Rants & Musings

Is the term “Payor” healthcare’s oxymoron?

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One of the great things about fall is that as I prune back the vestiges of my virtual garden I am able to collect basketful upon basketful of overly ripe metaphorical tomatoes, perfect for tossing at aberrant analogies and inappropriate idioms.

It’s a curious time.  We give away money to the middle class and rich so they can upgrade their BMWs on the backs of the poor.  The feds market that idea as though that pittance will either jump start the economy, or to hide the fact that that the administration has managed to budget for a nine trillion dollar deficit gap over ten years.

By now we know there are no quick fixes, no magic formulas for fixing the economy.  Finding a formula that works will be more difficult than learning how to neatly fold a fitted bed sheet.

“Is it the essential paradox of the age of Obama that we have to destroy the village in order to save it, bust the budget in hopes someday we’ll balance it?” Nancy Gibbs, Time, September 9, 2009.

“It takes an idiot to raze a village.” Paul Roemer, today.

Congress is trying to decide what the final bill will look like without ever having read the first draft.  How will we know when they have something that makes sense?  Do we watch the Congressional chimney to see if the smoke is white or black?  Does that mean we have a bill, or is it simply that the chef burnt the Peking Duck?

Then there are the payors.  Get me started, or don’t.  We all know that one of the driving factors for reform is the behavior of the payors.  A friend asks—for full disclosure I note that she is one of “them”—why do people view health insurers differently from auto, life, or home owners insurance.  She was serious.

Here’s my take on the answer.  If the health insurance firms provided life insurance they’d be exhuming the deceased and trying to prove they weren’t dead.  Car smashed, get a check.  House leaks, get a check.  Die, get a check.  Need surgery.  Not so fast.  Let’s see if you’re covered for that.  If not, whew.  If yes, let our doctors decide if you really need the surgery.  It won’t cost you a minute of your time as our doctors don’t even need to examine you.  You see how this plays out?

It happened to me after my heart attack, albeit with my disability payor, sort of the evil step sister of the health side.  My doctor put me on six months disability, naturally, the payor declined to pay.  There doctor, who never examined me decided I was fine, at least that’s what their letter stated.  How do we know these doctors even exist?  Have they ever been seen in the daylight?

Most Americans don’t believe that insurance companies are interested in helping people.  They like us fine when people are payors.  They are much less fond of us when people become patients.  It’s a simple matter of flow theory.  As long as the flow of cash is in-bound, all is well.  When people move to the dark side, from payors to patients, payors have no patience.

Is there anyone who believes that there is a single payor in the country whose mission statement says anything about doing all we can to help those who need us?  Of course not.  Payors have claims adjusters.  What is their role?  It’s certainly not to adjust the payment higher.

Do payors incent their employees to pay out as little as possible?  I believe they do.  Do payors penalize or retrain people who pay out too much?  I believe they do.  Do they design the claims and dispute process so as to make it so cumbersome on patients and doctors that parties give up prior to settling?  I believe they do.

I believe the payor business model is not much different from that of tobacco companies.  For years tobacco firms claimed there was no public evidence to support the fact that nicotine was addictive.  It turns out they buried the evidence.  Payors claim they are not bad actors.  Some claim the moon landing was faked.

I am a firm believer that pictures can sometimes convey more than mere words.  To me, this link explains a lot about what’s wrong with healthcare.

http://www.youtube.com/watch?v=Z7Forzj5-O0 Start playing at 6 minutes and 40 seconds.

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Patient Relationship Management (PRM)-why men can’t boil water

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poker_head_pic

There was a meeting last week of the scions of the Philadelphia business community. The business leaders began to arrive at the suburban enclave at the appointed hour. The industries they represented included medical devices, automotive, retail, pharmaceutical, chemicals, and management consulting. No one at their respective organizations was aware of the clandestine meeting. These men were responsible for managing millions of dollars of assets, overseeing thousands of employees, and the fiduciary responsibility of international conglomerates. Within their ranks they had managed mergers and acquisitions and divestitures. They were group with which to be reckoned and their skills were the envy of many.

They arrived singularly, each bearing gifts. Keenly aware of the etiquette, they removed their shoes and placed them neatly by the door.

The pharmaceutical executive was escorted to the kitchen.

“Did your wife make you bring that?” I asked.

He glanced quickly at the cellophane wrapped cheese ball, and sheepishly nodded. “What are we supposed to do with those?” He asked as he eyeballed the brightly wrapped toothpicks that looked banderillas, the short barbed sticks a matador would use..

“My wife made me put them out,” I replied. “She said we should use these with the hors d’oeuvres.”

He nodded sympathetically; he too had seen it too many times. I went to the front door to admit the next guest. He stood there holding two boxes of wafer thin, whole wheat crackers. Our eyes met, knowingly, as if to say, “Et Tu Brutus”. The gentleman following him was a senior executive in the automotive industry. He carried a plate of freshly baked chocolate chip cookies. And so it went for the next 15 to 20 minutes, industry giants made to look small by the gifts they were forced to carry.

The granite countertop was lined with the accoutrements for the party. “It’s just poker,” I had tried to explain. My explanation had fallen on deaf ears. There is a right way and a wrong way to entertain, I had been informed. Plates, utensils, and napkins were lined up at one end of the counter, followed in quick succession by the crock pot of chili that had been brewing for some eight hours, the cheese tray, a nicely arrayed platter of crackers, assorted fruits, a selection of anti-pastas, cups, ice, and a selection of beverages. In their mind, independent of what we did for a living and the amount of power and responsibility we each wielded, we were incapable of making it through a four hour card game without their intervention.

I deftly stabbed a gherkin with my tooth pick. “Hey,” I hollered “put a coaster under that glass. Are you trying to get us all in trouble? And you,” I said to Pharmacy Boy, “Get a napkin and wipe up the chili you spilled. She’ll be back here in four hours, and we have to have this place looking just as good as when she left.”  I thought I was having the neighborhood guys over for poker; I was wrong. So was each of the other guys. We had been outwitted by our controllers, our spouses. Nothing is ever as simple as it first appears. We didn’t even recognize we were being managed until they made themselves known.
Who’s managing the show at your shop, you or the patients?  The answer to that question depends on who owns the relationship, who controls the dialog.  If most of the conversation about your organization originates with them, the best you are doing is reacting to them as they initiate the social media spin, or try to respond once the phone started ringing.  It’s a pretty ineffective way of managing.  It’s as though they dealt the cards, and they know ahead of time that your holding nothing.
There are times when my manager isn’t home, times when I wear my shoes inside the house—however, I wear little cloth booties over them to make certain I don’t mar the floor.  One time when I decided to push the envelope, I didn’t even separate the darks from the whites when I did the laundry.  We got in an hour of poker before I broke out the mop and vacuum.  One friend tried to light a cigar—he will be out of the cast in a few weeks.

Be afraid. Be very, very afraid.

saint

Work Flows–learn to color outside the lines

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munch_scream

Somewhere out there is the person or persons who invented Chuck e Cheese. I am convinced that whoever deserves the credit either does not have children, or if they do, does not take their children to Chuck e Cheese under any circumstances. If you’ve never been, it’s one of those places whose true cacophony must be experienced first-hand. The FDA should conduct clinical trials of blood pressure medicines there. The formula is simple; machines that make noise plus kids that make noise equals happy kids. Some parents are immune to the noise. I’m not some parents–never have been, don’t see it happening any time soon. I could feel the pressure build, the parents around me were coping the best they could. One father whose eyes looked like those in Edvard Munch’s painting “The Scream” was popping Xanax like they were jellybeans.

I collected a group of parents and we sequestered ourselves behind the skeet-ball. “We’ve got to come up with something to ensure we never have to do this again,” I whispered, trying to rally my charges.

“I can’t do this anymore,” replied a frail-looking man who had developed a nervous tick.

I paused and pondered as an idea flittered past my id. Then I started a smile which soon covered my face.

“What?” asked Tick man.

“Yes, tell us,” implored The Scream.

It was a coloring outside the lines idea if there ever was one. “WebEx,” I barked as the idea began to take shape. “We do virtual birthday parties on WebEx. We each login our children from the comfort of our home. No screaming kids, no cold pizza, no spilled soda. It’s perfect. While they’re doing that, we can be in another room watching football.”

The idea had legs right up until the point where my wife overheard it. “You old Grinch. Get back over here with your son.” I caved, but I’m holding the idea in reserve.

Thinking outside the box. In creating the vision for re-engineering your work flows, why start there? That’s where everyone starts. Remember, if everyone’s thinking outside the box, all that means is that the box has moved and everyone is back in it. Why not create a vision that includes something like re-engineering all non-clinical patient-facing activities? A stretch goal is not trying to reduce billing calling by fifty percent. That’s what world class providers are trying to do. Other stretch goals might be asking questions like;

1. What would have to happen to the practice to be able eliminate eighty percent of all patient complaints?
2. What would it take to move half of all patient contacts to the web?
3. What would happen to first patient satisfaction if you set a goal to use social media to explain how to resolve claims problems?

So, where are we? We need a project champion, who has executive sponsorship, and who is willing to create a vision that has some legs.

Oh, I forgot to mention that after we left Chuck e Cheese we had all the seven year-olds over to our house for a sleep over.  I should have stayed at Chuck e Cheese; it was quieter.

sainttop5

Why is change management so important?

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If  EHR is about anything it’s about change.  So much of what exists today has to do with creating and moving documents.  Did you know?

  • Of all documents handled each day in the average office,
    90% are merely shuffled
  • Currently, 90% of corporate memory exists on paper
  • There are over four trillion documents in the U.S. alone,
    growing at a rate of 22% per year
  • Professionals spend 5-15% of their time reading information,
    but they spend up to 50% looking for it
  • Corporate paper-based documents are growing at the rate of
    200% per year
  • 19 copies are made from each paper document
  • 22% of all documents are lost
  • 7.5% of paper documents are lost completely
  • 3% of the remainder get misfiled
  • $20.00 is spent on labor to file a document
  • $120.00 is spent on labor searching for the misfiled paper documents
  • $250.00 is spent on labor to search for lost files

From Price Waterhouse

black saint 2

Reform: confessions of a drive-by mind

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My wife said she had to call DC.  “All of it?” I asked.  Failed to even crack a smile—she must have left her funny bone in her briefcase.  I described her mom’s dog as a tennis ball with lips which seemed to be bred to be terrified of everything.  That had me zero for two, and losing ground quickly.

Today’s social networking technology allows one to take umbrage with everything from reform to how your neighbor shovels the snow from their sidewalk.  It’s an especially neat set of tools for those of us who have borderline control issues.  Which I do not, I told the unfunny woman next to me.  “You want to tell people how to tie their shoes because you think you do it better than them,” she remarked.  “Which is probably why flying bothers you so much; your nagging belief that the pilot isn’t qualified.”

Where was I before I interrupted myself?  Now, before anyone starts name-calling, I shall admit that I can be a bit of a heterodox.  Sometimes instead of talking I write, it’s like taking my thoughts for a walk in the park with an occasional pause at a fire hydrant.

I am beset by several unanswered questions about reform.  What do you think?  Is healthcare reform an attempt to make America a risk-free society, to rid people of what might be in order to exercise control where none exists?  Is it possible Jerry Springer was asked to provide ad hominem comment over the healthcare reform legislation, or that the plot line was a rerun of something written by David Mamet?  Does the tedium of reading the bill’s thousand-plus pages make stamp collecting seem like a full contact sport?

It’s too bad the Administration had the misfortune of drafting the reform legislation without having the luxury of hiding behind the Iraq maelstrom as we did during the Cheney presidency.  We may find some solace in that even with it now looking like some form of reform—version 5.0—will pass this year, our system will still be better than the UK’s, which is essential since they do much better with Shakespeare than us—I think it has something to do with their dedication to the diction of the British English.  “O, yet defend me, friends; I am but hurt.” (Claudius in Hamlet.  Is this where Python got the idea for, “I’m not dead yet?”)

We would be more likely to turn Hamlet into a navel gazing rap musical, than try to do it justice by reciting the original English.  Perhaps that is why we enjoy PBS as it gives our snobbery a chance to imagine the world as a series of Masterpiece Theater renditions.

If the reform effort still smacks of vestiges of nineties healthcare kitsch, it may be because nostalgia is still what it used to be and never was.  Either way, it looks like we will have something more concrete at which we can pit our opinions.  It will cost in the neighborhood of nine hundred million dollars, and yet we still aren’t able to distill the main talking points on two or three PowerPoint slides.

saint

What should you budget for change management and work flows?

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fruitflyhumor

They came in waves from just over the horizon, each wave approaching from different elevations, and different points on the compass. They were legion; too many to count, too many for which to be able to set a winning defense. We marshaled our forces, knowing we were helpless. As I sat there awaiting the final assault I was reminded of some of the great World War II black and white movies; Midway, Twelve O’clock High, Tora, Tora, Tora. Wave after wave of Japanese and German fighters attacking the apparently helpless US forces.


Our defense perimeter established, we waited and watched. The first wave circled twice above the cellophane covered bowl. Tiny holes were cut into the cellophane allowing the fumes from the apple cider vinegar to waft upwards. The lead fruit-fly banked left and made his assault on the target. He bounced off the cellophane, as did most of the initial flight. One by one, they recovered and made their way through the pin-prick holes. The second and third waves approached the half-covered Tupperware that held the pineapple slices. After several minutes passed we slapped the lid onto the container, trapping scores of them.

“It’s those Concord grapes,” my wife asserted, implicating the helpless grapes.

“Don’t blame the fruit,” I replied. “They’re just fruit.”  Here’s the segue, try to stay with me.

If you’ve ever flown into Chicago’s O’Hare airport you may have witnessed scores of planes stacked in the air space awaiting permission to land.  I recently made reservations for a trip to Chicago. I used Southwest’s web site to make my flight to Midway—they don’t fly into O’Hare but the illustration still works. I’m the type of person who is more suited to using a well-functioning online service to complete my business. Even so, it would not be unusual for me to be having an animated one-way conversation with my computer. I started talking to the website after having to enter the same data time after time. Don’t get me wrong; I got a great deal on the airfare—three tickets for less than I paid for one last time. The site’s design allowed me to book a hotel. I entered data to reserve three rooms to coincide with the dates of my flights. A nanosecond later, I had a confirmation code for one non-refundable, no cancellation allowed room for the night before my plane even went to Chicago. By now I was speaking to my computer in tongues.

Like with the fruit, don’t blame the computer. The software did as it was programmed.  A lot of healthcare providers are going to be amazed by what they do and don’t see from their EHR system.  The system will do exactly what it programmed to do.  That’s great news if your organization’s work flows are an exact match for those built into the code.  We both know they aren’t.  That when it becomes necessary to build work arounds.  Unfortunately, you’re building them to match your work flows to their code.  For those new to the process, you are now designing your organization to move even further away from how it presently runs.  The further away you move, the more you will require change management.  Unless you budgeted correctly months earlier, you have probably already run out of funds for work arounds and change management.  If that’s the case, your EHR system is approaching its do-over point.   For each dollar of IT spend, it probably makes sense to budget at least two dollars for these tasks.  I guess you can budget those dollars for EHR 2.0, but it may be someone else whose running the implementation.

black saint 2

EHR-step away from the scalpel

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So, I lunched today with a friend who is an executive at a healthcare consultancy.  She recently spent four days in a hospital, entering via the trauma center.  The purists among us would think, “If she only had a personal health record (PHR).”

As it turns out, she did.  From what I understood form our chat, the people in the hospital did not welcome her understanding of healthcare.  She handed someone on the trauma team her PHR from Google Health Vault.  According to her, she had downloaded enough data on her jump drive to where MRI’s were dripping from the USB.

At some point they determined she needed to have surgery because of something that appeared on her CAT scan.  Moments before seeing how well she could count backwards from 100, she was able to convince the surgeon that she did not require an operation because what they saw was a pre-existing condition which was documented on her PHR.  Step away from the scalpels.

I think the scalpel thing only served to spur her on.  After leaving the hospital, she requested a copy of her bill—all forty-three pages.  She read it, line by line.  They hate it when patients do that.  Her insurance covered everything, so it’s not like she was minding her pennies.  She was minding her sanity.  Seven hundred and some dollars for Tylenol.  She never took any Tylenol.  Somehow the billing system was tied to the fact that Tylenol was prescribed, independent of whether she actually took it.

Seventy-nine hundred dollars for a CT-scan.  Only ten times higher than the national average.

Where were the failure points?  People.  IT.  Process.  It’s a good thing she knew what she was doing or right now she’d be missing a thing-a-ma-jig—and they would have billed her for another Tylenol to manage that pain.

Without change management and work flow improvement, EHR will only make things worse.  There is a term of art for the intersection of work flows, people, and data—it’s called a mess.  To minimize the mess, to have any shot at an ROI, the sooner you employ adults to run the Program Management Office (PMO) for your EHR, the better your chances.

sainttop5

Pay attention to patients even when they’re not at your office.

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The wheel’s still turning, but the hamster is dead. One Brady short of a bunch. I like the ocean one because it reminds me of a bit done by the comic Ron White. In the bit he talks about the time he met a woman who was wearing a bathing suit made of sea shells which he held to his ear to find out if he could hear the ocean. Maybe you had to be there.

All day I’ve been operating as though I was one Brady short of a bunch—I actually have cufflinks with Marcia Brady’s picture on them, but we’ll save that for another day. The day’s highlight revolved around my daughter’s doubleheader field hockey matches–third and fourth grade girls. Their opponents looked better, older. In fact, I thought I saw one or two of them drive themselves to the field. Forty-eight degrees, first game at 8 AM. Not enough time to grab breakfast and get to the game on time. I dropped my daughter at the field and headed to a nearby convenience store to buy her a donut. As I pulled into the parking lot I noticed that I needed gas, so I figured why not multi-task it. I inserted the nozzle in the tank, went into the store, purchased a donut, and proceeded to drive away.

For the metrics lovers, those who like order over chaos, those whose desk is always neat, have you discovered my Brady moment? My purpose in going to the store was to buy a donut, not gas. My mind was focused on the donut, not on the gas. Once the donut was resting safely on the passenger’s seat my mission was over, or so I thought. Something was gnawing at me as I pulled away from the pump, something that flared at me in my rearview mirror. I knew what it was a full second before my body got the message to react to it. “Hit the break,” my mind screamed. I could see what remained of the black gas pump hose as it pirouetted helplessly behind my car. I fully expected the entire gas station to be consumed by a giant fireball like the one at the conclusion of the movie Rambo. Once I was convinced that neither I nor–it turns out that neither nor does not violate the rule of using a double negative in a sentence–anyone else in the vicinity was in mortal danger, I exited my car and walked to the pump.

My first reaction, and I don’t know why, was to see if the pump was still charging my credit card. Selfish? That means that subconsciously I had already made the decision to flee, but that I didn’t want to flee if my charge card was still open. I retrieved the severed hose from the ground and inserted it in the pump, thereby closing out the sale on my credit card. I looked around. There wasn’t anyone who had witnessed my little AARP moment. Since they hadn’t, I figured why bother anyone. Kismet; my turn on the hamster wheel.

I’m convinced it’s the little things that determine whether your initiatives succeed or fail. It’s usually nothing tricky, nothing that requires two commas worth of new technology. It’s being focused and being committed to excellence in the menial tasks which comprise each patient interaction, especially those that occur outside of the office. What little things are being overlooked in your practice?  Could social media solve some of these?  In a heartbeat, and for a cost that would surprise you.

Oh, and don’t forget to hang up the hose when you’re done.

black saint 2

What is meant by Healthcare 0.2 and 2.0?

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eat_more_chickensized

Last night I was explaining to my sister-in-law my notion about healthcare 0.2 and the need to transform it to healthcare 2.0.  She had no idea what I meant.  That’s a problem—not because she’s my wife’s sister but because she an executive at one of the top children’s hospitals.

I figured that if she didn’t understand what I meant, I may have also confused others—sort of like typing with a keyboard full of marbles.

I’ve written that healthcare is a 0.2 business being forced towards 2.0—H2.0.  What exactly do I mean by Health 0.2?  It could just as easily be 0.5 or 0.7.  The idea behind the label is that there is a large gap between where the healthcare business is, H0.2, and the future of the healthcare business, H2.0.

Permit me to share how I distinguish between the business of healthcare and the healthcare business.

  • The business of healthcare—clinical, care, patients
  • The healthcare business is paper intensive and duplicative and includes support business functions like:
    • Human resources
    • IT
    • Payroll
    • Vendor relationship management (VRM)
    • Patient relationship management (PRM)
    • Registration…and so forth

Successfully bridging the 0.2 to 2.0 GAP replies equally on foresight and planning.  For the change brought about by the bridge to take hold, change needs to be an ongoing event.

To begin the assessment, healthcare leaders must undertake an honest assessment of the organization’s strengths and weaknesses.  Sounds simple.  It’s not.  Hospitals are noted for their fiefdoms, and the fiefs, run mostly by doctors, aren’t big on being told there’s a better way to do things, nor are they keen on giving away control.

To change how the business is run, to make it more effective, and thus more efficient, requires that the major business functions be retooled.

We’ll take a look at how a hospital might go about this.

sainttop5

How’s the EHR vendor performing?

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cat

Many organizations have a Program Management Office and a Program Steering Committee to oversee all aspects of the EHR.  Typically these include broad objectives like defining the functional and technical requirements, process redesign, change management, software selection, training, and implementation.  Chances are that neither the PMO or the steering committee has ever selected or implemented an EHR.  As such, it can be difficult to know how well the effort is proceeding.  Simply matching deliverables to milestones may be of little value if the deliverables and milestones are wrong.  The program can quickly take on the look and feel of the scene from the movie City Slickers when the guys on horseback are tyring to determine where they are.  One of the riders replies, “We don’t know where we’re going, but we’re making really good time.”

One way to provide oversight is to constantly ask the PMO “why.”  Why did we miss that date?  Why are we doing it this way?  Tell me again, why did we select that vendor?  Why didn’t we evaluate more options?  As members of the steering committee you are responsible for being able to provide correct answers to those questions, just as the PMO is responsible for being able to provide them to you.  The PMO will either have substantiated answers, or he or she won’t.  If the PMO isn’t forthcoming with those answers, in effect you have your answer to a more important question, “Is the project in trouble?”  If the steering committe is a rubber stamp, everyone loses.  To be of value, the committee should serve as a board of inquiry.  Use your instincts to judge how the PMO responds.  Is the PMO forthcoming?  Does the PMO have command of the material?  Can the PMO explain the status in plain English?

So, how can you tell how the EHR effort is progressing?  Perhaps this is one way to tell.

A man left his cat with his brother while he went on vacation for a week. When he came back, he called his brother to see when he could pick the cat up. The brother hesitated, then said, “I’m so sorry, but while you were away, the cat died.”

The man was very upset and yelled, “You know, you could have broken the news to me better than that. When I called today, you could have said the cat was on the roof and wouldn’t come down. Then when I called the next day, you could have said that he had fallen off and the vet was working on patching him up. Then when I called the third day, you could have said he had passed away.”

The brother thought about it and apologized.

“So how’s Mom?” asked the man.

“She’s on the roof and won’t come down.”

If you ask the PMO how the project is going and he responds by saying, “The vendor’s on the roof and won’t come down,” it may be time to get a new vendor.

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