Category Archives: e-health

Free market for surgery: interview with Allevion CEO Arnon Krongrad, MD

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Surgery can be expensive, scary, dangerous and even deadly. Yet it’s hard for patients and even for referring physicians to navigate the system. So I was intrigued when I was contacted by Dr. Arnon Krongrad , CEO of Allevion, Inc., a healthcare logistics company that markets surgery packages. The company’s Surgeo online marketplace let’s patients shop for the surgeon of their choice.

I explored the topic in depth with Dr. Krongrad in this email interview.

What are the limitations of referrals to surgeons by primary doctors?

Conventional surgeon referrals by other doctors, such as primary physicians, rely upon limited knowledge about a limited number of surgeons. For example, primary physicians tend to know a relatively small handful of surgeons for specific procedures, such as vision correction. The simple reality is that in today’s environment, when primary doctors are pressured to churn patients, type into EMRs, and speak ICD-10, they have little time to sort through choices of surgeons. They will reflexively refer to the familiar, which may or may not be optimal. Primary physicians, like the rest of us, might welcome systematic, easy access to knowledge about choice of surgeons.

It looks like your surgeons are selected based on the opinions of their peers. Are there more objective, quantitative ways to rate surgeons?

Surgeo’s purpose is to simplify access to quality care. In surgery, quality comes from the surgeon. The question, then, is how to qualify surgeons. This is an urgent question as our increasingly consumerist ecosystem demands transparency regarding cost and quality. It is a question with obvious and easy answer but a conceptual framework will help us to manage and make progress.

First of all, no, there are no objective, quantitative ways to rate surgeons. We should be clear. We are not talking here about waiting room times or adequacy of parking. We are talking here about clinical quality: blood loss, rectal perforation, positive margins, and the like. A system that has not produced an objective, quantitative way to transparently, uniformly, and broadly present cost – a much more cleanly quantifiable dimension of care – has only just begun to think about objective, quantitative ways to present surgeon quality.

As we think about surgeon quality, we should recognize that surgeons do not operate in a vacuum. Most critically, they operate on patients, who are varied, and produce outcomes that are varied. Let us use prostate cancer surgery as an example. The factors other than surgeon skill that affect various outcomes vary. For example, cure is affected by cancer grade and preservation of erections is affected by diabetes. So which outcome – cure, erections – are we looking at when we ask about surgeon quality? Once we decide, have we collected patient data in a way that would permit us to explain variation in outcomes between surgeon A and surgeon B? No, we’re just not there yet.

Secondly, formulaic objectivity, laudable as it might be, is not the only way to go. The other way is subjectivity, the argument for which was previously laid out in this article. In brief, the principle relates to the instantaneous ability of subject experts to detect artistry when they see it. It argues that surgeons know quality surgery when they see it. As one very senior surgeon who has taught surgery all around the world said it: “I can tell within a minute of skin incision if a surgeon is good.”

There are data, most notably in bariatric surgery, to show that subject expert peer credentialing correlates with objectively measured outcomes, such as hospital readmission. In other words, we think we can do well by patients and payers by applying the collective, subjective wisdom of surgeons.

Do other factors affect surgeon qualification? Any surprises?

Yes. Surgeo’s surgeons are qualified using a published, multi-factorial surgeon credentialing process that includes but is not limited to peer input. The idea is to try to get as close as possible to surgeons who know what they are doing and who exemplify the high standards of service and mission.

The additional steps have yielded some surprises. For example, Surgeo recently rejected the application of a very well known, very high volume, well published surgical specialist whose peers think highly of him. We rejected the application upon discovering what his peers did not know: that he has a history of numerous high-dollar malpractice payouts, including one incomprehensible loss at jury trial. This example relates to the opening comments: doctors do not investigate surgeon qualifications as fully as they might if given motivation and time. Surgeon qualification takes time, effort, and more than one criterion.

What do surgeons think of your approach?

Doctors generally are under siege. They are all looking for simplicity, fairness, and respect for their abilities and integrity. Surgeo delivers those and surgeons love the surgeon driven, clinically rational product design and administrative approach. The model works because it satisfies patients and providers. It has also satisfied payers, as when we used it in a previous chapter to satisfy Blue Cross and develop surgery bundles for the network.

What has been the most surprising reaction of your surgeons?

Surgeons are often paralyzed by the freedom that Surgeo offers. They have no idea how much to charge for their services because nobody has ever asked them before. Surgeo does not negotiate prices with its downstream vendors. Surgeo does not set allowed amounts or ask for discounts. This is unfamiliar to most doctors. This seems bizarre. Have you ever met a lawyer who has no idea what his hourly rate is?

What’s the history of Surgeo? What is its future?

One day, two things happened: Congress said everyone was getting healthcare and a man with cancer told me he could not get healthcare: surgery for his newly diagnosed cancer.

I tried to help him and ran into inflexibility and apathy. The solution ultimately involving sending him from Oregon, my surgical team from Florida, and a surgical robot spot purchased on eBay for 1% of retail from Colorado to an operating room in Trinidad. The exercise delivered a flat-fee surgery package at a price he could afford and worked for all involved. We then developed the model domestically and sold surgery packages to individuals and large payers. You can see a presentation of that case here.

Surgeo is a public, interactive, online face of surgery packaging and pricing software engine that was designed in-house under the direction of Kimberly Langer, our Chief Product Officer. Kim was formerly with a large payer, where she designed large enterprise claims related software. She built Surgeo to scale in a way that can work with payer EDI streams for easier network integration and for presentation to members of service choices and out-of-pocket costs. Kim also built it to accommodate our customers who want privately labeled software by which to market their own surgery packages. We’re seeing demand for that from financial and provider organizations.

You cover a variety of surgeries. Are there any surgeries that have been more popular than expected?

Penile implant surgery. We did not even think about this when we first set out. It turns out that there are huge problems related to this procedure. First of all, authentic conversation about male sexuality and erectile function is in very short supply and men with diabetes, cancer, and other conditions associated with erectile dysfunction have very few places to turn for substantive learning. Secondly, the pharmaceuticals for erectile dysfunction have taken over the airwaves and displaced much of the conversation about other, very effective treatments. We were amazed, for example, that one national network of diabetes activists, whose constituents have up to 70% prevalence of erectile dysfunction, has not discussed erectile dysfunction in 10 years!

What makes the challenges even greater is that penile implant surgery is often not covered by payers. We hear regularly from patients who thought they had what they call “really good insurance” that penile implant surgery is not covered. The way things are going, with CMS having dropped covered for vacuum erection devices, it won’t surprise us if penile implant surgery is just uniformly dropped.

We are getting sad, pleading calls from men with diabetes, obesity, cancer, and others who would like to restore their erections, relationships, marriages, and mood. These men are finding a delivery system that is broadly opaque and unhelpful. In response, we built in response is a national penile implant surgery package network. It features peer credentialed surgeons, comprehensive flat-fee packages, finance navigation, and financial protection in the event of complications. It offers plenty of choice.

The risk protected, flat-fee penile implant surgery package network is a model for efficient delivery of non-covered services. It can help payers to help direct members who do need those services.

What do you mean by financial protection in the event of complications?

Surgeo packages protect surgical patients against financial surprises by bringing in qualified surgeons. This is not a guarantee of elimination of complications but it helps. The second protection is inclusion in the flat-fee package of ancillary procedures. For example, gastric sleeve surgery includes hiatus hernia repair if it is needed: no surprise bill. In some cases, such as penile implant and laparoscopic hysterectomy, we are able to also include third-party products that take financial responsibility in the event of surgical complications. Think of it like getting collision insurance when renting a car.

What explains the variations in package prices?

We are just now starting to see a geographically distributed free market of uniformly defined surgery packages. Surgeons in Houston are looking and seeing prices in Birmingham and adjusting accordingly. So some of the variation is explained by the absence of a transparent market. Variation will probably shrink as price transparency sets in as it has on Surgeo. We see surgeons routinely not wanting to the most expensive.

Image courtesy of David Castillo Dominici at FreeDigitalPhotos.net

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

DocChat puts ER docs online (podcast)

DocChatPicture_FounderwithLogoandSloggan_11.18

Dr. Steve Okhravi and his son Michael decided to do something about overuse of the emergency room. They founded DocChat to leverage telemedicine for triage and to counteract the forces of defensive medicine that send many patients to the ED that don’t belong there. Early results are strong and they are looking to scale.

I asked the Okhravi’s about their service in this podcast interview.

  1. (0:14) What unmet need are you addressing?
  2. (1:33) Are patients to blame for unnecessary visits to the ED, or do physicians deserve some of the blame?
  3. (4:26) DocChat uses emergency room physicians instead of primary care. Why?
  4. (7:00) Is DocChat appropriate for geriatric patients?
  5. (10:08) Your service is not covered by insurance. Who is the paying customer now and what do you expect in the future?
  6. (12:23) You offer a subscription service as well as charging per call. Is this the type of business where a subscription makes sense?

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

Are privileged people wasting their time using healthcare portals?

Should I enter the portal or not?

Should I enter the portal or not?

A new study on use of electronic health portals by patients with chronic kidney disease is another example of telling us something we already know: people with lower socioeconomic status don’t adopt healthcare innovations to the same extent as those with higher status. In this case, white, young, married, commercially insured, higher income patients used the portal more.

Here’s what the lead author told NPR about the study:

“Despite the increasing availability of smartphones and other technologies to access the Internet, the adoption of e-health technologies does not appear to be equitable,” Abdel-Kader says. “As we feel we are advancing, we may actually perversely be reinforcing disparities that we had been making progress on.”

Presumably the portal users expected to receive some sort of benefit as a result of logging in. However, from what I can understand from the NPR story and study abstract, the researchers were unable to document the clinical benefit (better blood pressure control) that they were expecting to find.

So maybe a better conclusion is that relatively privileged people with the luxury of time and bandwidth on their hands tend to waste time and resources on a portal that doesn’t provide benefits, while those with lower status focus on more important and productive pursuits.

Ok, that conclusion may not be correct either, but I have real doubts about the usefulness of this research.

It’s ironic that the authors –while bemoaning barriers to access and arguing passionately for policies to address it– published their study and accompanying editorial behind a paywall in the Clinical Journal of the American Society of Nephrology rather than with an open access publisher such as PLOS. I’m curious about the details of the study but not enough to pay $27 for the article and another $27 to read the editorial. I’m going to spend my $54 on something better.

Image courtesy of basketman at FreeDigitalPhotos.net

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

Mercy Virtual’s Randy Moore: ROI isn’t good enough (Podcast)

Randall Moore, MD. President of Mercy Virtual

Randall Moore, MD. President of Mercy Virtual

Mercy Health has been doing big things in digital health. Last year I interviewed EVP Shannon Sock after he spoke in Boston. And recently I met Mercy Virtual’s president, Randall Moore, MD at Qualcomm Life’s Connect2015 conference to ask him some follow-up questions after his talk.

  1. (0:10) You came out on stage and said ROI isn’t a high enough bar to cross. You really have to consider cash flow. Say more about that.
  2. (1:16) You showed a compelling video of a patient’s experience. How much of that is vision and how much is real? For example, do you really have ‘warm handoffs’ to the ER when someone arrives after calling ahead?
  3. (3:34) Many people at the conference have been sanguine about the new ‘value based’ models. But you said hospital-based ACOs are likely to fail. Why?
  4. (6:07) You discussed radically reducing length of stay and increasing market share to stay viable. Does your business model rely on putting your competitors out of business?

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

Digital health at Walgreens: Podcast interview with Adam Pellegrini

Adam Pellegrini, Walgreens VP, Digital Health

Adam Pellegrini, Walgreens VP, Digital Health

Consumer adoption and scale-up were big themes at last week’s Qualcomm Life Connect 2015 meeting in San Diego.  Many digital health initiatives are still stuck in the concept, prototype and pilot stages, but Walgreens has been charging ahead. The presentation from Adam Pellegrini, Walgreens VP for digital health was refreshing and inspiring. I caught up with him afterwards to follow up on some key points:

  1. (0:12) How does Walgreens use its Balance Rewards loyalty program to generate engagement with digital health?
  2. (1:13) What is the role of Walgreens pharmacists in telehealth?
  3. (2:49) What consumer friction points are you obsessing about in healthcare today?
  4. (4:06) What is Walgreens doing with telehealth outside the US? Are you bringing lessons from abroad here?

#qualcommconnect

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

 

par8o and IRCDA team to automate clinical assessment with SCAMPS

Scamp meet SCAMP

Scamp meet SCAMP

par80 and the Institute for Relevant Clinical Data Analytics (IRCDA) have teamed up to enable sophisticated clinical decision support at the point of care using SCAMPS. I asked Dr. Adam Sharp,  par80’s cofounder, president and chief medical officer to explain.

  1. What are SCAMPs? How do they differ from evidence-based protocols?
    • SCAMPs are Standardized Clinical Assessment and Management Plans. SCAMPs outline a data-backed, consensus-based, care pathway for a diverse patient population with a particular diagnosis or condition. Data is collected on the treatment and outcomes of that population, analyzed, and then used to improve the care pathway
    • While evidence based protocols can answer highly specific medical questions, the traditional methods are inadequate to address the interdependent questions related to defining effective care
    • SCAMPs aim to bridge the gap with a method that is integrally linked to continuous improvement
    • Additionally, SCAMPs aim to reduce the cost of delivering care to patients while improving quality by focusing on standardization of care and reduction of unnecessary utilization
  2. What are some examples of SCAMPs? What value do they provide?
    • There are a wide variety of SCAMPs, ranging from the inpatient to outpatient to ER settings. Some examples of SCAMPs are the Congestive Heart Failure SCAMP (inpatient) Distal Radius Fracture (outpatient), and Acute Kidney Injury (ICU)
    • They reduce variability in care. The algorithm drives consistency among participating providers. In addition to providing a layer of liability protection, organizations want to drive towards best practice guidelines. SCAMPs do so from the grassroots level
    • SCAMPs gain support from providers because in spite of a foundational algorithm driving decisions, providers are free to diverge from the SCAMP recommendation, so long as they provide a reason. This empowers providers to use their own intelligence alongside the best practice guidelines laid out by the SCAMP
    • Finally, a SCAMP is never perfect. After using it in the field for a given amount of time, the data is collected and analyzed by IRCDA’s analytics team. The output is then used to reevaluate the SCAMP and to change the algorithm to account for the decisions doctors made. These iterations ensure care pathways are constantly improving based on the latest empiric evidence
  3. And what is IRCDA? How does it relate to SCAMPs?
    • IRCDA is the Institute for Relevant Clinical Data Analysis. In 2006, clinicians in the Cardiology Department at Boston Children’s Hospital began to toy with a new methodology. This methodology would ultimately create SCAMPs
    • As success grew and institutions around the world became interested, IRCDA was created in 2010 to spread and promote SCAMPs to interested institutions
  4. You’re a founder of par8o, which you describe as a healthcare operating system. You’re partnering with IRCDA to implement SCAMPs. How does all of this fit together? If par8o is the operating system, what does that make IRCDA, SCAMPs, and hospitals?
    • IRCDA, SCAMPs, and hospitals in many ways represent a microcosm of the healthcare system as a whole. A major benefit of working with IRCDA is that it touches so many major components of the healthcare industry
    • It ranges across healthcare settings (inpatient, outpatient, ER) in addition to focusing on the most important players in the industry – the providers
    • As healthcare’s operating system, par8o wants to layer itself onto as many aspects of care as possible. Doing so will allow us to bring efficiency to all parts of the industry
    • Finally, pathways in healthcare are manifold. From taking a patient through the right care pathway, to following a pathway created by an insurance company for specialty pharma, to finding eligible patients for clinical trials, the foundation par8o builds with care pathways will have many implications for driving efficiencies in other aspects of healthcare
  5. How are EMRs involved in this initiative?
    • par8o integrates with all EMRs via the Direct protocol developed by HHS Office of the National Coordinator (ONC). SCAMPs can be initiated out of an EMR using a direct message – the direct message will trigger a draft SCAMP to be created in par8o and will notify the provider that they must complete the SCAMP
    • Therefore, so long as the EMR supports Direct messaging, par8o can use that functionality to integrate
  6. What impact will this partnership have for patients?
    • Patients will benefit because par8o’s technology will address two key pain points currently in the SCAMP process. The first is unwieldy data entry – par8o will enable providers to complete SCAMPs from their mobile phone. Using decision support, the forms will seem less onerous
    • Additionally, by leveraging form versioning technology, par8o will enable faster iterations on SCAMPs. Faster iterations means the data gathered during SCAMP collection can be leveraged sooner, resulting in enhanced care for affected patient populations
  7. This is clearly a first step. How do you see development rolling out over the next few years?
    • Over the next few years, par8o has a big vision. To start, our aim is to successfully launch a pilot program at a single institution. We hope to ease data entry issues and therefore increase adoption. Additionally, we hope to see faster iterations between SCAMP versions
    • In the future, in addition to expanding to more member institutions, we would like to see a social element brought to SCAMPs where providers are able to participate in chat forums and share the latest literature concerning that area of care
    • par8o also plans to build a SCAMPs “Editor”, which would enable the IRCDA team to build and version their own SCAMPs, greatly increasing the iteration process

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

Checking the symptom checkers

I have a small problem

I have a small problem

Online “symptom checkers have deficits in both diagnosis and triage, and their triage advice is generally risk averse,” according to a new study in BMJ by Harvard researchers. Some of the press coverage of the study has been pretty critical of the symptom checkers, but the study itself is quite balanced.

Symptom checkers are a lot better than “Google Diagnosing” (typing a list of symptoms into Google and seeing what comes up). They’re very similar to nurse triage lines used by health plans, which is no great surprise considering that many of the triage lines use the same logic that drives the symptom checkers. They’re inferior to a primary care physician, but of course physicians aren’t infallible either.

People use symptom checkers to self-diagnose and to figure out if they need to go the emergency department, doctor’s office or can treat at home. Not surprisingly, the symptom checkers err on the side of suggesting patients seek care. No producer of these tools wants to get sued for recommending self-care to someone who should have called an ambulance. But in this regard symptom checkers are similar to nurse triage lines and also –at least in my experience– to physicians who are covering call. Too often they suggest a trip to the ED.

There’s an opportunity to reframe the next generation of symptom checkers as tools for navigating the medical system. That means not just suggesting a diagnosis and level of care, but pointing to an appropriate specialty, facility, or individual clinician to follow up with. This could be especially useful for patients in areas with fewer specialists and sub-specialists, and those with rare or hard to diagnose conditions. Primary care physicians could use such a tool as well to help direct referrals.

Image courtesy of David Castillo Dominici at FreeDigitalPhotos.net

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