. We then apply a proprietary algorithm to that data and information and, factor in their demographic information to all the different benefit plans that are available to them.

And we provide a recommendation from top to bottom depending upon how many choices they have. We don’t say, ‘Here’s your co-pay, co-insurance, deductible, premium.’ It’s ‘Here’s your premium, here’s how much we think you’re going to pay, an estimated out-of-pocket cost.’ So we provide premium plus cost of care, and then the maximum out-of-pocket cost; the total financial exposure.

The approach we’ve taken has been pretty been fascinating. We have been giving people peace of mind in their benefit decision because very simply, the way we display the benefit recommendations, they can see the total financial impact of their decision. They know their baseline of what they’re going to pay in premium and they know their worst-case scenario.

What people don’t typically know is that middle figure. We take the mystery out of it and present it in a way that the user can start to think about what trade-off they may want to make. So if they spend a little bit more money in premium, they can see what the total impact might be and the decrease in estimated out-of-pocket cost or total maximum out-of-pocket cost.

Williams: So, when people think about shopping on these exchanges or marketplaces, there are many barriers, especially for those who don’t make their living like you and I do, thinking about this sort of thing every day. You just went through co-pay, co-insurance deductible, premium. But of course there are other sorts of things to consider – PPO, HMO, POS, narrow networks – all sorts of things that someone may have to deal with. And even the just the notion of it, is it a marketplace or an exchange, it’s pretty hard.

I don’t want to put words in your mouth but to get to the point of making the sort of trade-offs that you’re describing, does the user have to understand all that terminology?

Donlan: They really don’t. Since we keep this focused on essentially the financials, they see what the impact is on those three levers – the premium, estimated out-of-pocket cost and maximum out-of-pocket cost. We provide filters and using sliders, just as someone might use when they’re shopping for an airline ticket at You can very easily start to understand what the impact might be of your risk. So you have your ability and your tolerance for risk.

It’s very easy to say that, ok, if I’m willing to pay a little bit more every month, what might the decrease in cost be and how might it change the total financial exposure? These are the things that keep the stories off of the New York Times and the Wall Street Journal. We avoid a situation where a family chooses a plan without realizing that the maximum out-of-pocket was $30,000 and then, all of a sudden, they’re bankrupt. We are very clear and upfront about what that total cost is for the health plans so there’s level of transparency. What we’re finding with our clients is that it has given people a lot of peace of mind in order to buy.

We’ve seen with one of our grow their business based on number of applications submitted by over 130 percent. At the same time, they decreased their call center calls by nearly 40 percent. That tells us that people are coming to the shopping platform, they’re navigating it in a way that they would with any contemporary shopping/e-commerce site, and they’re transacting and making the purchase.

We’re seeing a lot of really positive results by taking this approach; it took us a long time to get here. We are applying the lessons that we have acquired over these 10-plus years; understanding the decision points and understanding the complexities of these decisions and figuring out how to make it simple.

On the backend, the way I like to describe it is it’s kind of like an iPhone. The shopping platform is very easy to use, very easy. All the magic essentially happens behind the scenes. We do the hard work behind the scenes so that the user can have a more enjoyable and seamless experience when they’re navigating the site.

Williams: I know you’ve been at this for quite awhile. But for most people, they’re just getting exposure to the kind of shopping experience that you’re describing. I’d like you to push fast forward and think about where we get to in five years. Once it’s kind of routine to use this sort of platform, what kind of extensions might there be on it? What’s next for an employer, beyond trying to get people to buy and use the platform? Where does it go from here?

Donlan: I think we’re just scratching the surface right now, David. And what’s going to be really fun to watch in the market is how levels of personalization continue to get enhanced just like you’ve seen in many other industries. So we spend a lot of time looking at the financial services industry as an example, and think that there are a lot of parallels into what we’re doing in the benefits world.

So the concept of someone thinking about their overall benefits portfolio and how an individual may want to allocate dollars across that benefits portfolio from a health and financial protection standpoint is pretty exciting to me. And in order to make that successful, data and information are going to be key to drive personalization. You can envision a world just as if someone was sitting down with their financial advisor and they’re saying that they want to have a child and they want to retire in 40 years and they want to have a house in Florida when they retire, etcetera. And that financial adviser answers, “OK, here’s what your portfolio needs to look like.”

But that portfolio may change once you have children and maybe multiple children. Maybe you choose to send one of your children to a private school instead of public school. I think the same will hold true when someone looks at this holistic benefits portfolio and how they allocate dollars. Having a child is a good example. You may adjust your benefits portfolio and start allocating more dollars towards life insurance than you would have when you didn’t have children.

So, that’s where the really exciting times are ahead of us is. It’s getting people to take ownership of their health and financial security portfolio.

Williams: I’ve been speaking today with Joe Donlan, president and co-founder of ConnectedHealth. We’ve been talking about private health insurance exchanges. Joe, thanks so much for your time.

Donlan: Thank you, David. I really appreciate talking to you today.

Health insurance exchange for employers: Interview with ConnectedHealth

Joe Donlan, co-founder and president of ConnectedHealth

Joe Donlan, co-founder and president of ConnectedHealth

With all the fighting over ObamaCare and the botched launch of the federal exchange, it’s easy to lose track of the fact that online insurance marketplaces are an efficient and effective way to compare and select coverage. Exchanges are catching on in the private sector and I expect their growth rate to increase as people get used to them.

ConnectedHealth provides an exchange platform for active employees (as opposed to retirees). They focus on helping employees understand what’s available to them and the full financial consequences of their decisions. Their platform is designed to serve companies who may have a mix of employees: group eligible (i.e., full time, permanent workers), part-time employees, and 1099 independent contractors. Employers are offering the platform in order to attract and retain employees and to help those employees make the most of their benefits and avoid surprises.

In this podcast interview, ConnectedHealth co-founder and president, Joe Donlan explains how it works.


By David E. Williams of the Health Business Group.

DocASAP: multi-channel platform for booking doctor appointments (podcast)

DocASAP CEO Puneet Maheshwari

DocASAP CEO Puneet Maheshwari

DocASAP provides an online platform that enables consumers to book appointments with health care providers through multiple channels, including insurance company websites, consumer health sites, and providers’ own websites. It also smooths the specialist referral process by allowing physician offices to book appointments on behalf of their patients.

In this podcast interview, founder and CEO Puneet Maheshwari describes how DocASAP is differentiated from other offerings, discusses the company’s strategic partnership with MultiPlan, and speculates about the uses for the transaction data generated by the platform.

By David E. Williams of the Health Business Group.

Doctor’s office of the future meets office of the past

Doctor patient tablet

I went to an appointment today with a doctor in a high-paying specialty who presumably has the resources to organize his office the way he wants. I was very satisfied with the doctor’s thoroughness, empathy and communications skills –which for me were the key things I was looking for. But I was also struck by the mix of modern, sleek information technology with some old-fashioned (even retrograde) administrative processes.

The nurses and medical assistants had iPads, which they used to call patients, record information and manage the workflow. The electronic medical record was clearly a bit clunky so the doctor made use of a medical scribe to whom he dictated information as he performed the exam. It’s kind of crazy that he needed to add a person to the process when the EHR was introduced, but I’m glad he did because it meant he could focus completely on the exam and not at all on the computer. That definitely helped the doctor/patient experience. I also noticed that the scribe was trained to turn away when the doctor cued her that private parts were going to be exposed.

Meanwhile, the check-in process reminded me of 1975. I received a clipboard with a set of forms that looked like they had been photocopied a few times. There was a space for my Social Security Number. I left it blank and you should, too, unless you want to open yourself up to identity theft. They asked for my insurance information even though they had photocopied my card, they wanted my pharmacy information in two different places and asked redundant questions about my medical history.

I’ve learned from experience not to bother complaining about the Social Security Number question –better to let them bring it up if they insist- but I did ask if I really had to fill out the pharmacy information multiple times. They said yes: one copy for my medical record and one for some other file they maintain.

These are small annoyances in the scheme of things, but they are noticeable in a customer-service oriented world where websites like Amazon and devices like the iPhone are engineered with the convenience of the consumer in mind.

photo credit: juhansonin via photopin cc

By David E. Williams of the Health Business Group

Healthcare Social Media Review is up at BrandEngagement

BrandEngagement hosts a thoughtful, thorough edition of the Healthcare Social Media Review, a roundup of blog posts about the use of social media in health care. My post about the value of patient reviews is featured in a section on Patients & Social Media. The other post in that section is by Forbes writer Dan Munro, who writes that ZocDoc is the only health care app to make the list of top mobile apps.

ZocDoc lets patients find doctors and make appointments. It’s kind of like OpenTable, which does the same for restaurants. But interestingly, neither Munro –who focuses on the service for consumers– nor the commenter –who talks about data sales– puts their finger on the key driver of ZocDoc’s business model, which is that physicians are the main customers.

Like OpenTable, ZocDoc is a lead generation tool that providers (whether restaurants or doctors or dentists) will pay for in order to get customers in the door. But ZocDoc’s value proposition goes a bit further, which is that it also enables providers to enrich their mix by picking up more desirable commercial patients and even those from specific high-reimbursing health plans.

So ZocDoc is more like an OpenTable that lets restaurant owners bring in more high-tipping, beautiful people and screening out those who are less desirable and less profitable.

ZocDoc does have some potential utility for consumers but I hope next year’s list of apps will include something where the consumer is the app’s true target customer.


By David E. Williams of the Health Business Group.

New York cracks down on fake online reviews with $350,000 in fines

Kudos to New York Attorney General Eric T. Schneiderman, who pursued a major investigation of the fake online review business that ended with agreements with 19 companies to cease writing fake reviews and to pay fines totaling more than $350,000. Online reviews matter, which is why some companies are willing to pay $1 to $10 per review to boost their reputations on sites like Yelp and Google Local.

I’m a fan of online reviews in general, and for health care providers in particular. But I acknowledge that fake reviews are a problem. The online review companies understand this and are going after fakes with filtering software and other approaches. So it’s good to see law enforcement join the fray to help protect consumers and enable online review sites to flourish. As Schneiderman says:

Companies that continue to engage in these practices should take note: “Astroturfing” is the 21st century’s version of false advertising, and prosecutors have many tools at their disposal to put an end to it.”

The battle against fake reviews is far from helpless. In addition to automated fake-detection tools and legal action, there are business models and community structures that can clean things up. Angie’s List, for example, does not suffer from fake reviews the way free sites do. On the flipside, Angie’s suffers from limited traffic as a result of its paywall –and it also doesn’t understand how to adjust its rating scheme for health care. They’ve asked me literally twenty times to rate Northeast Surgical Center, even though I’ve told them I’m not a patient there.

But eventually someone will figure out how to build a trustworthy, open community that generates high quality reviews and couples them with objective data on quality of process and outcomes.


By David E. Williams of the Health Business Group.

Highmark’s Care Cost Estimator looks promising

Highmark Health Services, a big Blue Cross Blue Shield plan is rolling out its Care Cost Estimator, a transparency tool designed to get members to make cost-saving choices. The video embedded below does a good job of explaining the tool. In watching it, I’m impressed at just how far these tools have come over the past couple of years.

The site is similar in concept to a travel website like Orbitz. It allows users to select the type of care they need, and then see an array of provider choices and associated costs. The costs include total costs and out-of-pocket costs that are specific to the member. It claims to incorporate all aspects of the benefit design and benefit use to calculate the actual out-of-pocket costs. The site also displays patient reviews of the providers.

The real potential of the site is described at around the 2:20 mark, where the video refers to “reference based benefits,” which set an allowable price for a specific procedure and then make the patient pay anything above that amount. Reference pricing has the potential to produce major cost savings at least for certain procedures. I wasn’t aware that Highmark was utilizing this approach. In any case, in order to make reference-based pricing effective, transparency tools like this are an absolute must.

I don’t know whether the site is as easy to use and as useful as the video makes it seem. But if so, this is a big step forward for Highmark, its customers and members.

By David E. Williams of the Health Business Group.

Patient reviews: Don’t throw the baby out with the bathwater

Patient advocate Trisha Torrey (Tragic Reminders of the Uselessness of Doctor Ratingswarns us not to trust online doctor reviews; health care journalism scold Gary Schwitzer picks up the story and runs it uncritically. There’s some worthwhile information in the blog post, but the case against reviews is seriously overstated and the alternative paths proposed are not as useful as they sound.

Torrey provides two examples of negligent physicians who received good ratings on various sites such as Healthgrades, Vitals, and RateMDs. One orthopedist later admitted performing fake surgeries and a family doctor turned out to be a drug abuser and dangerous prescriber.

Here’s Torrey’s advice:

So what do we empowered patients learn from all this?

First – that trusting reviews on a doctor ratings website is folly.  Clearly – you cannot trust them.  They are people’s opinions based on things like how polite the receptionist is – NOT helpful when it comes to the need for real care.

Second – that there are ways to find a doctor and his or her credentials online that are safe and useful, including information about malpractice.

And finally – that just because a doctor is nice, does not mean he or she is competent – and vice versa.  If you ask a friend for a referral to a doctor, and that friend uses the word “nice” – dig deeper!

As we move into 2014, and the Affordable Care Act kicks in, finding the right doctor is bound to become more difficult.  But that does not mean we can or should take shortcuts.  Read the USA Today expose cited above… it will make your toenails curl and will compel you to be very careful.

Doctors ratings are shortcuts – dangerous shortcuts.  Just don’t go there.

I beg to differ.

On the first point, reviews vary widely in quality. But they are definitely not all “based on things like how polite the receptionist is.” For example, the Yelp reviews on my physician’s practice go into considerable detail about the workings of the practice and how the clinical skills of its various doctors. Yelp also has an algorithm to put the most useful reviews toward the top, and sure enough the first one for my practice is from a woman with chronic illnesses who’s been going to the practice for 10 years. She has 3 verified “check-ins” with Yelp from the practice. Her first name, town and profile are provided, and it’s possible to see the distribution of ratings she gave to other businesses and to read her reviews. Anyone who wants to spend the time could get a very good sense of the types of people reviewing the practice and could calibrate those comments and reviews with others written by the same people.

There is plenty of room for improvement in the Yelp system, but it’s a heck of a lot better than Torrey –and many other critics of online reviews– gives it credit for. Spend 15 minutes looking at Yelp reviews of doctors and form your own opinion.

On the second point, Torrey would have us believe that it’s easy to find “useful” information, including information about malpractice. But the same USA Today article she cites to expose the family practitioner is mostly about how abusive doctors can run amok for years –or forever– without having their medical licenses suspended or any information about the bad behavior coming to light. As the article notes, “The doctors’ names are a mystery: identifying information is stripped from the Data Bank’s public file. Full access is limited to medical boards, hospitals and other institutions that are supposed to weed out bad doctors.” And malpractice cases that are settled (the majority) are not made public.

Overall I’m surprised that a patient advocate would be so quick to trash reviews by fellow patients and accept as adequate what little information comes out of the medical profession and other official sources not completely committed to transparency.


By David E. Williams of the Health Business Group.