Monthly Archives: June 2011

Harvard Pilgrim CEO Eric Schultz speaks with the Health Business Blog (Part 1 of 4)

Recently I sat down with Harvard Pilgrim Health Care (HPHC) CEO, Eric Schultz for a wide-ranging discussion on the health care business. In this first of four segments I ask Eric to share his thoughts on the role of health plans in influencing cost and quality, what HPHC brings to Accountable Care Organizations (ACOs), and whether there’s any difference between the current shift toward global payments and what we witnessed in the 1990s.

HPHC has been named the top health plan in the US seven years in a row by the National Committee for Quality Assurance (NCQA), so a lot of people in the industry are keeping a close watch on what Eric and his team are doing.

OrganizedWisdom CEO explains the launch of Startup Health (transcript)

This is the transcript of my recent podcast interview with OrganizedWisom CEO Steve Krein.

David E. Williams:            This is David Williams, co-founder of MedPharma Partners and author of the Health Business Blog.  I’m speaking today with Steve Krein, CEO of OrganizedWisdom.  Steve, I understand that you have some news to announce about Startup Health.

Steve Krein:            Yes.  First of all, thank you so much for having me.  We are down at the Department of Health and Human Services’ Health Data Initiative Forum in Washington, DC where, in a few minutes, we’re going to be announcing the launch of an initiative called Startup Health. It’s an initiative focused around inspiring, educating and providing resources to entrepreneurs who want to build health and wellness companies.

We’re doing this at a time when the barriers that used to exist to innovate around health and wellness –teams of researchers and scientists and capital and time that was needed to really make meaningful change– all those barriers have come down. With new technologies like mobile apps, someone can download an iPhone or iPad app software development kit for $99.

The focus of this conference is the treasure trove of amazing government data and public data that they’ve made available for free to entrepreneurs to innovate on.

We’re doing this at a time when entrepreneurs have never had so much opportunity, yet there is still no road map for the entrepreneur to go from point A to point B to point C to point D and, over a long period time, get access to the mentorship, guidance, resources, tools, technologies, talent pools and capital. So since there’s no road map, we, as entrepreneurs in the health and wellness space recognize a huge need to connect all the dots.

So I’m incredibly excited that one of our investors and board members, Gerald Levin, who is a former CEO and chairman of TimeWarner, is chairing this initiative. We could not be more excited about the opportunities that exist for entrepreneurs today, but even more importantly, what we can do to help them turn their ideas into long-term sustainable businesses and make meaningful change in the world.

Williams:            Who are the founders of this initiative?

Krein:            This initiative is being launched by OrganizedWisdom.  The team at OrganizedWisdom has been working to codify and identify all the things we’ve done over the last several years of building our health and wellness company and turn it into a program that can teach other entrepreneurs to do that.  So OrganizedWisdom is not only going to help mentor the entrepreneurs and show them what we’ve done right and what we’ve done wrong and what they might want to do differently, but also get access to our technology, whether it’s to build an app or to test an app or test an idea. We’ll give access to our technology, to an API that we’re going to be releasing later this year.

Gerald Levin, whom I mentioned, is going to chair it, but there are others who are launch partners with us.  I’ll talk about the first two that I think are most relevant to today’s announcement. We’re the newest member of the Startup America initiative, which is the White House’s initiative that was announced earlier this year that Steve Case, the former CEO and Chairman of AOL, is chairing. Scott Case, one of the co-founders of Priceline is the CEO.

We’re going to be announcing today upcoming roundtables called Startup Health Roundtables.  The first one is going to be hosted by Startup America and we’re going to do it in partnership with them in New York City.

The second roundtable is with our second partner that we’re announcing, the Department of Health and Human Services who we think has done an extraordinary job.  Todd Park and his team have unleashed so much amazing data.  We’re going to have our second roundtable with HHS and that’s going to be the focus of the first two.

Then the third announcement that we’ll be making is that we’ll be doing one in San Francisco where we’re going to have Thomas Goetz at the Health 2.0 conference doing an organized roundtable around Startup Health.

Those are some of the upcoming things that talk about who’s behind Startup Health.  I think there’s some incredible work being done by the accelerators like Rock Health and the soon to be launched Blue Print Health that we want to help make more visible and promote as unbelievable resources for the community.

As I mentioned, Health 2.0 is also a part of one of the many companies and organizations that’s pledging.  Already today, hundreds have pledged their support to this health and wellness start up ecosystem, which we think has been never truly organized in a way that made it obvious who the investors in this space are, who the entrepreneurs are, who the organizations are and who the businesses are.

So this Startup Health pledge is the second part of our announcement today and it’s something that we feel is going to help us connect the dots and let people identify themselves as passionate about the space.

Williams:            No doubt there’s some degree of skepticism about the role of big federal agencies encouraging entrepreneurship and yet you’re speaking quite positively about the HHS initiative.  Why is that?

Krein:            If you were down here, you would see that there are 50 companies that have tapped into one or many of the data sets that the government has made available.

I think Todd and his team and everybody here at HHS in cooperation with the US CTO, Aneesh Chopra, elevated the game around this space and participated in a way that says we’re helping to make available to entrepreneurs the data that they can innovate on.  There’s such energy in this room down here, filled with several hundred people, 50 companies presenting their apps and their version of innovation related to how the data could help their business.

OrganizedWisdom separately has launched two applications down here that support our mobile health toolbox.  One is called “How Healthy is Your Community?”  OrganizedWisdom’s team ran a code-a-thon a couple of weeks ago, divided up the tech team into two groups and said, taking two different data sets, what can we do to innovate on our product?  This “How Healthy is Your Community” app is giving doctors the tools or the data from the government that they can share openly with their patients in a very easy way.

The second app that we did that won (and we featured both of them here) is taking data from the National Institutes of Health. We said why shouldn’t a patient of a doctor be able to sign up for alerts from NIH?  In the old world, you’d say well, NIH is never going to build that and we said in this world, they don’t have to, we can build it.  So they made the data free, we innovated on it and now a second tool for patients and their doctors has come down.

I’m just incredibly optimistic about the Obama Administration kicking off what I think will continue for many years, which is a different type of government that’s participating by just making things available for entrepreneurs to do something with.

The atmosphere here is very different than any kind of skepticism that you could have because they did exactly what they said they were going to do.  I watched Todd a year ago say he was going to unleash this data and they did.  It’s called and any entrepreneur can go to that site and see all the data that’s available for them to use in their products.

Williams:            Last question before I let you get back to the meeting.  How will we know if this program Startup Health is successful?

Krein:            We’re looking at this and it comes down to the innovation that we believe is going to become evident in the coming years.  It’s now going to take place with new businesses that are started.  I say “businesses,” not apps, but businesses that are started as a result of access to mobile software development kits and the data.

So we’ll look at how many entrepreneur companies can we help through this program, how many investors can we help get introduced to incredibly gifted entrepreneurs who have a passion, who want to be connected with entrepreneurs with a passion for health and wellness.

How many organizations have we been able to connect?  Whether it’s HHS or Startup America or other initiatives that might have been never tapped into before in the previous generation of business development and also corporations who are incredibly excited about finally being able to tap into entrepreneurial innovation in their products or platforms or businesses.

One of the things that we’re doing down here at the HHS Health Data Initiative event is asking any investor or entrepreneur or organization or business to go to and take the pledge.  The pledge is very simple.  It just let’s you raise your hand and say you are committed to the health and wellness start up ecosystem.  There’s a little drop box that lets you say what you’re interested in and whether you’re an investor or whether you’re an entrepreneur or whether you’re a business or organization or even a journalist for that matter, which I think is incredibly important to raising the awareness here.  I think the more people that take the pledge that are committed to this space, the more we can shine the spotlight on the incredible work that’s being done and inspire others to come in and get into the space and bring their talents here.

Williams:            Sounds great.  Well Steve, I wish you great success with this.  We’ve been speaking about Startup Health, a new initiative that’s being announced today by OrganizedWisdom down in Washington, DC.  I look forward to following up and seeing how it goes.

Google Health is gone. Why did they pull the plug?

Google Health was announced in 2007 yet never caught on. Now the company is dumping the offering. I can understand why the current product is being discontinued but am surprised to see Google abandon the consumer health focus so explicitly. It’s not as though someone else has run away with the market; and there are massive financial opportunities in the long run for someone who can get it right.

A physician/entrepreneur friend sent the following observation, which I agree with.

I’m not surprised about the announcement since Google Health failed the “what’s the point” test.

The one most exciting thing I’ve seen in consumer health since Google Health began is doctors being available on patient support group listservs.  If Google had set up a service for such patient support groups and somehow induced some doctors to be available they would have gotten a lot more done.  I don’t know if Google could have generated enough revenue to support such a service, but I never understood how they planned to support Google Health either, and the patient support groups at least pass the “what’s the point” test.

Meanwhile, the best overall post mortem I’ve seen about Google Health is by John Moore of Chilmark Research, who’s been skeptical of the initiative for some time. He cites multiple yellow flags and provides some lessons learned.

Yellow flags

  • Quick departure of Google Health Adam Bosworth
  • Initial pilot with Cleveland Clinic had weak uptake
  • Did not support the standard Continuity of Care Record
  • No one really leading the effort over time and not many resources seemed to be committed

Lessons learned:

  • Google never really provided any value to the consumer
  • The doctor needs to be involved to get the patient interested
  • Google’s departure from the field may lead Microsoft to pare back its resources

Podcast interview with NaviNet CMO Michael Ross (transcript)

This is the transcript of my recent podcast interview with Michael Ross, Chief Medical Officer of NaviNet.

David Williams: This is David Williams, co-founder of MedPharma Partners and author of the Health Business Blog.  I’m speaking today with Dr. Michael Ross, Chief Medical Officer of NaviNet.  Dr. Ross, thanks for being with me today.

Michael Ross:            You bet David.

Williams:            Tell me about NaviNet. In particular, what is the core challenge that your company addresses?

Ross:            NaviNet is an 11 year old company focused on real-time health care communications. We provide core customers, which are largely health plans –but also governmental entities and — with a linkage that enables administrative simplification. It gives doctors the ability to receive key pieces of information in their offices that support their financial and administrative functions. It serves as a conduit between payers and doctors in real time to enable information exchange.

Williams:            How widely deployed is your solution?

Ross:            We operate in all 50 states and communicate to about 70% of the doctors across the country.  We have 30 health plan customers, which translates into about 460,000 unique physicians, 90% of which are in small group practices of ten or fewer physicians.  We also have solutions deployed to about thousands of hospitals and ancillary care facilities. It’s about 800,000 transactions per day going across the network; about 300 million transactions a year.

Williams:            That’s quite high coverage. How did you get from zero up to that point?

Ross:            You know, our work started off with largely regional customers and that was Blues plans. And then, as the national payers started to emerge, it enabled us to get a footprint into a much larger provider network for purposes of servicing these national payer needs and delivering that financial and administrative information.

Importantly, for about the past two years or so, NaviNet has layered on clinical transactions that flow between our payer customers and our provider offices.   Those transactions include gaps in care and other things that are derived from the plans’ care engines that provide or serve as a transmission channel for things that are going on outside of the doctor’s offices.

So the electronic health records and other tools that the docs are using locally, if they have to be enabled on those kinds of solutions, really give them insights into what’s happening in their practice environment. The layering of the clinical transactions with data supplied by the plans gives them a view of what kinds of things are going on outside of the individual offices, a much wider purview on behalf of that patient.

Williams:            It sounds as though your paying customers are mainly the health plans, but a lot of the users are on the provider side.  Do I have that right or how does it align?

Ross:            You do have that right, but about 5% of our revenues and an increasing percentage of it are derived from provider revenues.  We recently launched our practice management and EMR solution, which we are now rolling out in the provider community together with our mobile solution.  The practice management and EMR solution is financed by the physician offices.

Williams:            It seems as though a lot of what you’ve built up over time is based on an e-prescribing platform, if I’ve understood that right. So I wanted to hear about if that’s the case and about how, as we transition into an era that’s characterized more by electronic health records, how in fact you’re thinking about moving along with that.

Ross:            It’s really interesting.  The NaviNet enterprise has purchased a solution, Prematics, in December. Prematics’ focus was on using an e-prescribing Trojan horse as an entrée to clinically messaging physicians when they’re at that teachable, impactable moment behind the examiner’s door.

What the acquisition of Prematics, now relabeled the NaviNet Mobile Connect Solution, provides is that last few feet from what were historically clinical messages deployed on the NaviNet portal to get them into the doctor workflow.

The vast majority of docs write one or more prescriptions for roughly 85% of their encounters. Therefore if they’re up on the e-prescribing solution, it affords a phenomenal opportunity to render other clinically relevant message that the health plan has where they’re actionable.  That really was the genesis.

The acquisition was taking the clinical messaging pieces that NaviNet had been doing for the past couple of years and getting them in front of the docs when they can do something about that.

It ties to such broad adoption that’s going on in general with mobile.  Seventy-five percent of practicing docs are now using smartphones.  What’s phenomenally interesting over and above that is the trajectory of the tablet, and specifically the iPad, as a form factor that docs are using for a variety of different things when they’re rendering care to patients.  What we’re seeing happen right now is that iPads are deployed in roughly 28% of doctors’ offices today, but if you ask them what their plans are within the next year with respect to acquisition of that specific form factor, it’s getting upwards of 90% or more.  NaviNet’s mobile solution is deployed on iPad in addition to iPhone and iPod Touch and Android form factors together with our earlier deployments, which were largely Windows Mobile.  What we’re tying to is a dramatic sea change in the use of mobile technology for care-giving. It’s just fascinating to watch.

Williams:            What level of receptivity do physicians have to this kind of mobile solution if they’re also implementing an electronic health record at the same time, as I assume many are?

Ross:            That’s such a great question.  I’ll make a couple of observations about electronic health records in general.  Keep in mind that 90% of our docs are in practice configurations of ten or less and while those docs may in fact be contemplating EHRs with some of the incentives around Meaningful Use that are out there right now, a large number of them are not, particularly in the small doc offices.

What the NaviNet Mobile Connect offers the docs is the opportunity to take a more incremental, modular approach to automating what they do in terms of acquisition of technology in their office.  We tend not to deploy in those practices that are already down the EHR pathway. But importantly, we can and do.

I think one thing that’s important in EHRs is that there are documentation management tools and they serve a very important function in that regard.

Open questions in our minds are: do you really need to take the three inch thick chart into each and every encounter, particularly with what’s going on with the iPad right now? Do you prefer to have essential pieces of information available to you in the exam room; discharge summaries, patient clinical summaries just in general, e-prescribing, labs, referrals, authorizations?  Would you prefer to have those kinds of key pieces in the care-giving process, assuming those things are integrated with the EHR, and then to go back into the equivalent of the three inch chart or the electronic health record for more specific information if those are lacking?

These are open questions as we evolve NaviNet Mobile Connect from what it is today, namely a clinical messaging platform that is layered on top of an e-prescribing workflow tool into itself becoming Meaningful Use capable.

We’re working on that and trying to sort through some of those issues, mindful that, as you suggested, the docs are hearing much more about and considering their options with EHRs.

Williams:            I’m sure that even as the physicians are shifting along in technology that health plans aren’t standing still in terms of what they’re expecting from you or in terms of what they’re business objectives are?  How do you look at the health plans going forward?

Ross:            One of the areas that health plans are struggling with and that they’re looking for NaviNet to help with is this area of medical home and accountable care.  Clearly in the past year and a half, there’s been a sea change that involves the shifting of care coordination responsibilities from the payers, who historically have done that with less than optimal results, to the doctors who have the trust and relationships with the patient.

The plans are putting significant amounts of money on the table to support the doctors in doing this care coordination and they’re looking for NaviNet to help them deliver the tools to the docs to support those kinds of efforts.  Mobile is certainly a piece of that, but I think where you’re going to see NaviNet go is the support of a clinical dashboard.

We’re already deployed in 70% or more of the physicisn practices around the financial/administrative clinical messaging component.  It would seem that we are a very logical place.  The plans expect us to be the one that convenes a clinical dashboard that can be shared across multiple stakeholders.  Some of those will be in the medical home and/or the ACO.  Some of those may in fact reside at the health plan leveraging people resources; pharmacists, nurses, etc. that today are working with the health plans, but tomorrow may be extensions of the physicians.

All of the tools, whether that is NaviNet’s portal that will have enhanced clinical capabilities or NaviNet’s portal PM and EMR, which is an option for some practices, will be available.

We also will be able to relate to other practice management and EMR systems as well and the mobile will be multiple views, with multiple access points for those offices to support future requirements.  The plans have really aligned the economics to help doctors move in this direction in the next year or two.

Williams:            What is the role of the patient?  Do you have applications that touch the patient either directly or indirectly?

Ross:            While a critical component of this whole medical home care coordination piece, we will likely get to that through partnerships.  We’re looking at various types of solutions that help do that; some of them are portal-based, some of them are SMS text-base, some of them are IVR-based.  Frankly, the social networking arena gets particularly interesting as well to support patient engagement.  That will likely happen through partners.

That said, I think that our payer customers today expect us to be a general contractor and provide them with turnkey solutions, end-to-end solutions and that doc/patient communication conduit will be a critical component of that if we’re going to be successful in optimizing the medical home initiatives.

Williams:            What else do you see going on in the environment that presents either opportunities or threats to you?  I’m thinking for example about the shift of physicians towards employment and away from some of these smaller practice settings.  What are some of the things that you’re seeing and how do you evaluate them and look for opportunities?

Ross:            I do think the dynamic you just expressed is spot on.  Doctors, particularly those that are a little bit further in their career, are looking at the hurdle rate that some of these medical home ACO type of initiatives are going to impose and wondering whether, at that stage in their lives, there may be a more convenient way to get there by

Several plans that we work with, they’re hoping that by us supplying the tools and them supplying the incentives, they can help smaller practices to not be forced into that acquisition mode and to have alternatives.  I think that that’s one sea change that you’ve correctly identified.  NaviNet is well positioned either way, were that to happen or were that to not happen.

The payment reform issues are real and so I think a lot of my comments thus far have focused around the medical home because it’s more tangible, it’s more real, there are standards set out.  ACOs, which clearly the Feds have incentivized through the Affordable Care Act, feels more like a work in progress, but one that NaviNet will also be able to play a role in.

If you keep in mind some of our core assets around financial and administrative transactions and now increasingly into the clinical arena, I do think that we have a role to play as ACOs mature.  We’re certainly mindful that if you’ve seen one ACO, you will have seen one.  Some of the core transactions that we support will probably be significant and there will be a role to play in integrating financial, administrative and clinical as ACOs shape up.

Williams:            I’ve been speaking today with Dr. Michael Ross.  He is Chief Medical Officer of Navi Net.  Dr. Ross, thanks so much for your time.

Ross:            Likewise David.  I really appreciate it.

PatientKeeper CEO Paul Brient on Accountable Care Organizations (Transcript))

This is the transcript of my recent podcast interview with PatientKeeper CEO Paul Brient.

David Williams:            This is David Williams, co-founder of MedPharma Partners and author of the Health Business Blog.  I’m speaking today with Paul Brient, CEO of PatientKeeper.

Paul, Accountable Care Organizations (ACOs) are getting a lot of attention these days after the issuance of the draft regulations.

Paul Brient:            Certainly ACOs are a topic of almost every conversation I have with health care organizations. The concept is not a new one necessarily.  It looks fairly similar to delegated capitation arrangements that many payers attempted or, in some cases, successfully put in ten or fifteen years ago.

The best general characterization of ACOs is they are very, very good concepts, the right idea.  The legislation and the regulations to put it in practice, however are difficult at best for providers and members and the community to understand. It sparked much more confusion than clarity.

If you look at the specifics of the legislation and some of the requirements of ACOs, which makes sense, and then compare that to the size of the panels that they’re requiring, there is a major overhead problem.

The minimum panel size is 5,000 people.  With the governance and infrastructure requirements to properly manage a population, it just can’t be done anywhere near a scale of 5,000 people. You need hundreds of thousands or more people to effectively manage a population.  So it will be interesting to see how this plays out in the real world.

Williams:            Since you mentioned it, let’s go back to the delegated capitation concept and the similarity to ACOs. Why is this ACO concept coming to the fore now?

Brient:            We have a fundamental problem in our society, which is that health care costs are increasing at a rate faster than the domestic product. That can’t go on forever.

One thing you can say for sure about capitation was that it was fairly effective at controlling costs.  The population in general, the commercial population, responded negatively to it in many places. But in California, capitation still is the norm and in fact, many folks in California are quite happy with it.

We have a large client out there, HealthCare Partners, that was one of the ACO pilots.  They’re a full delegated risk capitation health group, both from the hospital side and on the primary care side.  It services about 500,000 patients, does a great job and they’re regarded as a very premier place to get your health care.

So in some parts of the country capitation has survived. It has certainly been an effective technique of managing costs and actually ensuring quality.

Harvard Pilgrim Health Care, which got started in a capitation clinic model, had some of the best quality ratings back when they had that model and some of the worst customer satisfaction ratings. I always found that very interesting because people don’t necessarily evaluate their providers based on the same quality measures that you might evaluate them if you were a health provider.

Williams:            So let’s go back to today.  You mentioned this issue about panel size and overhead problem.  You could have a 5000 patient panel, but the requirements might be such that the infrastructure would be more like the size of something you need for somebody 20 times bigger than that.  How did that happen and how will folks deal with it?  Will the smaller ACOs just not exist or will they find a way that’s more efficient?

Brient:            This is just a draft document.  When the comments come back –if the Meaningful Use guidelines are any indication of how this might play out– I suspect one of two things will happen.  One is they might raise the panel size.  I think that’s unfortunately impractical just given the way health care is organized in this country. I think what they’ll end up doing is watering down the requirements maybe to the point where it’s pretty ineffective.

If you look at Stage One Meaningful Use for example, the requirements on provisional entry are one medication order per year per patient for 30% of your patients.  Clearly that’s not going to make a difference to anybody and I suspect that the next version of ACO legislation will contain some watering down, hopefully not that much watering down.

If you read the current requirements, they’ve got boards and dedicated physician executives and all this stuff in there that you just can’t do to support 5,000 people, which is three or four PCPs.  So that’s just not going to work well.

Williams:            You mentioned that when Harvard Pilgrim started out, they had high quality and yet they didn’t have such great patient ratings.  One of things that’s said that’s different about ACOs compared to the old capitation models is that there is more direct incorporation of quality measures.  Will that help address some of that gap?

Brient:            Well, I think this is the dichotomy of consumer selection of health care and quality delivery of health care.  People don’t understand the quality metrics very well. If you look at what people really care about, they want to go see the doctor that they want to go see, they want to be able to see the doctor when they would like to see the doctor, they would like convenience, ease of access, good communication, more time with the physician. It’s not clear that the ACO model will help or hurt that.

There’s pieces in the legislation, and certainly in the press releases around the legislation, that are trying to reassure people that oh yes, you can still go see whatever doctor you want. But the model falls apart if people are going outside of the ACO.  So I’m not quite sure how to balance those two things.  I don’t think they’re reconciled well yet.  I don’t know whether it’s marketing and PR versus reality, but if an ACO is really going to work, you’ve got to get your care within the context of that ACO and the relationships that providers have are really important.

I think that was the frustration with capitation plus just the general suspicion that people know their  doctor is being incented to, in a sense, manage the cost of health care, which means in everyone’s mind not giving them the services that they would like or deserve.

Williams:            For those organizations that are moving toward an ACO model, either because they’re comfortable that they can handle the draft regulations as written or because they think that there will be some adjustment over time, how are such organizations thinking about their information strategy and does it represent a shift in priorities from where they were heading otherwise?

Brient:            Well, I think it depends on the organization.  HealthCare Partners is a client of ours and uses our technology to integrate across hospitals and the primary care practices. They’re already set up to do it.  They already have the technology in place.  You have to be able to give your primary care physicians the visibility into what is happening to those patients when they leave the primary care office.  That is a very good thing for lots of reasons.  It puts the primary care physician back into the role of providing health care, which is a role that ironically managed care has taken them out of because of the changes in the reimbursement and how little time they get to spend with the patients.  Directionally that makes a lot of sense.

From an IT perspective, you have to have infrastructure to be able to give them this ability. What happens is if one of your patients shows up in the ED and you don’t know about it, you really can’t do much about it. Whether you’re above or below the cost targets or whether you effectively manage them or not, it’s a crapshoot.  So certainly from an IT perspective, some organizations have the IT infrastructure in place.  Integrated delivery systems, in many cases, have a lot of it.

Where a lot of scrambling is going on is when you go out into smaller traditional communities and towns, a couple of community hospitals and a physician community, that are mostly small physician practices and they don’t have the infrastructure in place.  They’re lucky to have an EMR, much less a networked EMR. With Meaningful Use role, all that stuff is getting built, but it’s going slowly.

So I think there’s going to be a real challenge for ACO formation in the near term outside of places that already have the relationships and the infrastructure in place.

Williams:            Sounds like as PatientKeeper you’re already supporting some entities that are in a capitation mode, so presumably a lot of that applies to the ACOs.  How does your suite of offerings at PatientKeeper support what Accountable Care Organizations will need to do?

Brient:            Well the whole idea behind PatientKeeper is to give our physicians complete visibility into everything that’s happening to their patients.  That often is within a given hospital, but we have a variety of customers that either have or are in the process of extending their reach and connecting their community so that when your patient shows up, you essentially see their whole longitudinal medical record across the whole continuum of care.

You don’t need to be in an ACO.  But certainly if you are in an ACO, that enables you to be more effective at what you’re doing.  I think the question is one of these chicken and egg things.  The question is do you need an ACO to force that or are some of the Meaningful Use provisions going to create that anyway?  I have a lot of trust in physicians that given the right information, given the right time, they generally make the best possible decisions for the patients within their skill set.

I don’t think getting an extra five percent in incentive payments is going to cause them, if they have the right information, to make a better decision.  I think what it will do potentially is cause them to go buy the infrastructure so they have information in the first place so they can make a better decision. But I’m not even sure that’s enough.

Meaningful Use is actually more meaningful towards achieving that goal because it requires them and it puts real money into infrastructure. It’s very explicit, whereas the ACO legislation is much more about ACO governance.  There are a few sections in there about using technology to make this work. But there’s a lot of technology needed to make that happen and actually a lot of it is covered in the Meaningful Use requirements.  The timing doesn’t line up so great because ACOs start in 2012 and most people are still struggling through Stage One of Meaningful Use.

Williams:            Let me change the topic just slightly and talk about readmissions.  I saw an article recently that was looking at whether clinicians or case managers could predict whether a patient would be readmitted to the hospital within 30 days and whether they could predict the reason for that readmission.

What is showed was that they were unable to do so. The article left off at that point, but it seemed to me that what was missing there was a feedback loop.  People didn’t have any chance to learn about whether somebody was readmitted and why. They don’t know very well what’s going to happen, but there’s not a way for them to learn.  Is there something in what you do with PatientKeeper that could help address that problem?

Brient:            Well, that’s very much what we’ve been doing for the past six or seven years with HealthCare Partners.  It’s very specifically focused around readmission and transitions of care from the hospital back into the community.  That is certainly an area where there is a lot of opportunity for improvement.

There are always no-brainer costs and quality improvements and this is clearly one where you reduce cost and you improve quality and you improve patient satisfaction hands down, unequivocally.  No one wants to go back to the hospital and it’s expensive.

So we’ve been actually working a lot with Health Care Partners and they’ve been able to impact the readmission rates very significantly, but they do it proactively.  What happens is those physicians, once they get ready to discharge the patient, they actually use our system to write orders for what should happen post-discharge.  Those orders go to the primary care physician and to their EMR and to a care manager.  The care manager is responsible for quarterbacking and making sure the patient gets the follow-up care that the discharging physician says is needed and also makes sure the primary care physician knows about the fact that the patient is getting discharged.

If you look at the model outside of an organization like that, especially with hospitalists, a patient presents at the ED, they go to the ED, they get taken care of, and the PCP might not even ever know that that ever happened.  In some cases the hospital doesn’t even know who the PCP is.  So that’s not a recipe for great transition back into the community. It’s very easy to fall through the cracks and end up back in the hospital.

So I think there is a big opportunity across the country around readmissions, but it’s tricky to get right. The hospitalist movement has ironically made that more difficult.  In the old days, you went and saw your family practice guy. If you needed to go to the hospital, they admitted you, they rounded on you, they took care of you, and they were the continuum of care manager.

That’s not very efficient necessarily nor effective. Physicians didn’t necessarily have a lot of people in the hospital, so they weren’t necessarily the best people to manage you while you were in the hospital, but at least they made sure that you transitioned in and out effectively.

So I think it’s a big opportunity and if ACOs could focus, that would be a good area to focus on

Williams:            That’s a helpful perspective.  Paul, before we close, any other topics that are top of mind today?

Brient:            It’s both exciting and concerning.  The government is really trying to figure out how to fix health care.  It’s a challenging thing.  It’s a political process and obviously the ACOs are all focused around Medicare and the government is the payer, but historically Medicare has not been a very aggressive manager of care.

They’ve got very low administrative costs, they’re very excited about that, but largely what they do is set payment rates and pay claims.  Medicare Advantage and ACOs are, in some ways, a step towards managing care in Medicare.  Unfortunately it will subject to the political process which will be difficult.

Williams:            I’ve been speaking today with Paul Brient, CEO of PatientKeeper.  We’ve been talking about Accountable Care Organizations.  Paul, thank you very much.

Brient:            Thank you so much.