Healthcare Exchanges offer a way forward

In my last Healthcare blog¬†I argued that because of the structure of our payment system, the network effects of the providers, and reimbursement rules healthcare isn’t a free market. I believe that the exchanges in the Affordable Care Act aka Obamacare, actually offer a path forward that may take us closer to a freer market for healthcare than anything we currently have.

First I need to say that they are not an immediate silver bullet the exchanges only offer a way forward and do not guarantee any changes in the market. Furthermore, if the exchanges do provide the changes I’d like to see it will take time, several years in fact, for those changes to have a broader impact on the market.

What are the exchanges? They are essentially a market place where a customer can select a type of insurance with a specific network that meets their needs. How is this different than what we have had in the past? Well, typically health insurance has been only offered through your employer and you get what they offer. If you don’t have a full time job, you’re basically out of luck and paying a huge monthly premium. The exchanges level that playing field by increasing the pool of people that will be using those types of insurance and allowing across state competition for health insurance. For example, there’s only one Blue Cross Blue Shield provider across all the exchanges in the US. That’s a pretty big change.

Because there is competition based on meeting the needs of the customers there will be much faster feedback to the “plans” as they are called. If members don’t like a specific offering, they won’t make any money and the next year will be forced to make a different offering to attract more members. Furthermore, there will be switching across the plans as people realize they dislike certain features. I believe this will happen for several years until a “dominate” plan design emerges based on the success of those plans. Healthier members, low turn over, and acceptable level of revenues for the insurers. Expect these metrics to be similar to the mobile industry in the US (ARPU, Churn, etc..).

Because of the relatively fast feedback on the products in the market and the possibility to have at least three offerings on the exchange (Gold, silver, bronze), insurers can experiment with different types of plans and benefits. The most popular one at this point is something called Accountable Care Organization, which is somewhat similar to an HMO, but is supposed to be better (we’ll see). ACOs as they are called will have to keep track of the overall quality and re-admission rates with a goal of continually driving up quality of care and reduce re-admissions. Additionally, these are narrower networks of care than a traditional PPO that most people have become accustom to.

That’s fine, but that doesn’t really help with the fact that it’s a networked economy and that there’s still a huge imbalance of knowledge. Well, here’s where the insurers can changes things up. Instead of focusing on the narrow set of providers in their region, they can look to create a network based upon the specific of the member’s conditions and have those members go to the specialty providers that offer the best care for those conditions. Even if they are out of state or out of the country.

Granted this data is a bit out of date, however it’s likely to be accurate, according to the Innovator’s Prescription (pg 96) there are facilities that have become so specialized in certain conditions (hernia repair) that their cost to treat those conditions is $2,300 while a general hospital costs an average of $7,000 and has a much lower re-admission rate than the general hospital. With this in mind an insurer could use these specialty clinics and even fly their members to receive treatment and still save money.

This would dramatically change the shape of the network for the members of those insurers and improve overall care and results. It would also dramatically change the interaction with providers in the member’s region as well. Some hospitals are already feeling the pain in this such as Seattle’s Children’s Hospital (which is suing over being excluded).

I don’t think being exclusive it the right direction, I think creating a strong partnership with members through health coaching and care management can help drive better results and education between the provider, insurance company, and member.

This will require continual experimentation with the types of networks, the way the insurance companies interact with their members to take it from a confrontational interaction (from the member’s perspective), and how the providers plan to engage with insurers. There needs to be incentives to encourage providers to recommend non-traditional recommendations. Incentives to support healthy living for the members. Only experimentation in all of these areas can inform the insurers how to engage better to dramatically improve the health and reduce the cost of our nation.

Lean as a tool for new and mature companies

Today, I finished the book “The Lean Startup” by Eric Ries. Despite the focus on entrepreneurship, I think this book has applications at many levels. First though, I must say that I’ve been using Lean for several years and I walked into this book with an understanding of Lean and how  to apply it at a company. What does Lean mean though? Well, it certainly doesn’t mean cutting staff, reducing the amount of money you have or anything along those lines. It’s a methodology for managing projects, processes and products. It does this by basing decisions on actionable data.

What is actionable data? Well, it’s data that you can do react to quickly if the data is showing trends. This could be a positive trend or a negative trend. If you see something going well and a process is improving over time, (which is abnormal processes typically go out of control over time) then you want to understand how and why it is improving. If it is getting worse over time, you want to understand why and work to improve the process. This isn’t just for machines but also for business processes.

Once you have valid metrics there are several different things you can do. You can simply jump in and try to fix whatever problem is there or you can take a different track. The other track is to do some root cause analysis of the situation. This is called the Five Whys. This is a series of questions that ask Why to understand the real cause of the problem. In one case you may have had a new employee upload something to the production server and it kills the production server. Understanding why might not be as simple as saying, don’t do that again. First you might want to know why the action of the employee took down the server, was it something he did that no one else would have done or was it something else. As you dive down you may realize part of the problem was lack of training but there were issues that would have arisen eventually from someone else. This deeper understanding allows you to make changes at multiple levels rather than installing knee jerk reactions.

That’s a reactionary use of Lean, some other interesting uses of Lean have to deal with experimenting with your product. Ries argues that most companies wait to long to engage customers and put too much effort into the first version of the software. He argues that a company should create a minimum viable product that can be tested to get the basic point across of the end product. Doing this early allows for experimentation with customer feedback. In the software world this is pretty easy to do. You can get to something that early adopters can use and then test changes. As you can route different users to different versions of your website for the product you can have slightly different tests to see what increases the metric that matters. Getting people to continue using your product, but you need to have very targeted metrics to understand what is actually happening with your software. If you use the incorrect metric you will do a lot of work that isn’t driving usage and isn’t driving your revenue.

If you decide to change the way users interact with your GUI, it would be useful to have a goal metric to truly understand if the GUI is an improvement over the previous GUI. This could be tracking the number of clicks it takes to get to an important function. The number of times the user uses your product, the number of times a new user uses the product, but stops using a specific GUI. Once you see your metric moving in the correct direction and you can be sure that it is the result of your changes, then you should end you experiment understand why the users reacted the way they did and try to learn what you should test next.

The early goal is rapid experimentation with purpose and data to back up the decisions you make. These techniques will work with any company, but will also be very successful for a startup.