How Health Policy Played a Role in the Recent Spate of Mega-Mergers Involving National Health Plans

By Ken Perez, vice president of healthcare policy, Omnicell, Inc.

Ken Perez
Ken Perez

“If at first you don’t succeed, try, try again.”

During the first half of 2017, two mergers, each pairing national health plans—Aetna with Humana and Anthem with Cigna, respectively—were blocked by two federal judges, both of whom concluded that the mergers would reduce competition in the health insurance market and, therefore, raise prices.

Departing from the horizontal merger approach, three national health insurers are now involved in proposed or possible vertical mergers. CVS Health announced its intent to acquire Aetna in December 2017; Cigna announced its plan to acquire pharmacy benefits manager Express Scripts in March 2018; and Walmart is reportedly in acquisition talks with Humana. Because of their size, the interesting value delivery chains they would create, and potential synergies, these corporate combinations have been described as disruptive and industry game-changers.

From a health policy standpoint, what has contributed to these mega-mergers?

First, the specter of a single-payer healthcare system—as most ardently promoted by Sen. Bernie Sanders (I-Vt.)—has been greatly diminished by the election of Republican Donald Trump as president in 2016, continued Republican majorities in both the House of Representatives and the Senate, and perhaps most saliently, the passage of the Tax Cuts and Jobs Act of 2017 (TCJA) in December 2017.

It is a truism in Washington, D.C. that taking back something that has been given to the public is hard, if not impossible. Since a single-payer healthcare system would clearly entail a major expansion of the federal government that would require not only the repeal of the TCJA’s tax breaks for individuals and corporations, but also the imposition of additional tax increases, it would appear to be a political impossibility for at least until 2021.

Second, Medicare Advantage (MA), Medicare’s managed care program, increasingly is where the action is for health plans. Congressional Republicans strongly support MA, and the program is gaining in popularity with Medicare beneficiaries. The Centers for Medicare and Medicaid Services projects that 20.4 million people will enroll in MA for 2018, an increase of 9 percent over 2017, about three times faster than the growth of the total Medicare enrollee population. More than a third (34 percent) of Medicare beneficiaries are enrolled in MA.

The proposed mega-mergers involving Aetna, Cigna and Humana secure control of significant shares of the Medicare population, including sizable shares of the MA enrollee pie.

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Health IT Startup: Fit4D

Fit4DWith a mission to improve the lives of people living with diabetes and chronic conditions worldwide, Fit4D delivers scalable and effective programs through an optimized mix of technology human-based interactions.

Founder’s story:

David G. Weingard
David G. Weingard

At just 36 years old, David Weingard was diagnosed with Type 1 diabetes. With no family history of diabetes, he was confused and overwhelmed about the diagnosis. He had two sessions with his doctor on how to use insulin and that was it. Having received limited support and education on his diagnosis, Weingard was left to manage his diabetes on his own and needed help.

He then found Cecilia, a certified diabetes educator (CDE), who compassionately gave him the correct steps to follow to help him become productive again, personally and professionally. Cecilia sparked an idea for Weingard – to scale the personalized coaching he received, to millions of people living with diabetes, but using a technology platform. With the daily vigilance and management of his diabetes, he left his corporate job and founded Fit4D.

Market opportunity

Fit4D has established business partnerships with clients that include major health plans and providers such as Humana, HealthFirst and several Blue Cross Blue Shield plans, along with major pharmaceutical and medical device companies. The company delivers scalable and cost-effective diabetes management programs through an optimized mix of human-based touch points and technology to deliver measurable outcomes in an affordable manner.

Fit4D is driving improvements in diabetes outcomes across the socio-economic spectrum, achieving a relatively high enrollment rate, lowering blood sugar levels, and delivering significant cost-savings and ROI for clients.

Results include:

Who are your competitors?

Fit4D is unique in that we scale and deliver personalized one-on-one support through the optimization of human touch and technology. There are other companies in the market that are combining patient healthcare services with a heavy focus on technology, such as Livongo and Omada; however, they don’t offer a personalized patient approach to diabetes. Fit4D emphasis on combining human touch with a dedicated CDE throughout the length of the program, allowing the patient to build a strong fruitful coaching relationship. As a result, our service is highly valued for the likes of payers, providers, pharma and medical device companies.

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Lessons from HIMSS 2018: The Need for Cloud, “Killer Apps” and Connectivity, But Are They Already Here?

By Donald Voltz, MD, Aultman Hospital, department of anesthesiology, medical director of the main operating room, assistant professor of anesthesiology, Case Western Reserve University and Northeast Ohio Medical University.

Dr. Donald Voltz
Dr. Donald Voltz

In his HIMSS keynote address, Alphabet’s former executive chairman and now current technical advisor Eric Schmidt warned attendees that the “future of healthcare lies in the need for killer apps.” But he also cautioned that the transition to a better digitally connected health future isn’t just one killer app, but a system of apps working together in the cloud.  He also advocated transforming the massive amount of data held in EHRs into information and knowledge.

Schmidt is correct in his assessments.  There is a need for interoperable “killer apps” for new health IT priorities and procedures. The apps need to deliver better patient outcomes by integrating and optimizing patient data while driving healthcare facility financial incentives such identifying cost savings and streamlining insurer payments. These types of needs are accelerating convergence in the health care sector for interoperability across clinical, financial, and operational systems, not simply EHR connectivity.

One of the cloud “killer apps” that is a strategic component of convergence and hospital growth are Annual Wellness Visits (AWVs). First introduced by private insurers and then by CMS in 2011 as part of its preventative care initiative under the Affordable Care Act (ACA), AWV’s are designed specifically to address health risks and encourage evidence-based preventive care in aging adults.

The typical visit requires a doctor or other clinician to run through a list of tasks like screening for dementia and depression, discussing care preferences at the end of life, asking patients if they can cook and clean independently and are otherwise safe at home. Little is required in the way of a physical exam beyond checking vision, weight, and blood pressure.

On its own merit, some could argue that while this app can greatly contribute to better patient care, it does not significantly impact hospital and clinic growth, but when integrated with other apps, it becomes a key healthcare growth catalyst with its treasure trove of patient data. That data, when streamlined, can enable expedited payments to government and private insurers, help lay the foundation for AI and other knowledge initiatives as cited by Schmidt.

Chronic Care Continuum App     

Another “killer app” is the care continuum integration of treatment for chronic diseases ranging from diabetes to dementia and behavioral and mental health issues such as the U.S. opioid epidemic, heroin addiction, alcoholism and suicide. The ECRI Institute released its “Top 10 Patient Safety Concerns for Healthcare Organizations” in March 2018 and cited the management of behavioral health needs in acute care settings as the 6th highest ranked safety concern.

“Organizations should consider working with other partners, such as psychiatrists, behavioral health treatment programs, clinics, medical schools and teaching programs, and law enforcement,” says Nancy Napolitano, patient safety analyst and consultant, ECRI Institute. “Being able to communicate remotely and seamlessly, assessing risk and complexity, as well as delivering high-quality connected care are critical. Relationships and partnerships are what get you what you need.”

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Infographic: HIPAA Healthcare Data Breaches – Looking back at 2017

By Manisha Kathooria

Over the past 5 years, healthcare data has fallen prey to unethical attacks that compromise sensitive patient information. If you look back at 2015, it was the worst year in healthcare data security when data breaches hit an all-time high by affecting 113 million individuals approximately.

As of today, the number of breaches reported to the Office for Civil Rights (U.S. Department of Health and Human Services) has been consistently increasing. Also, the number of individuals affected does not seem to improve despite regulatory enforcement procedures and laws drafted to put a check on this.

This infographic by Kays Harbor establishes a comparative analysis and infers how data breach patterns have evolved in all these years up to 2017. It highlights the following major findings:

  1. HIPAA data breaches reported in 2017 were more than double the number of breaches in 2016. Though, the individuals that are estimated to be affected by these breaches was much less than the past four years.
  2. Healthcare providers again made it to the top of the list for reporting 231 data breaches – highest in all these years.
  3. Information technology continues to be a major reason for these breaches so far, showing an upward trend in contribution of hacking and IT incidents resulting in data loss.
  4. Kentucky based healthcare organization, Commonwealth Health Corporation reportedly filed a breach confirmation related to theft affecting 697,800 individuals.
  5. While Texas reported maximum hacking incidents, breached entities in California filed maximum thefts two years in a row.

Furthermore, it discusses the trends and predictions by the C-suite in healthcare industry for the coming year. David Muntz, principal at StarBridge Advisors said, “There seems to be a growing gap between the demand and supply of cybersecurity professionals that needs to be addressed. On the positive side, vendors are providing strict countermeasures for vulnerable products and services which will result in HIPAA being perceived as an enabler for data sharing as well.”

As a matter of fact, 2018 has set all hopes high and CIOs are looking forward to a decline in the breached numbers with active cybersecurity measures challenging the perils of vulnerable healthcare systems.

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Is Blockchain the Remedy for the Ailing Healthcare System?

By Lisa Bowman, editor, Data for XYZ.

Technological advancements have taken healthcare from a basic level to what, in comparison, seems sophisticated and state-of-the-art. For example, MRI, CT, PET and ultrasound technologies have drastically improved diagnostics and treatment in healthcare. Technology’s impact on communication has also radically changed healthcare. Images and information can be sent and received instantly, allowing medical professionals to consult and collaborate with each other regarding a patient’s diagnosis and treatment.

With digital means of recording and accessing patient medical history, continuity of care is easier than ever. With all of the changes technology has brought to the healthcare system, it would seem that patients and providers would be more than satisfied with the level of care and efficiency.

Unfortunately, reality says the contrary. According to a 2017 Gallup poll, over 70 percent of Americans think the healthcare system in the US is “’in a state of crisis”’. Patients, providers, and insurance companies face frustrations daily. Patients struggle to interpret their benefits and get approved for treatment. Denial of benefits and delayed payments plague patients and providers. The problem isn’t a lack of technology, as previously discussed. The problem is a lack of a mechanism to capitalize on existing technology. Information is already digital in the majority of medical offices, and a range of methods for electronic communication already exist. What the healthcare system needs now is a streamlined way of getting information where it needs to go in real time.

Blockchain to the Rescue

At first mention, it may seem far-fetched that blockchain technology would help the healthcare system. Most people know little about what blockchain technology, and if they are aware of it, it’s most often associated with cryptocurrency. Interestingly, the same blockchain technology that makes cryptocurrency possible is being applied in many arenas outside of cryptocurrency due to its ability to securely and efficiently verify and log transactions.

The blockchain is essentially a ledger of events that updates in real time. In cryptocurrency, for example, algorithms verify authenticity of coins, and coins are sent and received once verification is determined. The transaction is then stored in the blockchain. This is appealing to many people for many reasons. One reason is that quicker transfers of currencies are possible when the middle man is eliminated. Algorithms can do in seconds what banks take days to do. Another reason is that information is encrypted, which means privacy and security of information.

In terms of healthcare, a company called Solve.Care has undertaken the challenge of solving the existing problems in the healthcare system using the blockchain. The biggest plagues in healthcare are rooted in the administrative area. Many hours are spent tracking down information that should be easily and instantly available to relevant parties. For instance, it may take days or weeks to receive a letter denying an insurance claim.

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Artificial Intelligence Can Help with These 3 Public Sector Challenges

In recent years, the public sector has become increasingly aware of the multifaceted potential of big data. These days, government agencies around the world collect vast amounts of data from people’s activities, behaviors, and interactions—a virtual treasure trove of information that the public sector can utilize and turn into actionable insights, and later, into actual solutions.

The big challenge, however, is that government agencies are falling under more and more pressure to find relevant insights from complex data while relying on limited resources and technologies with inadequate capabilities. And with the sheer size of data being generated nowadays, it’s becoming more difficult to extract meaning from what the data hides beyond their colossal façade.

Thankfully, there is one critical technology that is redefining the way public sector agencies study and utilize data, and this is artificial intelligence. Today, artificial intelligence solutions that make use of technologies like machine learning and topological data analysis can automatically process big data and discover patterns and anomalies no matter how complex and seemingly disjointed these different points of data are.

Precisely because of these advantages, artificial intelligence solutions are now being used by numerous public sector agencies and institutions around the world.  In this article, we’ll fill you in on the basics of three important areas of the public sector in which AI is currently making waves.

Financials

The financial industry is one of the biggest producers and exchangers of data, and as such, it stands to benefit immensely from artificial intelligence technologies. Every day, government-owned banks and other financial institutions buy, borrow, and trade currencies and financial products, generating massive amounts of data from customers, partners, and other stakeholders.

By using artificial intelligence solutions for financial services, institutions can develop an intelligence framework that will allow them to cater to customer needs, understand and manage regulatory risks, and proactively prevent money-laundering activities. This way, public sector financial services are able to assume a position of strength over increasingly complex challenges.

Population Health

In many jurisdictions over the world, value-based care is being adopted as an alternative healthcare model that focuses more on accountability, and on the type and quality of service provided to patients instead of the volume of care provided. With this increased emphasis on value, government-aligned health providers and insurance systems have begun using artificial intelligence software in order to become more agile and proficient at managing the risks of patient pools.

This way, even with the immensity and complexity of patient data, public sector providers and health payers are able to better understand clinical variations, as well as automatically predict individual and subpopulation risk and health condition trajectories. Through insights gained from these data, clinicians and other personnel across the healthcare spectrum can then better determine the best and most affordable courses of care, in addition to being able to confidently recommend the most appropriate health programs for their governments to implement.

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7 Ways AI Is Changing Medicine As We Speak

Artificial intelligence is a topic that should interest us all, as it changes the world with every second. And the healthcare system is one of the areas that AI has already started to revolutionize. These are the main ways in which that is happening.

  1. Precision Medicine

Due to the introduction of personalized diagnosis and precision medicine, now doctors can treat a patient’s condition, by taking into account his/her background, as opposed to merely treating the disease. This is accomplished by using proteomics, which is a type of DNA mapping, as well as advanced AI machine learning.

  1. Killing Occam’s Razor

Occam’s Razor is also known as the Law of Parsimony, and it refers to providing a range of solutions to a given problem. Also, according to this principle, the simplest solution is, most of the time, the correct one. Considering that both machine learning and AI doesn’t have the human assumption element, their capacity of reading and analyzing amounts of data can significantly increase the accuracy of the diagnosis.

Accordingly, this can be really helpful in diagnosing elderly patients, in particular, as they are more likely to suffer from various diseases at the same time.

  1. Google Can Spot Eye Disease

DeepMind is a Google-owned AI company that has come up with a way of diagnosing eye disease. After assessing and attentively analyzing the medical records of a significant number of patients, it has created machine learning technology that should help doctors diagnose eye illness earlier. This merely outlines that, even though AI is innovating almost every field, it still relies on human help.

  1. Automated Cancer Treatment

It appears that AI can also play an important role in treating cancer, which affects more and more people. Accordingly, the CareEdit tool can be utilized by oncologists for crating practice guidelines. To be more specific, the tool analyzes considerable amounts of data such as past treatment regimens, aiming at comprising a clinical decision support system that should help physicians treat each patient. This can significantly enhance the rate of survival, while cutting down the costs associated with the treatments.

  1. Virtual Health Assistant

Interestingly enough, at the time being, there are apps that carry the roles of personal health coaches. This functions the same way as a customer service representative at a call center. What is more, the digital assistant can do as much as take notes, ask questions, even provide specific advice while streaming the information to the healthcare provider. This has the role of simplifying the process.

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5 Facts About Medical Billing and Coding Education You Should Know

Medical billing services are one of those topics that can never be discussed enough if you are related to the healthcare industry. Hence, laying down opportunities for students to adapt and see themselves in the role of a medical biller and coder is a process we all should know.

Many people are choosing this field because of higher earnings at the end of the day. And this makes medical billing and coding education a highly beneficial and suitable career in the long run, in an environment where healthcare providers are shifting to electronic health records.

You can become a certified medical reimbursement specialist by passing a medical billing certification exam that is held by American Association of Professional Coders (AAPC).

  1. Medical Billing and Coding Education – As a Career Move

You become a certified professional biller (CPB) after taking the CPB exam, answering 200 multiple choice questions within a time limit of five hours and 40 minutes. It only takes a mix of interest and passion for a healthcare professional to go through this guide.

The certified medical billing specialist (CMBS) examination consists of a 100 multiple choice questions, and by successfully answering them, you can become an authentic medical biller. However, medical coding or just coding requires the students to follow different criteria set.

Certified medical coder (CPC) certification brings you up to speed with the coding world, and by passing it, you become a certified coder. This gives you an edge over the others without a certification when the companies are looking to hire medical coders. The CPC exam, however, has 150 multiple choice questions with reading materials available online.

  1. Certified Medical Biller’s Salary

The certifications are not mandatory, but they help you in landing a well-paid job. According to a survey in 2012, a medical biller earned $16.42 an hour, bulking up to $34,000 a year. With added experience, the pay will increase over time. An experienced certified biller and coder can quickly earn up to $50,000 a year.

Medical billing online jobs are abundantly available since it is an emerging field. The reward is also generous with the option of being able to work from home. Many people are managing more time for their friends and family by working as a part-time or remotely.

There is a four-week online course for medical billing as well. It takes more of your ability than the actual duration to influence your medical billing career. There are many online medical billing programs you can get enrolled in and start learning. By the time medical billing and coding education ends, you’ll feel accustomed to all the complicated medical jargon.

There are courses available for both the mediums. You can study online and appear in the exams at $129 per credit hour. Or you can attend regular classes at a university. For students living outside the US, the tuition fee jumps up to $315 per credit hour.

Federal student aid programs allow students to have loans and grants for pursuing medical billing courses. You can also look for AHIMA merit-based scholarships if you’re a student with distinction.

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Health IT Startup: NeuronUP

NeuronUPNeuronUP is an online platform for professionals working in neurorehabilitation and cognitive stimulation with patients with cognitive deficits related to Alzheimer’s, Parkinsons, traumatic brain injury, ADHD, normal aging, etc.

Elevator pitch

In the United States alone, there are millions of people living with Alzheimer’s,Parkinson´s, traumatic brain injury, Multiple sclerosis, and ADHD. There is an absolute necessity to help rehabilitate people with these conditions and NeuronUP can help.

 Founders’ story

Iñigo Fernández de Piérola
Iñigo Fernández de Piérola

NeuronUP was born out of the psychology clinic of our boss, CEO and founder, Iñigo Fernández de Piérola. During his work as a psychologist, he realized that a lot of his time was spent making or searching for materials to use with his patients. Much of the content he found online or elsewhere wasn’t very useful, was very expensive or was geared only towards children. Setting out to fix that problem, NeuronUP got its first spark of life.

Marketing/promotion strategy

Being an online platform, NeuronUP puts a lot of energy into SEO to try to capture relevant searches. We get a lot of word of mouth traffic from pleased clients too. Once a month for our Spanish speaking-client base, we host online chats with renowned people working in the neurosciences. NeuronUP Academy is very popular and keeps people coming back to the site. We would like to implement that for our English-speaking clients as well in the future.

Market opportunity

Our target audience are the professionals working in neuropsychology, occupational therapy and speech therapy. With the millions of people in the world with cognitive deficits related to neurodegenerative diseases, brain injuries,mental illnesses, neurodevelopmental disorders and mental disabilities, these professionals need and deserve help to save time and energy putting together their rehabilitation strategies.

Who are your competitors?

Our clients are only professionals who can direct the rehabilitation strategy based on what each individual patient needs. Other similar products like BrainHQ and Cognifit will sell to the end user and we feel like that isn’t the best strategy.

How your company differentiates itself from the competition and what differentiates NeuronUP?

Professionals are able to create a strategy easily for each individual patient by working with NeuronUP.  Activities such as worksheets, serious games, simulators and content generators can be personalized to the patient for maximum efficacy. Content is also classified by the cognitive function being worked, which allows for rehabilitation at the clinic or at home.

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Are Mobile Health Apps Really Making A Difference?

By James Cumming, CEO, Daily Posts UK.

James Cummings
James Cummings

Smartphones have come a long way over the years and have become far more than simple tools for making calls and sending texts. Now, your smartphone can make financial transactions, secure your home or car, and yes, monitor your health and lead you towards a healthier lifestyle.

A variety of mobile health apps currently exist for android and iOS devices, and each app brings something unique to the table. Some are entirely free, while some charge a small fee for their services. But before we look at some of the reigning health apps currently available, let’s first look into the usefulness of mobile health apps in general. 

Do mobile health apps really work?

According to Domains4Less, “Gone are the days when health professionals could only see and help patients in person. And limited are the days when websites and phone calls were the only alternative to physically speaking to a patient. Health apps are the new frontier …”

The current breed of mobile health apps available serve mainly two functions, one of which is  the recording or collection of your vitals which, depending on the app, may then be shared with a health care provider. Other apps function by providing you immediate access to health information like workouts and nutrition data which can help you live a healthier lifestyle. This means that with the help of an app or a combination of apps that deliver the above functions, you can stay healthy and may not actually need to see a doctor unless you are suffering from very serious symptoms.

Even though there is no empirical evidence yet of how much health apps contribute to healthy living, there is proof that such digital tools do make you take greater notice of changes in your health, such as weight increase, the need for more physical activity, or an erratic heart rate and thus gives you an opportunity to get these issues under control. If you use such apps consistently, they are bound to eventually contribute positively to your health.

Other ways specialized health apps can help include:

Some mobile health apps that are changing lives 

  1. Doctor on Demand

This app is free to download but requires subsequent payments. The price is worth it, however, considering the benefits of the app. With Doctor on Demand, you can conveniently organize video visits with certified physicians who can promptly provide you important medical advice anywhere you are in the world via your phone. Doctors on the app can provide treatment via the app for cough/cold, allergies, minor infections, flu, as well as emotional health concerns. The services are also covered by insurance (depending on your health insurance provider).

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