The Revolution in Magazine Processes "How not to fall behind in an era when everything you think you know might be wrong."

The title could have just as well read

The Revolution 

in 

Health Processes

Conventional print magazines, newspapers have weathered a sea-change in their business model.
And so has medicine and health process.

Health care financing, and administration also are struggling to change even as our current medical system is overwhelmed with increased expenses.  The similarity between magazine process and health process are remarkably alike.

Prominent news publishers, such as the Washington Post, New York Times and many others went out of business at the same time re-inventing their 'product' in a more efficient manner.  In some cases ownership shifted quietly behind the scenes. There were major reductions in staff, overhead and outright elimination of tasks that served no purpose or had been replaced by digitalizing the industry.

Even as this is occurring health organizations are burdened with daily organizations while being mandated by government, CMS, the Affordable Care Act, Insurers, and expansion of new covered benefits such as remote monitoring, telehealth and mobile health care.  The uptick in  expenditures for health IT is overwhelming many, both large and small.  There is no room for error. During the past five years some large institutions spent millions of dollars to purchase EHRs only to find they could not perform as advertised. Providers, and hospitals did not know or have experience in systems that were new and untested in a real world setting.

Health care operated mostly on a cash basis until the birth of managed care, capitation, and other obtuse forms of risk management.  In health affairs risk management used to have to do with risk of disease and/or treatments. Insurance companies were required to have an actuarial basis for setting premium rates against history of their insured disease risks.

Today this risk is carried not just by the insurance company, it has been shifted to hospitals and providers. Other calculations are being considered such as quality of outcomes, measured by re-admission rates to the hospital. The latest in the quirky world of health high finance is the 'accountable care organization. (ACO).

The name was coined by Elliott Fisher as a philosophical term during it's germination period.  Theoretically the organization that saves the most gets a 'kickback' a larger reward incentive than the rest of the providers/hospitals.

The health care company of 2005 is gone. its processes, procedures and priorities would be nearly unrecognizable today. In fact, the medical practice that existed in 2010 is gone too. In a period of accelerated transformation, nothing is more striking than the scope—and pace—of change in the processes through which these companies engage their customers (patients)  The very terms physician and patient devolved into provider and consumer. Physicians are no longer generalists or specialists they are primary care providers. It’s not just peripheral or incremental change, either. What the industry is going through in 2015 is a revolution in processes. In advertising, content creation, marketing, back-office functions and everything in between, what was done just a few years ago has been rendered obsolete, as new ways to interact with and serve stakeholders push the old ways into the trash bin. 

What’s changed is that technology is transforming every single phase of the business. It’s ubiquitous. It’s impacting the business on a wholesale level.”  It’s a new world of “VUCA,” says Lenny Izzo, group president of legal media at ALM. “That’s an acronym for Volatility, Uncertainty, Complexity and Ambiguity. It’s an old military term

Providers and hospitals have become 'punch-drunk' much like boxers and football players suffer from TBD or traumatic brain disorder.

Uncertainty comes in the form of new competitors. It comes with the decline in traditional branding-based display advertising, and the rise of new formats like cost-per-lead sales and programmatic advertising. Complexity comes in the form of tying together new expensive technologies that cross email, web, billing, production, ad-management, and content creation. Ambiguity comes in the form of not having the expertise to evaluate expensive new systems, and sometimes not knowing the right KPIs. Volatility? How about not knowing whether a new software system that cost $1 million will be relevant in 18 months?

This report is an on-the-ground look at process change in magazine media companies and how it’s affecting, well, nearly everything, from organizational structure and staffing needs, to assumptions about efficiency and newly essential skillsets. We’ll look at overall philosophies and approaches, and then explore, mainly through case studies, what publishing companies and executives are actually doing. 

Radical changes in process are driven by several things, of course. But mostly, it’s a function of two things: emerging technologies that enable new methods of serving markets, and a quest within companies for efficiency driven by economic necessity.

The revolution in health is not just in health IT, it includes changes in medical group administration, payment reform, relationships between providers, hospitals and providers, referral patterns and a new dynamic between regulators, licensing boards and providers of health care.

Interestingly, for health provider and magazine publishers, there’s a significant paradox in process change. Because the business model is in a seemingly permanent state of flux, and because technologies become obsolete so quickly, both types of companies find themselves betting huge amounts of money on unproven ideas. “Maybe the paradox of process is that you’re forced to be hyper-efficient in the things you understand, to finance what you hope is our future,” 

Note: Much of this article has been taken word for word from anaticle found on FOLIO  an internet magazine about the publishing business. It was a simple task to substitute health for magazine or publishers.. A true example of 'convergence'

Accountable Care Organizations: The Next IRS

The invention of the ACO is associated primarily with one man – Dr. Elliot Fisher, director of the Center for Health Policy Research at Dartmouth Medical School.

Fisher’s statement that he can invent rules for assigning patients to doctors and doctors to hospitals is no more or less logical or useful than the statement by the inventors of the Kevin Bacon game that they can assign a Kevin Bacon number to virtually any actor.

Elliott Fisher, shown here with Dartmouth Atlas founder Jack Wennberg, is credited with coining the phrase Accountable Care Organization.

By Kip Sullivan, October 2010

The “accountable care organization” (ACO) is the latest fad in American health policy. It remains an unknown concept to the vast majority of the public, including most doctors, but it is all the rage among health policy analysts as well as lawmakers who sit on heath policy committees in Congress and in state legislatures.

Although the assumptions used by ACO proponents to justify ACOs have been around since the dawn of the HMO movement, the ACO label is relatively new. It was invented late in 2006 during a discussion at a public meeting of the Medicare Payment Advisory Commission (Medpac). The seminal article announcing the concept appeared in December 2006. By 2009 the ACO had become so fashionable among congressional Democrats it was mentioned in all three draft health care “reform” bills prepared by Democrats during the first half of 2009 (two of those bills originated in the Senate and one, the Tri-Committee bill, was written in the House). The ACO movement’s crowning achievement to date is the inclusion of ACO provisions in the final “reform” legislation – the Patient Protection and Affordable Care Act (PPACA)

The Affordable Care Act created a new kind of “cooperative” health insurance arrangement heralded by supporters of health reform.  The co-ops were founded on the idealistic belief that community members could band together to create health insurance companies that would be member-driven, service-oriented, and would not have to answer to shareholders or turn a profit. But the 23 co-ops that were created had significant start-up costs, no experiential data upon which to set premiums, generally had to pay extra to lease physician and hospital networks, and had few people in the companies and none on their boards with insurance experience.  The idealism has quickly faded.  After receiving hundreds of millions of dollars in government start-up loans, most co-ops are surviving now on what remains of more than $2 billion in federal “solvency loans” and on the promise of future “shared risk” payments that are likely to produce only a fraction of the revenue co-ops have booked.

The History and Definition of the “Accountable Care Organization”

The definition of “ACO” bears a striking resemblance to the definition and history of “HMO,” a term coined in 1970. As was the case with the HMO, the ACO has been promoted primarily for its alleged value as a cost-cutting tool. Like the HMO concept, the ACO concept is vague and has multiple definitions which vary depending on who you ask. Like the HMO, the ACO is defined as an entity that will be “held accountable” for providing comprehensive health services to a defined population. As was the case with the HMO, “accountability” for cost will allegedly be achieved by shifting some or all of the insurance risk now born by insurance companies and public programs like Medicare to providers, and “accountability” for quality will allegedly be achieved by subjecting providers to report cards. 

The principle difference between HMOs and ACOs, at least for the foreseeable future, will be their size. Whereas HMOs, like most insurance companies, generally have enrollees in the hundreds of thousands, the ACO has so far been defined as having a much smaller number of enrollees, possibly as few as 5,000 (that’s the minimum number of Medicare beneficiaries who must be in an ACO according to PPACA’s Section 3022). The other major difference between HMOs and ACOs, at least for the near term, will be the extent to which they bear insurance risk. Whereas HMOs function like insurance companies (they bear 100 percent of the risk that the premiums they charge will not be enough to cover all necessary services for their enrollees), ACOs will bear little or no insurance risk for the first few years. However, judging from published papers by Elliot Fisher and other proponents of ACOs, proponents want ACOs eventually to bear all insurance risk, just as HMOs have.

ObamaCare Co-ops: Cause Célèbre or Costly Conundrum? 

By Grace-Marie Turner and Thomas P. Miller Overview     

Portions of this blog were taken from publications from PHNP, Physicians for a National Health Program 

Affordable Care Act------Silk Scarf or Pig's Ear ?

Silk Scarf or Pig’s Ear ?

President Obama and the Democrats insist that the Affordable Care Act is working and has increased the number of insured, yet most Americans do not like the law.

The question now is what kind of bang did we get?  

Figures from the Heritage Foundation in their Consumer Power  Report “Obamacare Squandered $1.2 Billion on Failed Exchanges

It all began when HBX was enrolling carriers for each state. At best it was a difficult sell with much arm-twisting   In Maryland, Mississippi, New Mexico, and South Dakota, officials had to beg and plead just to get one carrier into the state’s private market.

Continuing problems are ongoing in many state exchanges. There’s only one insurance carrier – Blue Cross Blue Shield – in West Virginia’s exchange.

Hawaii is another consensus pick, and some experts say the state might never be able to support its Obamacare exchange. Hawaii was near the bottom for total enrollment, signing up just 15 percent of its eligible population, and had the second-worst mix of young adults. The state’s exchange also suffers from the fact that Hawaii had a low uninsurance rate to begin with – meaning there’s a smaller pool of potential customers there, which makes the state less attractive to insurers. Hawaii’s “Health Connector” has signed up the smallest number of people of any state in the country and has no plans to finance their operations moving forward. Their current plan appears to be to all-but-close-up-shop and outsource all of the exchange functions to the state Department of Human Services. The state’s leading insurance company says it is time to pull the plug. Expect this one to be official any day now.

Health care analysts are also keeping an eye on premiums in Maryland, Mississippi, New Mexico, and South Dakota, where officials had to beg and plead just to get one carrier into the state’s private market.

The expected rise in premiums will vary greatly from state to state, smaller states with fewer enrollees and a bias toward older and sicker people will see sharp rises in premiums.  It’s impossible, though, to say with any certainty whether a particular state will see an above-average price increase next year.   Maryland, Mississippi, New Mexico, and South Dakota,  are among those HBXs to watch.   Minnesota’s exchange has been a disaster, and they recently brought in [Deloitte] on a nine-month $4.95 million contract to fix it. It is unclear whether they will be successful.

Vermont, the tiny state with giant ambitions to use Obamacare as a stepping stone to single-payer, government-run health care is still facing enormous problems dealing with its tiny population. They are using CGI, the same vendor that failed on the federal healthcare.gov, and have given them a deadline of July 2 to get the site working. It is unclear what Vermont will do if they fail to deliver by that date.

The total is $ 1.2 billion…..and it is not over, yet

Health IT Potpouri

There is an overwhelming amount of information about HIT on the web, blogs, email newsletters and a Google search will turn up literally hundreds of resources.

For this week, May 8 2014 I have compiled this list of hot topics and links:

Innovation event brings new ideas, ROI ROI -- whether the "I" stands for innovation or for investment -- will be among the many topics up for discussion at the National Healthcare Innovation Summit, which kicks off May 13 in Boston. The organizers promise "the kinds of innovations that people can take home and use tomorrow." When EHR design is a 'what not to do' Among the healthcare developers workshopping better approaches to technology design at HxRefactored in Brooklyn next week will be Stephen Buck, who'll offer some "lessons learned" from looking closely at leading EHRs -- specifically, how not to design a user interface. EHR incentive payouts climb to $23B More than 370,000 Medicare and Medicaid eligible providers have earned an EHR incentive payment so far, with 64,000 new participants attesting to meaningful use for the 2013 reporting year. Health agency inks $71M EHR contract The Defense Health Agency has put a foot forward with revamping its clinical information systems after it inked a bridged contract with a Reston, Va.-based technology and defense company.

The current landscape of data exchange networks is disjointed, with health care systems scrambling to uncover sustainable business models. The need for interoperability is greater than ever. What will the model look like in the future and what are organizations doing to move toward more valuable data exchange? Ashish Shah, Medicity’s CTO, and I recently discussed these industry drivers with Anthony Brino, editor of Government Health IT. Read the article HIE at a Crossroads.

Carolinas HealthCare System CareConnect got an early start on creating a robust network for data exchange. Take a look at this recent case study highlighting Medicity’s role in connecting the health care ecosystem to enable a 360-degree view of patients across the care continuum.

Still no consensus on digital/mobile/connected health Posted: 06 May 2014 10:06 PM PDT A while back — three months, to be exact — I asked readers if they had a preferred term to describe “the application of new, personalized technologies to healthcare.” I gave you the choice of digital health, connected health, wireless … Continue reading →

Interoperability beyond doom or gloom

HIE among U.S. non-federal acute care hospitals has been trending upward since 2008, in fact, and it took some major leaps forward in 2013.

An EHR 'buying spree'? Maybe not quite

M*Modal Drives Anywhere, Anytime Medical Dictation with Enhancements to iOS Mobility Solution

Posted: 05 May 2014 09:01 AM PDT

Understanding that physicians require more comprehensive, flexible clinical documentation solutions that reflect the fast-paced highly mobile health care environment, M*Modal today announced enhancements to its Fluency Flex™ Mobile dictation application for iOS 6.0+ devices. Moving beyond the capture of clinical notes during … Continue reading →

Patients want online access to records

More than half of people with chronic conditions say the ability to get their electronic medical records online outweighs the potential privacy risks, according to a new survey by Accenture.

Big chill for telemedicine?

New guidelines issued by the Federation of State Medical Boards could have a chilling effect on the growth of telemedicine -- especially in rural areas and among low-income patients, say some patient advocates, healthcare providers and healthcare companies.

An EHR 'buying spree'? Maybe not quite

Some analysts are predicting the next "great wave" in EHR purchasing among U.S. hospitals to be just around the corner. But do the numbers really bear that out?

EHR certification criteria under fire

The hits keep on coming for the new EHR certification criteria, as the American Medical Association and Telecommunications Industry Association send their complaints to ONC on the heels of similar criticism submitted earlier by the EHR Association.

The “unconfirmed rumor of a huge acquisition” that HIStalk (a.k.a. the National Inquirer of health IT) tweeted about on Wednesday apparently is that IBM was going to acquire Epic Systems. Mr. HIStalk on Thursday expressed some reservations.   @DaLAWon Much … Continue reading →

• » Why EHRs are Key to Better Clinical Data

EHR certification criteria under fire

The hits keep on coming for the new EHR certification criteria, as the American Medical Association and Telecommunications Industry Association send their complaints to ONC on the heels of similar criticism submitted earlier by the EHR Association.

$11 Billion DoD EHR Contract

Posted: 01 May 2014 10:51 AM PDT

Nextgov has a great article up which outlines many of the details of the soon to be bid out Healthcare Management Systems Modernization contract. I’d prefer to call it the DoD EHR Contract or AHLTA replacement contract. Certainly there’s more … Continue reading →

10 technologies on the rise

Explore Medical Practice Insider's guide to emerging apps and devices for the medical practic

If you want to learn more about ACO formation and Operational Issues: Attend

this event either in person, or as a webinar.

Press Release: Brookings/Dartmouth Fifth ACO Summit Announces New Keynote Speakers Sean Cavanaugh & Alice Rivlin

A Hybrid Conference and Internet Event The Leading Forum on Accountable Care Organizations (ACOs) and Related Delivery System and Payment Reform Sponsored by Engelberg Center for Health Reform at the Brookings Institution and Dartmouth Institute for Health Policy and Clinical Practice June 18 - 20, 2014 Hyatt Regency on Capitol Hill, Washington, DC Online In Your Own Office or Home live via the Internet with 24/7 Access for Six Months www.ACOSummit.com

For Summit registration information, visit www.ACOSummit.com/registration.php, email registration@hcconferences.com, or call 800-503-3597.

Brief EHR Notes, 40% EHR Replacement, and $23 Billion EHR Market http://ow.ly/2GkTlr

Brief EHR Notes, 40% EHR Replacement, and $23 Billion EHR Market | EMR and HIPAA

RT @kevinmd: Brevity is the soul of a good EMR note http://t.co/AuHO9FWPp2— athenahealth (@athenahealth) May 4, 2014 It's amazing how this has shifted.

Outsourcing IT for Small & Mid-size Hospitals

Repeal the President’s Health Care Law

I wrote in several posts why Obama Care will be de-constructed by the American Culture for many reasons.  Eventually it will be re-constructed in a manner consistent with the American Cultual beliefs,  which will avoid intruding on basic Constitutionally guaranteed freedoms. (regardless of what the Supreme Court has ruled.

All early signs point to erosion of ObamaCare

    All Signs Lead to the Destruction of ObamaCare
    Vital Signs Diminishing for Obamacare Is Life Support Imminent?
    The Fears About IPABs in the Affordable Care Act
    Death Spiral ? Is this the Black Hole for the Affordable Care Act?
    Will the Affordable Care Act Overwhelm the Health System?

    ACO Expectations May be Unrealistic
   

Senator Orin Hatch has initiated a Legislative proposal has connected changes leading to a uniform health insurance system:


Title 1: Repeal the President’s Health Care Law
        Section 101: Repeal Obamacare
Title 2: Replace Obamacare With Sustainable, Patient-Centered Reforms
        Section 202: Create a New Protection To Help Americans With Pre-Existing Conditions
Section 203: Empowering Small Business and Individuals with Purchasing Power
Section 204: Empowering States With More Tools to Help Provide Coverage While Reducing Costs
Section 204: Expand and Strengthen Consumer Directed Health Care
Title 3: Modernize Medicaid to Provide Better Coverage and Care to Patients
        Section 301: Transition to Capped Allotment to Provide States with Predictable Funding and Flexibility
        Section 302: Reauthorize Health Opportunity Accounts To Empower Medicaid Patients
Title 4: Reducing Defensive Medicine Practices And Getting Rid of Junk Lawsuits
        Section 401: Medical Malpractice
Title 5: Increasing Price Transparency to Empower Consumers and Patients
        Section 501: Requiring Basic Health Care Transparency to Inform And Empower Patients
Title 6: Reducing A Distortion in the Tax Code That Increases Health Costs
        Section 601: Capping the Exclusion of An Employee’s Employer-Provided Health Coverage

There is no reason why employer group coverage cannot be continued with the caveat that it must conform to not banning pre-existing issues, and eliminating any cap on benefits.
Tax code issues regarding health benefits should not have a limit, nor require a threshold of income under which deductions can be claimed.
The IRS should be prevented from administering penalties, nor punish using a penalty and/or fine mechanism.

Taken together the aforementioned ideas will lead to an end result. Each section must be evaluated against a background of common sense without regard to self-interest in any part of the health system.

If we want a re-birth of our system we cannot drag along the dysfunctions present in our present system.
I would add the aspect of improving the health of our citizens.  This may not be properly measured by outcome studies based on reducing costs. The metrics need to be re-evaluated for that component of reform.

The underlying and most important goal is to improve access and quality of care. While Obamacare addresses costs, it does little if nothing to improve access. This challenge requires more funding for primary care physicians education and reassess certain specialties now included in primary care listings. Many internist are not primary care oriented, although considered PCP, nor are obstetricians/gynecologists.

Meet the Press with Mayo Clinic and Cleveland Clinic

Visit NBCNews.com for breaking news, world news, and news about the economy

Dr. John Noseworthy, President and CEO at Mayo Clinic, appeared on Meet the Press with David Gregory alongside with Dr. Toby Cosgrove, CEO of Cleveland Clinic, this past Sunday to discuss the impact of the Affordable Care Act and the future of health care in America.

issues covered by Dr. Noseworthy included:

1. The need to modernize the health care delivery system to drive quality at lower cost.
2. Dealing with the sustainability of Medicare in the long term.
3. Using available technology such as telemedicine to improve patient care and deliver knowledge.
4. Funding research through the National Institutes of Health.

Dr. Noseworthy emphasized the Mayo Clinic has remained outside the political arena. 

Mayo Clinic and Cleveland Clinic represent the best of IDNs (Integrated Delivery Systems). Most healthcare in the U.S. is delivered by much smaller organizations. MC and CC easily are converted to a formal Accountable Care Organization and are being promoted as ideal models for quality of care, and reduced costs.  Not all organizations have these  full potentials.  The expense and investment for smaller institutions may not have a return on investment nor demonstrate cost savings.

ACO Expectations may be Unrealistic

According to a survery of  115 Hospital C-Level executives reveal that about 18% are participating in accountable care organization activities.  This figure is increased from 5% % in 2012.   Half of respondents expect to be in an ACO by the end of 2014.

Whether that lofty figure can be reached remains to be seen. Provider alliance Premier Inc. conducted the new survey in August but only recently released results. The spring 2012 survey found that nearly 52 percent of respondents expected to be in the ACO arena by the end of 2013. Now, Premier estimates only 23.5 percent will reach that goal.

A further analysis of hosptial size revealed: 

Non-rural hospitals are most likely to participate in an ACO, followed by hospitals in integrated delivery systems; and rural hospitals are least likely to participate, followed by standalone facilities.

Large hospitals are moving more quickly toward ACOs than smaller ones, although the majority of surveyed hospitals are making infrastructure investments to manage population health.

This may be effected by the availability of capital resources which are often lacking in smaller institutions, and a much smaller group of medical providers and/or a lack of specialty access.

These investments include lifestyle and wellness coaching by more than 70 percent of respondents, telemedicine by almost half of rural facilities compared with one-third of non-rural hospitals, and patient-centered medical homes, which are popular for all types.

The efforts include a wide variety of investments to increase utiilization of the ACO as a public health resource. 

* The investments include lifestyle and wellness coaching by more than 70 percent of respondents, telemedicine by almost half of rural facilities compared with one-third of non-rural hospitals, and patient-centered medical homes, which are popular for all types.

* Fifty-one percent of responding hospitals are partnering with large local employers to improve care.

* Large numbers of respondents are gearing up for analytics to support population health. More than 72 percent are integrating claims and clinical data, half are using predictive analytics to forecast needs and 46 percent are using a data warehouse to reduce information silos.

* More than 40 percent are partnering with insurers, particularly for upside-only shared savings programs.

The programs require strategic rethinking of hospital scope of care.  The effort will require integration of previously unlinked services in preventive medicine, and health, wellness and nutrition.

The full report from Premiere Inc can be found here.

Looking Back at 2013

This report is somewhat late due to last minute projects at the end of 2013 and the confusion about the individual mandate, the botched launching of health benefit exchanges and some other unexpected tasks

We reviewed the 'best"  Health Train Express posts of 2013 as measured by the number of comments and our analytics.

IRS VIOLATES HIPAA FACES LAWSUIT BY A "J Holiday Message for Health and Wellness WHY AREN'T DOCTORS INVOLVED IN HEALT Does Obama really want the Affordable Care Act Covered California What They Said Before the Train Wreck: The To Sebelius will be a no-show at Obamacare hearing The Beginning or The End to the Affordable Care Act There were many more 'favorites".  The highest number of page views was in the category of the Affordable Care Act. This was to be expected, given the high ranking of the ACA for search engines. Visit the sites on Health Train Express for many more interesting topics. Health Train Express has archived our posts dating back to 2005.  The focus of posts has changed over the  years, and reveals the dynamism of health care and reform.